"Dr. Bernstein isa truepioneer indeveloping practical approaches tocontrollinga devastating disease that isgrowing at epidemic proportions in thiscountry."

—Barry Sears, PhD, author of The Zone

DR. BERNSTEIN'S

Diabetes

SolutionNEWLY REVISED

&

M' UPDATED

THE COMPLETE GUIDE

TO ACHIEVING

NORMAL BLOOD SUGARS

LkkAA

r r? "

Richard K. Bernstein, MD

Dr. Bernstein's

Diabetes Solution

Theories, no matter how pertinent,

Cannot eradicate the existence of facts.

—Jean Martin Charcot

Dedicated to the Memory of My Dear Friends

Heinz I. Lippmann, MD,

and

Samuel M. Rosen, MD,

Who fervently believed that people with diabetes are

entitled to the same blood sugars asnondiabetics

Dr. Bernstein's

Diabetes SolutionNewly Revised and Updated

The Complete Guide

to Achieving Normal Blood Sugars

Richard K. Bernstein, MD,FACE, FACN, FCCWS

Foreword by FrankVinicor, MD, MPHRecipesby Karen A. Weinstock and Timothy J. Aubert, CWC

mi 837

LITTLE, BROWN AND COMPANY

New York Boston London

Copyright©1997,2003,2007 by Richard K.Bernstein, MD

Glucograf* is a registered trademarkof Richard K. Bernstein, MD

All rightsreserved. Exceptas permittedunder the U.S.CopyrightAct of 1976,no partof this publication maybe reproduced, distributed, or transmitted inany form orby anymeans,or storedin adatabase orretrieval system,withoutthe priorwritten permissionof the publisher.

Little, Brown and CompanyHachette Book Group237 Park Avenue, New York, NY 10017Visit our Web site at www.HachetteBookGroup.com

Originally published in hardcover by Little, Brown andCompany, 1997Newlyrevisedand updatededition, March 2007

Little,Brownand Company is a division of Hachette Book Group, Inc.The Little, Brown name and logo aretrademarksof Hachette Book Group, Inc.

Illustrations by Terry Eppridge

Author's Note

This book is not intended as a substitute for professional medical care.The reader should regularly consult a physician for all health-relatedproblems and routine care.

The author is grateful for permission to include the following previouslycopyrightedmaterial:Figure 1-3. Reproduced from the Journal of Clinical Investigation, 1967;46:1549-1557. By permissionof The AmericanSociety for Clinical Investigation.Figure 9-1. Reproduced from Journal of theAmerican Dietetic Association,1995; 45:417-420. Copyright © by The American Dietetic Association.Reprintedby permissionof The AmericanDietetic Association.Figure 19-1. Reproduced from Humalog PI.Reprinted by permission of EliLilly and Company.

Library ofCongress Cataloging-in-Publication Data

Bernstein, Richard K.

Dr. Bernstein's diabetes solution: the complete guide to achieving normalblood sugars / Richard K. Bernstein; foreword by FrankVinicor; recipesbyKaren A. Weinstock and Timothy J. Aubert.— Newly rev. and updated,

p. cm.

Doctor Bernstein's diabetes solution

Diabetes solution

Includes index.

ISBN 978-0-316-16716-1

1. Diabetes— Popularworks. 2. Blood sugar monitoring — Popularworks. I. Title. II. Title: Doctor Bernstein's diabetes solution. III. Tide:

Diabetes solution.

RC660.4B464 2007

616.4'62 —dc22 2006026483

10 9 8 7 6 5

RRD-VA

Printed in the United States of America

Contents

Forewordby Frank Vinicor,MD,MPH vii

Prefaceto the NewlyRevised and Updated Edition ix

MyLife with Diabetes: Well Beyond a HalfCenturyand Counting xii

Acknowledgments xxi

Before and After: Fourteen Patients Share Their Experiences 3

PART ONE

Before You Start

1. Diabetes: The Basics 33

2. Tests: Baseline Measures ofYour Disease and Risk Profile 52

3. YourDiabetic Tool Kit:Supplies YouWill Need and Where

to Get Them 66

4. How and When to MeasureBloodSugar 75

5. Recording Blood Sugar Data: Using the Glucograf III Data Sheet 83

6. Strange Biology: Phenomena Peculiar to DiabetesThat

Can Affect BloodSugar 91

7. The Laws of Small Numbers 102

8. Establishinga Treatment Plan:The Basic Treatment Plans

and How We Structure Them 109

PART TWO

Treatment

9. The BasicFood Groups, or Much of What You've Been

Taught About Diet Is Probably Wrong 123

10. Diet Guidelines Essential to the Treatment ofAll Diabetics 138

11. Creating a Customized Meal Plan 167

12. Weight Loss — IfYou're Overweight 184

13. How to Curb Carbohydrate Craving or Overeating

Using Self-Hypnosis or Low-Risk Medications 19614. UsingExercise to Enhance InsulinSensitivity 211

15. Oral Insulin-SensitizingAgents,Insulin-Mimetic Agents,

and Other Options 235

16. Insulin: The Basics of Self-Injection 249

17. Important InformationAboutVarious Insulins 264

18. SimpleInsulin Regimens 276

19. Intensive Insulin Regimens 284

20. Howto Preventand CorrectLow BloodSugars 317

21. How to Cope with Dehydration, DehydratingIllness, and Infection 344

22. DelayedStomach-Emptying: Gastroparesis 357

23. Routine Follow-upVisitsto YourPhysician 381

24. What You Can Expectfrom VirtuallyNormal BloodSugars 385

PART THREE

Your Diabetic Cookbook

25. Recipes for Low-Carbohydrate Meals 391

Appendices

AppendixA:What About theWidely Advocated DietaryRestrictions

on Fat,Protein, and Salt,and the Current High-FiberFad? 443

Appendbc B: Don't PermitHospitalization or Lengthy Outpatient

Procedures to ImpairYour Blood SugarControl 462

Appendix C: Drugs That MayAffect BloodGlucoseLevels 465

Appendix D: Foot Care for Diabetics 473

Appendix E:Polycystic Ovarian Syndrome 477

Glossary 482

RecipeIndex 493General Index 495

Forewordby FrankVinicor, MD, MPHDirector, Division of Diabetes Translation

National Center for Chronic Disease Prevention

and Health Promotion

Centers for Disease Control and Prevention

Atlanta, Georgia

We are learninga lot about diabetes — especially during thepast five to ten years. This accumulation of new knowledgeis both encouraging and at the same time verychallenging.

On the "challenging'' side:

• Diabetes seems to be everywhere and steadily increasing in itspresence. Think about it — 1 in 3 babies born in 2000 will develop diabetes in their lifetimes. Every day, about 1,400 peopleare diagnosed with diabetes in the United States. And now nocountry in the world is free from diabetes, and its growth.

• We now do know how to prevent type 2 diabetes, but today fortype 1 diabetes, neither prevention nor a long-lasting cure isavailable.

• Once diabetes is present, good care based on solid science nowcan prevent much ofthe devastation formerly caused by elevatedblood sugars. But there remains a sizable gap between what weknow to do and how well and widely we are doing it. In otherwords, the "translation" of diabetes science into daily practicestill has a way to go.

Nonetheless, in spite of these and other important challenges, weareallbetter preparedto dealwith diabetes in 2007than we were evena few years earlier, let alone decades ago. Remarkableprogress has occurred. Forexample, many people at high risk for type 2 diabetes donot develop it. Modest weight lossand increased physical activity havebeen shown to eliminateor at least delay the development of this typeof diabetes by 60-70 percent — regardless of race, ethnicity, or age.

In addition, for both types 1 and 2 diabetes, we now have many

viii Foreword

more effective medications which, when taken appropriately and incombination with proper nutrition and activity, will result in controlled plasma glucose, blood pressure, andblood fats — with definitereduction in the likelihood of eye, kidney, nerve, and heart problems.In other words,while the goals of diabetes research still in large partshould be prevention or cure, even now the devastation formerlycaused by this conditiondoes nothave tohappen!

Nowadays, too, we have better ways to follow and keep track ofdiabetes — with improved health care systems, better educationalprograms, less painful self-monitoring of blood sugars, more quicklyavailable and accurate glycosylated hemoglobin levels, waysto identifykidney problemsearly, and so forth. We canknow what is goingon!

So, in fact, we areactually seeingan improvement in diabetes carein the United States, although not with allpeople and not yet to an adequatelevelor fast enough.

What does all this have to do with Dr. Bernstein and this edition of

Diabetes Solution7. As mentioned earlier, the rate of accumulation of

new diabetes knowledge is quite remarkable and daunting. Yet Dr.Bernstein stays on top of it all. The care pattern for diabetes has become much more complex and demanding,and Dr. Bernsteinand hisapproachhave proved equalto the challenge. In essence, diabetes is inmany ways"lesseasy" than in the past— forthe patient or for his/herhealth care professional. There are lots of nutritional approaches toconsider, lots of medications to be used in varying combination, andoften less time within a busy office practice to make all these wonderful advances real and meaningful for people facing diabetes. Thisnewly revised edition presents the advances in diabetes thinking andmanagement with passion, compassion, caring, and conviction. Certainly, forsome people, hisapproaches are not easy! But they do reflectevolvingmedicalscience aswellashis personal experiences in managing his own diabetes. He does not ask anyone to do anything that hehimself would not do, and for this I have respect and admiration. Heis offering to persons challenged by the presence or risk of diabetes away to be in charge of the disease. And he is ensuring that importantadvances in diabetes scienceget out there now to make a difference inpeople's lives. Take a look! Think about the ideas and suggestions —they can further our mutual and ongoing effort to prevent, capture,and control this disease called diabetes.

Preface to the Newly Revised andUpdated Edition

Since the publication of the revised edition of Dr. Bernstein'sDiabetes Solution in 2003, many new developments have occurred in the fieldof diabetes research, and as each significant

one hascome along,I have furtherrefinedmy techniques for normalizing blood sugars. This newly revised and updated edition discussesnew oral medications, new insulins, new dietary supplements, newhardware (tools for the diabetic), and other new products. It also explores new methods that I havedeveloped for more elegantly controlling blood sugars.

Exciting new approaches to weightlosswill be found here, including the use of a new, injectablemedication (an amylin analog) that iswonderfully effective for alleviating carbohydrate craving and overeating.

This newly revised and updated edition builds upon the prior twoeditions ofthis book and upon my two earlierbooks about diabetes. Itis designed asa tool for patientsto be used under the guidanceoftheirphysicians or diabetes educators. It covers, in a step-by-step fashion,virtually everything that must be done to keep blood sugars in thenormal range.

In these pages I attempt to present nearly everything I know aboutblood sugar normalization, how it can be accomplished and maintained.With this book, and with the help ofyour physicianor diabeteseducator, I hope that you will learn to take control of your diabetes,whether it's type 1 (juvenile-onset), as mine is, or the much morecommon type 2 (maturity-onset) diabetes. To my knowledge, there isno other book in print addressed strictly to blood sugar control forboth types of diabetes.

x Preface to theNewlyRevisedand UpdatedEdition

This volume contains much material that may be new to manyphysicians treating diabetes. It ismy hopethatdoctors andhealthcareprofessionals will use it, learn from it, and do their best to help theirpatients take control of this potentially deadly but controllabledisease.

Although thisbook contains considerable backgroundinformationon diet and nutrition, it is intended primarily as a comprehensivehow-to guide to blood sugar control, including detailed instructionson techniques for painless insulin injectionand so on. It must, therefore, leave out other related issues (such aspregnancy), some ofwhichrequire their own volumes. My officetelephone number is listed several times in this book, and we arealways happy to hear from readerswho seek our latest recommendation for a blood sugar meter, otherequipment, or new medications.

I urgeyoutovisittheWebsite for thisbook,www.diabetes-book.com.The site contains some of my recent articles, a history of blood sugarself-monitoring, links to other sites, testimonials from readers whohavetried the program, an opportunity to share your own experiencesin an ongoingchatgroup for diabetics andtheirlovedones,and more.The site also permits you to forward information by e-mail to anyoneyou think could benefit from this book.

Recent news releases and advertisements have described "developments" and products that are not mentioned here, and you may becurious about them. If a medication is not discussed here, then it is

likely I have deliberately omitted it as either useless or potentiallyharmful, or it was not available when this volume was written. Thereare many drugs, old andnew,usedin the treatmentof diabetes. Some,like metformin, or Glucophage, are truly wonderful, but others, suchas the sulfonylureas, are insidious and can destroy your body's remaining insulin-producing capability, if it hasany. I haveomitted anything I think is either too far into the future to be of near-termconsequence or is simply not going to be effective at getting you ontrack. I haveneither the time nor the space to attempt to debunk every"miracle cure" that comes along, most of which are neither miraculous nor cures.

Should you become pregnant while on this program, of all themedications mentioned in this book, metformin, aspirin, and insulinare the only ones that have been tested in pregnant women. Nevertheless, check out all your medications with your obstetrician andpharmacist — ideally beforeyou become pregnant.

Preface to the Newly Revised andUpdated Edition xi

Manythousands of diabetics have successfully used this program.Like them, if you, with your physician's help, seriously follow theseguidelines, you should be able to avoid the discomfort of inappropriatebloodsugar swings. Youmayevenbe able to prevent or reverse thedevelopment of manyof the grave complications long associated withchronically highblood sugars.

Finally, much of what I will cover in this book is in direct opposition to the recommendations of the American Diabetes Association

(ADA) andothernational diabetes associations. Why? Because if I hadfollowed those guidelines, theywould have killed me long ago. Suchconflicts include the low-carbohydrate diet I recommend; the avoidance of oral agents (such as sulfonylureas) that burn out survivinginsulin-producing betacells in type 2 diabetics; my utilization of certain nutrients to lower insulin resistance; my preference for certaininsulins over others, which I avoid; my desire to preserve remainingbeta cells (an alien concept to traditional practice); andmy insistencethatdiabetics are entitled to the same, normal bloodsugars thatnondiabetics enjoy, rather than the ADA's current insistence upon higherlevels.

Most important, unlike the ADA guidelines, ours work.

My Life with Diabetes

WELL BEYOND A HALF CENTURY AND COUNTING

I do not know of many diabeticswho developed the illnessaroundthe time I did, in 1946, who are still alive. I know of none who donot suffer from active complications. The reality is, had I not

taken charge of my diabetes, it's very unlikelythat I'd be aliveand activetoday.Many myths surround diet and diabetes,and much of whatis still considered by the average physician to be sensible nutritionaladvicefor diabeticscan, overthe long run, be fatal.

I know, because conventional "wisdom" about diabetes almostkilled me.

I developed diabetes in 1946 at the ageof twelve, and for more thantwo decades I was an "ordinary" diabetic, dutifully followingdoctor'sorders and leading the most normal life I could, given the limitationsof my disease.

Over the years, the complications from my diabetesbecame worseand worse, and like many diabetics in similar circumstances, I faced averyearlydeath. I was still alive, but the qualityof mylifewasn'tparticularly good. I have what is known as type 1, or insulin-dependent,diabetes, which usually begins in childhood (it's also called juvenile-onset diabetes). Type 1diabetics must takedailyinsulin injectionsjustto stay alive.

Backin the 1940s, whichwerevery much still the "dark ages"of diabetes treatment, I had to sterilize my needles and glass syringes byboiling them every day, and sharpen my needles with an abrasivestone. I used a test tube and an alcohol lamp (flame) to test my urinefor sugar. Many of the tools the diabetic can take for granted todaywere scarcely dreamed of back then — there was no such thing as arapid, finger-stick blood sugar-measuring device, nor disposable in-

My Lifewith Diabetes xiii

sulinsyringes. Still, eventoday, parents of type 1diabetics have to fivewith the same fear my parents lived with — that something could godisastrously wrong and they couldtry to wakeup their childand discover him comatose, or worse. For any parent ofa type 1diabetic, thishasbeen a real and constant possibility.

Because of my chronically elevated blood sugar levels, and theinability to control them, my growth was stunted, as it is for manyjuvenile-onset diabetics evento this day.

Back then, the medical community hadjust learned about the relationship between high blood cholesterol and vascular (blood vesseland heart) disease. It was thenwidely believed that the cause of highblood cholesterol was consumption of large amounts of fat. Sincemany diabetics, even children, have high cholesterol levels, physicians were beginning to assume that the vascular complications ofdiabetes — heart disease, kidney failure, blindness, et cetera — werecaused by the fat thatdiabetics were eating. Asaresult, I was put on alow-fat, high-carbohydrate diet (45 percent of calories were to becarbohydrates) before such diets were advocated by the AmericanDiabetes Association or the American Heart Association. Because car

bohydrate raises blood sugar, I had to compensate with very largedoses of insulin, which I injected with a 10 cc"horse" syringe. Theseinjections were slowand painful, andeventually they destroyed all thefatty tissue undertheskinof my thighs. Inspite of thelow-fat diet, myblood cholesterol became veryhigh. I developed visible signs of thisstate — fatty growths on my eyelids andgray deposits around the irisofeach eye.

During my twenties and thirties, the primeof life for most people,manyof my body's systems began to deteriorate. I had excruciatinglypainfulkidney stones,a stone in a salivary duct,"frozen"shoulders, aprogressive deformity ofmy feet with impaired sensation, and more. Iwould point theseout to my diabetologist (whowas then president ofthe American Diabetes Association), but I was inevitably told,"Don'tworry, it hasnothingto do with yourdiabetes. You're doing fine." ButI wasn't doing fine. I now know thatmost of these problems are commonplace among those whose diabetes is poorlycontrolled, but thenI was forcedto acceptmy condition as"normal."

By this time I wasmarried. I had gone to college and trainedasanengineer. I had smallchildren, and even though I wasnot much morethan akid myself, I feltlike an old man. I hadlost the hairon the lowerparts of my legs, a sign that I had developed peripheral arterial dis-

xiv My Lifewith Diabetes

ease — acomplicationofdiabetes that caneventuallyleadto amputation. During a routine exercise stress test, I was diagnosed with cardiomyopathy, which is a replacement of muscle tissue in the heartwith fibrous (scar) tissue — a common cause of heart failure anddeathamongthosewith type 1diabetes.

Even though I was "doing fine," I suffered a host of other complications. My vision deteriorated: I suffered night blindness, microaneurysms (ballooning of thebloodvessels inmy eyes), macular edema(swelling of the central portion of my retinas), andearly cataracts. Justlying in bed caused pain in my thighs, due to a common but rarelydiagnosed and barely pronounceable diabetic complication callediliotibialband/tensor fascialata syndrome. Putting on aT-shirt wasagonizingbecause of my frozen shoulders.

I had begun testing my urine for protein and found substantialamounts of it, a sign, I had read, of advanced kidney disease. In thosedays — the middleandlate 1960s — thelifeexpectancyofatype 1diabetic with proteinuria was five years. Back in engineering school, aclassmatehad told me how his nondiabetic sister had died of kidneydisease. Before her death she had ballooned with retained water, and

after I discovered my own proteinuria, I beganto havenightmares ofblowing up like aballoon.

By 1967 I had these and other diabetic complications and clearlyappeared chronically illand prematurely aged. I hadthree small children, the oldest only six years old,and with goodreason was certainIwouldn't live to see them grown.

At my father's suggestion, I started workingout daily at alocal gym.He thought that if I were to engage in vigorous exercise, I might feelbetter. Perhaps exercise would help my body help itself. I did feelslightly less depressed about my condition — atleast I felt I was doingsomething— but I couldn't build muscles or getmuch stronger.

Aftertwo years ofpumpingiron,I remained a 115-poundweakling,no matter how strenuously I worked out. It wasat about this time, in1969, that my wife, a physician, pointed out to me that I had spentmuch of my life going into, experiencing, or recovering from hypoglycemia, whichis astate of excessively lowbloodsugar. It was usuallyaccompanied by fatigue andheadaches, andwas caused by the unpredictable action of the large doses of insulin I was taking to cover myhigh-carbohydrate diet. During suchepisodes, I became confused andunruly and snapped at people. These frequent hypoglycemic episodeshad taken their toll upon my parents, and weretaking their toll upon

MyLifewithDiabetes xv

my wife and children. The strain on my family was clearlybecominguntenable.

Suddenly, in October of 1969, my life turned around.I had been the research directorofacompany that made equipment

forhospital laboratories, but recentlyI had taken a new job asan officer of a housewares corporation. I was still receiving trade journalsfrom my old field, and one day I opened the latest issueof a publication calledLabWorld. I came upon an advertisement for a new deviceto help hospital emergency rooms distinguish between unconsciousdiabetics andunconscious drunksduringthe night,when laboratorieswere closed. Knowing that an unconscious person wasa diabetic andnot drunk could easily help hospital personnel save his life. What Istumbled upon was an ad for a blood sugar meter that would give areading in 1minute, usinga single dropofblood.

Since I'd been experiencing many blood sugars that were too low,andsince the testsI hadbeen performing on my urinewere whollyinadequate (sugar that showsup in the urineisalready on its wayout ofthe bloodstream), I figured that if I knew what my blood sugars were,perhaps I could catch and correct my hypoglycemic episodes beforethey made me disorientedand irrational.

I marveled overthe instrument. It had a 4-inch galvanometer witha jeweled bearing, weighed 3 pounds, and cost $650.1 tried to orderone, but the manufacturerwouldn't sell it to patients, only to doctorsand hospitals.

Fortunately, my wife, as I've said, wasa physician, so I orderedonein her name. I started to measure my blood sugar about 5 times eachday, andsoonsaw that the levels were on aroller coaster. Engineers areaccustomed to solvingproblems mathematically, but you haveto haveinformationto work with.Youhave to know the mechanics ofa problem in order to solve it, and now, for the first time, I was gaining insight into the mechanics and mathematics of my disease. What Ilearned from my frequent testing was that my own blood sugarsswung from lowsof under 40 mg/dl to highsofover400mg/dl abouttwicedaily. A normalblood sugar level isabout85mg/dl.* Small wonder I wassubject to suchvastmood swings.

*Althoughmost medical journalsand textbooks throughout the world measureblood glucose in mmol/1 (millimoles per liter), most physicians, laboratories,and blood glucose metersin the UnitedStates measure blood glucose in mg/dl

xvi MyLifewithDiabetes

In an effort to level my blood sugars, I began to adjust my insulinregimen, and went from one injection a dayto two. I made some experimental modifications to my diet, cutting down on the carbohydrates to permitme to take less insulin. The veryhighandlowbloodsugar levels became less frequent, but few were normal.

Three years after I started measuring my blood sugar levels, my diabetic complications were still progressing, andIwas stilla 115-poundweakling. Mysense of gaining insight intothelong-term complicationsof my diabetes haddiminished, and soI ordered acomputer search ofthe scientific literature to see if exercise could prevent diabetic complications. In those days, computer searches were not the simple, almost instantsearches they are today. In 1972 you madeyourrequest tothe local medical library, whichmailedit toWashington, DC,whereitwas processed. It took about twoweeks for my $75 printoutto arrive.

There were quite a few entries of interest, and I ordered copies ofthe original articles. For the most part these were from esoteric journals and dealt with animal experiments. The informationI had hopedto find didn't exist. I didn't find a single article pertainingto the prevention of diabetic complications by exercise.

What I did find was that such complications had repeatedly beenprevented, andeven reversed, in animals. Not through exercise, but bynormalizing blood sugars! To me, thiswas atotalsurprise. All of diabetes treatment was heavily focused in other directions, such aslow-fat diets, preventing severe hypoglycemia, and preventing apotentiallyfatal extreme highbloodsugar condition called ketoacidosis. Thus ithad not occurredto me that keepingblood sugarlevelsascloseto normalas possible for as muchof the time as possible would makeadifference.

Excited by my discovery, I showed these reports to my physician,who was not impressed. "Animals aren't humans," he said, "and besides, it's impossible to normalize human blood sugars." Since I hadbeentrained as anengineer, not as aphysician, I knewnothingof suchimpossibilities, andsince I was desperate, I hadno choice but to pretend I was an animal.

I spentthe next year checking my blood sugars 5-8 timeseach day.Every few days, I'dmakeasmall, experimental change in my dietorin-

(milligrams perdeciliter). Blood glucose values in thisbookareasa rulegiven inmg/dl. Ifyou should need totranslate from onetotheother, 1mmol/1 = 18 mg/dl.

My Lifewith Diabetes xvii

sulin regimen to see whatthe effect would beon my bloodsugar. If achange brought animprovement, I'dretain it. If it madebloodsugarsworse, I'd discard it. I discovered that 1 gram of carbohydrate raisedmy blood sugar by 5 mg/dl, and Vi unit of the old beef/pork insulinloweredit by 15mg/dl.

Within a year, I had refined my insulin and diet regimen to thepointthat I hadessentially normal bloodsugars around the clock. After years of chronic fatigue and debilitating complications, almostovernight I was no longer continually tired or "washed out." Peoplecommented that my gray complexion was gone. After years of sky-high readings, my serum cholesterol and triglyceride levels had nownot only dropped, but were at the lowend of the normalranges.

I started to gain weight, and at last I was able to build muscle asreadily as nondiabetics. My insulin requirements dropped to aboutone-third of what they had been a year earlier. With the subsequentdevelopment of human insulin, my dosage dropped to less than one-sixthof the original. The painful, slow-healing lumps the injections oflarge doses of insulin left under my skin disappeared. The fattygrowths on my eyelids from high cholesterol vanished. My digestiveproblems (chronic burningin my chest andbelching after meals) andtheproteinuria thathadsoworried meeventuallyvanished. Today, myresults from even the most sensitive kidney function tests are all normal. I recently discovered thateven the calcified muscle liningthe arteries in my legs has normalized. As chief of the peripheral vasculardisease clinic of a major medical school, I had been teaching physicians that acure for this Monckeberg's atherosclerosis wasimpossible.I proved myselfwrong. My deformed feet, the droopyeyelids, and thelossofhairon my lowerlegs are not reversible and stillremain.

I hadthe newsensation of beingthebossofmy own metabolic state,andbegan to feel the same sense ofaccomplishment and reward I hadin engineering when I solved a difficult problem. I had taught myselfhow to make my blood sugars whatever I wanted them to be and wasno longer on the roller coaster. Things were finally under my control.

Backin 1973,1 felt quite exhilarated with my success, and I felt thatI was on to something big. Since getting the results of my computersearch, I hadbeen a subscriber to all of the English-language diabetesjournals, and none of them hadmentioned the need for normalizingblood sugarsin humans.

In fact, every few months I'd read another article saying that bloodsugarnormalization wasn't even remotely possible. How was it that I,

xviii My Lifewith Diabetes

an engineer,had figured out how to do what was impossible for medicalprofessionals? I wasdeeplygrateful forthe fortuitous combinationof events that had turned my life, my health, and my family aroundand put me on the right path.At the very least, I felt, I wasobligedtoshare my newfound knowledge with others. Millions of "ordinary" diabetics wereno doubt sufferingneedlessly, as I had. I was sure that allphysicians treating diabetes would be thrilledto learnhow to so easilypreventand possibly reverse the grave complications of this disease.

I hoped that if I could tell the world about the techniques I hadstumbled upon, physicians would adopt them for their patients. So Iwrote an article detailing my discoveries. I sent a copy to CharlesSuther, who was then in charge of marketing diabetes products forAmes Division of Miles Laboratories, the company that made myblood glucose meter.He gave me the only encouragementI received inthis new venture, and arranged for one ofhis company's medical writers to edit the article for me.

I submitted it and its revisions to many medical journalsover a period ofyears — a period during which I wascontinually improving inhealth, and continually proving to myself and my family, if to no oneelse,that my methods werecorrect. The rejectionletters I receivedaretestimony that peopletend to ignore the obviousif it conflictswith theorthodoxy of their earlytraining. Typical rejectionlettersreadin part:"Studies are not unanimous in demonstrating a need for 'fine control'" (the New England Journal ofMedicine), or "How many patientswould use the electric device for measurement of glucose, insulin,urine, etc.?" (Journal of theAmerican Medical Association). As a matterof fact, since 1980, when these "electric devices" finally were madeavailable to patients, the worldwide market for blood glucose self-monitoring supplies hascome to exceed $4 billion annually. Look atthe arrayofblood glucose meters in any pharmacyand you can get anidea of just how many patientsuse, and will use, the "electricdevice."

Trying to coverseveral routessimultaneously, I joined the major laydiabetes organizations, in the hope of moving up through the ranks,where I could get to know physicians and researchers specializing inthe disease. This met with mediocre success. I attended conventions,

worked on committees, and becameacquaintedwith many prominentdiabetologists. In this country, I met only three physicianswho werewilling to offer their patients the opportunity to put these new methods to the test.

My Lifewith Diabetes xix

Meanwhile, Charlie Suther was traveling around the country touniversity research centers with copies of my unpublished article,which by now had been typeset and privately printed at my expense.The rejection by physicians specializing in diabetes of the concept ofblood sugar self-monitoring, even though essential to blood sugarcontrol,wasso intense,however, that the managementofhis companyhad to turn down the idea of makingmeters available to patients until many years later. His company and others couldclearly have profited fromthe sale ofblood glucose metersandtest strips. However, thebacklash fromthe medical establishment prevented it on a number ofcounts. It was unthinkable that patientsbe allowedto "doctor" themselves. They knew nothing of medicine— and if they could, howwould doctors earn a living? In those days, patients visited their doctors once a month to "get a blood sugar." If they could do it at homefor 25 cents (in those days), why paya physician? But almost no onebelieved therewas anyvalue to normalblood sugars anyway. In somerespects, blood glucose self-monitoring still remains a serious threatto the incomes of many physicians who specialize in the treatment ofthe symptoms of diabetes and not the disease. Drop into your neighborhood ophthalmologist's office and you will find the waiting roomthree-quarters filled with diabetics, many ofwhom arewaiting forexpensive fluorescein angiographyor laser treatment.

