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Thursday, November 27, 2008

The Diabetes Diet Wars

So, you’re a type 2 diabetic and you want to know what to eat? It seems such a simple question. After all, scientists all around the world have been studying the subject for nearly a century. How long does it take to discover which foods are good and bad for a type 2 to eat?

Going by the results, a very long time.

Welcome to the diet wars.

Which camp are you in? Do you follow the low-fat dietary guidelines of the ADA, AHA and USDA? Those guidelines usually start with something like "People with diabetes have the same nutritional needs as anyone else". That is technically accurate, but it implies that we must meet those needs in the same way as everyone else; and that is simply not true. Somehow they blithely ignore the fact that everyone else doesn’t have insulin resistance and a struggling or defunct pancreas. They will often follow with something like "The message today: Eat more whole grains! Whole grains and starches are good for you". But we all know that will raise our blood glucose levels, don’t we? No problem – they have a solution for that too: "Your doctor may need to adjust your medications when you eat more carbohydrates". In fact, despite the "same as anyone else" preamble the recommended diet is very low-fat and high-carb. It leads, in my opinion, inevitably to over-medication and progression.

I did the approved training with the dietician, but I kept having this radical thought as I saw my numbers go into the stratosphere and realised I would have to ask the doctor for lots of medications if I ate as the dietician recommended – what if there was a way of eating that gave all of the benefits of those grains and starches without doing that to my blood glucose? Much later I have started to read the book "Good Calories, Bad Calories" by Gary Taubes. I'm so glad he wrote it because he supports with science many of the decisions I made using logic and my meter some years ago.

Or are you in the low-carbohydrate camp, following weight-loss diets such as Atkins or South Beach and similar, or ultra-low-carb diabetes control diets such as that recommended by Dr Richard Bernstein? Or are you following something less radical such as Gannon and Nuttall’s LoBAG (Low Biologically Available Glucose) diet?

If I had to choose one of those it would be Gannon and Nuttall; but I don’t belong to any of those warring camps. I know my signature of "Everything in Moderation – Except Laughter" seems rather boring, but I chose it with care. The more I read about diabetes, the more I realised that extremes can kill us. In blood glucose terms both hypo- and hyper- are to be avoided; normal numbers are my aim. The same applies to lipids (cholesterol, especially triglycerides), weight, blood pressure and all of the various medical indicators we have to be aware of. I am honestly mystified as to why the experts keep urging us to go to extremes of low-this and high-that.

Another part of the problem is the word "diet"; it implies a short-term restriction to meet a goal such as weight loss. Diets do not work for us. As diabetics we have a chronic, life-long, life-threatening condition that is directly affected, more than most other conditions, by the food we eat at every meal. We do not need a short-term quick-fix diet. Instead we need to each discover for ourselves a "way of eating" that is delicious and enjoyable to ensure that we can happily follow that way for the rest of our lives, but which also meets our nutrition needs while aiding, rather than exacerbating, our diabetes control or other health problems.

But people like labels so I call my way of eating "low-spike" because that is my aim: to minimise blood glucose spikes after I eat. Compared to the ADA guidelines I eat low-carb, but I don’t count carbs because that is not my aim; instead I read my meter after I eat, review what I ate, and adjust the menu next time if the result was unacceptable. It’s pretty simple really. Occasionally I check to be sure nothing vital is missing, but the only thing I seem to be missing after six years of eating low-spike is complications.

So I’ll keep doing what I’m doing and let the others keep fighting the diet wars.

Cheers, Alan
Everything in Moderation - Except Laughter

PS That was my third and final dLIfe column.

Tuesday, November 25, 2008

Miracles and Wonders

What an interesting world we live in. As Paul Simon wrote, these are the days of miracles and wonders.

When I was diagnosed with type 2 back in 2002 I was totally ignorant of diabetes. I lived in a naive world that didn’t talk about such things; I had no idea that my aunt and several other close relatives were diabetic. Mum wasn’t, and Dad died of a war-related heart condition in his fifties. I was a blank slate.

Six years later, I read and write on several diabetes forums. I see many posts from shocked, scared, newly-diagnosed type 2 diabetics who are following terrible dietary advice and wondering why they get worse. I sometimes reflect on how lucky my ignorance was for me.

Of course, better knowledge may have caused me to get fit earlier and maybe stave off that diagnosis, but I doubt it. For example, despite all the information available on smoking I had only given up the noxious weed a year before, after nearly forty years of forty a day. Why would I have lost weight or become fit on the vague possibility of diabetes? I most likely would have changed the same things as the vast majority of the type 2 diabetes population – nothing.

That fortunate ignorance meant that I had no pre-conceptions at all. I knew no more about carbohydrates, protein and fats than any other ordinary guy, I had never heard of Atkins or Ornish, or the low-fat versus low-carb diet wars, and I had no guilt or shame about the condition being my fault. Far too many newly-diagnosed type 2s appear on the forums with that hang-up.

