How tight is right and how to get there
With the explosive development of new classes of blood glucose-lowering medications offering an increased number of treatment choices, the question for physicians and for people with diabetes is how tight is right and how to get there. In an editorial in Archives of Internal Medicine, Dr David Nathan says: ‘For now, the approach to the type 2 diabetes epidemic should include attempts to prevent the disease and to treat it with the medications known to be safe and effective. Given the magnitude of the epidemic and the central and demonstrated role of glycemic control in ameliorating the toll of microvascular and neuropathic complications, we should continue to emphasise a goal of HbA1c levels of less than 7.0% for patients likely to benefit and the aggressive application of other interventions that reduce cardiovascular disease risk as demonstrated in clinical trials.’
Step 1 in treating new-onset type 2 diabetes and reducing the risk of complications, according to the American Diabetes Association and the European Association for the Study of Diabetes in its 2006 consensus statement, is lifestyle interventions to improve glucose, blood pressure, and lipid levels and to promote weight loss or at least avoid weight gain – and lifestyle interventions should remain an underlying theme throughout the management of type 2 diabetes, even after medications are used. The 2008 update published in Diabetes Care (PDF) advises that:
- People with diabetes should strive to achieve and maintain hemoglobin A1c (2–3 month average blood glucose) levels under 7%.
- Physicians should begin treatment with lifestyle intervention and metformin (because of its effect on glycemia, absence of weight gain or hypoglycemia, good tolerability profile, and relatively low cost).
- If that does not achieve or sustain the glycemic goals, then step 2 is adding another medication (eg, sulfonylureas, basal insulin) within 2–3 months.
- If the above therapies do not work, then step 3 is starting or intensifying insulin therapy.
GI Group: Treating diabetes is a team effort and the most important member of your team is you.
‘Working with a healthcare team is the best way you can avoid the serious complications that diabetes can cause,’ says Dr Alan Barclay, coauthor of The Diabetes & Pre-diabetes Handbook (New Glucose Revolution for Diabetes in the US and Canada). ‘That’s the clear message from numerous studies of people with diabetes in recent years. Make sure you know as much as possible about your diabetes, are involved in the decisions about treatment and act on the advice that you are given. If the combination of weight loss (if necessary), a healthy diet, physical activity and medication delivers near normal blood glucose levels, your diabetes is well managed and your risk of complications is much lower. Knowledge is your best defence. Working with your healthcare team, here’s what you need to aim for:
- Hemoglobin A1c – under 7%
- Blood glucose levels 4–8mmol/L (72–144 mg/dL)
- Blood pressure – under 130/80
- Cholesterol – under 4 mmol/L (156 mg/dL)
- A healthy weight
- A healthy eating plan
- Regular exercise
- Regular eye checks, and
- Regular foot examinations.
Australia/New Zealand: The Diabetes & Pre-Diabetes Handbook
USA/Canada: New Glucose Revolution for Diabetes
Squelch hunger pangs with low GI low-energy-dense foods
In October GI News, Catherine Saxelby reported that researchers from Johns Hopkins Bloomberg School of Public Health found they could drop the calorie (kilojoule) content of a lunch meal by half if they substituted ground (minced) white button mushrooms (a low calorie, low-energy-dense food) for beef mince (much higher in both departments) in familiar dishes like lasagna, ‘sloppy Joe’ (a kind of savoury mince) and ‘chili’ (as in con carne). The study participants didn’t rate the taste of the mushroom meals any differently from the beef meals. And despite consuming fewer calories with the mushroom meals, they didn’t compensate by eating more later in the day.
‘Energy density’ simply means how many calories there is in each mouthful of a food.
- A food that is high in energy density has a large number of calories in that mouthful. Most modern-day snacks for example are energy-dense. They pack a lot of energy (the scientific term for calories/kilojoules) into a small volume (your mouth).
- A food that has a low energy density has fewer calories for the same mouthful of food.
It’s not rocket science to work out that tucking into too many energy-dense foods will pile on the pounds. This is because most of us tend to eat roughly the same weight of food each day regardless of calories. If we can choose foods that offer fewer calories for the same amount of food, we will be able to manage our weight more effectively. We may also reduce our risk of type 2 diabetes according to a large prospective study published in Diabetes Care that suggests that the energy density of our diet may itself be a risk factor for diabetes, regardless of BMI, total energy intake and other known risk factors for diabetes.
The bottom line: Don’t worry about calculating numbers or investing in another diet book. A healthy, low GI diet rich in fruit and vegetables, unprocessed or minimally processed fibre-rich grain foods (the low GI ones of course) and lean protein – legumes, fish, skinless poultry, low-fat dairy foods – is a low-energy-density way of eating that squelches those hunger pangs and helps you manage blood glucose levels.
Hot Flashes, Hormones, and Your Health
Dr JoAnn E. Manson with Shari Bassuk, McGraw-Hill
Although subtitled ‘Breakthrough findings to help you sail through the menopause,’ this book is more a guide to the latest scientific evidence on the risks and benefits of hormone therapy and whether you should start or stop from the Professor of Medicine, Harvard Medical School and Chief, Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital. Chapters cover treating the symptoms of menopause; the rise, fall and (cautious) return of hormone therapy; evaluating the risks and benefits; and how to calculate (and reduce) your risk of five health outcomes associated with hormone therapy.
Regarding type 2 diabetes, here’s the ‘bottom line’ according to Manson: ‘Hormone therapy may lower the risk of type 2 diabetes. However, many women at risk for diabetes are also at heightened risk for developing coronary heart disease and stroke and therefore are not good candidates for hormone therapy.’ So check it out and talk to your doctor.
Dr Neal Barnard, The Reverse Diabetes Diet
Australian lecture and book signing tour
All lectures will be followed by a book signing and are free and open to the public.
To RSVP to any of these events, please e-mail: email@example.com
Brisbane Monday, Dec. 1, 6:30 pm
Where: State Library of Queensland Cultural Centre Auditorium 2
Sydney Wednesday, Dec. 3, 6:30 pm
Where: State Library of NSW, The Dixson Room
Melbourne Thursday, Dec. 4, 6:30 pm
Where: The University of Melbourne, Elisabeth Murdoch Building, Theatre A, Building 134
(Gate 3 entry off Swanston Street)