With Suther's backingin the form of free supplies, by 1977 I wasable to get the first of two university-sponsored studies started in theNewYorkCity area. Theseboth succeeded in reversing early complications in diabetic patients. As a result of our successes, the two universities separately sponsored the world's first two symposia on bloodglucose self-monitoring. By this time I wasbeing invited to speak atinternational diabetes conferences, but rarely atmeetingsin the UnitedStates. Curiously, more physicians outside the United States seemedinterested in controlling blood sugar than did their American colleagues. Some ofthe earliest converts to blood glucose self-monitoringwere from Israel and England.

By 1978, perhaps as a result of Charlie Suther's efforts, a few additionalAmericaninvestigators were tryingour regimen or variations ofit. Finally, in 1980, manufacturers began to release blood glucose meters for use by patients.

This "progress" was entirely too slow for my liking. I knew thatwhile the medical establishment was dallying there were diabetics dy-

xx My Lifewith Diabetes

ingwhoselives couldhave beensaved. I knew also that thereweremillions of diabetics whose quality of life could be vastly improved. So in19771 decidedto giveup my job andbecome a physician — I couldn'tbeat 'em, so I had to join 'em. This way, with an MD after my name,my writings might be published, and I could pass on what I hadlearned about controllingblood sugar.

After a yearof premed courses and another year of waiting, I entered the Albert Einstein College of Medicine in 1979.1 was forty-fiveyears old.Duringmy first year ofmedical schoolI wrotemy first book,Diabetes: The GlucografMethod forNormalizing Blood Sugar, enumeratingthe full details of my treatment fortype 1,or insulin-dependent,diabetes.

In 19831 finally openedmy own medicalpractice nearmy home inMamaroneck, New York. By that time, I had well outlived the life expectancyof an"ordinary" type 1 diabetic. Now,by sharing my simpleobservations, I was convinced I was in a position to help both type 1and type 2 diabetics who stillhad the best years of their lives ahead ofthem. I could help others take control of their diabetes as I had mine,and live long, healthy, fruitful lives.

The goal of this book is to share the techniques and treatments Ihave taught my patientsand used on myself, including the very latestdevelopments. If you or a loved one suffers from diabetes, I hope thisbook will giveyou the tools to turn your life around asI did mine.

Acknowledgments

I wouldliketo thank the following people, whose aidand guidancemade this book possible:

Frank Vinicor, MD, MPH, past president of the American Diabetes Association, who took time from hisoverwhelming schedule towrite the foreword.

Stephen Stark, novelist, critic, andessayist, whose suggestions abouttone, clarity, and structure wereof immeasurablevalue.

Pharmacists Stephen Freed andDavid Joffee, who wrotethe important appendix"DrugsThat MayAffect BloodGlucose Levels." PatriciaA. Gian, dear friendand director ofmy medicaloffice,who shared thestresses of this endeavor and gave me invaluable aidand guidance allalong the way. Two top-of-the-line professionals, Elizabeth Nagle, myeditor, and Channa Taub, my literary agent, whoseefforts made thisundertaking possible. Peggy Leith Anderson, copyeditor nonpareil.Karen A.WeinstockandTimothy J. Aubert, for the recipes.

Finally, my loveand thanks to my wife,Professor Anne E.Bernstein,MD, FAPA, FABPN, who allowed me to steal so much time that reallybelongedto her.

Dr. Bernstein's

Diabetes Solution

Before and After

FOURTEEN PATIENTS SHARE THEIR EXPERIENCES

You're the only person who can be responsible for normalizingyour blood sugars. Although your physician mayguide you,theultimate responsibility is in your hands. This task will require

significant changes in lifestyle that may involve some sacrifice. Thequestion naturally arises, "Is it really worth the effort?" As you will seein this chapter, others have already answered this question for themselves. Perhaps theirexperiences will give youthe incentive to find outwhether you can reap similar benefits.

Thomas G. Watkins is aforty-year-old journalist. His diabetes was diagnosed twenty-three years ago. For the past nine years he's been followingone of the treatment protocob described in this book for people who require insulin.

"Following the instructions of several diabetologists over a periodof years, I hadthe illness 'under control' At least that's what theytoldme. After all, I was taking two shots a day, and adjusting my insulindoses depending on urine testresults, and later on blood sugar measurements. I was also following the common recommendation thatcarbohydrates fill at least 60 percent of my caloric intake.

"But something was not right; my life was not 'relatively normal'enough. Iwas avoiding heavy exercise for fear of mybloodsugar dropping too low. My meal schedulewas inflexible. I still had to eat breakfast, lunch, and dinner even when I wasn't hungry. Aware that recentresearch seemed to associate highblood sugars with an increased riskof long-term complications, I tried to keepblood sugars normal,butwound up seesawing daily between lows and highs. By the end of

4 Before andAfter

1986,1had ballooned to 189 pounds and was at a loss for how to loseweight. My'good control' regimen hadleft me feeling out of control.Clearly, something had to be done.

"In that year, I attended a meeting of medical writers atwhich Dr.Bernstein spoke. It became clear thathis credentials were impressive.He himself at that time had lived with the disease for four decades and

was nearly free of complications. His approach hadbeen formulatedlargely through self-experimentation. His knowledge of the medicalliterature was encyclopedic. Some of his proposals were heretical; heattacked the usual dietary recommendation and challenged dogmasurrounding such basics as how insulin ought to be injected. But itseemed likehewas doing something right. During histalk, Ihadto usethe bathroom twice; he didn't.*

"I decided to spend aday athisoffice to gather material for anarticle to bepublished intheMedical Tribune. There, hisindependence ofthought became clear. 'Brittle' diabetes [entailing anendless sequenceof wideblood sugar fluctuations] was a misnomer that usually indicated an inadequate treatment plan or poor training, morethan anyinherent physical deficit, he said. Normal blood sugars round-the-clock were not just an elusive goal but were frequently achievable, ifthe diabetic hadbeentaught the proper techniques. Beyond treatmentgoals, he armed his patients with straightforward methods to attainthem. His secret: small doses of medication resulted in small mistakesthat were easilycorrectable.

"Bythen, my interest had become more personal than journalistic.In early 1987, still wary, I decided to give it atry. The first thingI noticedwas that this doctor visitwas unlikeanyprevious ones.Most hadlasted about 15 minutes. This took 8 hours. Others said I had no complications; Dr. Bernstein found several. Most said my blood sugarswere just fine; Dr. Bernstein recommended I make changes to flattenthem out and to lower my weight. Those hours were spent detailingthe intricacies involved in controlling blood sugar. His whole approach blasted thetheory espoused bymy first doctor — thatI shoulddepend on him to dole outwhatever information I needed. Dr. Bernstein made it clear that for diabetics to control their disease theyneeded to know as much as their doctors did about the disease.

Very highbloodsugars cause frequent urination.

Beforeand After 5

"Two arguments commonly rendered against tight-control regimens arethat they increase the incidence oflow blood sugar reactionsandthat they cause subjects to gain weight. I have found the oppositeto be true: I shed about 9 pounds within four months aftermy firstvisit,and,years later, I have kept them off.And oncethe guesswork ofhow much to inject was replaced by simple calculations, my bloodsugarlevelsbecame more predictable.

"For the first time since I was diagnosed, I felt truly in control. I nolonger amatthe mercy of wide moodswings thatmirror wideswingsin blood sugar. Though I remain dependent on insulin and all theparaphernalia that accompany its use, I feel more independent thanever. I am comfortable traveling to isolated areas of the world, spending an hour scuba diving, or hiking in the wilderness, without fear ofbeingsidetracked by diabetes. Nowif I feel likeskipping breakfast, orlunch, or dinner, I do so without hesitation.

"I no longer have delayed stomach-emptying, which can cause verylowblood sugars right after ameal followed byhighblood sugars manyhours later. My cardiac neuropathy, which is associated with an increased risk for early death, hasreversed. Though I eat more fat andprotein than before,my blood lipidshaveimproved and are now wellwithin normal ranges. My glycosylated hemoglobin measurements,used bylife insurance companies to detect diabetics among applicants,wouldno longer give me away. Mostimportant, I now feel well.

"Many doctors will not embrace Dr. Bernstein's work, for the simple reason thatDr. Bernstein demands acommitment of time, energy,andknowledge not only from patients, but from physicians. Diabeticsare the bread and butter of many practices. For decades, the usualtreatment scenario hasbeen ablood test,ashort interview, a prescription for a one-month supply of needles, a handshake, and a bill. Butthatis changing. In the past few years, evidence has been amassing insupport of Dr. Bernstein's modusoperandi. Nolonger isthe oldhigh-carbohydrate diet unquestioned; moreandmore doctors are espousing a multiple-shot regimen controlled by the patients themselves.Most important, though, tight control is being associated with fewerof the diabetic complications that can ravage every major organ system in the body. Dr. Bernstein's scheme provided me with the toolsnot onlyto obtain normal bloodsugars, but to regain a feeling of control I had not had sincebefore I was diagnosed."

6 Before andAfter

Frank Purcell isa seventy-six-year-old retiree who, like many ofmymarried patients, works closely with his wife to keep his diabetes on track.Eileen, who goes by the nickname Ike, tells the first partofhis story.

Ike: "Frankhad been treated for many years for diabetes, and hadbeentreated orally because hewas atype 2.As far as wewere aware, hehad a functioning pancreas. The thing was, as a younger man, he'dbeen told that he had highblood sugar, but it was ignored. This wasgoing back to hisarmy days, in 1953 orso. Noonesuggested medication, no one called it diabetes, and nothing more wasdone. They justsaid he had high blood sugar. They called it 'chemical' diabetes. Itshowed up on bloodtests, but not on urinalysis. I guess in thosedays,having it show up on a urinalysis was some sort of determinant. Hedid modifyhisdiet— he stopped eating somuch candy, andhe tookoff weight — he lostabout 30 pounds in those days.

"In about 1983, Frank had a mild heart attack. He began to see acardiologist, who has been monitoring his health care very carefullysince then. For about two to three years, he took beta blockers andmaybe oneortwoheart medications. As far as wecould tell, hisheartproblems were verymuchin resolution — I mean he'dhadaheart attack, he'd had no surgery, andseemed to be doingokay. But when hestarted working with the cardiologist, the doctor notedthathisbloodsugar thingwas ongoing, and he began to feel it was of concern. Heprescribed Diabinese, which was the oral medication of choice of thetime, I guess, and hemonitored Frank's blood sugar about every fourmonths.

"I mightsay thatI never even knewwhat anormal bloodsugar was.No one ever talked about it. I had no idea whether it was 1,000 or 12.

The onlything wewere ever toldwas thatit was high orwasn't high.This went on and on forcloseto sevenor eightyears. If he had seenDr.Bernstein back then, who knows what could have been different? Buteventually, the cardiologist said he thoughtFrank ought to see an endocrinologist. He didn't feel hewas able tocontrol Frank's blood sugarwell enough himselfwith medication, and so he felt the conditionwarranted closer attention.

"Wewent to see agentleman whowas chiefof the diabetes clinic atamajor hospital here in upstate New York, where welive. Now, this isaverywell thoughtof medical facility. Thedoctor met with us,andhekept Frank on the Diabinese, and monitored him every three monthsor so. Hisblood sugars were 253,240, andhe wouldsay, 'Let's try another pill.' It was always medication. Glyburide, Glucophage — the

Before and After 7

wholebit. But trying to gethisblood sugar down wasverydifficult.Noone evermentioned diet, really. And rarely wasit everbelow 200whenwe went in. Rarely.When I finally found out what the numbers meant,I said to the doctor, 'Don't you think we ought to see a dietitian? Imean,we'reeatingthe same foodwe always have.'We wereon the normal diet that anybody'son. I had friends who are diabetics who watchcertain things that they eat,and so I thought it made acertain amountof sense. Hesaid, 'Sure. That's areally goodidea.'

"He gave us the name of a young woman, and we saw her threetimes. She said, 'Eat eleven carbohydrates every day,' and she gaveus the food pyramid — we didn't need her for that — and nothingchanged, except Frank stopped eating dessert. He would have the occasional bowl of ice cream, or a piece of cake when he felt like it, ora cookie. I always bought the newest foods that came out — low-fat, low-sugar. I was more concerned about fat during that stage, as Irecall.

"This went on until God intervened. I mean that. What happenedwas, Frank had anattack of serious hypoglycemia [low blood sugar].No one had warned us that this could happen. No one had told uswhat hypoglycemia looked like. I thought it was a stroke. Hewas outofhishead. He couldn't answer questions. The only thing that gave mesome smidgen of doubt was that he got up and walked to the bathroom and put on histrousers. I called 911. When the medic gothere,hehooked him up to some glucose, puthimonagurney and trundledhim out of here, and headed for the medical center. In the middle ofthe ride, Frank woke upand said, 'What the hell am I doing here?' Theyoung man said he certainly seemed to be coming out of his strokewell. Bythetimewegot to thehospital, hewas virtually himself.Whenthey decided to do a finger stick, his blood sugar was 26, 26 mg/dl. Ididn't have the education in diabetes that I've gotten with Dr. Bernstein, but I knewenough to knowthat this was not good. Who knowswhat it wasbeforehe got the intravenous?

"Now, we'll never know if he accidentally took his oral medicationtwice thenightbefore — it's very possible — but I tell you, however ithappened, it was the Lord who was watching over Frank and said,'Now it's time todo something.' As scary as itwas, itwas also ablessing.

"I have a doctor friend who's aclose colleague of Dick Bernstein's.My friend had had an uncle who'd beenveryillwith diabetes and itscomplications, but hislife hadbeen prolonged in amuch morecomfortable fashion by Dick Bernstein. I would talk to my friend about

8 BeforeandAfter

Frank's diabetes, and he'd sayto me,'Nothing'sreally goingto change.You're not going to get hisblood sugars down untilyousee DickBernstein.' Even though my friend is a doctor, I brushed off his advice.Frank was seeing a doctor. Why would some private doctor be anymore capable than the head of the diabetes clinic atamajor medicalcenter? But after this episode with hypoglycemia, Frank went to myfriend's office with me, and my friend laid it out for him, told us ingrinding detail what we could expect from Dr. Bernstein, what itwouldbe like, andhowhehopedwewouldrelate to Dick, because he'srather controversial, andhowhardit was going to be — how much ofacommitmentit was going to take. Wewentaway thinking, 'Let's giveit a try.'"

Frank: "To be honest, when I first met Dr. Bernstein, I felt he wassomewhat of a flake. I had worked with doctors in the army,and I wasused to aparticular kind of guy. Dr. Bernstein — now, he's ahorse ofanother color. Until I came across him, I never met a doctor who wasso focused on onething. He issocompletely directed toward this onefailing of the human body that I kind of thought that maybe it was alittle too intense.But the results have been rather spectacular, and I'mvery happy with him. He has specific programs, he has direction, hehas goals, and heisnot sidetracked byanything other than tending todiabetes. He's given mearegimen. Ikeep track of myblood sugar, andit's pretty much under control. Instead ofblood sugar counts of over200,1 nowget them inthe range of 85 to 105,which was thegoal hesetfor me. I takeinsulin in the morning andbefore middayand eveningmeals, and before I go tobed. Idon't eat ice cream, and I don't doalotofthings Iused todo routinely.When I first came toDr. B., Iwas lookingvery pale and wan, and now I'm looking much ruddier and healthier. I'm a little irritated with this constant puncturing of my fingers,but I just do it automatically now, like second nature.

"WhenI found out Iwas going to have to inject insulin, I justbrokedown and cried. It was like the final straw, and I thought, 'My life isover.' Now I hardly thinkabout it. I use Dr. Bernstein's painless injection method and it doesn'tbotherme atall. It only takesasplitsecond.Theneedle issotiny, I can barely feel theshots of minute doses of insulin.I use the 'lovehandles' on the sides ofmywaist. Now,I'm a prettyskinny guy, so there isn't much there, butI can hardly feel it. He mademe do it in the office. He showed me — did it to himself— and thenhe made me do it. Since then, I just do it routinely, all on my own. If

Before andAfter 9

I'm out, I do it wherever I am — atatable in arestaurant, in the men'sroom, et cetera — I'm not the least bit ashamed and no one seemsmuch to notice."

Ike: "About theinsulin, I had the feeling that it was going to beinevitable, and when Frank got the news he just broke into tears andreally felt that this was the final insult. He'd had many physical problems, and insulin seemed like avery low blow for him.Buthe did it,stayed with the program, and within amonth to six weeks, we beganto feel that we were on top of this, knew what was going on. He canmanage his blood sugar when it's alittle low, when it's alittle high. Heknows just what to do. His overall health has improved since thebeginning. Dr. Bernstein really gave us aneducation."

Joan Delaney is a fifty-three-year-old mother and financial editor. Herstory is not unusual.

"I mustadmit that the prospect of following this newregimen fordiabetes control seemed daunting atfirst. My life, I thought, would bedominated by needles, testing, and confusion. However, after a fewweeks, the program became a simple part of my day's routine, likeputting on makeup.

"Before Ibecame apatient ofDr. Bernstein, Iwas somewhat resignedto the probability of suffering complications from diabetes. AlthoughI took insulin, I in no way felt I had control of the disease. I had legpains atnight. Myhands and feet tingled. I had gained weight, havingno understanding of the exchange dietmy previous doctor hadthrustinto myhands. Ibecame chronically depressed and was usuallyhungry.

"Now that I follow a blood sugar normalizing program, I know Iam in control of my diabetes, especially when I see that number normal most of the time onthe glucose meter. Best ofall, I feel good, bothphysically and emotionally. I am now thin. I eat healthful, satisfyingmeals andam never hungry. Myleg pains have disappeared, as hasthetingling in my hands and feet. And now that I am in control of the disease, I no longer find the need to hide from friends the fact that I havediabetes."

About65 percent ofdiabetic men are unable to have sexual intercourse,because high blood sugars have impaired the mechanisms involved inat-

1o Before andAfter

taining erection ofthe penis. Frequently partial, albeit inadequate, erections are still possible; such "borderline" men maystillbeable to enjoyadequate erections for intercourse, after extended periods of normalblood sugars. We have seen such improvements in anumberofpatients —but only in those whose problem was caused mainly by neuropathy(nerve damage), as opposed to blockages ofthe blood vessels that supplythe penis. When we initially sawL.D„ in the pre-Viagra era, he asked meto evaluate his erectile dysfunction. I found that the blood pressuresin his penis and his feet were normal, butthat the nerve reflexes in thepelvic region were grossly impaired. L.D.'s comments refer in partto thisproblem.

"I'm a fifty-nine-year-old male, married, with three children. Approximately four years ago, after being afflicted with type 2 diabetesforaboutten years, I noticed that I was always tired. In addition, I wasquite irritable, short-tempered, and had difficulty maintaining concentration for extended periods of time. Otherwise I was feeling well,with the exception that I was becoming impotent, having difficultymaintaining an erection during sexual intercourse. At the time, I hadno knowledge whether these conditions were interrelated.

"AfterDr. Bernstein taught me to measure my blood sugars, I discovered that they averaged about 375 mg/dl,which is very high.Withmy new diet and small doses of insulin, they are now essentially normal all the time.

"I began to feel betterthan I hadin years, both physically and mentally. The problem with impotency has improved. I maintain a dailycheckof my blood sugars and feel that my overall improvementhasalso helped me recuperate quickly from atotal hip replacement without any complications."

RJN, MD, is board certified in orthopedic surgery. Hehas been followingone ofthe regimens described in this book for the pastthree years.

"I am fifty-four years old and have had diabetes since the age oftwelve. For thirty-nineyears I hadbeentreated with a traditional dietand insulin regimen. I developed severe retinopathy, glaucoma, highblood pressure, and neuropathy that required me to wear a legbrace.Both of my kidneys ceased functioning, and I was placed on kidneydialysis for many months until I received a kidney transplant. Thedialysis treatments required me to be in the hospital for about5hours

Before andAfter 11

pervisit,3 times aweek.They were verydebiUtating andleft me totallyexhausted.

"Years of widely fluctuating blood sugars affected my mental andphysical stability, with great injury to my familylife asa result.The resultantdisability also forced me to give up my surgical practice, and tosuffer almost total loss of income.

"Frequent low blood sugars would cause me to exhibitbizarre behavior, so that people unaware of my diabetes would think I was taking drugsor alcohol. I washostile, anxious, irritable, or angry, and hadextreme mood changes. I would experience severe physical reactionsthat included fatigue, twitching of limbs, clouding of vision, headaches, and blunted mental activity. I sufferedmany convulsions fromlow blood sugars andwasplaced in hospital intensive care units.Whenmyblood sugars werehigh, I had no energyandwasalways sleepy. Myvisionwasblurredand I wasusually thirstyand urinating alot.

"For the past three years, I have been meticulously following thelessons that Dr. Bernstein taught me. I measure my blood sugars anumber oftimes eachdayandknow how to rapidly correct slightvariations from my target range. I follow a very low carbohydrate diet,which makes blood sugarcontrol much easier.

"In return for my conscientious attention to controlling blood sugars, I'vereaped anumber of rewards. Myneuropathy is gone, and I nolonger require a leg brace. My retinopathy, which was deteriorating,has now actually reversed. I no longer suffer from glaucoma, whichhad required that I use special eyedrops twice each day for more thanten years. My severedigestive problems have markedly improved. Mymental confusion, depression, and fatigue have resolved so that I amnow able to work full-time and productively. My blood sugar controlhas been excellent.

"I now deal with my diabetes in a realistic, organized manner, andasa result I feel stronger, healthier, happier, and more positiveaboutmy life."

J.L.F. isseventy-one yearsoldandhasthree grandchildren. Hestillworksas a financial consultant, and wasa navalaviator in World War II. Hisblood sugars are currently controlled by diet, exercise, and pills calledinsulin-sensitizing agents. Thanks to thediet described in this book, hischolesterol/HDL ratio, an index of heart disease risk (seepage 57), has

12 Before andAfter

dropped from a veryhigh risk level of7.9 to a below-average level of3.0.His hemoglobin A1C test, which reflects average blood sugar for the priorfour months, has dropped from 10.1 percent (very high) to 5.6percent(nearly in the nondiabetic range). His R-R interval study (see Chapter2), an indicator ofinjury to nerves thatcontrol heart rate, has progressedfrom aninitial value of9percent variation (very abnormal) toa currentvalue of33percent, which isnormal for hisage.

"I probably had mild diabetes formost of my adult lifewithout realizing it. It first appeared as lethargy, later as fainting, stumbling, orfalling, but asrare occurrences. I also had difficulty attaining full erection ofmy penis.

"In early 1980,1 beganto experience dizziness, sweating, arm pains,tendencies to fainting, andthe symptoms usually associated with heartproblems. An angiogram revealed severe disease of the arteries thatsupplied my heart. I therefore had surgery to open up these arteries.All waswell for the next sevenyears, and I again enjoyed good health.

"In late 1985,1began to notice a loss of feeling in my toes. My internist diagnosed it as neuropathyprobably due to high blood sugar.He did the usual blood test, and my blood sugarwas 400. His advicewasto watchmy diet,especially to avoidsweets. I returned foranothercheckup in 30 days. My blood sugar was 350. Meanwhile, my neuropathy was increasing, along with the frequency of visits. My bloodtest results were consistently at the 350 level, my feet were growingmore numb, and I was becoming alarmed.

"I feltokay physically, walked atleast two milesaday, worked out inthe gym once or twice a week, worked a full schedule as a businessconsultant, and didn't worry a great deal about it. But I did begin toinquireof friends and acquaintances aboutanyknowledge or experiencethey might haverelative to neuropathyor diabetes.

"My first jolt came fromastory from one ofmy friends who had diabetes, foot neuropathy, deep nerve pain in his feet, and a nonhealingulceron a toe. He told me that asthe neuropathy progressed, amputation of the feet was likely, elaborating by describing the gruesome'salami surger/ ofuncheckeddiabetes.

"That's when I became emotionally unglued, asthey say. One thingabout aging and disease, you think a great deal about the utter horrorofbecoming acripple, dependent upon others foryour mobility. Suddenly foot numbness is no longer acasual matter, more like ahead-oncrash into reality.

"Then I met awealthycardealer at the golf club,with his legscut off

Beforeand After 13

ashighaslegs go, who explained he hadn'tpaid too much attentiontohis diabetes at the time and his doctor couldn't help him. He couldnever leavehis chair, except for reliefand sleep, and he had to be liftedfor that. Oh, he was cheerful enough. He joked that they would cuthim off at the middle of his butt the next time, that is, if he didn't die

first. A displayof courageto others wasa macabrenightmare to me. Igot serious about getting someone, somewhere, to tell me what to doabout my ever-worseningnumbness, which by now had spreadto mypenis. My condition became an ever-present, gnawing anxiety withme, acreepingpresenceI couldn't fightagainst becauseI simply didn'tknow how to fight it.

"Then, in earlyApril 1986, mywife and I went to visit Dr.Bernstein.The first visit lasted llh hours. Each detailof diagnosis and treatmentwasdiscussed. Each symptom of the disease, howeverminute, wasdescribed in greatdetail, the importance of eachbalancedwith another,with specific remedies for managing them. Take the seemingly insignificant matter of scaly feet, a common, dangerous symptom of diabetes. Dr. B. prescribed mink oil, rubbed into the feet morning andnight. Practiced as directed, instead of split skin and running footsores, you have skin as soft and smooth as velvet. Consider the alternative — feet split, painful, and slow (if at all) to heal — which canchange your entire life.Special shoes, debilitating gait, not to mentionthe horrible possibility of progressive amputation; all things thatreallycan happen if your diabetes is not treated properly.

"What is of highest importance, I believe, is the in-depth explanation ofdiabetes, its causes, symptoms, and treatment. He givesyou therationale for treatment, so that you have a comprehensive understanding ofwhat is wrong and how it can be corrected.

"First, through frequent finger-stick blood testing, we came to anunderstanding as to the specifics of how to attack my diabetes. Westartedwith diet. It wasn't just eat this, don't eat that, but eat this forthese reasons and eat that for other reasons. Know the reasons and the

differences. Knowing the how and why of diet keeps you on the track,and the discipline of that knowledge makes control easy. Forwithoutcontinuous diet observance,you will surelyworsen your diabetes. Heexplains that the effect of uncontrolled diabetes on the heart can bemuch more deleterious than the other popular demons — cholesterol, fat in the diet, stress, tension, et cetera — demons not to be ignored, obviously, but merely put into proper perspectiveto the mainvillain — diabetes.

14 Beforeand After

"Well, the results forme arethe numbness ofmy feetand penis haveregressed, and my erections have improved. My feet are now beautifully supple and healthy. The severe belching, flatulence, and heartburn after meals have disappeared. The other ills of diabetes haveapparently not greatly affectedme, and now that I know that controllingmy diabetes is the key to ahealthyheart,I expect to reducegreatlyany future risk of heartattacks.

"One great result of my ability to normalize my blood sugars hasbeen the stabilizing of my emotional attitude toward the disease. I nolonger have a sense of helplessness in the face of it;no longer wonderwhat to do; no longer feel hopelessly dependent on peoplewho haveno answers to my problems. I feel free to exercise, walkvigorously, enjoy good health without worry, enjoy my precious eyesight withoutfear of diabetic blindness,yes, even havea new confidence in normalsexual activities.

"All of the enjoyments of health that were slowlyebbing away arenow within my control, and for that I thank my new knowledge andskills."

LeVerne Watkins isa sixty-eight-year-old grandmother and associate executive director ofa social service agency. When wefirstmet, she hadbeentaking insulin for two years, after developing type 2 diabetes thirteenyears earlier. Hercomments relate inpart to the effects of large amountsof dietary carbohydrate, covered by large amounts of insulin, while shewasfollowing a conventional treatmentplan.

"In less than two years, my weight had increased from 125 to 155pounds; my appetitewas always ready for the next snack or the nextmeal.All my waking hours were focused on eating. I always carried abag of goodies — unsalted saltine crackers, regular Coca-Cola, andglucose tablets. I always had to eat'on time.' If I wasa half-hour lateatmealtime, my hands would begin sweating, I would become very jittery, and if in a social gathering or a conferenceor meeting at work, Iwould have to force myself to concentrate on what was taking place.During a meeting that I waschairing, the lastthing I remember sayingwas,'Oh, I'm so sorry,' before I toppled out ofthe chair to wake up andfind myself in the emergencyroom of a local hospital.

"During a subway ridewhich generally took about 25 minutes, thetrain was delayed for close to 2 hours and — to my utter dismay — Ihad forgotten my bag of goodies. As I felt myself 'going bananas,'

Before andAfter 15

sweating profuselyand perhaps acting a little strange, a man sittingacross from me recognized my MedicAlert bracelet, grabbed my arm,and screamed, 'She has diabetes!'

"Food, juice, candy bars, cookies, and fruit came from all directions. It wasa cold,wintery day, but people fanned and fed me. And Iwas so grateful and sovery embarrassed. I stoppedridingthe subway,and rescheduled as many meetingsand conferences as I could to takeplace directly after lunch so that I would have more time before thenext snackor meal would be necessary.

"I felt that I had no control over my fife; I was constantly eating, Ioutgrew allmy clothing, shoes and underwear included. I had been arather stylish dresser since college days. Now I felt rather frumpy, tosay the least. Once, I tried to discuss with my diabetologist how I wasfeeling about gaining weight and eating all the time. I was told, 'Youjust don't have any willpower,' and 'If you put your mind to it, youwouldn't eat so much.' I was very, very angry, so much so that I neverconsultedhim again.