What a great benefit that ignorance was, because I then embarked on a voyage of discovery over the next few years, learning what I needed to fight my personal battle against this condition from every source that I could. I listened to and read doctors, dieticians, books, the web, the net and most important of all, other diabetics. What a wonderful modern miracle the internet is; used with discretion and judgement, it is an empowering tool for all patients of any affliction wanting to understand, to learn, and to find others who can support and empathise with them. We can discuss our problems with family, friends, doctors and nurses - but only another diabetic can really relate to how we feel about this condition.

At the start, no-one had told me that if I went below certain carbohydrate levels my brain would atrophy, nor that even a little more protein would lead to dialysis and that a little more fat would fill my arteries with plaque, nor that I would go insane if I tested too often, nor that artificial sweeteners would kill me, nor that it was dangerous to aim for normal HbA1c’s, nor a whole lot of other rules that so many doctors, dieticians, and diabetes authorities seem to have. By the time I did start to hear these alarms and scares, and I have been told all those and worse over the past six years, I was discovering that they were almost all completely wrong.

Along the way I read Jennifer's advice to the newly diagnosed. It was so simple and yet so effective. As an ex-engineer the concept of test, review, adjust was a basic one to me. Plan and execute an action, test the outcome, review the result and then change the plan next time for a better result. A process of iteration. Always aiming to improve.

That is what caused me to ponder on miracles and wonders. Not the Wonders of the World, although they were fun to visit, but the wonders of modern science and technology. The internet was a modern miracle that helped me immensely; another was the blood glucose meter. It is only a few short decades since the first blood glucose meter was developed for home use. It is only in the past two decades that it became possible to use meters intensively at home in the way so many type 2’s I know have done; using post-prandial testing to develop a better lifestyle complemented by medications when necessary, rather than using medications to combat and overcome an incorrect diet.

We have some miraculous tools available to us as type 2 diabetics in the 21st century if only we utilise them correctly. Take advantage of them.

Cheers, Alan

Everything in Moderation - Except Laughter

PS This was my second dLife column.

Monday, November 24, 2008

Turning Points

There are turning points in all our lives. Some we only recognize in hindsight, while others are immediately obvious.

My life changed completely on the 18th of February, 2002, four days before my 55th birthday.

I went to see the doctor for a routine physical after a blood draw to renew a standing prescription for a statin. I had been placed on the statin a couple of years earlier by a previous doctor who said, "your cholesterol is a little high", but you don’t need to worry - we have a pill that fixes that." He prescribed Lipitor 20mg. He never mentioned my 120Kg (260lbs) weight, or my fasting BG’s of 7.9mmol/l(140mg/dl), or diet, or exercise, or even the hint of diabetes. Just the instruction to "take this pill." So I took the pill, and changed nothing else. I was fat and happy. Does that sound familiar to anyone?

Then, on the day my life changed, I sat in the doctor’s office and went into shock as he told me I had leukemia. You thought I was going to say Type 2 Diabetes, didn’t you? Nope – on that day in February 2002 he told me I had CLL. Happy birthday...

I went home in a daze. But by the time I reached home, I had made up my mind to be “officially retired” and that I was going to do some of the things I had always wanted to do. I was not going to die with my song unsung. So I told my wife, as she opened the door, that I was going to travel around the world. I had always wanted to travel but always spent the time or money on something more important or more responsible. It was only later in the day I got up the courage to tell her why. A year later we went around the world for the first time.

Over the next two months I went through all the fun things of confirming my cancer diagnosis; a multitude of blood tests and a bone marrow aspiration. I got on the Web and searched for things I could do to help myself beat it. I found nothing.

The depression of diagnosis set in. I was told I was on “W&W: Watch and Wait." Wrong. “W&W” really means “Wonder and Worry.”

And then, in early May I was told by my doctor I also had Type 2 diabetes. Oh joy. But this was different. The doc told me to get a meter, and suggested I test fasting and pre-dinner blood glucose levels, and gave me targets for these numbers. What he didn’t give me was any advice on how to achieve those targets, except to "lose 8% of your body-weight."

The CLL diagnosis had primed me. There I was, all frustrated and depressed, and suddenly I had a goal that I could achieve. I designed my own weight-loss cooking and eating plan, and put it into practice. And it worked. When I lost the 8%, I just kept going. But it wasn’t enough. My A1C only dropped from 8.2% to 7.5%, despite my weight loss. So I started searching for more information. Over the next couple of months, I attended dietician’s appointments and a course with a dietician. My weight loss stalled and my blood sugars got worse as I started adding extra carbohydrates to follow the dietician’s advice. And then, like a new world, I discovered the anarchy of Usenet’s diabetes groups and eventually the most powerful, simple, logical advice I’ve seen before or since for new type 2 diabetics.