"On my own,I triedWeight Watchers, but the dietI hadbeengivenby the dietitian to whom the diabetologist had referred me did notmesh with the WeightWatchers diet. So along I limped, trying to accept that I was getting fatter each day, was always hungry, had nowillpower, and most of the time was feeling unhappy.

"My husbandwasmy constant support through all this. He wouldsay, 'Youlook goodwith a few more pounds Gobuy yourselfsomenew clothes,' especially when I wouldaskhim to zip somethingthat Iwas trying to squeeze into. He always clipped newspaper and magazinearticles aboutdiabetes andwouldremindme to watch specials onTV. He encouraged me to be active in the local diabetes association,and would accompany me to lectures and various workshops. Then,on Sunday, April 3, 1988 — Easter Sunday — he clipped an articlefrom the New York Times entitled 'Diabetic Doctor Offers a New Treatment.' Little did I realize that this thin news article would be a new be

ginning of my life with diabetes. I must have read it several dozentimes before I finally met with Dr. Bernstein. Since that first meeting,I haven't had one single episode of hypoglycemia, which I had formerly experienced veryoften. Following theregimen of correcting myhigh and low blood sugars, taking smalldoses and different kinds ofinsulin, and eating meals calibrated for specific amounts of carbohydrates and protein, my outlook brightened and I began to feel moreenergetic and more in charge of myselfand my life. I could now hop

16 BeforeandAfter

on the train, ride the subway, drive several hours, and not fear one ofthose low blood sugar episodes. I started once again to exercise everyday. My stamina seemed to increase. I didn't have to push hardto accomplish my daily goals at work and at home. Within a couple ofmonths, I was back to 129 pounds, had gone from size 14 to size 10,and ten months laterto size 8 and 120pounds. Even the swelling andpainin my rightknee — arthritis, I wastold — abated. I feel great. Myself-esteemand self-worthare whole again. I now take only 8 units ofinsulin each day, whereI had previously been taking 31 units.

"I am also conquering my uneasyand frightening feelings about thelong-termconsequences ofhaving diabetes. While I oncethought thatheart disease, kidney failure, blindness, amputations,and many otherhealth problemswerewhat the future probably held forme, I now believethat they are not necessarily outcomes of livingwith diabetes.

"But my life is not perfect. I stilloccasionally throw caution to thewind by eating too much andeating foods I know are taboo. Stickingwith my diet of no bread, no fruit, no pasta, no milk, seemed easywhen it wasnew,but now it isnot easy, and loadsofmy efforts go intomaking salads, meat, fish, or poultryinteresting and varied. My fantasies are almostalways of some forbidden food — ahot fudge sundaewith nuts, or my mother's blueberrycobbler topped with homemadeice cream. But when all is told, I feel that I am really lucky. All my efforts have really paid off."

AD. is a fifty-five-year-old former typesetter whose diabetes was diagnosed fourteen years ago. As with many other people who use our regimen, his test ofaverage blood sugar (hemoglobin A1C) and his tests forcardiac disease risk (cholesterol/HDL ratio) simultaneously dropped fromhigh levels to essentially normal values.

"I watched my mother deteriorate in frontof me from the complications of diabetes, finally resulting in an amputationof the legabovethe knee, and a sorrowful existenceuntil death claimed her.My oldestbrother,who was also diabetic, was plagued with circulatory complications that resulted in the amputation of both feet, with unsightlystumps. Diabetes robbedhim of a normal existence.

"When I began to experience the all-too-familiar diabetes symptoms,my future looked bleak andI feared the same fate. I immediatelysearched for help,but for two years floundered around getting much

Before andAfter 17

medical advice but not improving. In fact, I was getting sicker. Mydoctorhad said, 'Watch your weight,' and prescribed a singledailyoralhypoglycemic pill for my type 2 diabetes. It sounded easy, but it wasn'tworking. My glucose levelswere in the 200 rangeall too often, and occasionally reached400.1 was constantly exhausted.

"I startedDr. Bernstein's programin 1985. Sincethen I have recovered my former vitality and zest for life.At my first visit, he switchedme to another approach — a fast-acting blood sugar-lowering pill 3times a day, beforemeals, along with a slower-acting pill in the morning and at bedtime. My regimen was totally overhauled to eliminatefoods that raised blood sugar, and to reduce greatlymy consumptionofcarbohydrates in general. Macaroni and ravioli hadbeen importantparts of my diet since birth. I had to give these up. I didn't mind agreater emphasis on protein. I even began to include fresh fish inmy diet.

"My initialreaction wasthat theserestrictions weretoo high a priceto pay, and that I would be unableto continue them for long. Also, Iwasaskedto check myblood with ablood sugarmeter for aweek priorto every visit to Dr. Bernstein. That meant sticking my finger severaltimes a day. I waswilling to discipline myself for a short period in order to be able to return to a more active, vigorous life and to put mymalaise to rest. At the beach, I wassorely tempted to giveup the diet,while watching family and friends eat without restrictions. But sincemy body was feeling healthier, I continued with the program. Afterabout two months, with many dietary slips on my part, I managedtobetter discipline myself because I sensed it made me feel better. Myglucose level startedto descend to 140,130,and finally to 100 or lesson a consistent basis.

"Dr. Bernstein also encouraged me to purchase a pedometer, a device that clipped to my belt and measured the distance that I walkedeach day. Ibegan to walkdaily, holding3-poundweights and swingingmy arms. This was yet another thing to bother with, and I felt it wouldcut into my free time. But the resultwasan invigorating high. By thistime, I didn't mind pricking my fingers several times each day, as itshowed me the way to better blood sugars. Fortunately for me, NewRochelle hasmany beautiful parks. I choseGlenIsland Park because itis nearLong Island Sound and nicelykept. This meant gettingup earlierin the morning to walkduringthe week,but that was no problemsince I am an earlyriser. I bought some cast-irondumbbells for addi-

18 Before andAfter

tional exercise. I learned about arm curls, overhead raises, arm circles,and chest pulls. I didn't realize that there were so many different exercisesthat you could do at home to benefit your health.

"My glucose levels arenow consistently within or near the normalrange,not at the sorry levels which nearlyput me in the hospital.Thatall-consuming fatigue is gone,and I feel that now I'm in control ofmydiabetesinsteadofthe reverse. With adherence to the program, I knowthat I don't have to suffer the same debilitating effects that afflict somany other diabetics."

Harvey Kent isfifty-one. He has known abouthisdiabetes for approximatelysixyears, andwe suspect thatheprobably hadit for three tofouryears prior to his diagnosis. He has a family history of diabetes, and hisstory isfairly typical.

"I went in for a routine physical. I've always had high risk factors —both my parents had diabetes, my brother had diabetes, and my sisterhas diabetes. My brother, who was forty-nine, passed away recentlyfrom diabetic complications. My sister, who is fifty-nine, ison dialysis.When I found out I had it, I felt I was going down the same slipperyslope. I'd been trying to lose weight, but not very successfully. Thedoctor I was seeing,an endocrinologist,kept upping my medication.Everytime I went to seehim, I wound up taking more and more, andmy blood sugars weren't goinganywherebut up.

"I kept having the feeling that as far astreatment went, nothing washappening. I wasn't in bad shape, but then I watched my brother passaway, and I thought, 'I've got to do something.'

"I happen to live in Mamaroneck, New York, near Dr. Bernstein,and mywife suggested that I seehim forasecondopinion. I kept wondering, 'Is there another approach?' That's really how it started. Thestandard approach was always to tell me to lose weight, to exercise,andto take medication. I wastrying to do allthose things, but I wasn't having much success at anyof them exceptthe taking of medication.As itturned out, Dr. Bernstein still said the same three things, but his approach to each ofthe categories wasradical, especially on the diet.Thediet has been a major factor — I've lost a lot ofweight.

"Once I started getting a senseof what Dr. B.was talking about —which was reallyright from the firstvisit; he's very thorough in his explanations— I kind of figured it out. Just to demonstrate the effects ofdiet, he told me to stayon my same diet and measure my blood sugars,

Beforeand After 19

but I startedcutting back on the carbohydrates, so by the time we satdown to negotiate a meal plan, which was maybe the third or fourthsession, he just confirmed what I'd already started about a monthbefore.

"Before I met Dr. Bernstein, I'd been under treatment for diabetesby three different doctors.The guy I was seeing before Dr. B. is an en-docrinologist/diabetes doctor with a fairly large practice. He neveroncesaid to me, 'You know,by controlling yourblood sugars, most ofthese complications are reversible.' When Dr. B. told me that — well,for a diabetic who's stuck with this disease for the rest of his life, that'sniceto hear. Nobodyever tells youthis. At least I don't rememberanyone everexplainingthis to me. I'vebeen amember ofthe ADA [American Diabetes Association] for several years, and no one ever saidanythinglike that to me, anywhere. Iwaslucky. I hadn't developed thatmany complications — not like my brother and sister— but I knewhow fast they could get you.

"With my olddoctor, I'dbeentoldto monitormy blood sugars andthen come in everythreemonths.What it wassupposedto do, I wasn'tsure— keep you honest, maybe, but I couldn't figure that out. I waschecking my fasting blood sugars in the mornings.They wereaveraging somewhere about 140 mg/dl. And when I'd go in, the doctorwould do blood work, scratch the bottoms of my feet, and check myeyes, then say, 'See me in three months.' The whole thing would takemaybe half an hour and then I'd see him again in three months. Iwasn't sure what the whole thing was about. The thing is— and Ifound this out with my sister and my brother— it's a slippery slope.You start out as a type 2 and you get this kind of treatment, and youburn out your pancreas, and beforelong,you're insulin-dependent.

"When I sawDr. B., he did a very extensivemedical exam and uncovered everything there was to uncover. He checkedeverything. Hefound that I had an anemia, and so we started doing things to dealwith that. I had not had retinopathyor neuropathy. I had some proteinin my urine, a potential sign of kidney disease. But he said that couldbe from my old kidney stone,or it couldbe from the diabetes. He saidwe'd wait awhile until my blood sugars were normalized, then testagain and find out, because if it wasthe diabetes, it should clear up.

"The first thing he did was get me off Micronase and onto Glu-cophage. Micronase is one of those oral hypoglycemic agents thatstimulate your pancreas, and he said, 'Why are you doing this? You'reburning your pancreas out quick.' He looked at my blood sugars care-

20 Beforeand After

fullyand told me I waslow at particular times of the dayand told mewhat I had to do to cover the valleys as well as the peaks. Insulin. Inever wanted to take insulin. My father did it, and the idea justbrought back horrible memories. My other doctor would say, 'All elseis failing, now you have to go on insulin.'What Bernstein says is, 'Iwant you to take insulin in orderto coveryour peaksand to keep yourpancreas from burning out.'This seems to me a much more sensibleapproach.

"My wife is very perceptive about the whole thing, and she saidwhat I really needed was a coach, and Bernstein is very much like acoach. Having read up about him and knowing that he was an engineer,you can see the difference in his approach.You can see lessof themedical model and more of an engineering model: he's putting youback together,taking your components and manipulating them in order to accomplish something. He's a diabetic himself, he knows thething insideand out, andso you getthe sense that he'smuch more actively involved. Now I measuremy blood sugars 5 times a day, but instead of just jotting them down and saying come back in threemonths, he adjusts the medication, using it to tweak the peaks and valleys, to get the most optimum response. Now I haveexcellentcontrol.

"The diet takes some getting used to. Most diabetics, I would surmise, love to eat. Especially if you come from a culture where food isthe coin of the realm. People ask me now,'What do you eat?' I say, 'Ihave turkey, some salad, and a Diet Coke.' I used to be a big pancakeeater. Talk about your carbohydrate! Every Saturday and Sundaymorning for years I would make pancakes for my wife. Now I makethem for her and for my daughter and don't have any — or occasionallystealjust a bite — and I miss it, but I am so much more in controlnow, and I feel so much better. I've seen so much of my family godown the slippery slope,it seems a small sacrifice for good health.

"Since the time I started seeing Dr. Bernstein, I've lost close to 30pounds. My blood sugars have dropped by about 35 percent, butmy weight loss was not on a weight loss diet, just on Dr. Bernstein'smeal plan.I still haveawayto go,but for the firsttime I feel like I'm incontrol."

J.A.K. isa sixty-seven-year-old business executive whohadhad type2 diabetes for twenty-four years, and had been taking insulin for twenty,when hestartedon ourregimen. Hewrites thefollowing:

Beforeand After 21

"I visited Dr. Bernstein on the recommendation of some goodfriends, as I had just lost the central vision in my right eye due to sub-retinalbleeding.

"It took hours of instruction, counseling, and explanationto makeme clearly understand the relationships between diet, blood sugarcontrol,and physical well-being. I washoping for the possibilitythat Imight experience an improvement in my already deteriorated physicalcondition. I havediligently followed up on what I wastaught, and theresults are obvious:

• I no longerhavecrampsin my calves and toes.• The neuropathy in my feet hasnormalized.• Variousskin conditions havecleared up.• Tests for autonomic neuropathy(R-R intervalstudy) totally nor

malized in only two years.• The difficulty I had with digestion hascleared up completely.• My weight dropped from 188 to 172 pounds in six months.• My originalcholesterol/HDLratioof5.3 put me at increasedrisk

for a heart attack. With a low-carbohydrate diet and improvedblood sugars, this value has dropped to 3.2,which puts me at alowercardiac risk than most nondiabetics of my age.

• My daily insulin dose has dropped from 52 units to 31 units, andI no longerhave frequent episodes of severe hypoglycemia.

• My overall physical condition and stamina have improved considerably.

"All these improvements occurred because I learned how to controlmy blood sugars. As a matter of fact, my glycosylated hemoglobin (atest that correlates with average blood sugar during the prior fourmonths) dropped from 7.1 percentto 4.6 percent,so that I am now inthe samerange asnondiabetics. I havedeveloped full confidencein myabilityto managemy own diabetes. I understandwhat is happening. Ican adjust and compensate my medications asthe need arises.

"If I haveto miss a meal, for whatever reason, I can adjust accordinglyand am not tied to aclock, asI wasbeforeI learned thesenew approaches to blood sugarcontrol.

"I would saythat not only hasmy physical condition improved, butmy mental attitude is far better today than it was ten or fifteen yearsago. My only regret is that I did not learn how to be in charge ofmy diabetesyearsearlier."

22 Before andAfter

Lorraine Candido has had type 1 diabetes for more than twenty yearsand has been mypatient for ten. She is in her sixties, andsheand herhusband, Lou, her "copilot," work together tokeep her blood sugars normal. Like a lotof happily married couples, Lorraine andLou sometimesalmost speak asone. When Lorraine comes infor treatment, Lou is withher. When shecalls onthephone, Lou isonthe other line. They talk abouthowstarting theprogram changed their lives:

Lorraine: "I had alot of complications.Bladderinfections, kidneyinfections — and then my eyes.My feetwerenumb up to my heels.Asa matter of fact, one day I waswalkingbarefootand I wasn't aware ofit but I had a thumbtack in my foot allday long. I had neuropathy ofthe vagusnerve. I had an ulcer from medication. My mother had hadeye problems,and sowhen I went to an ophthalmologist,he said, 'Youhave some of your mother's problems.We'll keep an eye on you; comeback in a year.' And I thought, 'Uh-oh.'When Dr. Bernsteinexaminedmy eyes, he said, 'Oh, I'll make an appointment for you.'Right away Ihad laser surgery."

Lou: "I firmly believe that if she hadn't gone to Dr. Bernstein, shewould've been blind. Her last two visits to the eye doctor she got excellent reports. As a matter of fact, he said he had no idea where thefluid in one eye had gone, but it was all gone."

Lorraine: "I was elated. He said my left eye had made greatprogress and I was doing well.

"When I first met Dr. Bernstein, I had no idea what I was gettinginto. All I knew was that I wasn't feeling well and I was going nowhere.I was kind of scared, didn't know what I was getting into, and didn'tknow if I wanted to. It was plain and simple. I liked Snickers candybars.He said,'No.' I couldn't haveanything I liked and wanted, and wekind of butted heads— but then I realized, 'Hey, come on, is therereallya candy bar worth dying for?'

"He's a very gentle gentleman. I think he's extremely caring; you'renot treated like cattle, you're treated as a person, and he answers allyour questions. Between the two ofus,at the beginningwe had alot ofquestions. Really, I don't know if I could livewithout him.

"We found him — it's kind of embarrassing, but our son used tohave a newsstand, and Lou would go help him out on Sundays, andLou would bring me home the papers to read. Well, in one of thosehorrible tabloids — you know, when they run out ofweird stuff, theyrun unusual medical stories reprinted from somewhere else — theheadline on this was'Diabetic Heals Himself,'and you know, we didn't

Before andAfter 23

think that much about it. But I wasn't feeling well, and so we madesome inquiries. Now of course we're in a different state and nobody Iknew had ever heard of him, but we called his office. I didn't talk to anurse or someone, he got on the phone himself and he offered us references. Well, that settled it rightthere. I mean,how many doctors doyouknowof who'd offer youreferences? So Lousaid, 'Pack up,honey,we're going.'"

Lou: "Shehad a doctor up here in Springfield, Massachusetts, shewas seeing and I was getting pretty concerned about it. Her feet weregetting numb, she had kidney problems. I don't have diabetes, but Ihappened to havethe same doctor asmy internist,and I said to him,'Isn't there something you can do for my wife?' He had a son whoworked at the Joslin Clinic, which we hadheard was very good. 'Canwe take her to the Joslin Clinic?' But he said, 'What can he do for herup there that we can't do for her here?' We got sort of scared. Theywere running her the standard way they treat diabetics — standardbut safe. Safe for them, but not much help for Lorraine.

"AtDr. Bernstein's, to start, it was a 10-hour training period— two5-hour sessions that she had to take at the start."

Lorraine: "It was my husband, me, and the doctor. No waitingroom for hours. Now, to be honest, when we walked out of there —

it's a 2-hour drive between our house and there — I didn't want to do

it. But on the drive back home after the first session, we talked. Wetalked constantly, and I knew I didn't want to do it, but I also knew Iwas going to do it. Common sensejust dictated it. I wanted to live,andI wantedboth feet and both eyes. It was plain and simple.The feelingin my feet has come back almost 100 percent, by the way."

Lou: "We found out about the diet on the first visit, and it tookabout a month to get her blood sugars into the target range. She hadbeen running 300,400mg/dl blood sugars prettyregularly."

Lorraine: "I was kind ofreluctant to start with. It was clear that Dr.

Bernstein's program wasn't a ride in an amusement park. In some respects,it was awhole new way of living,and we had to changeallourgrocery lists — but I had a supportive friend here in Lou. When Istartedon the diet, we pretty much atethe same food. He didn't haveto, but he did. He would have a few extras here and there and I

wouldn't, but it was years before I could go into the supermarket, becauseit felt like I couldn't have anything there. It was very hard to getused to. I resented being told what to do and how to do it."

Lou:"It's very difficult. You have to understand something. When

24 Before andAfter

she started the program she was close to sixty years old, and we wereaccustomedto livingin a particular way."

Lorraine: "We have grandkids — we've been married forty-fiveyears — we have sixkids andseven grandkids, andthey comeover forchocolate chip cookies and icecream."

Lou:"The program works—"Lorraine: "Because I'm still here."

Lou:"— but it's difficult to do, becauseyou reallyhave to be dedicated."

Lorraine: "Let's put it this way. There are no hot fudge sundaeshere. Ever. Not for Thanksgiving, not for Christmas, birthdays, anniversaries— there are no deviations from the program. The firstweek, because of the change in diet, I lost 15 pounds. You looked atwhat you wereeating, measuredit —"

Lou: "It was a combination of things. The amount of insulinchangeda lot. She wastaking sometimes 80 to 90 units of insulin on adailybasis, and now she's taking 13^2 units. Insulin is the fat-buildinghormone, so reducing your dosage changes things substantially. Andyou'rechanging the amount of carbohydrate you'retaking in, and soshe lost all this weight."

Lorraine: "Altogether, I lost 85 pounds. I wear junior size clothes.Call me stubborn, but I still resent being told what to eat."

Lou: "Let me put it this way. You five a quality of life and give upwhat you have to —"

Lorraine: "Like fudge."Lou: "Or potatoes. The point is, you have to decide somewhere

along the line. Are you going to live and enjoy the rest of your lifewithout problems,or are you goingto fight the realityof the situationand go down the tubes? It'sa choice."

Lorraine:"It's an attitude. I don't like his program, but it works. I'mstill here. I miss the goodies I givemy grandkids, allthe cookies, candybars,ice cream.And the holidays. Everything's kind of restricted."

Lou:"The irony of this is,my wife, sinceshe lost allthe weight, shedresses in very sporty clothes. Now,I'm aracewalker. She doesn't exercise, but because ofheredityorwhatever, shehasbeautiful,stronglegs,and so she wears these spandex tights and such, and people ask her,'How much do you run?'"

Lorraine: "He's a champion racewalker, very self-disciplined. Notme. I had a conversation with God, and He said, 'Don't sweat.' I'm

Lou's cheerleader. I stayhome and readbooks."

Before and After 25

Lou: "She walks withme sometimes. ButI laugh my ass off."Lorraine: "It's fun to go shopping and buy junior sizes with my

granddaughters — but I don't let them borrow my clothes. Before Istarted the program, I neverthought abouthow I looked,how I felt—allI know is, the clothes I wasbuyingwereone size fits all."

Lou: "Now look at her."

By the way, Lorraine's cholesterol/HDL ratio has dropped from a highcardiac risk 5.9 to a verylowrisk 3.3.

It isn't unusual for people with diabetes to make major changes in otheraspects of their lives once their blood sugars have been restored to normalafter years ofpoor control. The changes that we see include marriages,pregnancies, and reentry into the workforce. The story ofElaine L. fallsinto the last category. She also points outthe disablingfatigue thatshe experienced when her blood sugars were high. This problem has led otherdiabetics, desperate to retain their abilities to function productively, toabuse amphetamines. Elaine is a sixty-year-old mother and artist. Herstory is not unusual.

"When I developed diabetes twenty-one years ago, I began a fruitlessodysseyto learnallI could about this disease and to have the toolsto be able to deal with the psychological and physical roller coasterthat I wasexperiencing.

"The hardest thing to cope with was the total loss of control overmy life. I was told that I was a 'brittle' diabetic and that I would justhave to endure the very high and very low blood sugars that were totally exhausting me. I feared that my eyeswould be damaged. I'm anartist,and this frightened me the most. I knew that this diseasewas destroying my body every day and that I washelpless.

"We went from doctor to doctor and to major diabetes centersaround the country. I never could get a handle on how to become'controlled.' I was given a gold star for 'good' blood sugarby one doctor; told I 'had imbued the number 150with mystical significance' byanother; informed that ifmy blood sugars werehigh afterlunch today,I could correct them before lunch tomorrow. All the while, I was feeling worse and worse. I stopped painting. I was just too tired. I was soscared to read any more of the diabetes magazines, because I keptlearning more and more about what was in store for me.

"I'd been diabeticabout five years when an uncle in Florida advisedme to read Dr. Bernstein's first book. It made a lot of sense, but when

26 Before andAfter

I read it, I thought, 'Diabetes has robbed me of so much already, Idon'thave anymore timeoreffort to give to it — andwhowants to bea professional diabetic?' Of course, there was alot of anger anddenialandevenattempts to forget about being diabetic. Maybe I could forgetabout it for awhile,but it never forgot about me.

"Aseedwas now planted, however, in spiteofmyself. I knew that nomatter whathappened down theroad, I needed to feel that I hadtriedeverything possible, so that I would never have to say, 'I wish I haddone more.'

"I was very wary of my first visit to Dr. Bernstein's office. I reallythought Iwould hate having to change my diet yetagain. I didnot relishthe idea ofmultiple daily injections, testing my bloodsooften,andkeeping records. The fact isthatI didhate all of thatuntil I found Iwasrecording better andbetter bloodsugars. The diet wasn't anymorerestrictive than the American Diabetes Association diet I had been fol

lowing, andmost important, I was feeling better andmuch less tired.In fact, I began to paint again and soon rented a studio. I now paintfull-time, but this time I actually sellmy work.

"The regimen that I feared has, in the end,given me the freedom ofwhich I had dreamed."

Although Elaine does notmention it inher story, her cholesterol/HDLratio dropped from an elevated cardiac risk level of4.74 to the "cardioprotective" level of 3.4, as her long-term blood sugars approached normal. Furthermore, her weight has dropped from 143 pounds to 134pounds, and her hemoglobin A1C has dropped from a very high 10.7 percent to a nearly normal 6.0percent.

Carmine DeLuca is in his early sixties and has hadtype2 diabetes sinceabout ageforty-five. Like many ofmypatients, hehadbeen in"standard"treatmentandfound hiscondition gettingprogressively worse.

"I wastaking pills, triedsome diet changes, but afterabout ten yearsmy diabetes justgotworse. Through the years, as adiabetic, I hadseensome articles about Dr. Bernstein, and he had appeared several timesin the local newspaper. A colleague at work mentioned this Dr. Bernsteinto me, the sameguywho hadbeen in the paper. Shesaid, 'If youever want to go to someone, go to this guy' And I heard from a fewother peoplearoundthe area who said, 'He'sexcellent.'

"Over the years, I've had trouble with my eyes, my feet, and myhands, but that was before Dr. Bernstein saw me. I had tried to watch

Before andAfter 27

my diet, but beingItalian, you know, you're always involved with thepasta, thebread, andso forth, andsoI really didn't doverywell on dieting. Apparently the pill that I was taking was hterally burning meout. I was just going to a general doctor,an internist, and what did heknow? I used to keep blood sugar about 140 to 160, and then all of asudden it started hittingthe200 mark, andit was starting to hit it consistently, and then closeto 300,and then over 300,and the nerve endings in my feet were gone, andthe feeling in my hands. I did have, atage fifty, two cataracts. I don't know if you want to blame it on diabetes, but I guess you can. Finally, when it was so high, I said, 'Well,something hasto be done. What have I gotto lose?'

"And so when thetimecame, I thought, let mego tothebest. Everybodytalks about how excellent he is, so I made an appointment. Myblood sugars were veryhigh,in the high300s, like375. When I sawDr.Bernstein, Ihadno idea whatIwas getting myselfinto.I hadjustheardthat he was one of the best, and so I said, 'Lemme do it.' He struck meas very, very knowledgeable. I learned an awful lot — he told methings about diabetes that I just never heard about, even from peoplewith diabetes. He made you feel good, because he Hterally grew upwith it. He was very professional, yet you could sit down and talk tohim. He said he was always available, available 24hours a day, and hehas been,no matterwhat. Yougointo that, andyou feel prettygood.

"I've lost weight since I started seeing him. A few pounds hereandthere, but the thing is,even though I haven't taken off a lot of weightyet, everybody says, 'Hey, you look great.' But you could see, priortoseeing Dr. Bernstein, that it was tearing me down, people could see Iwasn't looking that good.

"Starting the program was tough, but it was carbohydrates thatwere killing me. He put me on the diet. I never had a problem withcholesterol, but for some reason, every time you turn around, peopleare talking about high cholesterol this, high cholesterol that, so Ithought about it. But I didn't give a damn about carbohydrates; nobody talks about carbohydrates and cholesterol. At least until Dr.Bernstein said,'You don't eatthis, you don't eatthat,'and I said,'Theseare all carbohydrates.' And so I'm on the dietand,boom, I startlosinga little weight.

"The thing wasto getusedto doingwithout the carbohydrate, butit'sokay, because I like meat, I like salad, I likevegetables. I caneat allthe cheese I want— I mean,within reason. My blood sugar hasbeengood, averagingunder 100,and I feel like a million.

28 Before andAfter

"I'm strictly on insulin and onepill, and we've reduced the insulin,and as my blood sugar improves, I think we'll reduce it even more. Isee him now every twomonthsor so, and for aweekprior, I measuremy sugars 4 timesaday andbring thechart to him. He really analyzesit — youknow, 'All right, take this, don't dothis.We'll reduce this. Don'teatthat.' He's gotasystem all hisown andit'sgreat. It works. It canbea pain in the neck, but hey. He tells me I'm agood patient. I'm here toprove thatit's not impossible to change, and theresults are there."

Mark Wade, MD, is one ofmany physicians with diabetes. He is boardcertified inpediatric medicine. His lovely wife notlong ago gave birth totheir third child. His story has a number ofparallels with my own.

"Dr. Bernstein's program turned my life around. Prior to meetingDick Bernstein at age thirty-four, I had spent twenty-two years of myfife as what I then considered a well-controlled insulin-dependent,juvenile-onset diabetic. I'd never been hospitalized for ketoacidosis [aserious condition caused by high blood sugar in combination withdehydration] or severe hypoglycemia, hadwhatI considered good circulation and nerve function,exercised daily, and ate pretty much whatever I felt like eating.

"However,cuts and lacerations took months or years to heal insteadof days, andalways leftugly scars. Once ortwice each year, Iwould developpneumonia that typically lasted four months andhadme,without fail, out of school or work for two and a half months per episode.My mood swings went from kind andlovable to short-tempered, hotheaded,and uncaring fourto five times daily, congruentwith my routine blood sugar swings from high blood sugars (300 to 500) aftermealsto hypoglycemia (less than 50)beforemeals. This Dr. Jekyll/Mr.Hyde personality made me very unpredictable and unpleasant to bearound, and came closeto causingme to lose my wife and the closenessof family and friends. I was forced to eatmy meals at exactly thesame times each dayin order to avoid life-threatening episodes of lowblood sugar. Even so, I hadto adjust my lifearoundthe inevitable periods of hypoglycemia. If I didn't eat, my life was in trouble, and unfortunately sowerethe people who hadto interactwith me when I washypoglycemic. Most of the times thosewerethe ones I loved most.

"My trainingasaphysician, asan intern and resident, averaging 110hours aweek ofwork, wasat times anightmare, though I did it, tryingto balance rounds, clinics, emergencyroom and ICU schedules, screen-

Before andAfter 29

ing patients, longhours ofreading, and anunreal demand on physicaltolerance, emotionalstability, andconsistency thatalmostdrove me tothe breaking point. My mission was to be an excellent doctor, and Iwas, with acalm, cooldemeanor whichI presented externally. But inside I was a mess, and my interactions with my loved ones and closefriends were horrible. I was an avid basketball player, jogger, andweight lifter, but despite doing these activities daily, I found my performance and endurance were usually modulated by my blood sugar —and was never really surewhether I would be able to perform for 10minutes or 2 hours. In addition, despite my high level of exercise, 1to\Vihours daily for twelve years, I was never able to develop a muscular or athletic body type, eventhough I worked hardat it.

"I was always extremely conscientious about testing andexercisingandeating anddoctor visits, to thepointthatmy friends thoughtIwasneurotic. I wasconsistently following the conventional guidelines recommended to diabetics, and I thought I was a rather model patient.The problems that I described above, I had been led to believe, were anatural part of life for adiabetic. Nooneshowed me thatmy lifecouldbebetter, that I could control my diabetes rather thanlet my diabetescontrol me,thatwithrecognition of a few principles thatare really justcommon sense, a few extra finger sticks anda few extrainjections andbetter control of my dietary intake — I could be in charge for real!

"Nine years ago, I met Dick Bernstein. Dr. Bernstein not only gaveme the most complete, comprehensive, logical, reasonable, and informative teaching on diabetes that I have ever encountered, but hisuniquely expert and comprehensive physical examination and testingilluminated for me the most accurate picture of my overall health andthesubtle tolls thatthe previous management of my diabetes hadpermitted. Then with a personalized, comprehensive, tightly controlledbut reasonable diet, exercise, and a blood sugar-monitoring plan, heput me in controlof my diabetes for the first time. Sure, the diet plan,finger sticks, and 5 to 8 painless insulin injections a day for my program require a high degree of discipline and self-control, but it'sdoable, it works, andthis comparatively small sacrifice brings me thefreedom of lifestyle, quality of life, and longevity thatnondiabetics takefor granted.

"The results have been as follows: I can eat or fast whenever I

choose. I plan my day around my activities rather than around mymeals, have the ability to be much more flexible in my scheduleand participation in activities, and now have the ability to adjust my

30 Beforeand After

daily activities easily to accommodate 'emergencies' or suddenchangesin schedule— activities and adjustments that nondiabetics take forgranted. Best of all, the wildmood swings have beeneliminated andI'm sick much lessoften and lessseriously."

Allof these people have been patients of mine andhave seen wonderfulimprovements in their health. Ifyou're curious about howpeople havefared using the prior two editions ofthis book, I urge you to look at thetestimonials on the Web site for this book at www.diabetes-book.com/testimonials/testimonials.shtml and those in reader reviews of theprioreditions on www.amazon.com to see similar reactions from peoplewho have tried the program but have never been under my directcare. For somereason, readers in theUnited Kingdom presentmore complete and more impassioned reviews. Many of these can be seen atwww.amazon.co.uk. It is wellworth a visit. These people havebeen successful in spite of the major obstacles imposed by their National HealthService.

PART ONE

Before You Start

1

Diabetes

THE BASICS

Diabetes is so common in this country that it touches nearlyeveryone's fife — orwill. The statistics on diabetes are staggering, and a diagnosis can be frightening: diabetes is the

third leading cause of death in the United States. According to themost recent statistics compiled by the National Institutes of Health(NIH), as of 2005, a staggering 7 percent of the U.S. population, ornearly 21 million people, have diabetes, with 14.6 million diagnosedand6.2 millionwho have not yetbeendiagnosed. Thisnumberwillnodoubt increase. Most death certificates ofdiabetics do not fist diabetesas the underlying cause of their heart attacks, strokes, or fatal infections. If it were included, it mightwell be the leading cause of death inthe United States. Recent reports predict that 95 percent of peopleborntoday in theUnited States will eventually develop diabetes.

Even more alarming, the incidence of type 2 — or what was onceknown as maturity-onset diabetes — among children eighteen yearsold and younger has skyrocketed. A Yale University study of obesechildren between ages four and eighteen appeared in the March 14,2002, issue of the New England Journal ofMedicine. The study foundthat nearly a quarter had a condition that's often a precursor to diabetes. According to USA Today's story on the report the same day,"The incidence of type 2 diabetes, the form that usually occurs inadults, has increased in young people, especially Hispanics, blacks,andNative Americans. Some regional studies suggest the incidence oftype2in children has jumped from less than 5%, before 1994, to up to50%." That children are increasingly getting a disease that once targeted fifty- to sixty-year-olds presents anewand frightening potentialpublic health disaster.

34 BeforeYou Start

Each year, tens of thousands of Americans lose their eyesight because of diabetes, the leading cause of new blindness for peopleagestwenty-five to seventy-four. Ninety-five percent of diabetics havetype2diabetes. Because 80 percent of type2diabetics are overweight,manyinappropriately feel thatthedisease istheir own fault, the resultof some failure of character.

Since you are reading this book, youora loved onemayhave beendiagnosed recently withdiabetes. Perhaps youhave long-standing diabetes and are not satisfied with treatment that has left you plaguedwith complications such as encroaching blindness, foot pain, frozenshoulder, inabilityto achieve or maintain a penileerection, restrictivelung disease, hip andleg pain, or heart or kidneydisease.

Although diabetes is still an incurable, chronic disease, it is verytreatable, and the long-term "complications" are fully preventable.For morethansixtyyears, I'vehadtype 1diabetes, also called juvenile-onset or insulin-dependent diabetes mellitus (IDDM). This form ofdiabetes is generally far more serious than type 2, or non-insulin-dependent diabetes mellitus (NIDDM), although both have the potential to be fatal.* Most type 1 diabetics who were diagnosed backabout the same time I was are now dead from one or more of the seri

ous complications of the disease. Yet after living with diabetes formore than sixty years, instead of being bedridden or out sick fromwork (or dead, the most likely scenario), I am more fit than manynondiabetics who are considerably younger than 1.1 regularly work12-hour days, travel, sail, and pursue avigorous exercise routine.

I am not special in this regard. If I can take control of my disease,you can take control of yours.

In the next several pages I'll give you a general overviewofdiabetes,how the body's system for controlling blood sugar (glucose) works inthe nondiabetic, and how it works — and doesn't work — for diabet-

* Fora periodof time,manypeople considered the designations type 1and type2out of date, replacing them with the terms IDDM and NIDDM, which areslighdymisleading and are losingcredence. While it is true that most of thosewith type 2 can stay alive without injecting insulin, many patientswho sufferfrom type 2,or so-called NIDDM,do inject insulin to preservetheir health.Theterms"autoimmune diabetes" for type 1and "insulin-resistantdiabetes"for type 2are more precise, but are unlikely to takeoverfor the much-easier-to-say type 1and type 2. The situation is further complicated by the recent discovery thatmost type 2 diabetesalso has an autoimmune component.

Diabetes: TheBasics 35

ics. In subsequent chapters we'll discuss diet,exercise, and medication,and how you can use them to controlyour diabetes. If discussion ofdiet and exercise sounds like "the same old thing" you've heard againand again, read on, because you'll find that what I've observed is almost exactly theopposite of"the same oldthing," which iswhat you'veprobably been taught. The tricks you'll learn can help you arrest thediabetic complications you may now be suffering, may reverse manyof them, andshould prevent theonset ofnew ones. We'll also explorenew medical treatments andnew drugs thatare now available to helpmanage bloodsugar levels and curtail obesity.

THE BODY IN AND OPT OF BALANCE

Diabetes is the breakdown or partial breakdown of one of the moreimportant of the body's autonomic(self-regulating) mechanisms, andits breakdown throws manyother self-regulating systems into imbalance. Thereisprobably not a tissue in thebodythat escapes the effectsof the high blood sugars of diabetes. People with high blood sugarstend to have osteoporosis, or fragile bones; they tend to have tightskin; they tendto have inflammation andtightness at theirjoints; theytend to have manyother complications that affect every part of theirbody, including the brain, with impaired short-term memory andeven depression.

Insulin: What It Is, What It DoesAtthe centerof diabetes is the pancreas, a large glandabout the size ofyour hand, which is located towardthe backof the abdominal cavityand is responsible for manufacturing, storing, and releasing the hormone insulin. The pancreas also makes several other hormones, aswell as digestive enzymes. Even if you don't know much about diabetes,in all likelihoodyou'veheard of insulin and probablyknow thatwe all have to have insulin to survive. What you might not realize isthat only a small percentageof diabetics must haveinsulin shots.

Insulin is a hormone produced by the beta cells of the pancreas.Insulin's major function is to regulate the level of glucose in the bloodstream, which it does primarily by facilitating the transport of bloodglucose into most of the billions of cells that make up the body. Thepresenceof insulin stimulates glucosetransporters to move to the surface of cells to facilitate glucose entry into the cells. Insulin also stimu-

36 BeforeYou Start

lates centers in the hypothalamus of the brain responsible for hungerand satiety. Indeed, there is some insulin production even as one begins to eat, before glucose hits thebloodstream. Insulin also instructsfat cells to convert glucose and fatty acids from the blood into fat,which the fat cells then store until needed. Insulin is an anabolic hormone, which is to saythat it is essential for the growth of many tissuesand organs.* In excess, it can cause excessive growth— as,for example, of body fat and of cells that line blood vessels. Finally, insulinhelps to regulate, or counterregulate, the balance of certainother hormones in the body. More about those later.

One of the ways insulinmaintainsthe narrow rangeof normal levels of glucose in thebloodisbyregulation of the liver and muscles, directing them to manufactureand store glycogen, a starchysubstancethe body useswhen blood sugar falls too low. If blood sugar does falleven slightlytoo low— as may occur after strenuous exercise or fasting— the alpha cells of the pancreas release glucagon, another hormone involved in the regulation of bloodsugarlevels. Glucagonsignalsthe muscles and liver to convert their stored glycogen back into glucose (a processcalledglycogenolysis), which raises blood sugar.Whenthe body's stores of glucose and glycogen have been exhausted, theliver, and to a lesser extent the kidneys and small intestines, can transform some of the body's protein stores — muscle mass and vital organs — into glucose.

Insulin and Type 1 DiabetesAs recently as eighty-five years ago, before the clinical availabiHty ofinsulin, the diagnosis of type 1 diabetes — which involves a severelydiminished or absent capacityto produce insulin — was a death sentence.Most peoplediedwithin a few months of diagnosis. Without insulin, glucose accumulates in the blood to extremelyhigh toxic levels;yet since it cannot be utilized by the cells, many cell types will starve.Absent or lowered fasting (basal) levels of insulin also lead the liver,kidneys, and intestines to performgluconeogenesis, turning the body'sprotein store — the muscles and vital organs— into even more glucose that the body cannot utilize.Meanwhile,the kidneys, the filtersofthe blood, try to rid the body of inappropriately high levels of sugar.

*Anabolicand catabolichormones normallywork in harmony,building up andbreaking down tissues, respectively.

Diabetes:TheBasics 37

Frequent urination causes insatiable thirst and dehydration. Eventually, thestarving bodyturns more and more protein to sugar.

The ancient Greeks described diabetes as a disease that causes thebody to melt into sugar water. When tissues cannot utilize glucose,theywill metabolize fat for energy, generating by-products called ketones,which are toxic at very high levels and cause further water lossasthe kidneys try to eliminatethem (see the discussion of ketoacidosis and hyperosmolar coma, in Chapter 21, "How to Cope with Dehydration,Dehydrating Illness, and Infection").

Today type 1diabetes isstill avery serious disease, andstill eventuallyfatal if not properly treated with insulin. It can kill you rapidly whenyourblood glucose level is too low— throughimpaired judgment orloss of consciousness while driving, for example — or it can kill youslowly, by heart orkidneydisease, whichare commonlyassociated withlong-term blood sugar elevation. Until Ibroughtmy blood sugars under control, I had numerous automobile accidents due to hypoglycemia, and it's only through sheer luck that I'm hereto talk about it.

The causes of type 1diabetes havenot yetbeen fullyunraveled. Research indicates that it's an autoimmune disorder in which the body'simmune system attacks the pancreatic beta cells that produce insulin.Whatever causes type 1 diabetes, its deleterious effects can absolutelybe prevented. The earlier it's diagnosed, and the earlier blood sugarsarenormalized, the better off you will be.

At the time they arediagnosed, many type 1 diabetics still producea small amount of insulin. It's important to recognize that if they aretreated early enough and treated properly, what's left of their insulin-producing capabilityfrequently can be preserved. Type 1 diabetes typically occurs before the age of forty-five and usually makes itselfapparentquite suddenly,with such symptoms asdramaticweight lossand frequent thirst and urination.We now know, however,that assudden asits appearance may be, its onset is actually quite slow. Routinecommercial laboratory studies are available that can detect it earlier,and it may be possible to arrest it in these early stages by aggressivetreatment. My own body no longer produces any detectable insulinat all.The high blood sugars I experienced during my first year withdiabetes burned out, or exhausted, the ability of my pancreas to produce insuhn. I must have insulin shots or I will rapidly die. I firmlybelieve— and know from experiencewith my patients — that if thekind ofdiet and medical regimen I prescribe for my patients had beenutilized when I was diagnosed,the insulin-producing capabilityleft to

38 BeforeYou Start

me at diagnosis would likely have been preserved. My requirementsfor injected insulinwouldhave beenlessened, and it wouldhavebeenmuch easier for me to keep my blood sugars normal.

Blood Sugar Normalization: Restoring the BalanceAccording to the NIH, approximately 225,000 people died in 2002from diabetes, but it is likely that deaths due to diabetes are under-reported. (Is a diabetic's death from heart disease, kidney disease, orstroke, for example,really a death from diabetes?) It is the NIH's contention that "the risk for death among people with diabetes is abouttwice that of peoplewithout diabetes of a similarage."

Certainlyeveryone hasto dieof something,but you needn't die theslow, torturous death of diabetic complications, which often includeblindness and amputations. My history and that of my patients support this.

The Diabetes Control and Complication Trial (DCCT), conductedby the NIH's National Institute of Diabetes and Digestive and KidneyDiseases (NIDDK), beganin 1983 asa ten-yearstudy of type 1diabetics to gauge the effects of improved controlof blood sugar levels. Patients whose blood sugars were nearly "normalized" (my patients'blood sugars are usually closer to normal than were those in the intensivecare arm of the trial because ofour low-carbohydrate diet) haddramatic reductions of long-term complications. Researchers beganthe DCCT trying to seeif they could, forexample, lessenthe frequencyof diabetic retinopathy by at least 33.5 percent.

Instead of a one-third reduction in retinopathy, they found morethan a 75percent reduction in the progression of early retinopathy. Theyfound similarlydramatic results in other diabetic complications andannounced the results of the study early in order to make the goodnews immediately available to all. They found a 50 percent reductionof risk for kidney disease, a 60 percent reduction of risk for nervedamage,and a 35 percentreduction of risk for cardiovascular disease.This reduction continues to this day, many years after the study wasterminated.

I believe that with truly normal blood sugars, which many of mypatientshave,these reductionscanbe 100 percent.

The patients followed in the DCCT averaged twenty-seven years ofageat the beginning of the trial, so reductions could easilyhave beengreater in areas such ascardiovascular disease if they had been older orfollowed for a longer period of time. The implication is that full nor-

Diabetes: TheBasics 39

malization of blood sugar could totally prevent these complications.In anycase, the results of the DCCT aregood reason to begin aggressively to monitor and normalize blood sugar levels. The effort anddollar cost ofdoing sodoes nothave toberemotely as high as was suggested in the DCCT'sfindings.

The Insulin-Resistant Diabetic: Type 2Different from type 1 diabetes is what is officially known as type 2.This isbyfarthe moreprevalent form of thedisease. According to statisticsfrom the American Diabetes Association, 90-95 percent of diabetics are type 2. Furthermore, as many as a quarter of Americansbetween the ages of sixty-five and seventy-four have type 2 diabetes. Astudy published by Yale University found that 25 percent of obeseteenagers now have type 2 diabetes.

(A new category of "pre-diabetes" has been recently called latentautoimmune diabetes, or LADA. This category applies to mild diabetes with onset after the age of thirty-five, in which the patient hasbeen found to produce an antibody to the pancreatic beta cellproteincalled GADA, just as in type 1 diabetes. Eventually these people maydevelopovert diabetes and require insulin.When the symptoms ofdiabetes finally occur, they are often more severe than at the "onset" oftype 1 diabetes.)

Approximately 80 percent of those with type 2 diabetes are overweight and are affectedby a particular form ofobesity variously knownas abdominal, truncal, or visceral obesity. It is quite possible that the20 percent of the so-called type 2 diabetics who do not have visceralobesity actually suffer from a mild form of type 1 diabetes that causesonly partial loss of the pancreatic beta cells that produce insulin.* Ifthis proves to be the case, then fully all of those who have true type 2diabetes may be overweight. (Obesity is usually defined as being atleast 20 percent over the ideal body weight for one's height, build,and sex.)

Whilethe causeof type 1diabetes maystillbe somewhatmysterious,the cause of type 2 is less so.As noted previously, another designationfor type 2 diabetes is insulin-resistant diabetes. Obesity, particularlyvisceral obesity, and insulin resistance — the inability to fully utilize theglucose-transporting effects of insulin— are interlinked. For reasons

* Recentstudies show that even type 2 diabeticsexperiencesome degree of immune attack on their beta cells.

40

Hereditary Cravingfor Carbohydrate Foods

High DietaryCarbohydrate

Fig.1-1. The vicious circle of insulinresistance.

Truncal

Obesity

Insulin

Resistance

A

THigh

Blood

Sugar

Excessive

Insulin

Production

by ReducedNumber of

Beta Cells

Beta Ceil Burnout

BeforeYou Start

Overeating

A

Hunger

A

related to genetics (see Chapter 12, "Weight Loss— If You're Overweight"),asubstantial portionofthe populationhasthe potentialwhenoverweight to become sufficiently insulin-resistant that the increaseddemands on the pancreas burn out the beta cells that produceinsulin.These peopleenterthe viciouscircle depictedin Figure 1-1.Note in thefigure the crucial roleof dietarycarbohydrate in the development andprogression of this disease. This is discussed in detailin Chapter 12.

Insulin resistance appears to be caused at least in part by inheritance and in part by high levels of fat— in the form of triglyceridesreleased from abdominal fat — in the branch of the bloodstream that

feeds the liver. (Transient insulin resistance can be created in labora-

Diabetes: TheBasics 41

toryanimals byinjecting triglycerides — fat — directly intotheir liver'sblood supply.)* Abdominal fat is associated with systemic inflammation, another cause of insulin resistance, as areinfections. Insulin resistance by its very nature increases the body's need for insulin, whichtherefore causes the pancreas to work harder to produce elevated insulin levels (hyperinsulinemia), which can indirectly cause high bloodpressure and damage the circulatory system. High levels of insulin intheblood down-regulate theaffinity for insulin thatinsulin receptorsalloverthe body havenaturally. This"tolerance" to insulin causes evengreaterinsulin resistance.

So, to simplifysomewhat, inheritance plus inflammation plus fat inthe blood feeding the liver causes insulin resistance, which causes elevated serum insulin levels, which cause the fat cells to build even moreabdominal fat, which raises triglycerides in the fiver's blood supplyand enhances inflammation, which causes insulin levels to increasebecause of increased resistance to insulin.

If that sounds circular, it is. But note that the fat that is the culprithere is not dietary fat.

Triglycerides are in circulation at some level in the bloodstream atalltimes. High triglyceride levels are not so much the resultof intakeof dietary fat as they are of carbohydrate consumption and existingbody fat. (We will discuss carbohydrates, fat, and insulin resistancemore in Chapter 9, "The Basic Food Groups") The culprit is actuallya particular kind of body fat. Visceral obesity is a type of obesity inwhich a special kind of fat is concentrated around the middle of thebody, particularly surrounding the intestines (the viscera).A man whois viscerallyobese has a waist of greater circumference than his hips. Awoman who is viscerallyobese will have a waist at least 80 percent asbig around asher hips. All obese individualsand especially those withvisceralobesity areinsulin-resistant. The ones who eventually becomediabetic arethose who cannot makeenough extrainsulin to keep theirblood sugars normal.

Though treatment has many similar elements — and many of theadverse effectsofelevated blood sugar are the same— type 2 diabetesdiffers from type 1 in several important ways.

The onset of type 2 diabetes is slowerand more stealthy, but even inits earliest stages the abnormal blood sugar levels, though not sky-

* New evidence demonstrates a role for fat contained in muscle cells (intramy-ocyte fat) as another important factor in causing insulin resistance.

42 Before You Start

high, can cause damage tonerves, blood vessels, heart, eyes, andmore.Type 2diabetes isoften called the silent killer, and it isquite frequentlydiscovered through oneof itscomplications, such ashypertension, visualchanges, or recurrent infection.*

Type 2 diabetes is, at the beginning, a less serious disease —patientsdon't melt away into sugarwaterand die in a few months' time.Type 2, however, can through chronically but less dramatically elevated blood sugars be much more insidious. Because so many morepeople areaffected, it probably causes more heartattacks, strokes, andamputations than the more serious type 1 disease. Type 2 is a majorcause of hypertension, heart disease, kidney failure, blindness, anderectile dysfunction. That these serious complications of type 2 diabetescan progress isno doubt because it is initially milder and isoftenleft untreated or treated more poorly.

Individuals with type 2 still make insulin, and most will never require injected insulin to survive, though if the disease is treatedpoorly, they can eventually burn out their pancreatic beta cells andrequire insulin shots. Because of their resistance to the blood sugar-lowering effects of insulin (though not its fat-buildingeffects), manyoverweight type 2 diabetics actually makemore insulin than slimnondiabetics.

BLOOD SUGARS: THE NONDIABETIC

VERSUS THE DIABETIC

Since high blood sugar is the hallmark of diabetes, and the cause ofevery long-term complication of the disease, it makes sense to discusswhere blood sugar comes from and how it is used and not used.

Our dietary sources of blood sugar are carbohydrates and proteins.One reason the taste of sugar — a simple form of carbohydrate — delightsus is that it fosters production of neurotransmitters (principallyserotonin) in the brain that relieve anxiety and can create a sense ofwell-beingor even euphoria. This makescarbohydrate quite addictiveto certain people whose brains mayhaveinadequate levels of or sensitivity to these neurotransmitters, the chemicalmessengers with whichthe brain communicates with itself and the rest of the body. When

* A common early sign of mild chronic blood sugar elevation in women is recurrent vaginalyeastinfections that causeitchingor burning.

Diabetes: TheBasics 43

blood sugar levels are low, the liver, kidneys, and intestines can,through aprocess we will discuss shortly, convert proteins into glucose,butvery slowlyandinefficiently. The bodycannot convert glucose backinto protein, nor can it convertfat into sugar. Fat cells, however, withthe helpof insulin, do transform glucose into saturatedfat.

The taste of protein doesn't excite us asmuch as that of carbohydrate — it would be thevery unusual child who'd jumpup and downin the grocery store and beg his mother for steak or fish instead ofcookies. Dietary protein gives us a much slower and smaller bloodsugar effect,which, as you will see,we diabeticscan use to our advantagein normalizingblood sugars.

The Nondlabetic

In the fasting nondiabetic,and evenin most type 2 diabetics, the pancreasconstantlyreleases a steady, lowlevel of insulin.This baseline, orbasal, insulin level prevents the fiver, kidneys, and intestines from inappropriately converting bodily proteins (muscle, vital organs) intoglucose and thereby raising blood sugar, a process known as gluco-neogenesis. The nondiabetic ordinarily maintains blood sugar immaculatelywithin a narrow range — usuallybetween80 and 100mg/dl(milligrams per deciliter),* with most peoplehoveringnear 85 mg/dl.There are times when that range can briefly stretch up or down — ashigh as 160mg/dl and as low as 65— but generally, for the nondiabetic, such swings are rare.

Youwill note that in some literature on diabetes, "normal" may bedefined as 60-120 mg/dl, or even as high as 140mg/dl. This "normal"is entirely relative.No nondiabetic will haveblood sugar levelsas highas 140mg/dl except after consuming a lot of carbohydrate. "Normal"in this case has more to do with what is considered "cost-effective" for

the average physician to treat. Since a postmeal (postprandial) bloodsugar under 140mg/dl is not classified as diabetes,and since the individual who experiences such a valuewill usuallystill have adequate insulin production eventually to bring it down to reasonable levels,many physicians would seeno reasonfor spending their valuabletimeon treatment. Such an individual maybe sent off with the admonitionto watch his weight or her sugar intake. Despite the designation "nor-

* A deciliter is one-tenth of a liter, or a little over 3 ounces. A milligram is oneone-thousandth ofa gram, or about one three-thousandth of the weight of sugarin a levelteaspoon.

44 Before You Start

mal,"an individual frequendydisplaying ablood sugar of 140mg/dl isa goodcandidate for full-blown type 2 diabetes. I have seen"nondiabetics"with sustainedblood sugars averaging 120 mg/dl develop diabetic complications.

Let's take a look at how the average nondiabeticbody makes anduses insulin. Suppose that Jane, a nondiabetic,arises in the morningand has a mixed breakfast,that is,one that contains both carbohydrateand protein. On the carbohydrate side, she has toast with jelly and aglass of orange juice; on the protein side, she has a boiled egg. Herbasal (i.e., before-meals) insulin secretion has kept her blood sugarsteadyduring the night, inhibiting gluconeogenesis. Shortly after thesugar in the juiceor jellyhits her mouth, or the starchy carbohydratesin the toast reach certain enzymes in her saliva and intestines,glucosebeginsto enterher bloodstream. The mere presence of food in her gutas well as the rise in Jane's blood sugarsignal her pancreas to releasethe granules of insulin it has stored in order to offset a jump in bloodsugar (see Figure 1-2). This rapid release of stored insulin is calledphase I insulin response. It quicklycorrects the initialblood sugar increase and can prevent further increase from the ingested carbohydrate. As the pancreas runs out of stored insulin, it manufacturesmore, but it has to do so from scratch. The insulin released now isknown as the phase II insulin response, and it's secreted much moreslowly. As Jane eats her boiled egg, the small amount of insulin ofphase II can cover the glucose that, over a period of hours, is slowlyproduced from the protein of the egg.

Insulin acts in the nondiabetic as the means to admit glucose—fuel— into the cells. It does this by activating the movement of glucose"transporters" within the cells. These specialized protein molecules protrude from the cytoplasmof the cellsand their outer surfacesto grab glucose from the blood and bring it to the interiors of thecells. Once inside the cells, glucose can be utilized to power energy-requiring functions. Without insulin, the cells can absorb only a verysmallamount of glucose, not enoughto sustain the body.

As glucose continues to enter Jane's blood, and the beta cells in herpancreas continue to release insulin,some ofher blood sugar is transformed to glycogen, a starchy substance stored in the muscles andliver.Once glycogen storagesites in the muscles and liver are filled,excess glucose remaining in the bloodstream is converted to and storedas saturated fat. Later, as lunchtime nears but before Jane eats, if herblood sugar drops slightlylow,the alpha cells of her pancreas will re-

Diabetes: The Basics 45

• Phase 1 Phase II

1-J

C

3Wc

a

ECO

a. '<- Baseline - ^- Baseline

' Start of Meal Digestion Finished

Fig. 1-2.Phase I andphaseII insulinresponse ina normal, nondiabeticperson.

Terry Eppndge

lease anotherpancreatic hormone, glucagon, which will "instruct"herliver and muscles to begin converting glycogen to glucose, to raisebloodsugar. When sheeats again, herstore ofglycogen will be replenished.

Thispattern of basal, phaseI, then phaseII insulinsecretion is perfect forkeeping Jane's bloodglucose levels in a safe range. Herbodyisnourished, and things work according to design. Her mixed meal ishandled beautifully. This is not, however, how things work for eitherthe type 1 or type 2 diabetic.

The Type 1 DiabeticLet's look at what would happen to me, a type 1 diabetic, if I had thesame breakfast as Jane, our nondiabetic.

UnlikeJane,becauseof a condition peculiar to diabetics,if I take along-acting insulin at bedtime,I might awaken with a normal bloodsugar, but if I spendsometimeawake before breakfast, mybloodsugarmay rise, even if I haven't had anythingto eat. Ordinarily, the liver isconstantly removingsome insulin from the bloodstream,but duringthe first few hours after waking from a full night's sleep, it clears insulinout of the bloodat an accelerated rate. Thisdip in the level of mypreviously injectedinsulin iscalled the dawnphenomenon (seeChapter 6,"StrangeBiology"). Because of it, myblood glucose can riseeventhough I haven't eaten.A nondiabeticjust makesmore insulin to offset the increasedinsulin clearance. Those of us who are severely diabetic have to track the dawn phenomenon carefully by monitoring

46 BeforeYou Start

blood glucose levels, and canlearn how to use injectedinsulin to prevent its effect upon blood sugar.