This advice is written by a diabetic named Jennifer. In essence, she says to test after you eat to see what your food does to you. Then change what you eat to improve the results next time. That’s basically it. So simple, but so incredibly effective and powerful if you think about it and then put it into practice. Naturally, everyone who uses it adapts it for themselves. I modified it for my own use. Of course, it is simplistic to concentrate only on blood glucose levels, as other aspects of nutrition had to be reviewed as I made those changes. But I always made blood glucose control the first priority.

Serendipity is a wonderful thing. These days I spend a lot of my time trying to persuade newly diagnosed diabetics to follow that testing advice and I am out-spoken on the effects of diet on diabetes, but I make no claims about diet and leukemia. But something odd happened. My CLL numbers also all improved since I took control of my diet.

For several years I was involved in the excellent ACOR mailing list for support and information for the CLL, eventually becoming one of the list managers. My improvement led to me resigning from that a year ago; it became increasingly difficult to see old friends passing away or in pain as I improved. If the Sword of Damocles drops and the numbers start rising again I’ll return, but for now I just see the haemo a couple of times a year and get on with the rest of my life.

My haematologists remind me that it’s serendipitous, but they also tell me to keep doing what I’m doing. That sounds like good advice to me, so I will.

PS This was the first of three posts I wrote as a guest columnist on dLife.com. I have received permission to re-post them on my blog so that they don't get lost with time.

Cheers, Alan
Everything in Moderation - Except Laughter

Saturday, November 22, 2008

Snacks

One of the most common questions from newly diagnosed type 2s is "what can I eat as a snack".

What follows are just a few ideas based on my own menu and test results. Experiment, base your choices on the foods you like and develop your own choices to fill those "gotta have something" moments or to be sure you graze properly.

Nuts.
An occasional handful. My preferred mix is unsalted roasted cashews, brazils, hazelnuts, almonds and walnuts (or pecans). Peanuts are not nuts.

Olives.
Eat them in any form you like. I stopped buying pitted olives because I ate too many at a time. I found that eating marinated whole olives slowed down my snacking because it takes a little longer when you have to munch around the seed. I buy them cheap in large bottles and add chopped hot chili, onion and herbs to my own liking to the bottle to flavour them.

Cheesy dips.
Check labels for carb content or make your own. Use low-carb crackers or vege strips as dippers.

Other dips.
Try guacamole, hommus and similar.

Avocado.
I slice an avocado in half, twist so that I have a free portion and a seed portion, put the seed half in the fridge for ‘Ron (later on:-), sprinkle a little salt and maybe a squirt of lime-juice on the other half and eat it direct from the shell with a teaspoon. If it’s a big one I may get four serves out of one. Another option is to spread avocado on a cracker.

Half and quarter portions of fruit.
A quarter or half portion of an apple or orange or pear or similar can fill that gap without leading to a BG spike, the leftovers become another snack later in the day.

Roll-mops and similar fishy treats.
Not for all – but a great snack for those who like them.

Left-over salad from an earlier meal.
Makes another good ‘tween meal snack, dressed with a lttle balsamic vinegar and extra-virgin olive oil.

Crackers.
Check the carb content. I use a version that is 6gms carb per cracker and spread peanut butter or real butter with the secret Aussie wonder food on them.

Cheers Alan
Everything in Moderation - Except Laughter

Sunday, November 16, 2008

Experts

One of the most difficult things about incurable conditions, like type 2 diabetes, and how to treat them is the variety of opinions available to us. The major diabetes authorities disagree over treatment, medications, diet, causes, and the right targets to aim for. Sometimes the differences are trivial, but at other times they can be very significant. It gets even more confusing when you get to the differences between those authorities and the pro-active patients out there in the real world struggling to beat this thing.

In the 6 1/2 years since I was diagnosed with diabetes I've asked many experts many questions. Most gave excellent answers. But some didn't answer at all; some ignored my questions and only gave answers to the questions I hadn't asked but that they wanted to answer; and some gave me answers that were more like orders and made my condition worse. Most of the latter group were dieticians.

Asking experts is excellent advice. Believing experts as though they are infallibly beyond question is not.

To learn in any field, ask many experts, not one. When you do that you will find confusion, because they won't all agree. It is up to you to read and learn enough to be able to assess the worth of their advice and decide which expert's advice to trust and which to discard, and also to pass all the advice that you get through the filter of your own common sense.

Remember that not all experts have to have letters after their name; experience and expertise can make an expert. A relevant example that comes to mind is Gretchen Becker, a "Patient Expert" who I learned a lot from myself. Another would be David Mendosa, or Jennifer of "test, test, test" fame, or Jenny Ruhl; and many others.

My most important point is one that I repeat to every newly diagnosed diabetic.

Never forget that the person who will be most affected by poor advice from any source will be you – not me, not your doctor, but you. In my opinion, more than nearly any other condition, the success of management of diabetes depends on the diabetic. So, while medics can advise and prescribe – it’s your decisions and your actions that will decide your future.

Cheers, Alan
Everything in Moderation - Except Laughter.