As with Jane, the minute the meal hits my mouth, the enzymes inmy saliva begin to breakdown the sugars in the toastand juice,and almost immediately my blood sugar would begin to rise. Even if thetoast had no jelly, the enzymes in my saliva and intestinesand acid inmy stomachwould begin to transform the toast rapidly into glucoseshortly after ingestion.

Since my beta cells no longer produce detectable amounts of insulin, there is no stored insulin to be released by my pancreas, so I haveno phase I insulin response. My blood sugar (in the absence of injected insulin) will rise while I digest my meal. None of the glucosewillbe converted to fat, norwill anybe converted to glycogen. Eventuallymuch will be filtered out by my kidneys and passed out throughthe urine,but not beforemy body hasendureddamagingly high bloodsugar levels — which won't kill me on the spot but will do so overa period of days if I don't inject insulin. The natural question is,wouldn't injectedinsulin"cover" the carbohydrate in such abreakfast?Not adequately! This is a common misconception — evenby those inthe health care professions. Injected insulin — even with an insulinpump — doesn't work the same as insulin created naturally in thebody. Conventional insulin/diettherapyresulting in high blood sugarafter meals is a guaranteed slow, incremental,"silent" death from theravages of diabeticcomplications.

Normal phase I insulin is almost instantly in the bloodstream.Rapidlyit beginsto hustleblood sugar off to whereit'sneeded.Injectedinsulin, on the other hand, is injectedeither into fator muscle (not usuallyinto a vein) and absorbed slowly. The fastest insulin we have startsto work in about 20 minutes, but its full effect is drawn out over a numberofhours, not nearly fast enough to prevent adamaging upswing inblood sugars if fast-acting carbohydrate, like bread,is consumed.

This is the central problem fortype 1diabetics — the carbohydrateandthe drastic surge it causes in bloodsugar. Because Iknow my bodyproduces essentially no insulin, I have a shot of insulin before everymeal. But I no longer eat mealswith fast-acting or large amounts ofcarbohydrate, because the blood sugar swingsthey causedwere whatbrought about my long-term complications. Eveninjection by meansof an insulin pump (see discussion near the end of Chapter 19) cannot automaticallyfine-tune the levelof glucose in my blood the way anondiabetic's body does naturally.

Diabetes:TheBasics 47

Now, if I ate only the protein portion of the meal, my blood sugarwouldn't have the huge, and potentially toxic, surge that carbohydratescause. It would rise less rapidly, and a smalldose of insulin could actquickly enough tocover the glucose that's slowly derived from the protein. My body would not have to endure wide swings in blood sugarlevels. (Dietary fat, bythe way, has noeffect onblood sugar levels, except that it canslightly slow thedigestion ofcarbohydrate.)

In a sense, youcould lookat myinsulin shotbefore eating onlytheprotein portion of the meal as mimicking the nondiabetic's phase IIresponse. This is much easier to accomplish than trying to mimicphase I, because of the much lower levels of dietary carbohydrate(only the slow-acting kind)and injected insulin that I use.

The Type 2 DiabeticLet's say Jim, a type 2 diabetic, is 6 feet tall and weighs 300 pounds,much of which is centered around his midsection. Remember, at least80 percent of type 2 diabetics are overweight. If Jim weighed only170pounds, he might well be nondiabetic, but because he's insulin-resistant, Jim's bodyno longer produces enough excess insulin to keephis blood sugar levels normal.

The overweight tend to be insulin-resistant as a group,a conditionthat's not only hereditary but also directly related to the ratio of visceraland totalbodyfat to leanbodymass (muscle). The higherthis ratio, the more insulin-resistant a person will be. Whether or not anoverweight individual is diabetic, his weight, intakeof carbohydrates,and insulinresistance alltend to makehimproduceconsiderablymoreinsulinthan a slenderpersonof similar ageand height (seeFigure 1-3,page 48).

Many athletes, because of their low fat mass and high percentageof muscle, tend as a group to require and make lessinsulin than non-athletes. An overweight type 2 diabetic like Jim, on the other hand,typicallymakes two to three times as much insulin as the slender nondiabetic. In Jim's case, from manyyears of having to overcompensate,his pancreas has partially burned out, his ability to store insulin is diminished or gone, and his phase I insulin responseis attenuated. Despite his huge output of insulin, he no longer can keep his bloodsugars within normal ranges. (In my medical practice, a number ofpatients come to me for treatment of their obesity, not diabetes. Onexamination, however, most of these very obese"nondiabetics" haveslight elevations of theirHgbAlc test for average blood sugar.)

48

1

1 1^^ObcscDonnal subjects

w^ Obe* patients wi h diabetes

' fcinn >rraal tubje » ""

V inpatient*' vithdiabcte i

0 15 30 45 60 90 120 150 18Time (minutes)

10

Before You Start

Fig. 1-3. Serum insulinresponse toglucose consumption of individuals withandwithout type 2 diabetes.

Let's take another look at that mixed breakfast and see how it affects

a type 2 diabetic. Jimhasthe sametoastand jelly and juiceandboiledegg that Jane, our nondiabetic, and I had. Jim's blood sugar levels atwakingmay be normal.* Since he hasabigger appetitethan either Janeor I, he hastwo glasses of juice, four pieces of toast, and two eggs. Assoon asthe toastandjuice hit hismouth, hisbloodsugar beginsto rise.Unlike mine,Jim's pancreas eventually releases insulin, but he hasveryHttle or no stored insulin (his pancreas workshardjust to keep up hisbasal insulin level), sohe has impaired phase I secretion. His phase IIinsulin response, however, maybe partially intact. So, very slowly, hispancreas will struggle to produce enough insulin to bring his bloodsugar down towardthe normal range. Eventually it may get there,butnot until hours after his meal, and hours after his body hasbeen exposed to highbloodsugars. Insulin isnot onlythe major fat-buildinghormone,it also serves to stimulate thecenters in thebrain responsiblefor feeding behavior. Thus, in all likelihood, Jim will groweven moreoverweight, asdemonstrated by the cycle illustrated in Figure 1-1.

Since he's resistant to insulin, his pancreas has to work that much

*Waking, or fasting, bloodsugars arefrequendy normalin mildtype2 diabetics.After theyeatcarbohydrate, however, their postprandial blood sugars areusuallyelevated.

Diabetes: The Basics 49

harder toproduce insulin toenable him toutilize the carbohydrate heconsumes. Because of insulin's fat-building properties, hisbodystoresaway some of hisblood sugar asfat andglycogen; but hisblood sugarcontinues to rise, since hiscells areunable to utilize all of the glucosederived from his meal. Jim, therefore, still feels hungry. As he eatsmore, hisbetacells work harder to produce more insulin. Theexcessinsulin and the"hungry" cells in his brain prompt him to want yetmore food. He has just one more piece oftoast with a little more jellyon it, hoping that it will be enough to get him through until lunch.Meanwhile, his blood sugar goes even higher, his beta cells workharder, and perhaps a few burn out.* Even after all this food, he stillmay feel many of thesymptoms ofhunger. His blood sugar, however,will probably not goanywhere nearashighasminewould if I tooknoinsulin. In addition, hisphase II insulin response could even bringhisbloodsugardown to normalaftermanyhourswithout more food.

Postprandial (after-eating) blood sugarlevels that I would call un-acceptably high— 140 mg/dl, or even 200 mg/dl — may be considered by other physicians to be unworthy of treatment because thepatient still produces adequate insulin to bring them periodicallydownto normal,or"acceptable," ranges. IfJim, our type2diabetic, hadreceived intensive medical intervention before thebetacells ofhispancreas began to burn out, he would have slimmed down, brought hisbloodsugars into line,and eased theburdenon hispancreas. Hemightevenhave"cured" his diabetesbyslimmingdown, as I'veseen in severalpatients. But many doctors might decide such "mildly" abnormalblood sugars are only impaired glucose tolerance (IGT) and do littlemorethan"watch" them.Again, it'smybeliefthat aggressive treatmentat an earlystagecan save most patientsconsiderable lost time and personalagony bypreventing complications that willoccur ifblood sugarlevels are left unchecked. Such intervention can make subsequenttreatment ofwhat can remain — a mild disease — elegantly simple.

ON THE HORIZON

I include some hopeful forecasts of future treatments in this firstchapterbecause asyou're learning howto controlyour diabetes, hope

*Betacellburnout can be causedboth byoveractivity of the cells and bythe toxicity of high glucose levels.

50 BeforeYou Start

is a valuable asset. But your hope should be realistic. Your best hopefor controlling your diabetes is normalizing your blood sugars now.That does not mean that the future will not bring great things. Diabetes research progresses on a daily basis, and I hope as much as youdo for a cure, but it's still on the horizon.

Researchers are currentlytrying to perfectmethods for replicatinginsulin-producing pancreatic betacells in the laboratory. Doingthis ina fashion that'scomparatively easyand cost-effective should not be aninsurmountable task, and indeed the preliminary results arequite encouraging. Once patients' cells are replicated, they canbe transplantedback into patientsto actually curetheirdiabetes. After suchtreatment,unless you were to have another autoimmune event that would destroy these new beta cells, you would, at leastin theory, remain nondiabetic for the rest of your life. If you had another autoimmune attack,you would simply have to receive more of your replicated cells. Another very hopeful approach currendy undergoing clinical trials inhumans is the transformation of the precursors of beta cells (the cellsthat line the ducts of the pancreas) into actualbeta cells without evenremoving them from your body. This may be achieved by the simpleintramuscular injection of a special protein and is now being testedfor efficacy and possible adverse effects at three centers.

Another potential approach might be to insert the genes for insulinproduction into liveror kidney cells. These arepotential opportunitiesfor a cure, and have successfullycured diabetes in rats, but there arestill obstacles to overcome.

Yet another approach to replacing lost beta cells has been used bytwo competingcompanies to curediabetes in animals. The techniqueinvolves a series of ordinaryinjections of proteins that stimulate theremaining betacells to replicate until the lostoneshave been replaced.

A very promising new approach relieson the fact that most diabetics, even most type Is, have a few beta cells that still replicate.Theirimmune systems, however, make white cells called killer T cells thatdestroy the new beta cells as fast as they are made — or faster. If theculprit T cells can be isolated,they can be replicatedand used to createantibodies that canbe injectedinto diabetics to destroyalloftheirculprit T cells without impairing their overall immunity. A diabetic'sfew remaining beta cells would then be able to replicate, eventuallycuring the diabetes. It's possible that these new "former diabetics"would require antibody injectionsevery few years to prevent the appearanceof more culprit T cells.

Diabetes: TheBasics 51

With respect to the replication of beta cells, the catch for me andother diabetics who nolonger have any insulin-producing capacity isthat the cells from which new beta cells would be repUcated ideallyshould beyour own, and after more than six decades Imayhave none.Had my diabetes been diagnosed, say, a year earlier, orhadmy bloodsugars been immaculately controlled immediately upondiagnosis, theinjected insulin mighthave taken much of thestrain offmyremainingbeta cells and allowed them to survive.

Many people (including the parents of diabetic children) view having to use insulin as a last straw, a final admission that they are (ortheir child is) a diabetic and seriously ill. Therefore theywill try anythingelse — including things thatwill burnout their remaining betacells — beforeusing insulin.Many peoplein our culturehavethe notion that you cannot be well if you are usingmedication.This is nonsense, but some patients are soconvinced that they must do thingsthe"natural" waythat I practically have to begthem to use insulin,whichis as "natural" asone cango. In reality, nothingcouldbe more natural.Diabetics who still have beta cell function left may well be carryingtheir own cure around with them — provided they don't burn it outwith high blood sugars and the refusal to use insulin.

Tests

BASELINE MEASURES OF YOUR DISEASE

AND RISK PROFILE

The goal in the treatment program laid out in this book is togive you the tools and the knowledge to take control of yourdisease by normalizingblood sugars.Myinterest is not just in

treating the symptoms of diabetes, but in preventing or reversing itsconsequences and preserving pancreatic beta cell function. Essentialto treatment is learning to monitor your own blood sugars.

Before youbeginto monitor and then normalizeyour blood sugars,you should have a baseline analysis of your disease. How much haveyour beta cells "burned out" in part from high blood sugars? Haveyoualready developed some easilymeasured long-term compUcations ofdiabetes?What are your risksfor other diabetic compUcations?

Answering thesequestions willaid you and your doctor in learningthe extent and the consequences of the disease.Your test results wiUalso serve as valuable baseline data to which you will be able to compare the effects of bloodsugarnormalization. Onceyour blood sugarshavebeen normalized,such testscan be repeatedfrom time to time, toshow what you're achieving. Your improvements wiU give both youand your physicianongoingincentive for stickingto the program.

The remainder of this chapterdescribes a number of testsyour doctor or his laboratorycanperformin order to give both ofyou a pictureofyour diabetic condition. I havelaid these out notbecause it's necessary for you to memorize them, research them, and know aU the insand outs of them, but so that you can get the treatment you deserve.Byoutlining these tests,I'm giving you a "shopping list"of tests I perform on myself and on my patients.

Generally, I recommend as many as you can afford or your insurance or health maintenance organization (HMO) will pay for. Com-

Tests: Baseline Measures 53

pleting more of the tests wiU addmore dimensions to the picture yougain ofyourdisease. As some of these tests arecostly, anyor allmaybeskipped ifyoucannotafford them or ifyour insurance or HMOwon'tpay for them.

It is your physician's obUgation to provide you with copies of aUyour test results, whether from laboratory tests or from physical examinations. This is your right; however, you must request them. Thelaws governing medical records varystatebystate, and legislatures areUstening to health care consumers and making changes regularly. Atthis writing, however, it is most often the casethat medical records arethe property of the doctor, so do not neglect to request copies of anyresults. Such results can be potentially of great value when you visitanother physician or speciaUst for treatment of anyproblems.

BLOOD AND URINE TESTS

Glycated Hemoglobin (HgbA,c)Glucose binds to hemoglobin (the pigment of red blood ceUs) whennew red ceUs are manufactured. Since the average red ceU survivesabout four months, the percentage of hemoglobinmoleculesthat contain glucose (HgbAlc) provides an estimate of average blood sugarover this time frame. One of the benefitsofthis test is that it givesyourphysician an index by which to test the accuracy of your own bloodglucoseself-monitoring results.If your measurements are stricdy normal but your HgbAlc is elevated, then your doctor has a clue thatsomething is awry.

There are, however, a couple of significant drawbacks to this test.First is that the test is only a measureof average blood sugars.Second,elevatedblood sugars may take 24 hours to have any long-term effectonHgbAlc, andifblood sugar iselevated for only partofeach day andisnormalized or too lowthe restof the time,yourHgbA,c results mayappear deceptivelylow. Thus, if your blood sugars are only elevatedfor a few hours after meals, your HgbAlc may not be affected, butmany tissuesand organs throughout your body willbe injured.

The other drawback is that the upper and lower ranges of"normal"values reported by most labs are usuallyerroneously high and low, respectively. In other words, the ranges are usuallymuch too wide. Thus,it's up to your physicianto decide, basedupon his experience, what theproper normal range for his lab should be. Some doctors have their

54 BeforeYou Start

own formulas for estimating average four-month blood sugar levelsfrom HgbAlc. Anormal value should correspond to blood sugars ofabout 80-95 mg/dl. The experience I've had with the lab I use (thelargest in the United States) for my patients is that a truly normalHgbAlc ranges from 4.2 percent to 4.6 percent, which corresponds toblood sugarsof about 83-90 mg/dl.Mine isconsistently4.5 percent.Arecent study of "nondiabetics"showeda 28 percent increase in mor-taUty forevery 1percent increase in HgbAlc above 4.9 percent.

Because the blood contains more recentlymade red cellsthan olderones, recent blood sugars have more of an effect on HgbAlc thandoearUer blood sugars. The test value therefore levels off after aboutthree months. Any ailment that hastens red blood ceU loss will cause adeceptive shortening of thetime frame reflected bytheHgbAlc. Suchailments include Uver and kidney disease, blood loss, hemoglobinopathies, et cetera.High dosesof vitamins C and E can cause a deceptivelowering.

Serum C-Peptide (Fasting)C-peptide is a protein produced by the beta cells of the pancreaswhenever insulin is made. The level of C-peptide in the blood is acrude index of the amount of insulin you're producing. The level isusuaUy zero in type 1 diabetics, and within or above the "normalrange" in mildtype2obese (insulin-resistant) diabetics. Ifyourbloodserum C-peptide is elevated, thiswouldsuggest to your physician thatyour blood sugarmaybe controllable merely bydiet,weightloss,andexercise. If, at the other extreme, your C-peptide is belowthe limits ofmeasurabiUty, you probably require injected insulin for blood sugarnormalization. C-peptidemeasurements, to be mostsignificant, shouldbe checked aftera 12-hourfast whenbloodsugars arenormal.The testcan be best interpreted if blood sugar is measured at the same time,because in nondiabetics high blood sugars cause more insulin (andC-peptide)production than do lowblood sugars.

This test,while of interest, is not absolutely necessary.

Complete Blood Count (CBC)Part of most medical workups, this isa routine diagnostic test that candisclose the presence of ailments other than diabetes.A CBCmeasuresthe number of various typesof ceUs found in your blood — white cells,red ceUs, and platelets. Ahigh level of white bloodcells, for example,can disclose the presence of infection, while too few red blood cells

Tests: BaselineMeasures 55

can indicate iron deficiency anemia. Many diabetics have inheritedthyroid dysfunction, which can cause low-normal to low white ceUcounts. Awhite ceU countless than5.6 suggests that a full thyroid profile should be performed. This must include free and total T3 and T4.*

ACBC canalsodetectcertainhematologic maUgnancies, whichareusually moreeffectively treated theearner they arediscovered.

Standard Blood Chemistry ProfileThisbatteryof twelve to twenty tests is part of most routine medicalexaminations. It includes gaugesfor such important chemical indicatorsof healthasUver enzymes, bloodureanitrogen(BUN), creatinine,alkaline phosphatase, calcium, andothers. Ifyouhave a history of hypertension, your doctor maywant to add redblood ceU magnesiumtothis profile.

Serum Albumin

Although serum albumin is usuaUy included in the blood chemistryprofile, it is not widely appreciated that low levels are associated withdouble the all-cause mortaUty of high levels. It is thus very importantthat patients with low serum albumin receive further workup to determine the cause.

Serum Globulin

Globulins are antibodies produced by the immune system. They helpthe body to fight off infections and maUgnancy. If you experience frequent colds, sinusitis, diarrhea, or slow-healing infection of any type,you may have an immunoglobulin deficiency. If your total serumglobulinsare low, you should be testedfor specific immunoglobulins,such as IgA, IgG,and IgM.In my experience, 10-20 percent of diabetics have an inherited immunodeficiency disorder that may be treatable.

Cardiac Risk Factors

This isa battery of tests that measuresubstances in the blood that maypredispose you to arterial and heart disease.

* It's worth noting that one of the hallmarks of high blood sugars is fatigue.However, diminished thyroid function can causeprofound fatigue and coldness.If you're still "always tired" or "always cold" after normalizing blood sugars, talkto your physician about a thyroid profile.This test can be costly.

56 Before You Start

Important note: Sometimes, months to years after a patient hasexperienced normal or near-normal blood sugars and resultant improvements inthecardiac risk profile, we might see deterioration intheresultsof such testsas those for LDL, HDL,homocysteine, fibrinogen,andUpoprotein(a). All toooften, thepatient orhis physician will blameour diet.Inevitably, however, wefindupon further testing that his thyroidactivity hasdeclined. Hypothyroidism isan autoimmune disorder,like type 1 diabetes, and is frequently inherited by diabetics and theirclose relatives. It can appear years beforeor after the developmentofdiabetes and is not caused by high blood sugars. In fact, hypothyroidismcan cause a greater likelihood of abnormalities of the cardiacrisk profile than can blood sugar elevation. The treatment of a lowthyroid condition is oral replacement of the deficient hormone(s) —usually 1 piU daily. The best screening test is free T3 as measured bytracer dialysis. If this is low, then a full thyroid test profile should beperformed. Correctionof the thyroiddeficiency inevitably corrects theabnormaUties of cardiac risk factors that it caused.

Lipid profile. This profile measures fatty substances(lipids) in yourblood and includes total cholesterol, HDL(high-density lipoprotein),triglycerides, and direct LDL (low-density Upoprotein). Other cardiacrisk factors (discussedbelow) include C-reactive protein, fibrinogen,lipoprotein(a), and homocysteine, and may be more predictive. Abnormalities of these tests are frequently treatable and tend to improvewith normalization of blood sugars.

These tests should be performed after you have fasted for at least8 hours. The easiest thing is to have them scheduled in the morning.If you haven't fastedbefore the test, the results will be difficult to interpret.

Maybeyou've heard of"good"cholesteroland "bad" cholesterol?Well,this is why a reading for total cholesterol by itself won't neces

sarily reflect cardiac risk. Most of the cholesterol in our bodies, bothgood and bad, is made in the liver; it does not come from eating so-caUed"heart attack foods." If you'veeaten a meal that's high in cholesterol, your Uver will adjust to makelessof the "bad" cholesterol, LDL.Serum triglyceridelevels can vary dramaticallyafter meals,with high-carbohydrate meals causing high triglyceride levels. Some people —becausethey're obeseor havehigh blood sugarsor are genetically predisposed — make more or dispose of less LDL than they should,

Tests:Baseline Measures 57

which can put them ata higher risk for cardiac problems. High levelsof LDL increase the risk of heart disease, which makes LDLthe "bad"cholesterol. HDL, on theotherhand, isa Upid that reduces the riskofheart disease and is the "good"cholesterol. So it is the ratio of totalcholesterol to HDL (total cholesterol -s- HDL) that is significant. Youcould have a high total cholesterol and yet, because of low LDL andhigh HDL, have a lowcardiac risk. Conversely, a low totalcholesterolbutwith alow HDL would signify increased risk. Recently, asmorehasbecome known about cholesterol, research has shown that LDL occursin at least two forms— smaU, dense LDL particles (the hazardousform) andlarge, buoyant LDL particles. LDL particle size isnow beingmeasured by commercial laboratories. Larger particles, classified assize A, are considered benign, while smaller particles carry cardiacrisk. Associated with the test for particle size is apoUpoprotein B.When theApo Btestresult islower than 120 mg/dl, or when LDL particle size is class A, even high LDL levels are considered benign andshouldnot be treatedwithstatindrugs.

The only truly accurate measureof LDL is the direct LDL test. Thecustomary, calculated measure of LDL is estimated mathematicaUyand can result in values that are sometimes grossly in error.The directtest,however, maycostmore than the restof your Upid profile.

Also important to remember is that — aswewiU discuss in Chapter 9 — fats and cholesterol in the diet do not cause high-risk Upidprofiles in most people. On theotherhand,diabetics tend to have Upidprofiles that reflect increased cardiac risk, if their blood sugars havebeen elevated for several weeks or months.

Thrombotic risk profile. Thisprofile includes levels of fibrinogen,C-reactive protein, and Upoprotein(a). Theseare also"acute phase re-actants," or substances that reflect ongoing infection and other inflammation. These three substances are associated with increased

tendency of blood to clot or form infarcts (blockages of arteries) inpeoplewho havehad sustained high blood sugars.

In the casesof elevatedfibrinogenor Upoprotein(a), there is, addi-tionaUy, often an increased risk of kidney impairment or retinal disease.Obesity, even without diabetes, can cause elevation of C-reactiveprotein. In my experience,aU these tests are more potent indicators ofimpending heart attack than the Upid profile. Treatmentsare availablefor elevationsof each of these. Bloodsugar normalization wiU tend to

58 BeforeYou Start

reverse most of theseelevations overthe long term. Fibrinogencan beelevated by kidney disease, even in the absence of elevated blood sugars. It wiU tend to normalizeif kidneydisease reverses. Lipoprotein(a)wiU also tend to normalize somewhat by blood sugar normalization,although your genetic makeup (and low estrogen levels in women)canplaya greater role thanbloodsugar. AbnormaUy lowthyroidfunction is a common cause of low HDL and elevatedLDL,homocysteine,and Upoprotein(a). Although serum homocysteine is also a cardiacrisk factor, it wasrecently discovered that the usualtreatment for elevated values (vitamin B-12 and foUc acid supplements) actuaUy increased mortaUty.

Serum transferrin saturation, ferritin, total iron binding capacity (TIBC). These are aU measures of total body iron stores. Ironisvital,but it isalsopotentially dangerous. Levels that are too high canindicate a cardiac risk, cause insulin resistance, and are a risk factor forUver cancer. I wiU discuss insulin resistance at length in Chapter 6.Higher iron levels are more likely in men than in premenopausalwomen because of blood (iron) loss during menstruation. (This iswhy I recommend iron-enhanced vitamin supplements onlyfor thosewith an established need.) Iron levelsthat are too low (iron deficiencyanemia, which is more common in premenopausal women) can causean uncontroUableurge to snack,which in turn can lead to uncontrollable blood sugars.Both high and low iron stores can be easily determined and readily treated.

Renal Risk Profile

Chronic blood sugar elevationfor many yearscan cause slow deterioration of the kidneys. If caught early, it may be reversible by bloodsugar normalization, as it was in my own case. Unlessyou think frequent hospital visits for dialysis might be a nice way to meet people,it's wise to have periodic tests that reflect early kidney changes. It isalso wise to have aU these periodicaUy performed together, as the results of each can clarifythe interpretation of aU.

Several factors cause false positive results in some of these tests, soyou should keep them in mind when your doctor schedulesthe tests.Youshould avoid strenuous or prolonged lower-body exercise (whichwould include motorcycle or horseback riding) in the 48 hours preceding the tests. AdditionaUy, if on the day the tests are to be performed you are menstruating or havea fever, a urinary tract infection,

Tests:Baseline Measures 59

or active kidneystones, youshouldpostponethe testsuntil theseconditions have cleared.

Abasic renal riskprofile should include the foUowing:

Urinary kappa light chains. Ifearly diabetic kidney disease ispresent, this test reports "polyclonal kappa Ught chains present." Thismeans that small amounts of tinyprotein molecules maybe enteringthe urine,due to leaky bloodvessels in thekidneys. Because thesemolecules aresosmaU, theyarethefirst proteins toleak throughtinyporesin the bloodvessels of the kidneys that mayhave beenaffected bydisease.

This test requires a smaU amount of fresh urine. If the test reportstates "monoclonal Ught chains present," thereis a possibiUty of treatable maUgnancies of certain whiteblood ceUs.

Microalbuminuria. Thisless cosdy testcannowbe performedqualitatively (by dipstick) in your doctor's office, or quantitatively at outside laboratories. It, like the urinary kappa Ught chain test, can alsoreflect leakyvessels in the kidneys, but at a laterstage, sincealbuminisa sUghtly larger molecule.

A quantitative measurement requires a 24-hour urine specimen,which means you'U need to coUect aU the urine you produce in a 24-hour period in a big jug and deUver it to your physicianor laboratory.Given the potential embarrassment of carrying a jug fuU of urinearound at work, you might want to schedule your test on a Mondayand coUect the urine while at home on Sunday. Many of my womenpatients report that it's easierto coUect urine initiaUy in a clean papercup, and then pour it into the jug. An easier screening test is the measurement of the albumin-to-creatinine ratio in a first morning urinesample.

24-hour urinary protein. This test detectskidney damage at a laterstage than the preceding two tests; it also requires a 24-hour urine collection.Aswith the other tests, false positive resultscan occur foUowing strenuous lower-body exercise, as previouslynoted.

Creatinine clearance. Creatinine is a chemicalby-product of muscle metabolism, and is present in your bloodstream aU the time. Measuring the clearanceofcreatinine from the body is a wayofestimatingthe filteringcapacityof the kidneys. Test values are usuaUy higher than

60 BeforeYou Start

normal when a person is spilling a lot of sugar in the urine, and even-tuaUy lower than normal when the kidneys have been damaged byyears of elevated bloodsugars. It is not surprising to seean appropriate drop in creatinine clearance when blood sugars are normalizedand urine glucose vanishes.

The creatinine clearance test requires a 24-hour urine coUection,and your doctorwiU drawa smaU amount of bloodto measure serumcreatinine.The most common causeof abnormaUy lowvaluesfor thistest is failure of the patient to coUect aU the urine produced in a24-hour period.Therefore, if other kidneytests are normal, testswithlowvalues for creatinine clearanceshould be repeated for verification.

A low creatinine clearancewithout excess urinary protein suggestsa nondiabetic cause of kidney impairment.

When it is impractical to makea 24-hour urine collection, as for smallchildren, a new test requiring a smaU amount of blood, crystatin-c,can be performed. Crystatin-c is beUeved to be a more accurate measure of kidney function than creatinine clearance, but unfortunatelymany insurers still consider this test to be "experimental" and won'tpay for it.

Serum beta2 microglobulin. This isa verysensitive test for injuryto the tubules ofthe kidneys,which pass urine filtered from the blood.Aswith fibrinogen levels, elevatedvaluescan also result from inflammation or infection anywhere in the body. Thus an isolated elevationof serum beta2 microglobulin without the presence of urinary kappaUght chains or microalbumin is probably due to some sort of infection, not to diabetic kidneydisease. Suchelevation is commonplace inpeople with AIDS, lymphoma, and immunodeficiency disorders.

24-hour urinary glucose. This test too requiresa 24-hour coUectionof urine, and is of value for proper interpretation of the creatinineclearance.

Note: If, as you've been reading about these tests, you've imaginedyourself lugging around multiple jugs of urine, most of us only needone 3-liter jug. This should give you an adequate specimen for yourphysician to perform creatinine clearance, microalbumin, 24-hourprotein, and 24-hour glucose. Nevertheless, it's wise to bring hometwo empty jugs, just in caseyour urine output is very high.

Tests: Baseline Measures 61

As indicated under "Cardiac Risk Factors," significant kidney damage isalso accompanied byelevations of serum homocysteine and fibrinogen.

OTHER TESTS

Insulin-like Growth Factor 1 (IGF-1)Rapid correction of veryhighbloodsugars can,on occasion, cause exacerbation of a common compUcation of diabetes caUed proliferativeretinopathy. This condition cancause hemorrhaging inside theeye andblindness. Such exacerbations are usuaUy preceded by an increase inserumlevels of insulin-like growth factor 1.Abaseline level of IGF-1 intheblood should bemeasured inpeople with proliferative retinopathy.Repeat determinations shouldbe madeevery two to three months. Iflevels increase, bloodsugars should thenbe reduced moreslowly.

R-R Interval StudyThepurpose of this studyis to test the functioning of the vagus nerve,and it should be part of your initialdiabeticphysical examination. It isperformed like an ordinary electrocardiogram, but it requires fewerelectrical leads (i.e.,only on the limbs,not the chest).

The vagus nerve is the largest nerve in the body, running from thebrain to the lower body. It's the main neural component of theparasympathetic nervous system, or that part of the nervous systemthat takes care of vegetative, or autonomic, functions, the functionsthat run more or less on "automatic pilot" and which you don't actively have to think about to make happen. These include heart rateand digestion.

Like any other nerve in the body, the vagus nerve can be injured bylong-termexposure to highbloodsugars, but since it plays sucha central role in bodily function, damage to it can cause many more disorders than damage to most other individual nerves.

The vagusplaysa major role in a number of diabeticcompUcationsinvolving the autonomic nervous system, including rapid heart rate,erectile dysfunction in men, and digestive problems,particularlygas-troparesis, or delayed stomach-emptying (which we wiU discuss in detail in Chapter 22). The good newsis that when you'vehad your bloodsugars normalized over an extended period, it can slowly recover

62 Before You Start

proper function. (Many ofmy male patients who have been unable toachieve or maintain an erection report that after blood sugars havebeen normalized,that abiUty has returned.)

This nerve is unique in that its function canbe investigated simplyandcheaply. If thevagus nerve isworking properly, there should be aconsiderable difference in heart rate between inhaling and exhaling.By measuring thevariation ofyour heart rate with deep breathing, wecanget a picture ofjusthow much thefunction has been impaired. Innondiabetics, the heart rate increases when they inhale deeply andslows when theyexhale fully. So a twenty-one-year-old nondiabetic'sheart ratemight typicaUy slow asmuch as75 percent from inhaling toexhaling. This may drop to about 30 percent for a seventy-year-oldnondiabetic. Ayoung type 1diabetic withtenyears ofvery highbloodsugars maynot have anyheart ratevariation at aU. (Thevariation ismeasuredby lookingat the interval between "R-points," or peaks onthe tracing of the electrocardiogram. As you're probablyaware, eachtime your heart beats, the electrocardiograph traces a shape resemblinga mountain.Thetip of themountainistheR-point, sothe physician measures the intervalsbetween R-points.)

I consider this test an important, reproducible, quantitative measure of an important diabetic compUcation and perform it on aU ofmy new patients beforeblood sugars have been stabUized. I repeat itabout everyeighteen months, for several reasons. It's a very good index of how,with aggressive blood sugarcontrol, neurologiccompUcations can and do reverse, and it gives both patient and doctor good,concrete evidence of the success of treatment, and encouragement tokeep it up. Additionally, the digestive disorder of gastroparesis, whichI mentioned above, can be and frequently is one of the most difficultbarriers to bloodsugarnormalization, and canevenmakeblood sugarcontrol virtuaUyimpossiblein some people who require insulin. Alowheart rate variabiUtyon the initial test can be a good indicator that thepatient is likely to have a problemwith delayed stomach-emptying. Itcan alsogive the doctor clues as to causes of other problemsthat a patient maybe experiencing — sexual dysfunction, faintingupon standing when arising from bed, and so on.

Neurologic ExaminationIn addition to a standard physical examination,it is desirable(but notessential) that a routine neurologic exam be performed before bloodsugars are corrected, and again everyfew years thereafter. These tests

Tests: BaselineMeasures 63

arenot painful. They should include checking forsensation in thefeet,reflexes oflimbs and eyes, short-term memory, and muscle strength.In myexperience, performance on a number of the neurologic testsimproves after many months of essentiaUy normal blood sugars. Performance tends to deteriorate ifblood sugars remain high.

Eye ExaminationOne of the most valuable retinal studies, the Amsler grid test,can beperformedbyanyphysician or nursein less than a minute without dilating your pupUs. Since chronicaUy high blood sugars frequentlycause a number of disorders that can impairvision, your eyes, if normal, shouldbeexamined carefuUybyanophthalmologist every onetotwo years.

The ophthalmologist wiU evaluate the retina, lens, and anteriorchamber in each eye, and you can expect to have your pupils dilatedwith special drops.A proper retinalexamrequires the use of both direct and indirectophthalmoscopes and a sUt lamp.If an abnormaUtyis found,certainexaminations mayhave to be performedbya retinol-ogist every few months.

Examination of the Feet

Because ulcers of the diabetic foot are avoidable, even when bloodsugar is not weU controUed, you should askyour physicianto examineyour feet at every routine officevisit. Foot problems that aren't prevented or treated properly can lead to serious compUcations, even amputation. Your physician should train you in foot self-examinationand preventive care. In Appendix D, I have reproduced the same instructions I give my own patients on how to care for their feet.

Oscillometric Study of Lower ExtremitiesThis inexpensive test utilizes a simple blood pressure cuff connectedto a small instrument that should be in everydoctor's office.It givesanindex of the adequacyofpulsatilecirculation to the legsand feet.Sincelong-standing, poorly controUed diabetes can seriously impair peripheral circulation, this test is fairly important. AU diabetics shouldtake special care of their feet, but if you have an abnormal osciUomet-ric study, you have to be extra careful. People who have diminishedcirculation in the legs usuaUy also have significant deposits in the arteries that nourish the heart and brain and the arteries necessary forpenile erection. Therefore, if this study shows impaired circulation,

64 Before You Start

your doctor may want you to undergo tests thatwould help diagnosecoronary artery disease and, if you have certain symptoms, diagnoseimpaired circulation to the brain. OsciUometry canbe performed byanytrainedphysician in but a few minutes. It is taughtat manymedical schools throughout the world but rarely in the United States,where hands-on care is diminishing.

Musculoskeletal Examination

Prolonged high blood sugars can cause glycation of tendons. Glycation is the permanent fusing of glucose to proteins, and the simplestanalogy is bread crust. Think of the soft inside of the bread as yourtendons as theyshould be,and the crust aswhathappens when they'reexposedto elevated blood sugars overa longperiod of time. Glycationof tendons occurs in such common diabetic complications as Du-puytren's contractures of the fingers, frozen shoulders, triggerfingers,carpal tunnel syndrome, and iliotibial band/tensor fascialata syndrome of the hips and upper legs. All of these conditions are easilytreated if caught early and blood sugars are controUed. A musculoskeletal examination can identify these in their early, treatablestages.*

When to Perform These Tests

As valuable as they can be to you and your physician, none of theabovetests is crucial to our centralgoalof achieving blood sugar normalization. If you are without medicalinsurance,or if your insurancewon't pay for these tests,and financial considerations are a top priority, aU can be deferred. If, however, you are experiencing problems,such as impairment of vision, you should be tested immediately. Also,examinationof your feet, and learninghowto care for them properly,is vital and can prevent or forestall serious problems.

The most valuable of these tests for our purposes is the HgbAlc,because it alerts your physician to the possibility that your self-monitored bloodsugardatamaynot reflect the average blood sugarforthe prior three months. This can occur if your blood sugar-measuringtechnique or supplies are defective. More commonly, some patients,with a scheduled visit to the doctor approaching, wiU improve their

* For information on the proper treatment of these conditions, visit www.diabetes-book.com; select"Articles" and then the article tide that begins "SomeLong-TermSequelaeof PoorlyControlled Diabetes."

Tests: Baseline Measures 65

eating habits so that their blood sugar records improve. I have seenseveral teenagers whose falsified blood sugar data were discovered bythis test. I therefore suggest that HgbAlc be measured at regular visitsevery two to three months. This test costs about $65.

IdeaUy, the other blood and urine tests should beperformed beforeattempting to normalize blood sugar and annuaUy thereafter. If anabnormal value is found, your physician maywish to repeat thattestandrelated tests more often. The exception isthe fasting C-peptide test, asthere islittle value in repeating it except to see if pancreatic function isdeteriorating or improving. I certainly like to repeat the thromboticrisk and Upid profiles about four months and theneight monthsafterblood sugars have been normalized. The improvement that I frequently see tends to encourage patients to continue their efforts atblood sugar normalization. The R-R interval test should beperformedevery eighteen months. I consider it the second most important test Iperform on my patients after the HgbAlc

A final note: Dietaryvitamin C isimportant to goodhealth.In dosesabove 500 mg/day, however, vitamin C supplements can destroy theenzymeson blood sugar teststrips andcan also raise blood sugars. Fi-naUy, in levels higherthan about400 mg/day, vitamin C becomes anoxidantrather than anantioxidant andcan cause neuropathies. If youare already takingsupplemental vitamin C, I urgeyou to taperit offorlower your dose to no more than 250 mg daily. Only use the timed-release form.

Your Diabetic Tool Kit

SUPPLIES YOU WILL NEED AND

WHERE TO GET THEM

In order to monitor and control your blood sugarlevels,you're going to need certain tools. This chapter lists and describes them;you'U learn more about them in laterchapters. Also included are

suppUes for foot care and for treating dehydrating illnesses. For mostitems, approximate costs are Usted. Some expenses wiU be onetimeoutlays, such as for your blood glucose meter outfit. Others wiU continue on an ongoing basis.

The tools that all diabetics wiUneed areUsted first. Tools that onlyinsuUn users wiU need are Usted separately. Some are necessary, andsome areoptional. You can show your physician the list and he or shecan decide which items are appropriate for your needs.

FoUowing the tablesof supplies is a brief description of each,whatit's for, where you can purchase it, whether you'U need a prescription,and where in this book you'U find a complete description of its use.

If you can't locate some of these suppUes in your area, aU prescription items and most nonprescription items can be ordered viatelephone and credit card,check, or money order from RosedalePharmacy, (888) 796-3348.

Your Diabetic Tool Kit 67

SUPPLIES FOR ALL DIABETICS

Formeasuring and recording

blood sugar

Blood sugar meteroutfit (includinglancingdeviceand lancets)

Blood sugartest strips (at least1boxof 50)Glucograf III data sheets

Forremoving blood from clothing

Hydrogenperoxide

Fordehydration

Morton's LiteSalt, Featherweight Salt

Substitute, Diamel Salt-It, Adolf's Salt

Substitute, Nu-Salt Salt Substitute, etc.

For diarrhea

Lomotil (diphenoxylate HCl with

atropine sulfite)

Approximate cost

$40-$75*

$37/box

$12.95/pad of 26 double-sided

sheets(covers one year),at

Rosedale Pharmacy

$1

$2.50

$25/60ml dropper bottle; $4/100

tablets (genericprices)

For severe vomiting

Tigansuppositories (trimethobenzamide HCl) $45/box of 10,generic, 100mg

(children), 200 mg (adults)

For low blood sugars (required if taking medication

that lowers blood sugar)

Dextrotabs: 1-3 bottles of 100 tablets. $ 13/bottle of Dextrotabs

Also,in an emergency,B-D glucose tablets,

Dextro Energy,Dextro-Energen, Dex 4, Sweetarts,

or Winkies (kosher)

MedicAlert identificationbracelet $35-$700 (gold)

For urine testing during Illness

Ketostix (foil-wrapped), 1 package $9.50

* Seeyour pharmacist for current mail-in rebate or trade-in deals.f This is an important product. The bracelet and accompanying contact information (see page 71) can provide paramedics or other medical professionalswith considerable information in case of loss of consciousness.

68 Before You Start

For testing food for sugar

Clinistix or Diastix, 1 package $12

For foot care

Olive oil, vitamin E cream, coconut oil, $5-$12

mink oil, emu oil, etc.

Bath thermometer $20

For menu planning

The Complete Book ofFood Counts, 7th ed., $7.99 (paperback)

Corinne T. Netzer (Dell, 2005)

Bowes & Church's Food Values ofPortions $59.95(plasticcomb bound)

Commonly Used, 17thed.,JeanA.T.Penning

ton, ed. (Lippincott Williams &Wilkins, 2004)

The NutriBase Complete Book ofFood Counts $14.95 (paperback)

(Avery, 2001)

Artificial sweeteners

Stevia extract $18.95/2ounces liquid; $18/

1 ounce powder

Saccharin tablets $4.80/1,000 tablets (1/2 grain)

Equal tablets $2.95/100 tablets

SUPPLIES FOR INSULIN-USING DIABETICS ONLY

Insulins and insulin supplies*

Humalog (Lilly) or Novolog(Novo),2 vials $84/vial

Humulin R (Lilly) or Novolin R (Novo), 2 vials $39/vial

Lantus insulin, 2 vials $90/vial

Levemir (Novo), 2 vials $90/vial

Frio (to store insulin while travelingin $29

hot climates)

30-unit short-needle insulin syringeswith $29/box of 100

Vi-unitmarkings, such as B-DUltrafine II

(get at least 200 to start)

30-unit standard-needle insulin syringessuch $29/boxofl00

as B-D Ultrafine (for correcting elevated

blood sugarswith optional intramuscular

injections— get 100to start)

* The particular insulins to be used willvary from one person to another, as indicated in Chapters 17-19.

YourDiabetic Tool Kit 69

For low blood sugar emergencies

Glutose 15 (Paddock Laboratories) $15/3 tubes

Glutolliquid glucose* (PaddockLaboratories) $6/bottleGlucagonEmergencyKit $104

Metoclopramidesyrup $20/4-ouncebottle

RECOMMENDED DIABETIC TOOLS —

THE DETAILS

For All Diabetics

Blood sugar meter outfit. A blood sugar meter outfit should contain a bloodsugarmeter, a finger-stick device, and a smallstartup supplyof disposable lancets and test strips. The meterdoes the samejobas the one I bought decades ago, althoughmy old one weighed threepounds and some of the new models have footprints smaller than acredit card. They work quite simply: with one drop of blood from afinger stick, the instrument gives you a reading of your blood sugar.(See Chapter 4, "How and When to MeasureBlood Sugar.")

For small children and for people who develop calluseson their fingertips from frequent blood sugar testing, try Vaculance (Bayer),whichcan securea drop of blood from arms, buttocks, or abdomen. Iuse it myself occasionally.

Blood sugar meters are available at most pharmacies and chaindrugstores. Some are more accurate and reliable than others. Becauseof the rapid advances in technology, it wouldbe counterproductive torecommend a particular meter in this book.* If you want our currentrecommendation, please call our Diabetes Center at (914) 698-7525,Monday through Thursday,9:30a.m. to 3:00p.m. Eastern (U.S.) time.

Disposable 30-gauge lancets. Theseare used with or without yourfinger-stick device to puncture your skin for glucose testing. I reusemine until they become dull. The small supply packed with the various meter outfits should easilylast a year.

* For people with severegastroparesis(seeChapter 22).+The most accuratepersonalmeterasof thiswritingis the HemoCue. It ismuchlarger and more difficult to use than other meters and requires much moreblood. It is great for calibrating more portable meters.

70 BeforeYou Start

Blood sugar test strips. When youstick yourfinger, you'll put thedropofblood on or into oneof these. They work with your meter togive yourblood sugar readings.

Glucograf HI data sheets. SeeChapter 5,"Recording Blood SugarData."These are essential to record your blood sugars and other important data properly. They are available from Rosedale Pharmacyand www.rx4betterhealth.com. These are the only data sheets that Irecommend.

Hydrogen peroxide. Now and then,whenyou're sticking your fingers or injecting through your shirt, asI do, you may get a little bloodonyourclothing. Hydrogen peroxide isaneffective way to eradicate it.You can get small bottles for home, office, car, or travel. Available atanydrugstore andat many groceries. (See Chapter 16, page 261.)

For dehydration. Dehydrating illnesses, such asvomiting,diarrhea,or fever, are potentially fatal for diabetics. If you become dehydrated,theseproducts can helpyou replace lost electrolytes. Look for potassium chloride on the list of ingredients. These should be available atthe supermarket or grocery store. Their useis covered in Chapter21,"Howto Copewith Dehydration, Dehydrating Illness, and Infection."Theyshouldbe used asdirected bya physician.

For diarrhea. Diarrheacan causedehydration.The one product thatappears always to workis Lomotil (diphenoxylate HClwith atropinesulfate). This is a prescription drug. Generic versions are available atlower cost.

For vomiting. Vomiting can also cause dehydration, which,as notedabove, can be life-threatening for diabetics. Tigan suppositories (trimethobenzamide HCl) frequently relieve vomiting and should beused for no more than 1-2 days at a time,unless directedotherwisebyyour physician. They are available in 100 mg (children and elderly)and 200 mg (adults) dosages. Use rectally as directed in Chapter 21.This product requires a prescription. Generic versions are available.

For low blood sugars. If you experience low blood sugars, Dextrotabs are a good, controlledway of bringing them up by preciseincrements, while minimizing the risk of overshoot that you mightexperience with, say, a glass of fruit juiceor a soft drink. Each tablet

YourDiabetic Tool Kit 71

will raise theblood sugar of a 140-pound person byabout8 mg/dl. Ifyourun out of Dextrotabs and need an emergency supply of glucosetablets, you can use one of the following: B-D glucose tablets, whichwill bring up blood sugars approximately 25 mg/dl in most adults;Dextro Energy, approximately 15 mg/dl; Dextro-Energen, 20 mg/dl;Dex 4,20 mg/dl; Sweetarts, 10 mg/dl;* andWinkies, 2 mg/dl. Most ofthese are available through most drugstores; Winkies are onlyavailable atkosher food stores andatRosedale Pharmacy. (See Chapters 14,"Using Exercise to Enhance Insulin Sensitivity," and 20,"Howto Prevent and Correct Low Blood Sugars") Glucose tablets will not workrapidly enough for people withsevere gastroparesis (see Chapter 22).A liquid glucose product, Glutol, made by Paddock Laboratories,raises blood sugars almost instantly. As with most other productslisted here, contactRosedale Pharmacy ifyoucannotobtainGlutol locally. Dextrotabs arenot available atotherpharmacies but canbepurchased from Rosedale or from www.rx4betterhealth.com.

MedicAlert identification bracelets. These bracelets should be

worn at all times so that if you happen to become unconscious orconfused (for example, after a motor vehicle accident or a cerebralconcussion) when you're not with a trained companion, health careprofessionals willknowyou're a diabetic and takeappropriateaction.(Although necklaces arealso available, theyareless likely thanbraceletsto be noticed in an emergency. I therefore recommend onlythe bracelets.) Available bymailorder, using forms that your physician shouldbe able to provide, or phone(800) 432-5378. They're also on the Webat www.medicalert.org. By registering with MedicAlert (the cost atthiswritingis$45the firstyearand includes a stainless steelbraceletf)>youcaninformthosewhotreatyouhowyouwantto be treated, whichis crucial for maintaining reasonable bloodsugars. Furthermore, youcan have your complete medical history available to EMS or emergencyroom personnel. This includes any directives for care you mayhave in place (such as not to use a glucose intravenous drip if yourblood sugar is not too low).Phone or visit their Website for more information.

*Thesize of Sweetarts varies withthe packaging, so 10mg/dlcanlikewise vary.f MedicAlert also provides sterling silver and solid gold bracelets at additionalcost.

72 BeforeYou Start

Ketostix. These dipsticks are for testing your urine for ketoneswhenyouare in danger ofdehydration. (See Chapter 21.)

Clinistix or Diastlx. Theseare urine test strips for glucosesimilar toKetostix, but weuse them for testingfood (eventhough they are marketedfor testing urine).See Chapter 10, "DietGuidelines Essential tothe Treatment ofAll Diabetics," to learn how you can use them to determine if packaged or restaurant foods containsugaror flour. Available at most pharmacies.

Skin lubricants. In Appendix D you will find foot care guidelines,an importantpartofdiabetic self-care. Ifyourfeet aredry, youshoulduse an animal or vegetable oil lubricant. Don't use mineral oils orpetroleum-based products, asyourskin will not absorb them. Do notuse productscontaining urea or mostly glycols. Available at RosedalePharmacy, drugstores, and health food stores. Olive oil is available atmost food markets.

Bath thermometer. Many diabetics have impaired sensation in theirfeet. Without knowing it, you can scald and seriously injure your feetif showers or baths are too hot. Don't take foot care lightly.Poor footcare for diabetics can lead to amputation, especially if you have poorcirculation. Available at most pharmacies.

Books and publications. There are many books of food valuesavailable that canbe helpful in tryingto figure out your mealplan (seeChapter 11, "Creating a Customized Meal Plan"). They are optional,but the table lists a few I think are valuable. They are all available atmost bookstores and through Internet booksellers.

Artificial sweeteners. Aswewilldiscussin Chapter 10,"Diet Guidelines," the littlepackets of artificial sweetener you seeon restaurant tables in the United States are predominantlyglucose, lactose, or othersugars. Stay away from powdered sweeteners (except stevia extract),and always scan the lists of ingredients for any word ending in -ose.Also avoid maltodextrin. In the United States, use only tablet sweeteners or stevialiquid or powder. You can get saccharin or Equal (aspartame) tablets in anydrugstoreand in many groceries. Stevia is sold athealth food stores. If you havea sweettooth, there is no restriction on

YourDiabetic ToolKit 73

how many or how much of these you use. Cyclamates areavailable inCanada and elsewhere outside the United States. These won't affectyour blood sugar.

For Insulin-Using Diabetics

Insulins. The types ofinsulins I recommend are Humalog (lispro insulin); Humulin Ror Novolin R (regular human insulin); and Lantus(glargine insulin). For children, I recommend Levemir (detemir insulin), the onlylong-acting insulin currently available that canbe diluted. These and otherinsulins arediscussed at length in Chapter 17.

You should keep at least two vials of the insulins selected by yourdoctor on hand at all times. You may need a prescription, and yourphysician will select the insulin(s) appropriate for you. A thoroughdiscussion oftheir characteristics, use, storage, andadministration appears in Chapters 16-19.

Frio. This very clever product, a wallet-style cooler activated byimmersion in water, will keep insulin cool when you are travelingin hot climates. For periods shorter than six weeks, insulin need notbe kept refrigerated but should not be exposed to high temperatures. Frio is available in the United States from Medicool, Inc.,(800) 433-2469 or www.medicool.com/diabetes; Rosedale Pharmacy;andwww.rx4betterhealth.com. It isavailable in theU.K. from TotallyCool (+44-1437-741700) orwww.friouk.com.

Insulin syringes. Any 25- or 30-unit short-needle insulin syringewith V^-unit markings should be satisfactory. They come in boxes of100, and you shouldget at least 200 to start.Theyare available with aprescription at mostpharmacies. Their use is covered in Chapter 16,"Insulin: The Basics of Self-Injection." Syringes with longer needlesformorerapidcorrection of elevated blood sugars shouldalso beconsideredafter reading Chapters 16-19.

Glutose 15. You will want to show yourfriends and relatives howtoadminister thisglucose gel ifyouexperience confusion but not unconsciousness from dangerously low bloodsugars. Your confusion shouldlift rapidly as your blood sugar increases toward thenormal range. (SeeChapter 20, "How to Prevent andCorrect Low Blood Sugars.")

74 Before You Start

Glucagon Emergency Kit. Ifyou don'tlive alone, it's important thatyou have this for the remote possibility thatyou may become unconscious from dangerously low blood sugars. You will wantto trainyourfriends, colleagues, spouse, or other family members in its use. Available byprescription at most pharmacies. It's a good idea to attach abottle of metoclopramide syrup (below), byrubber band, to each ofyour Glucagon Emergency Kits. (See Chapter 20.)

Metoclopramide syrup. Glucagon cancause nausea, and a dose ofthis syrup when you regain consciousness should keep you from retching.Aprescription is required.

Glutol. People with severe gastroparesis (see Chapter 22) may notbeable to digest glucose tablets rapidly enough to bring blood sugarsback to acceptable levels in a hypoglycemic event. This glucose solution is the answer. For a 150-pound diabetic, 1 teaspoon should raiseblood sugar by about 13 mg/dl (40 mg/dl per tablespoon). If yourpharmacy doesn't carry it,it's available from Rosedale Pharmacy.

How and When to Measure

Blood Sugar

The nondiabetic body is constantly measuring its levels ofblood sugar and compensating for values that are either toohigh or too low.A diabetic's body has lost much or all of this

capability. With a little help from technology, you can take over whereyour body has left off and do what it once did automatically—normalizeyour blood sugars.

YOUR BLOOD GLUCOSE PROFILE

No matter how mild your diabetes may be, it is very unlikely that anyphysician can tellyou howto normalizeyour blood sugarsthroughoutthe day without knowing what your blood glucosevalues are aroundthe clock.Don't believeanyone who tellsyou otherwise. The only wayto know what your around-the-clock levels are is to monitor themyourself.

A table of blood sugar levels, with associated events (meals, exercise,and so on), measured at least4 times dailyover a number ofdays,is the key element in what is called a blood glucose profile. This profile, described in detail in the next chapter,gives you and your physician or diabetes educator a glimpseof how your medication, lifestyle,and diet converge,and how they affectyour blood sugars.Without thisinformation, it's impossible to come up with a treatment plan that willnormalize blood sugars. Except in emergencies, I try not to treatsomeone's diabetes until I receive a blood glucoseprofile that coversatleast one week.

Bloodglucosedata, together with information about meals,medica-

76 Before You Start

tion, exercise, and any other pertinent data that affect blood sugar, isbest recordedon the Glucograf III data sheet,illustratedon page 85.

How Frequently Are Glucose Profiles Necessary?If your treatment includes insulin injections beforeeachmeal,your diabetesis probablysevere enough to render it impossible for your bodyto automatically correct small deviations from a target blood glucoserange. To achieve blood sugarnormalization, it therefore may be necessary for you to record bloodglucose profiles every dayfor the restofyour life, so that you can fine-tune anyout-of-rangevalues. If you arenot treated with insulin, or if you have a very mild form of insulin-treated diabetes, it may only be necessaryto prepare blood glucoseprofiles when needed for readjustment of your diet or medication.Typically, this might be for one to two weeks prior to every routinefollow-upvisit to your physician, and for a fewweeks whileyour treatment plan isbeingfine-tunedfor the firsttime.Afterall,your physicianor diabetes educator cannot tell if a new regimen is workingproperlywithout seeing yourbloodglucose profiles. It iswise, however, that youalso do a blood glucose profile for 1 day at least every other week, soyou willbe assured that things are continuing as planned.

Selecting a Blood Glucose Measuring OutfitThe measuring system usually consists of a pocket-sized electronicmeter with a liquid crystal display. The outfit will include a separatespring-driven finger-stickingdevice and a supply of lancets. The meter is designed for use with disposable plastic strips, onto or intowhich a drop of blood is placed. Some brands of strips change colorwhen exposed to glucose, and the accompanying meter measurescolor change.Most strips, however, contain electrodesthat conduct orgenerate more or lesscurrent depending upon the amount of glucosein the blood.

About twentydifferent blood glucose meteringoutfitsare presentlybeing marketed in the United States. A few of these currently have adegree of accuracy acceptable for our purposes. Some systems routinely report blood glucose values that are 40-100 percent in error.This can be very dangerous to the user. How these have secured approval from the Food and Drug Administration (FDA) is a matter ofconjecture.Usually the problem involves poor quality control or poordesign of the plastic strips, or inability to calibrate the meter accurately for different batchesof strips.

Howand When to Measure BloodSugar 77

Although your supplier should be in a position to advise youproperly on the selection of systems for blood glucose monitoring, this is almost never the case. Even physicians and educators specializing in diabetes rarely conduct the studies necessary to evaluatethese products. Reports in medical journals that purportto be evaluating different bloodglucose self-measurement systems are frequendyfinanced by one of the manufacturers and often present grosslydeceptive conclusions. All this puts you, the consumer, in a difficultposition.

Designs advance so rapidly that it's impossible to predict what willbe available when you read this book. I frequently compare new meters for accuracy versus a major clinical lab. I also check the reproducibility of results. You can call our Diabetes Center at (914)698-7525 Monday through Thursdaybetween 9:30 a.m. and 3:00 p.m.Eastern (U.S.) time to find out what systemwe currently recommendfor our patients.

There are two things to look for in a meter: accuracy and reproducibility (precision). Other"features" are nothingmorethan marketing gimmicks. You want a meter that if you were to take severalreadings, oneimmediately after theother, wouldgive you the same results. The meters that I recommend are selected with precision andaccuracy in mind. Buy from a dealer who willrefundyour money if youfind the systemto be inaccurate. You can test the meter right in thestore by taking four readings in succession. They should be within 5percent of one another when blood sugars are within the 70-120mg/dl range. I have not found anymeters that are suitably precise oraccurate above 200 mg/dl. Ask your physician about the systems hehas evaluated. He can secure virtually anysystem from its manufacturer for study at no cost.

A number of my patients have been tempted by advertising forbloodsugar meters thatcontain abuilt-indevice to puncture the skinat sitesother than the fingertips (arms, buttocks, abdomen), where thepuncturecauses absolutely no pain. I have testedseveral oftheseproductsand found theirbloodsugar readings to be inaccurate. Far superior to these is the Bayer Vaculance for painless punctures of thesealternate sites. I use it myselfand a separate, very accurate meter. Ifbloodsugar ischanging rapidly, these alternate testsite results maylagbehind fingertip tests by as much as 20 minutes. In my experience,nearly all of the finger sticks thatI perform on anyone are painless because I use the technique described in the following section.

78 BeforeYou Start

MEASURING YOUR BLOOD SUGARS:

IMPORTANT TECHNIQUES

Many instruction bookletsgive inadequate or erroneous instructionsfor preparing and pricking the finger or putting the drop of bloodonto or into the test strip or electrode. If the instructions that followconflict with what you've been told, believe mine. My techniquesaren't based on something I read in medical school or in a medicaljournal. They're the ones I use on myselfeveryday. I've been measuring my own blood sugars for more than thirty-five years and haveperformed hundreds of thousands of finger sticks on myself andthousands of my patients.

1. If you've handled glucose tablets, skin lotion, or any food sincelast washingyour hands, wash them again. Invisible material onyour fingers can cause erroneously high readings. Certainlywashyour hands if they are soiled. If you are sitting in a car or someother placewhereyou cannot washyour hands, lick the appropriate finger enthusiastically and dry it on a handkerchief orclothing. Don't wipe your fingers with alcohol; this will dry outthe skin and can eventuallyfoster the formation of calluses. Neither I nor any of my patients have developed finger infections bynot using alcohol.

2. Unless your fingers arealreadywarm, it maybe necessaryto rinsethem under warm water. Blood will flow much more readilyfrom a warm finger. If outdoors in cold weather, store your meter in a pocket next to your body and put your finger under yourtongue to warm it.

3. Layout all the suppliesyou will need at your work area. Theseusually include a finger-stick device loaded with a lancet, yourblood glucose meter, a blood glucose test strip, and a tissue forblotting your finger after the test. If you haveno tissue,just suckoff the blood (unless your religion forbids consuming humanblood). Insert a disposabletest strip into your blood sugar meter.(Some test strips are supplied in individual foil packets. The accompanying instruction booklet may tell you not to handle thestrips directly but to hold them in the foil. This assumes thatyour hands are always dirty, which is absurd, since they must beclean for an accurate result.)

Howand When toMeasure BloodSugar 79

4. Many spring-activated finger-stick devices come with two rigidplastic covers for the end that touches your finger. Usually onecover is for thin or soft skin (as in small children), while the otheris for thick or callused skin.To geta shallower puncture, use thethicker-tipped cover; to get a deeper puncture, use the thinner-tipped cover. Most finger-stick devices havea rotarycontrol thatcan be dialed to the depth of the puncture that you prefer. Anevendeeper puncturemaybe obtained by strongly pressing yourringer against the lancet cover. A very shallow puncturemay beobtained by barely touching the fingertip to the cover. The pressureofthe finger on the cover determines how deepthe puncturewill go. It shouldbe deepenoughto provide an adequate drop ofblood,but not be so deep as to cause bruising or pain. Contraryto common teaching, the best sites for pricking fingers are actuallyon the back of the hand. Prick your finger between the firstjoint and the nail, or between the first and second joints (notoverthe knuckles), as shownby the shaded areas in Figure 4-1.Pricking these sites should be less likely to cause pain and morelikelyto produce a drop of blood thanwill pricking your fingerson the palmar sideof the hand.You will alsobe free from the calluses that occur after repeated punctures on the palmarsurface

T««iyEjjptldBO

Fig.4-1. Sites toprick on thedorsumofyourfingers.

Fig.4-2. Sites toprick on thepalmarsurface ofyourfingers.

80 BeforeYou Start

of the fingers.* When using this technique, I press the tip of thelancing device verygently against the finger, asthe skin is thinnerthere than on the palmar surface. If you find it repugnant toprick the dorsum (knuckle side) of your fingers, use the sites onthe palmarsurface illustrated in Figure 4-2. Personally, I actuallyuse all of the sites shown in both diagrams. As you will not besharing your finger-stick device, you need not discard the disposable plastic lancets with the metal point after every fingerstick. It is a good idea to discard them once a month, as they doeventuallybecome dull.

5. Over a period of time, you should use all the fingers of bothhands. There is no reason to prefer one finger over the others.Onceyou havepricked your finger, squeeze it (usea rhythmic action rather than steady pressure) with the opposite hand untilthe drop ofblood is about Vio inch (2 mm) in diameter. As yousqueeze, the index finger on your squeezinghand should be behind the distal (outermost) joint of the finger you aresqueezing.If flow is inadequate (see items7 and8), performadeeper fingerstick.

6. Touch the drop of bloodto the proper point on the test strips7. Most meters will start an automatic countdown as soon as the

strip has absorbed enough blood. The countdown, in seconds,usually appears on the displayscreenand concludeswith the appearance of your blood glucose value. If your meter has a timerbutton, pressit immediately after applying blood, without delay;do not stop to examine the strip in order to determine whetheror not you have appliedenough blood. (This comes later.) Sincethe accuracy of the testusually depends upon the timing, the de-

* My patients and I are much indebted to Mr. Ron Raab, president of Insulin forLife,Inc., of Caulfield,Australia, for this not-so-obvious technique. Mr. Raab'sattempts to publish this important finding wererepeatedlyscorned by medicaljournals and finallycame to myattention via personal correspondence. I use Mr.Raab'stechnique myselfand find it far superior to the palmar technique, which Iused for years. Bythe way, this techniquewasin common use by physicians seventy yearsago.Like so many things in medicine, it had to be rediscovered.+Mostmanufacturers providestripsthat havean invisible holeat their tip.Bloodis sucked into the strip by capillaryaction. The puncture site should point upward and the tip of the strip must be inserted into the drop of blood. With suchstrips, the blood should not be put on top of the strip as erroneouslypracticed bymany users.

How and Whento Measure BloodSugar 81

laybetween applying the blood and pressing the button shouldbe no greater than 1 second. This doesn't sound like much time,but you'll be an old pro in short order.

8. Most meters have an automatic timer that begins a countdownpreceded by an audible beep when the strip has been filled.Sometimesthe beep occursbefore the strip is full,so it is wise toleave the tip of the strip in the bloodfor 2seconds after the beep.After the 2 seconds have elapsed, you may examine the strip tomakesure it is adequatelycovered or filled with blood. If it is not,discardthe strip and start again.

9. Ifyougeta little blood on yourclothing, rub on some hydrogenperoxide witha handkerchief. Wait forthe foaming to stop.Thenblot and repeat the process. Continue until blood has disappeared. This works best while the blood is still wet.

10. When your meter finishes its countdown (or countup, dependingon the model), yourbloodsugar will beshownon the displayscreen. Write it down on your Glucograp III data sheet as instructed in Chapter 5.

11. If you are measuring someone else's blood sugars using yourpersonal equipment (not a wise practice), install a fresh lanceteach time, and wipe off the end cap of the finger-stick devicewith fresh bleach after each use. It is possible to transmit serious infectious diseases from one person to another via fingersticks.

Theentire process, from pricking thefinger to a final reading, takesas little as 5 seconds,and rarelymore than 30 seconds.

Note:Donot expect accurate blood sugars (orHgbAlc) ifyou havebeen taking more than 250 mg per day of a vitamin C supplement.Readings will be lower than the true values.

PREPARING FOR YOUR FIRST BLOOD

SUGAR CONTROL VISIT TO YOUR

PHYSICIAN OR DIABETES EDUCATOR

Make sure you have all the suppUes you and your physician havechecked off in Chapter3.Put a stringon your finger to remind you toask someone at the doctor's office to watch you measure your bloodsugar and to correct any errors you may make. (About 80 percent ofmynewpatients are not measuringtheirblood sugarsaccuratelywhen

82 BeforeYou Start

I first see them.) Bringalongat least two weeks'worth of your bloodglucose profiles. Ideally, these should be written on Glucograf IIIdata sheets (see next chapter),which havebeen designed for quick review by the physician or other health care professional. To compileyour profiles, blood sugars shouldbe measured:

• Upon rising in the morning• Immediatelybeforebreakfast• Five hours after every injection of rapid-acting insulin (if you

use one of these beforemealsor to coverelevated blood sugars);otherwise, before each meal

• Two hours after meals and snacks

• At bedtime

• Beforeand afterexercising, shopping, or running errands• Whenever you are hungry or suspect that your blood glucose

may be higheror lowerthan usual• Before driving a car or operating heavy machinery and hourly

while engagingin these activities

Once your blood sugars have been fine-tuned, it may not be necessaryfor you to checkthem 2hoursafter meals andimmediatelybeforebreakfast. Appropriatetimes fortestingwillbe specified in subsequentchapters.

Recording Blood Sugar Data

USING THE GLUCOGRAF III DATA SHEET

Your blood sugar levels are affected by a varietyof things: whatmedications you are taking (such as insulin or oral hypoglycemic or insulin-sensitizing agents), what exercise you may

haveperformed,whetheryou'vegotaninfectionor cold,what you ate,when you ate itl and others you will discover as you track your bloodsugars. Many people find, for example, that such things as publicspeaking or arguments will raise blood sugars. All of thesebits of information — not just your blood sugar levels — need to be recordedand taken into account. Without this detailed information— yourown personal Mood sugar profile — your physician or diabetes educator cannot assist you in developing an ongoing program for bloodsugar normalization. To my knowledge, none of the many forms orcomputer programs currently available for this purpose show adequateinformation in areadily usable format. The Glucograf III datasheet,* likeour program, was designed by adiabetic engineer (me) fordiabetics.

Glucograf III data sheetsare printed identicallyon both sides sothat each page provides space for two weeks' worth of data. If your

*Glucograf is a registeredtrademark ownedby RichardK.Bernstein,MD.Thedata sheet form is protected by U.S. copyright, and may not be reproduced forsale without permission of the author. Readers of this book who wish to havesome practice copies for immediate use may make photocopies of the form,which is reproduced at a reduced sizeon page85 in order to make it fit into thisbook Any photocopying shop can enlarge the image in order to provide youwith standard 8V4 x 11 sheets. Padscontainingenough pages to coverone yearcan be ordered by phone from Rosedale Pharmacy, (888) 796-3348.

84 BeforeYou Start

physician wants detailed information about the content of each ofyour meals, use one side to list meal content and the reverse to listmedication,blood sugars, exercise, the timesof your meals, and so on.The data sheet is designed so that you can fold it up and carry it withyou. I recommend carrying a fine-point pen (0.1 mm) with you aswell. It willhelp when space is tight— which is likely, particularlyinthe medication, exercise, food, etc. column, where much information must be written in a smallspace. If you willbe faxing your sheetsto your physician, do not use pencil, as it doesn't always transmitclearly.

The rest of this chapter is divided into sections corresponding tocolumn and field headings on the Glucograf III form, and explainsthe sortsof thingsyououghtto be recording and the most informativeways for doing so.

DATA FIELDS

Across the top of the data sheet, thereare several fields with space forentering important information.

name. Entering your name will ensure that the form will end up inyour chart at yourdoctor's office and not in someone else's.

doctor's phone. This fieldshould contain the telephone number atwhich you can reach your physician when you are asked to discussyour blood sugarand other data.

doctor's fax. Ifyouwill be faxing yourdata sheets, enteryourphysician's fax number as well. Alternatively, if you would usually scan ande-mail your form, you might enter his e-mail address here — or justput it in your "address book."

target bg. This is the blood sugar goalthat your physicianwillassignand that you will try to maintain.Althoughnormal is approximately80-90 mg/dl, in certain instances your physician mayopt for a highervalue for a brief period. If you'veendured veryhigh blood sugar levelsfor an extendedperiod of time,your physician willnot instantly try tonormalize your blood sugars, as you may at first feel uncomfortable(hypoglycemic) at a normal value. If you take insulin, he'll assign a

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86 Before You Start

series of intermediate target values, together with instructions forcorrecting blood sugars to reach theselevels asyouwork towardbloodsugar normalization. If your initial blood sugars showthat you are inthe 300-400 mg/dl range, he might seta target of, say, 175 mg/dl forabrief time. If you have gastroparesis (delayed stomach-emptying; seeChapter 22) and use insulin, you are at real risk for severe hypoglycemia. Your physician may therefore recommend a target wellabovenormal foran indefiniteperiodof time, to providea safety factor that reducesthe likelihood ofvery low blood sugars.

usual doses of insulin or oral agent. If you require insulin or aninsulin-sensitizing or insulin-mimetic agent* to maintain your targetrange, you willhave to follow a precise regimen. It will therefore beimportant to have your blood sugar medications spelled out so thatevenif you forget, you can always refer to the doses andtimes in thisfield. When you are to take a medication before a meal, cross out"post" (as shown below); whenyou are to takeone after a meal, crossout"pre."

If yourphysician asks youto change the dose of oneof yourbloodsugar-lowering medications, put aline through the prior dosage andenter the new dose to the right of the old one, as in the following example:

USUAL DOSES OF INSULIN OR ORAL AGENTUpon Arising £4=AH l^UAN

Min. pre/post bkfst.Min. pre/post lunch.

10 Min. pre /^dinner %X CflOHeJ- 2 X ZOO KefMin. pre/post snacks

At Bedtime

In this fictitious example, the patient hadbeen injecting 2 units ofLantusinsulin on arising when this data sheetwasstarted. In additionto insulin, he had been taking three 500mg tablets of metformin (aninsulin-sensitizing agent) 90minutes before dinner. During the weekthe sheet covers, his doseof insulin on arising was reducedto \Vi unitsand his dose of metformin before dinner was reduced to two 500 mgtablets. Retaining the olddoses in this field cangive your physician animportantat-a-glance history of the changes thatwere made.

* Insulin-sensitizing and insulin-mimetic agents arebloodsugar-lowering pillsthat youmaybe using. Theyarediscussed in detail in Chapter15.

RecordingBloodSugar Data 87

l unit will lower blood sugar [insert the abbreviation ofyour most-rapid-acting insulin from upperright-hand corner of theGlucograf form] .This field is for useonlyby people who takeinsulinanduse rapid-acting insulin to bring down elevated blood sugars. InChapter 19, we'll discuss guidelines for calibrating the effect that 1unit of rapid-acting insulin willhave upon yourblood sugar. Meanwhile, enter on the form the amount of blood sugar reduction thatyour physician suggests willbe achieved by injecting 1unit.

miscellaneous. This field (box) is for anyotherpertinentguidelinesor instructions thatyoumayhave difficulty recalling. Some people enter the times they should check their blood sugars. Thus, dependingon your regimen, you might write:

/ BG -on arising -bedtime-before meals -when hungry-2 hr post meals

If this field istoo small for all youwishto enter, usethe top marginofthe form.

bg effects of sweets. If you use insulin or oralagents, you will betaughthow to use glucose tablets to raise yourblood sugar rapidly. InChapter 20,we'll discuss how you will calibrate the effect that 1tablethas on yourblood sugar. Thus, if 1 Dextrotab raises yourblood sugar8 mg/dl, you would write:

1DT-*T8

Alternately, if your brand of glucose tablet isWackyWafers (whichmight raise your blood sugar 10mg/dl), you could write:

1WW-+T10

Youwill also learnto calibrate the effect1gramofcarbohydrate hason yourbloodsugar. If 1gram willraise yourbloodsugar 5 mg/dl,youwould write:

1gmCHO -> T5

exercise adjustments. This field is also used only if you use insulinor oralagents. It reminds you what to eat forvarious forms ofexerciseto prevent your blood sugar from dropping too low.Thus, if you were

88 Before You Start

planning to spend the afternoon at a shopping mall (which can betreacherous, because this often requires considerably more walkingthan we realize), you may be advised to eathalf a slice ofbread at thestart of every hour to keep your blood sugar from falling too low.Thus, you might write:

Mall — y2brd/hr

abbreviations. Space constraints make it necessary to use abbreviations.You may be tempted to use your own, but in order to avoid confusion, I recommend usingthe short list ofstandardizedabbreviationsprovided in the top right-hand cornerof the data sheet.Using theseabbreviations will helpboth you and your physician to know immediatelythe details of"events" that affectyour blood sugar.

DAY-BY-DAY RECORD OF EVENTS

As you can see, each day is broken up horizontally into threecolumns — time; blood sugar; and medication, exercise, food,etc. Vertically, each column is broken up into 3-hour blocks, except the 9 pmthru 1am and l am thru 6am blocks, which are4-hourand 5-hour blocks, respectively. During each day, you will experience various "events" involving your blood sugar. An event may bea meal, a dose of medication, exercise, or even a blood sugar measurement itself. These should be recorded in the corresponding column and time block. You should not record a dose of medication that

does not affect your blood sugarlevels, such as blood pressuremedication.

time. In this column, write the exact time of the event. If you measured your blood sugar at 1:30 p.m. on Tuesday, write 1:30 in the 12noon thru 3 pmblock of the time column forTuesday.

blood sugar. In this column, write all blood sugar readings. If forsome reasonyou do not haveyour blood sugarmeter with you (a minor crime) and you experience symptoms suggestive of low bloodsugar, write "low" in this column in the appropriate time blockand proceed with the instructions for correcting low blood sugar inChapter 20.

RecordingBloodSugar Data 89

medication, exercise, food, etc. This column is a catchall where

youshould record allevents otherthanblood sugar readings. Following are a few examples of events and howyou would record them inabbreviated form in the proper block:

Injected 5 units of Lantus insulin 5LAN

Ate breakfast B

Consumed more food at dinner than prescribed Tdin

Took 3 Dextrotabs (glucose tablets) 3DT

Tooktwo 500mg Glucophage (metformin) pills 2x500 MET

Walked 2 miles Walk2mi

Went shopping for 3 hours Shop 3 hr

Injected \Vi units Humalog insulin,intramuscularly (into a muscle) mH-IM

Sore throat all day Sore throat [enterat the top of theday's column]

Went to dentist Dentist

UNUSUAL OR UNEXPECTED

BLOOD SUGAR VALUES

Onceyour blood sugars have beenfine-tuned on one of the regimensdescribed in this book,weexpect that theywill remainwithin narrowlimits of your target value most of the time. There will, in all likelihood,be instances when yourblood sugars will deviate from yourtarget range.

Show What Caused Blood Sugars to DeviateSometimes you may stickprecisely to your diet and medication planbut then find yourself in a restaurant and simply incapable of lettingthe dessert cart go by without partaking of its wonders. Your bloodsugars will naturallyshowa precipitous rise. Or youmaygetsomeexercise that makes blood sugargotoo low. To makeit easyfor both youand your physician to understand and evaluate such connections, circlethe cause, then circle the resulting bloodsugarvalue, and connectthe two circles with a line. For example, a high morning blood sugar

90 BeforeYou Start

might be circled and connected to "snack" at bedtime the previousnight.

Circle Puzzling Blood Sugar ValuesEven though you stick to your regimen with an iron will, your datawill sometimes show an unexpectedlyhigh or low blood sugar value.Repeat the measurement after washing your hands (to remove anytraces of food or glucose) and ensure that you haven't inadvertentlyslipped on your measurement technique. If the unexpected readingpersists, circle thisvalue, asit mayrequire further investigation. Thereare several strange biologic phenomena that can afreet your bloodsugar, and these aredetailed in the nextchapter. Your physician or diabetes educator should help you figure out the cause of unexpectedblood sugar readings so that youcan preventor anticipatethem in thefuture.

Nowthat you have beenexposed to bloodsugarself-monitoring andthe recording of data,youcanbegin using this knowledge to normalizeyour blood sugars.

Strange Biology

PHENOMENA PECULIAR TO DIABETES

THAT CAN AFFECT BLOOD SUGAR

Sometimes, even whenyouthinkyou're doingeverything right,your blood sugars maynot respond as you expect. Often thiswill be due to one or moreof thebiologic curiosities that affect

diabetics. The purpose of this chapter is to acquaint you with somerealphenomenathat canconfoundyourplans, but whichyoucan fre-quendy circumvent if you are aware of them.

DIMINISHED PHASE I INSULIN RESPONSE

Figure 1-2, page 45, illustrates the normal, nondiabetic blood insulinresponse to a meal containing carbohydrate and protein. When glucose from dietary carbohydrate enters the bloodstream, beta cells ofthe pancreas respond — or should respond — immediatelyby releasing stored insulin granules. These granules may have been stored formany hours in anticipation of what is known as a glucose challenge.This rapid releaseis calledphase I insulin response.

The nondiabetic body will utilize this immediate releaseof insulinto prevent blood sugar from increasingsignificandy. As we discussedin Chapter 1,one of the hallmarks of type 2 diabetes is the diminishedability to do this. Therefore, blood sugars will shoot up after eating(carbohydrates in particular) and will be brought back into line onlyslowly by phase II insulin response(the release of newlymanufacturedinsulin). This blood sugar rise can be minimized,primarily by dietarymanipulation, but for some diabeticsby diet and/or oral agents or injected insulin.

A possible but unproven explanation for diminished or absent

92 Before You Start

phaseI insulinresponse in diabetics is that the beta cells are stillcapable of making insulin but not capable of storing it. In this model, insulin would be releasedalmost as soon as it is made. This inability tostore insulin could also explain the inappropriate release of insulinthat often occurs when blood sugar is alreadylow in very early type 2diabetes. Such individuals may experienceblood sugars that are bothtoo high and too lowin the sameday—even without medication.Analternate explanationis that the sensitivity of the beta cells to changesin the blood sugar diminishes, so that they respond inadequately tosuch changes.

GLUCONEOGENESIS, THE DAWN

PHENOMENON, AND DELAYED

STOMACH-EMPTYING

Youmay begin to notice as you regularly monitor your blood sugarsthat your fasting blood glucoseon waking in the morning is considerably higher than it waswhen you went to bed, even though you didn'tget up for a midnight snack.There are three common causesfor this:gluconeogenesis, the dawn phenomenon, and gastroparesis (delayedstomach-emptying).

GluconeogenesisGluconeogenesis, which we discussed briefly in Chapter 1, is themechanism by which the Uver (and, to a lesserdegree, the kidneys andintestines) converts amino acids into glucose. Dietary protein is notthe only source of amino acids. The proteins of your muscles andother tissuescontinuallyreceive amino acids from and return them tothe bloodstream. This constant flux ensures that amino acids are al

ways available in the blood for conversion to glucose (gluconeogenesis) by the liver or to protein by the muscles and vital organs. Somediabetics still make adequate insulin to prevent gluconeogenesis.However, once your insulin production drops below a certain level,your liver (and your kidneys and intestines) will inappropriately produceglucose and thus raise yourblood sugarevenwhileyou'refasting.

In all likelihood, you won't be able to control this phenomenon bydiet alone,particularlyifyou'rea type 1diabeticor a type 2 makingfartoo little insulin to offsetyour insulin resistance. For type 2s, appropriate weight loss and vigorous exercise may be most helpful in im-

StrangeBiology: PhenomenaPeculiarto Diabetes 93

proving the sensitivityof the liverand muscles to whateverinsulin remains. The most reliable treatments will involve medication, eithercertain oral agents or insulin. If you're obese, however, large doses ofinsulin can make you more obese and more resistant to insulin. So amajorgoal shouldbe to bringyourweight into line.

The Dawn Phenomenon

As youknow, I'm a type 1diabetic. I may no longer make anyinsulinat all. If I decide to fast for24hours — eatabsolutely nothing — I willneed to inject 2% units of long-acting insulin in the morning to prevent gluconeogenesis for18 hours. IfI check myblood sugar every fewhours, it will remain constant, confirming thattheinsulin issuppressing gluconeogenesis.

If, 18 hoursafter myfirst injection — andwhile still fasting — I inject another 2% units of insulin, common sense would maintain thatthissecond dose should suppress gluconeogenesis overnight.

SoI goto sleep andawaken 9-10hours later. On arising, I check myblood sugar. Instead of being constant, as it was during mywakinghours,it's now20-100mg/dlhigher than it was at bedtime.

If I were to try the same experiment a week later, I'd experienceabout the sameovernight risein bloodsugar. Why?

Although the mechanics of the dawn phenomenon aren't yet entirely clear, research suggests that thefiver deactivates morecirculatinginsulinduring the early morninghoursthan at other timesof the day.It doesn't matterwhether youmade the insulin yourself or injected it;theliver hasno preference. Withinadequate circulating insulinto prevent gluconeogenesis, your blood sugars maybe higher in the morning than theywereat bedtime.* This isn't a problemfor a nondiabetic,because a body with fully functional pancreatic beta cells will justmake more insulin.

Investigators have actually measured blood sugar every hourthroughout the night under similar circumstances. Theyfind that theentire blood sugar increaseoccursabout 8-10 hours after bedtime formostpeople whoaresoaffected. Thatdoesn't mean, however, that youshould sleep only 7 hours a night to try to avoid it. Both the time ittakes for blood sugar to increase and the amount of the increase vary

* Consuming alcohol at bedtimecan inhibitgluconeogenesis overnight, but notin a predictable fashion.

94 BeforeYou Start

from one person to another. An increase may be negligible in someand profound in others. This is one of many reasons why any trulyworkableprogram for blood sugarnormalization must be tailored tothe individual.

Though it is more apparent in type 1diabetics,many type 2 diabetics also show signs of the dawn phenomenon. As you will see, thetreatments described in this book enable us to circumvent this blood

sugar rise.

GastroparesisThis condition has a chapter all its own (Chapter 22), and we will discuss it there in detail.However, it's important to mention it in any listof factors that can lead to puzzlingblood sugar readings.

Most people who've had long-standing diabetes develop some degree of damage to the nerves that govern the muscles of the stomachand intestines. Gastroparesis diabeticorum (the weak or paralyzedstomach of diabetics) is caused by manyyears of elevated blood sugars. If you're a type 1,or a type 2who isn't makingsignificantamountsof insulin, it can haveunpredictableeffects on blood sugar.

Like diabetes itself, gastroparesis can be mild to severe. In extremecases, people maywalkaround for dayswith constipation,belchingorvomiting, midchest burning, and bulging stomachs.Much more common, however, is mild gastroparesis in which physical symptoms arenot apparent but blood sugarsare erratic.

The big problemswith gastroparesis ariseif you're taking insulin. Ifyou take your insulin before a meal to prevent a subsequent rise inblood sugar but the meal remains in your stomach and glucose doesn'tenter the bloodstream as predicted, the insulin can take your bloodsugardangerously low. I know threeindividuals whoexperienced dailyepisodes of unconsciousness and seizures from time to time aftermealsfor severalyears before I met them and diagnosed this condition.

Thereare,however, ways of greatiy improving blood sugarsin spiteof the unpredictabilityof this condition, and these are discussed inChapter 22,"Delayed Stomach-Emptying."

STRESS AND BLOOD SUGAR

Sustained Emotional Stress

For years,many physicians havebeenblaming emotional stressfor thefrequent unexplained blood sugarvariations that many patients expe-

Strange Biology. Phenomena Peculiar to Diabetes 95

rience. This is an evasive and possibly self-serving diagnosis. It putstheresponsibility for unexplained variations inblood sugar on thepatient's shoulders andleaves thephysician with no obligation to examine the treatment regimen. Certainly there is no question that stresscan have adverse effects upon your health. I have reviewed more thana million blood sugar entries from many patients, including myself.Onecommon feature ofallthis dataisthatmost prolonged emotionalstress rarely has a direct effect upon blood sugar. This kind of stresscan, however, have a secondary effect by precipitating overeating,binge eating, or indulgence in kinds ofeating that will increase bloodsugar.

I know many diabetics who've been involved in stressful marriages,divorces, lossof a business,slowdeath of a closerelative, and the countless other sustained stresses of life we all must endure. These stresseshave one thing in common: they aren't sudden but usually last days,or even years. I haveyet to see such a situation directly cause bloodsugar to increase — or, for that matter, decrease. An important thingto remember during sustained periods of life when everything seemsout of control is that at least you can control one thing: your bloodsugar.

Adrenaline SurgesMany patients have reported sudden blood sugar spurts after briefepisodes of severe stress. Exampleshave included an automobile accident without physical injury; speaking in front of a large audience;taking very important exams in school; and having arguments thatnearly become violent. I am occasionally interviewed on television,and I always check — and, if necessary, adjust — mybloodsugarimmediately before and after such appearances. Until I eventually became accustomed to such appearances, my blood sugar wouldinevitably increase 75-100 mg/dl, even though on the surface I mighthave appeared relaxed. As a rule of thumb, from personal experienceand from observingmy patients, I would saythat if an acute event isstressful enoughto start your epinephrine (adrenaline) flowing, as indicated by rapid heart rate and tremors, it is likely to raiseyour bloodsugar. Epinephrine is one of the counterregulatory hormones thatcause the liver to convert stored glycogen to glucose. This is part ofwhat is often calledthe "fightor flight" response, your body's attemptto provideyouwith enoughextraenergy eitherto overcome an enemyor run likeheck to get away. Type2 diabetics who makea lot of insulin

96 BeforeYou Start

are less likely to have their blood sugar reflect acute stress than arethose who make little or none.

An occasional blood sugar increase aftera verystressful event maywell have been brought on by the event. On the other hand, unexplained blood sugar increases extending for days or weeks can rarelybe properly attributed to stress. I know of no instances where prolonged emotional stress caused abnormal blood sugars in diabetic ornondiabetic individuals.Therefore,if you experiencea prolonged unexplained change in yourbloodsugarlevels afterextended periodsofnormal blood sugars, it is wise to seek out a cause other than emotional stress.

General Anesthesia

If not treated with specialdosing of insulin, type 1and most type 2 diabetics with previouslylevel, normal blood sugars may experience ablood sugar increase during surgery that is accompanied by generalanesthesia.

Insulin Resistance Caused by Elevated Blood SugarsThereare at least five causes of insulin resistance — inheritance, dehydration, infection, obesity, and high blood sugars. Insulin's ability to facilitatethe transport of glucose fromthe blood into Uver, muscle, fat,andother cells is impairedasblood sugarrises. This reducedeffectiveness ofinsulin,known as insulin resistance, has been attributed to a phenomenon called postreceptor defects in glucose utilization. If, for example, 1unit of injectedor self-made insulin will loweryour blood sugar from130 to 90 mg/dl, someone with insulin resistance caused by elevatedblood sugars mayrequire3 units to lower it from 430to 390mg/dl.

Considerwhat might happen if I, a type 1 diabetic, am fasting andinject just enough long-acting insulin to keep my blood sugar at 90mg/dl for 18 hours. If I eat 8 grams of glucose — enough to raise myblood sugar to 130mg/dl — the chances are that, because of the elevatedblood sugar, myblood sugarwon't just rise to 130mg/dl and remain there. It willcontinue to rise slowly throughout the day, so that12hours after I consumed the glucose, myblood sugar might actuallybe 165mg/dl. Insulin resistance, at least for type 1 diabetics,occurs asblood sugar increases, and so elevatedblood sugar should be correctedas soon as it's feasible. Delay willonly permit it to rise higher.Becausetype 2s still produce some insulin, their bodies are more likelyto correct the blood sugar rise automatically.

Strange Biology: Phenomena Peculiar to Diabetes 97

We will discuss dehydration as a cause of insulin resistance inChapter 21. Infections are discussed attheendof thischapter andalsoin Chapter 21.

THE CHINESE RESTAURANT EFFECT

Manyyears ago a patient asked me whyherbloodsugar went from 90mg/dl up to 300 mg/dl every afternoon after she went swimming. Iasked what she ate before theswim."Nothing, just afreebie," she replied.As it turned out, the "freebie" was lettuce. When I asked her just howmuch lettuce shewas eating before her swims, shereplied, "Ahead."

A head of lettuce contains about 10 grams of carbohydrate, whichcanraise atype 1adult's blood sugar about50mg/dl atmost. Sowhataccounts for the other 160 mg/dlrise in herbloodsugar?

The explanation lies in what I call the Chinese restauranteffect. Often Chinese restaurant meals contain large amounts of protein orslow-acting, low-carbohydrate foods, such as bean sprouts, bok choy,mushrooms, bambooshoots, andwater chestnuts, that canmakeyoufeel full.

How can these low-carbohydrate foods affect blood sugar so dramatically?

The upper partofthe smallintestinecontains cells that release hormones into the bloodstream when they are stretched, as after a meal.These hormones signal the pancreas to produce some insulin to prevent the blood sugar rise that might otherwise follow the digestion ofa meal.Large mealswill cause greater stretching of the intestinalcells,which in turn will secrete proportionately larger amounts of thesehormones. Since averysmall amount of insulin released by the pancreas can cause a large drop in blood sugar, the pancreas simultaneously produces the less potent hormone glucagon to offset thepotential excess effect of the insulin. If you're diabetic and deficientin producing insulin, you might not be able to release insulin, butyou will still release glucagon, whichwill cause gluconeogenesis andglycogenosis and thereby raise your blood sugar. Thus, if you eatenoughto feel stuffed, yourbloodsugar can goup by alarge amount,even if you eat something undigestible, such assawdust. Even a smallamount of an indigestible substance willcause ablood sugar increasein type 1diabetics ifnot covered by an insulin injection.

Complicatingmatters further, pancreatic betacells alsomake ahor-

98 Before You Start

mone called amylin. Amylin inhibitsthe effectiveness of glucagonandworks on the brain to causesatiety. It alsoslows stomach-emptying todiscourage overeating. Withfew or no beta cells, diabetics don't makeenough amylin, and consequentiy they tend to remain hungry aftereating and show an exaggerated Chinese restaurant effect. Since thelastedition of this book,amylinsubstituteshavebecomeavailable andhave found an important use in the prevention of overeating (seepage 204).

The first lesson here is: Don't stuffyourself. The second lesson is:There's nosuch thingasafreebie.* Anysolid food that you eat can raiseyour bloodsugar.* Ifyoucan'tcontrolyourovereating, seepage 247.

THE EFFECTS OF EXERCISE UPON

BLOOD SUGAR

Exercise can havevaryingeffects upon blood sugar, depending upon anumber of variables, including the type of exercise, how vigorously it'sperformed, whenit isperformed, andwhattypeof medication youareusing, ifany. These effects aretoovaried andnumerous todiscuss in thisbriefspace. Please see Chapter 14, "Using Exercise to Enhance InsulinSensitivity," if you are embarking on an exercise program or find yourblood sugars unpredictably affected byyourexisting exercise program.

THE HONEYMOON PERIOD

At the time they are diagnosed, type 1 diabetics usually have experiencedveryhigh blood sugars that cause a host of unpleasant symptoms, such as weight loss, frequent urination, and severe thirst. Thesesymptoms subsidesoon after treatment with injected insulin begins.After a few weeks of insulin therapy, many patients experience a dramatic reduction of insulin requirements,almost as if the diabeteswerereversing. Blood sugars maybecome nearly normal,even with discontinuation of insulin injections.This benign "honeymoon period" may

* Except for noncaloricfluids that flow through the intestines without causingdistention.

t Several readers from China have e-mailed me that their restaurants don't usesweetsaucesso this effectshouldn't apply to them. This is a misunderstanding ofthis effect— the Chineserestaurant effectis causedby any solid foods.

StrangeBiology: PhenomenaPeculiar to Diabetes 99

last weeks, months, or even as long as ayear. If themedical treatmentisconventional, thehoneymoon period eventually terminates andthewell-known roller coaster of blood sugar swings ensues.

Why doesn't the honeymoon period last forever? My experiencewith patients indicates thatit can, with proper treatment. Butthere areseveral likelyreasons why it doesnot with conventional treatment.Atthiswriting, however, they still remain speculative.

• The normal human pancreas contains many more insulin-producing beta cells than are necessary for maintaining normalblood sugars. For blood sugar to increase abnormally, atleast 80percent of thebeta cells musthave been destroyed. In early type1 diabetes, many of the remaining 20 percent have been weakened by glucose toxicity from constant high blood sugars and byoverwork. These betacells can recover if theyare given arest withthe help of injected insulin. Even if they recover, however, theystill must workat least five times as hard to match the job of anormal pancreas working at 100 percent capacity. Eventually,with conventional treatment, this overwork helps cause them tobreak down.

• It isnow believed that highbloodglucose levels are toxic to betacells. Even abriefbloodsugar increase after ahigh-carbohydratemeal maytake a small toll. Over time, thecumulative effect maywipe them out completely.

• The autoimmuneattack upon beta cells, the presumed cause oftype 1diabetes, is focused upon several proteins. One is insulin,and another is present on the special vesicles — or bubbles —that are formed at the outer membrane of the beta cell. Thesevesicles containinsulin. Normally, theyburstat the surface ofthecell, releasing insulin granules into the bloodstream. The morevesicles created when more insulin is manufactured, the greaterthe autoimmune attack upon the beta cell. If less insulin is released, lessof this proteinis exposedto attack.

Based upon my experience withthe fair numberof type 1diabeticsI've treated from the timeof diagnosis, I'm convinced thatthe honeymoon period can be prolonged indefinitely. The trick is to assist thepancreas and keep it asquiescentaspossible. With the meticulous useof small doses of injected insulin and withthe essential use of averylow carbohydrate diet, the remaining capacity of the pancreas, I believe,can be preserved.

100 Before You Start

INFECTION AND ITS EFFECT

ON BLOOD SUGARS

Another kind of stress to which your body can become subject —and which can muddy and in some instances wreak havoc on yourbest efforts to control blood sugars — is infection. I have saved thiscategory of stress for lastnot because it is the leastimportant, but because,when present, it can be the most important.

A kidney infection, for example, can triple insulin requirementsovernight. When blood sugar rises unexpectedly after weeks ofnormalvalues, it iswise to suspectinfection. I havenoted that my own bloodsugars rise24hours before the onsetof a sorethroat or cold.Everyonein my family takes Sambucol (an extract of the black elderberry tree)at the first signof a cold, and I highly recommend it. If you cannot locate it at a health food store near you, it can be obtained from (888)406-4066 by mail order; from Rosedale Pharmacy, (888) 796-3348;from www.rx4betterhealth.com; or at most health food stores.

Dental Infections

Quite often, dental infectionswon't be obvious,but high blood sugars cause dental infections, and in the typical vicious circleofdiabetes,these infectionscan causeveryhigh blood sugars.You cannot possiblycontrol blood sugars under thesecircumstances. I have seldom met along-standing diabetic over age forty (witha historyof uncontrolledblood sugars) who had allhis teeth.

Frequent dental infections can be a signof diabetes for those whohave not alreadybeen diagnosed. I havehad many patients who haveundergone multiple root canal or gum treatments prior to the diagnosis of diabetes.

If your insulin* "isn't working"— that is, your normal dose isn'tacting as you havedeterminedit should — and you havedeterminedthat your insulin isn't contaminated (for example, by reusing syringes) the firstplace to look is in your mouth.

First,look at your gumsto seeif there'sanysignof infection— e.g.,redness, swelling, tenderness to pressure. Put somewaterwith crushedicein your mouth for 30seconds. If a tooth hurts, you should suspectan infection.

Or oral agentsfor controllingblood sugar.

Strange Biology. Phenomena Peculiar to Diabetes 101

Get an emergency appointmentwith yourdentist immediately. Hecan determine if youhave asuperficial infection, andcanX-ray whereyour teeth are sensitive, but he should refer you to an endodontist (adentist whodeals withroot canals and the jawbone) oraperiodontist(who treats infected gums). This kindof infection isextremely common in diabetics and should be brought under control as rapidly aspossible in order to allow youto bring your blood sugars undercontrol. Wewill discuss this subject further in Chapter 21.

7

The Laws of Small Numbers

Big inputs make big mistakes; small inputs make small mistakes." That is the first thing my friend Kanji Ishikawa saystohimself each morning on arising. It is his mantra, the single

most important thing he knows aboutdiabetes.Kanji is the oldest surviving type 1 diabetic in Japan (he is,by the

way, younger than I, but afflicted with numerous long-term diabeticcomplications because of manyyears of uncontrolled bloodsugars).

Manybiological and mechanical systems respond in a predictablewayto small inputsbut in achaotic and considerably less predictablewayto large inputs. Consider for a moment traffic. Puta small number of automobileson a given stretch of highwayand traffic acts in apredictable fashion: cars can maintain speed, enter and merge intoopen spaces, andexitwithaminimum of danger. There's room for error. Double the number ofcars andthe risksdon't just double, they increase geometrically. Triple or quadruple the number of cars and theunpredictability of a safe tripincreases exponentially.

The name of the game for the diabetic in achieving bloodsugar normalization is predictability. It's very difficult to use medicationssafelyunless you can predict the effect they'llhave. Nor canyou normalizeblood sugar unless you can predict the effects ofwhatyou're eating.

If youcan't accurately predict your blood sugar levels, thenyoucan'taccurately predict yourneeds for insulin or oral bloodsugar-loweringagents. If the kindsof foods you're eating give youconsistently unpredictable blood sugar levels, then it will be impossible to normalizeblood sugars.

One of the primeintentsofthisbook isto give you the informationyou needto learn to predict yourbloodsugar levels andhowto ensure

The LawsofSmallNumbers 103

that your predictions willbe accurate. Here the Laws of SmallNumbers are exceedingly important.

PredictabiUty. How do you achieve it?

THE LAW OF CARBOHYDRATE ESTIMATION

The oldAmerican Diabetes Association (ADA) dietary recommendations allowed 150 grams of carbohydrate permeal. This, as you mayknow by now, is grossly excessive for people trying to control theirbloodsugars. Hereis one reason why.

Typically, 150 grams ofcarbohydrate would beagood-sized bowl ofcooked pasta. You maythinkthat byreading the ingredients label onthe package you can precisely compute how much ofthedrypasta youmustweigh out to dispense exactly 150 grams of carbohydrate. Now,ifyou're a nonobese type 1diabetic who weighs 150 pounds (68 kilograms) and makes no insulin, 1gram of carbohydrate will raise yourblood sugar by about 5 mg/dl. By using methods that we'll later describe, you cancalculate exactly how much insulin you mustinject tokeep yourbloodsugarat the samepoint afterthe mealasit wasbeforethe meal. This may sound elegant, but it will rarely work for a high-carbohydrate meal. What neither theADA northepackage tells you isthatfood producers are permitted a margin oferror ofplus or minus20 percentin their labeling of ingredients. Furthermore, many packaged products— for example, vegetable soup— cannot even matchthis error range, in spite of federal labeling requirements. So even ifyou perform the necessary calculations, your blood sugar after themeal can beoffbya carbohydrate error of5mg/dl multiplied by± 30grams (± 20 percent of 150 gm), orbyawhopping ±150 mg/dl forjustthis one meal. Ifyour blood sugar level before the meal was approximately 85 mg/dl, you've now got a blood glucose level anywhere between 235 mg/dland 0 mg/dl. Either situation isclearly unacceptable.

Let's try another example. Say you're a type 2 diabetic, obese, andmake someinsulin of your ownbut also inject insulin. You've foundthat 1gram of carbohydrate only raises your blood sugar by3 mg/dl.Your blood sugar would be off by ±90 mg/dl. If your target bloodsugar value is, say, 90 mg/dl, you're looking at a postmeal blood sugarlevel of anywhere from 180 mg/dlto 0 mg/dl.

That's oneof the many problems with theADA guidelines. Big inputs and big uncertainty.

104 Before You Start

But if youeatanamount ofcarbohydrate thatwillaffect yourbloodsugar by a much smaller margin of error, then you're going to haveamuch simpler time of normalizing blood sugar levels. My diet plan,whichwewillgetinto in Chapters 9-11,aimsto keepthesemarginsinthe realmof±10-20mg/dl. Howdo we accomplish this? Smallinputs.

Eating only a half-teacup of pasta is not the answer. Even smallamounts of some carbohydrates cancause big swings in blood sugar.And anyway, who would feel satisfied after such a small serving ofpasta? The key isto eat foods thatwillaffect yourbloodsugar in averysmall way.

Small inputs,small mistakes. Sounds sosimpleandstraightforwardthat it may make you want to askwhy no one has told you about itbefore.

Say thatinstead of eating pasta as thecarbohydrate portion of yourmeal, youeatsalad. If youestimate 2 cups of salad to total 12 grams ofcarbohydrate and are off not by 20 percent but by 30 percent, that'sstill an uncertaintyof only 4 grams of carbohydrate — a maximumpotential 20mg/dlrise or fall in blood sugar. A bigbowlof pasta for acouple of cups of salad? Not much of a trade, you may say. Well, wedon't intendthatyou starve. Asyou decrease the amount of fast-actingcarbohydrate you eat, you can often simultaneously increase theamount of proteinyou eat. Protein can, asyou may recall, also cause ablood sugar rise, but this takes place much more slowly, to a muchsmaller degree, and is more easily covered with medication. In addition, unlike the pasta, whichcanleave you feeling hungry aftera meal— I will explain this further in later chapters — protein leaves youfeeling satisfiedlonger.

In theory, youcould weigh everything youeat right downto thelastgram and make your calculations based on information provided bythe manufacturer or derived from some of the books we use. This information,asnoted above, isonly an estimate, with considerable margin for error. You will have onlyavague idea of whatyou're actuallyconsuming, andof the effect it willhave on bloodsugar.

The idea here is to stick with low levels of slow-acting, nutritiouscarbohydrates. In addition, stickwith foods that will make you feelsatisfied without causing hugeswings in blood sugar. Simple.

TheLawsof SmallNumbers 105

THE LAW OF INSULIN DOSE ABSORPTION

Ifyoudo not takeinsulin, youcanskipthissection.Think again of traffic. You're driving down the road and your car

drifts slightly toward the median. To bringit back into line, youmakea slight adjustment of the steering wheel. No problem. But yank thesteeringwheeland it couldcarryyou into another lane,or could sendyou careening off the road.

When youinjectinsulin, not allof it reaches yourbloodstream. Research has shown that there's a level of uncertainty as to just howmuch absorption of insulin actually takes place, and even as to howsensitive the bodyis to insulin fromonedayto the next.The more insulin youuse, the greater the level of uncertainty.

When youinject insulin, you're putting beneath your skin asubstancethat isn't, according toyour immune system's way ofseeing things, supposed to be there. So a portion of it will bedestroyed asa foreign substance before it can reach thebloodstream. The amount that the bodycan destroy depends onseveral factors. First ishow big adose you inject.The bigger the dose, themore inflammation and irritation you cause,andthemore ofa"red flag" you send uptoyour immune system. Otherfactors include the depth, speed, andlocation ofyourinjection.

Your injections will naturally vary from one time to the next. Eventhe most fastidious person will unconsciously alter minor things inthe injection process from day to day. So the amount of insulin thatgets into your bloodstream is always going to have some variability.Thebigger the dose,the bigger the variation.

A number of years ago, researchers at the University of Minnesotademonstrated thatifyou inject about 20 units ofinsulin intoyourarm,you'llget on average a 39 percentvariationin the amount that makesitinto the bloodstream from one day to the next They found that abdominal injections hadonly a 29percent average variation, andso recommended thatweuseonlyabdominal injections. On paperthat seemsfine, but in practice theeffects on blood sugar arestill intolerable.

Sayyou do inject 20 units of human insulin at one time. Each unitlowers the blood sugar of a typical 150-pound adultby 40 mg/dl. A29 percent variability will create about a 6-unit discrepancy in your20-unit injection, which means a 240 mg/dlblood sugar uncertainty(40 mg/dlx 6 units).The result is totally haphazard bloodsugars andcomplete unpredictabiUty, just by virtue of the varying amounts ofinsulin absorbed.

106 BeforeYou Start

Research and my own experiencedemonstrate that the smaller yourdose of insulin, the less variability you get. For type 1 adult diabeticswho are not obese, we'dideally liketo seedosesanywhere from lA unitto 6 units or at the most 7. Typically, you might take 3-5 units in ashot. At these lower doses, the uncertainty of absorption approacheszero, so that there is no need to worry about whether you should inject in your arm or abdomen or buttock.

I havea veryobesepatient who requires 27 units of long-actinginsulin at bedtime. He's so insulin-resistant that there's no way to keephis blood sugarunder controlwithout this massive dose. In order toamelioratethe unpredictability of largedoses, he splitshisbedtime insulin into four smallshotsgiven into four separatesitesusingthe samedisposable syringe. Asa rule, I recommend thata single insulin injection never exceed7 unitsfor adults and proportionally lessfor children, depending on theirweight

THE LAW OF INSULIN TIMING

Again, it's very difficult to use any medication safely unless you canpredict the effect it will have. With insulin, this is as true of when youinjectasit is of howmuchyoutake. Ifyou're a recent-onset type 1diabetic, fast-acting (regular) insulin can be injected 40-45 minutesprior to a mealtailored to yourdietplanto preventthe ensuingriseinblood sugar. Regular, "fast-acting" insulin, despite its designation,doesn't act very fast, and cannot come close to approximating thephaseI insulinresponse ofa nondiabetic. To a lesser degree this isalsotrue of the new,faster-acting lispro (Humalog),glulisine (Apidra), oraspart (Novolog) insulins. Still, these are the fastest we have. Smalldoses of regular start to workin about 45 minutesand do not finishfor at least 5 hours; lisprostarts to work in about 20 minutes and alsotakes at least 5 hours to finish. This is considerably slower than thespeedat whichfast-acting carbohydrate raises bloodsugar.

Many years ago, John Galloway, then medical director and seniorscientist of Eli Lilly and Company,performed an eye-opening experiment. He gave one injectionof 70units of regularinsulin (a verylargedose) to a nondiabetic volunteer who was connected to an intravenous glucose infusion. Dr. Galloway then measured blood sugarseveryfewminutes and adjustedthe glucose drip to keep the patient'sblood sugarsclampedat 90mg/dl. Howlongwouldyou guess the glu-

TheLawsofSmallNumbers 107

cose infusion had to be continued to preventdangerously low bloodsugars, or hypoglycemia?

It took a week,even though the package insertsays that regular insulinlasts only 4-12 hours. So the conclusion is that even the timingof injected insulin is very much dependent upon how much was injected. In practice, larger insulin injections start working sooner, lastlonger, and haveless predictable timing.

If you eat a meal not specifically tailored to our restricted-carbohydrate diet and try to coverit with insulin, you'll get a postprandial(after-eating) increase in blood sugar, eventually followed by a decrease asthe fast-acting insulin catches up.This means that you'llhavehigh blood sugars aftereverymeal, and you could still fall prey to thelong-term complications of diabetes. If you try to prevent the inevitable postprandial blood sugar spikeby waitingto eatuntil afterthestarttime ofyour insulin, you may easilymake yourself hypoglycemic,which could in turn cause you to overcompensate by overeating —that is, presuming you don't lose consciousness first.

Type 2 diabetics have a diminished or absent phase I insulin response,and sothey face aproblemsimilar to that oftype Is.They haveto waithours forthe phase II insulinto catchup if they eat fast-actingcarbohydrate or large amounts of slow-acting carbohydrate.

The key to timing insulininjections is to know how carbohydratesand insulin affect your blood sugar and to use that knowledge tominimize the swings. Since you can't approximate phase I insulinresponse, you have to eat foods that allow you to work within thelimits ofthe insulin you make or inject. If you think you'll miss out onthe ADA's great high-carb, low-fatdiet— which, statistically, has onlysucceededin raisinglevelsof obesity,elevatingtriglycerides and LDL,and causingan epidemic of diabetes and earlydeath — there is considerable evidence that restricting carbohydrate is healthiernot onlyfor diabetics but for everyone. This has recently been supported bya twenty-year study of 82,802 nondiabetic nurses published in theNovember 9,2006, issueof the NewEngland Journal ofMedicine. (Formore details on this point, see Protein Power, by Drs. Michael andMary Dan Eades, Bantam Books, 1996.)

If you consumeonly small amounts of slow-acting carbohydrate, youcan actually prevent postprandial blood sugar elevation with injectedpreprandial rapid-acting insulin. In fact, by restricting carbohydrate intake, many type 2 diabetics will be able to prevent this rise with theirphase II insulin response andwill not need injected insulin before meals.

108 BeforeYou Start

OBEYING THE LAWS OF SMALL NUMBERS

Essential to obeying the Laws of Small Numbers is to eat only smallamounts of slow-acting carbohydratewhenyou eat carbohydrate, andno fast-acting carbohydrate. Even the slowest-acting carbohydratecanoutpace injected or phase II insulin if consumed in greater amountsthan recommended later in this book (Chapters 9-11).

If you eat a small amount of slow-acting carbohydrate, you mightget by with a very small or no postprandial blood sugar increase. Ifyou double the amount of slow-acting carbohydrate, you'llmore thandoublethe potential increase in bloodsugar(and remember that highblood sugar leads to even higherblood sugar). If youfill up on slow-acting carbohydrate, itwill work asfast asa lesser amountof fast-actingcarbohydrate, and ifyou feel stuffed, you'llcompound it with the Chinese restaurant effect.

All of this not only points toward eatingless carbohydrate, it alsoimplies eatingsmaller meals 4 or 5 timesa dayrather than three largemeals. Ifyou're a type2diabetic and require no medication, eatinglikethis mayworkwell for you. The difficulty with this sort of plan is itsinconvenience, but somepeople don't mind and actually preferto eatthis way. One of my patients, a type 1 diabetic who still makes someinsulin, eats a couple of bites of protein every 20 minutes and takeslong-acting insulin. In a 16-hour day, that adds up to a lot of mini-meals and a lot of clock-watching. This routine would drive manypeoplenuts, but it almostworks for her.As long as she keeps up withher frequent little meals and covers the insulin, she's fine. When shemisses a few "meals," there inevitably is trouble.

Forthe type2 diabetic who doesn't needinsulin injections, smallermeals throughout theday can beavery effective way ofmaintaining aconstant levelof blood sugar.Sincethis kind ofdiet would be tailoredto work with a phase II insulin response, blood sugars should nevergotoohigh. Itwould, however, involve a certain amountof daily preparation and routinization that could be thrown off by changes inschedule — illness, travel, houseguests, and so forth. People whocover their meals with injected insulin and also correct small bloodsugar elevations with very rapid acting insulin, however, cannot getawaywith more than three dailymeals (Chapter 19).

8

Establishing a Treatment Plan

THE BASIC TREATMENT PLANS AND

HOW WE STRUCTURE THEM

Now that you know the different factors that can affect bloodsugar, we can begin to discuss treatment plans. Blood sugarnormalization for most diabetics canbe achieved throughone

of four basic plans. Although there are only two major types of diabetes— type 1and type 2 — there are so manyvariations, particularlyin type 2,that a treatment planthatworks for one diabetic won't necessarily work for another. Each planhasto be tailored to the individual.

The basic treatment plans increase in complexity with the severityof the disease.

For type 2 diabetes

Level 1: Diet (and appropriateweight loss)*Level2: Diet (and appropriateweight loss) plusexerciseLevel 3: Diet (and appropriate weight loss) plus exercise plus anoral insulin-sensitizing or insulin-mimetic agentLevel4: Diet (and appropriate weight loss) plus exercise plus insulin injections,with or without an oralagent

Fortype 1 diabetes

Same aslevel 4 above,with the addition ofmultiple daily insulininjections, with questionablebenefit from exercise in controllingblood sugars, andwith benefit fromoralinsulin-sensitizing agents

* Since 80 percent or more of type 2 diabeticsareoverweight,weight loss shouldbe an important part of treatment for the majority.

110 Before You Start

only when insulin requirements are excessive, aswith those whoare obese or who have polycystic ovarian syndrome (PCOS; seeAppendix E).

STRUCTURING A TREATMENT PLAN

What are normalblood sugar levels? What range do we find in nondiabetics? The answers depend upon whom you ask. I've seen figures inthe scientific literatureoverthe years ranginganywhere from 60 to 140mg/dl. My experience checking random blood sugar readings onnonobese nondiabetics, aswellas figures from large population studies, tells me that for most nondiabetics, blood sugar levels cover apretty narrow range of about75-95 mg/dl (by finger stick),exceptafter mealscontaining large amounts of fast-acting carbohydrates.

I usually select a target of 90 mg/dl for most of my patients whotake insulin. This target is not an average, but one we try to maintain24 hours a day. Evenifyou average 90 mg/dl but your blood sugars arebouncing backand forth between60 and 140 mg/dl, you'restillon theroller coaster. Our object is to find a treatment plan that will get youoff the roller coaster and keep you off.

For those who do not need insulin injections to maintain bloodsugars, and those insulin users who have demonstrated very stableblood sugars, I eventually set a target of 80-85 mg/dl. This assumesthat you're comfortable at such levels, that is, not experiencing symptoms of hypoglycemia (low blood sugars).

One of the most important considerations in setting up an initialtarget is that people who have had high blood sugar levels for manymonths or years usually experience unpleasant symptoms of hypoglycemia asblood sugars approach normal. Someone who has grownaccustomed to blood sugars consistently over 300 mg/dl may feel"shaky"at 100 mg/dl. In such a case, we might startwith 160 mg/dl asthe initial target.We'd then lowerthe targetto its ultimate value over aperiod ofweeks or months astreatment proceeds.

It's unusual when an initialmeal planand dosage of medication instantly result in the desired blood sugar profiles. Some people, a fewdays into their regimen, may find something objectionable, such asnot enough to eat for a certain meal.Because of this, it's often necessaryto experiment with a plan, making smallchanges basedupon personal preferences and blood sugar profiles.

Establishing a Treatment Plan 111

People tend to become discouraged if they cannot see rapid improvement, and so,where warranted, I try to make adjustments to theregimen everyfewdaysin order to demonstrate that our efforts are accomplishingpositiveresults.To this end, I ask patients to bring or tofaxto my officetheir blood sugar profilesabout one weekafter their final training visit, if initial treatment is by diet alone. If I've prescribedinsulin, I like to see profiles within a few days. I certainly try to makesure that no blood sugars are below70 mg/dl during this trial period.I ask all new patients to phone me at any time of the day or night ifthey experience a blood sugar under 70 or become confused abouttheir instructions. Additional repeat visitsor phone callsmay be necessary every few days or weeks, depending upon how rapidly bloodsugar profilesreach our ultimate target.

Many new patients come to my officefrom out of town, some traveling distances of thousands of miles. Clearly, frequent office visitswouldbe impractical in such cases. For thesepatients, I often schedulefollow-up "telephone visits" instead of office visits. Patients will faxtheir blood sugars to me on Glucograf III data sheets.

These subsequent office or telephone interactions enable me tofine-tune the original plan, and alsoto reinforce the training programby catchingany mistakesthat a patient may inadvertently make. Thisinteractivetraining is much more effective for patients than just reading a book or hearing a fewlectures.*

BEGINNING TREATMENT WITH YOUR

DOCTOR OR DIABETES EDUCATOR

Although the protocol will likelydiffer at every doctor's office, in thenext several pages, I'll try to give youan ideaof how things work at ourDiabetes Center. This way, you'll get a generalnotion of how a comprehensive diabetes treatment program should work.

In my experience, most patients will cooperate with a treatmentplan that shows them concrete results. Greatly improved blood sugars,weight normalization, halting or reversing diabetic complications,

* Nevertheless, I record my 4-6 hour training sessions for my patients and givethem the tapes.Readers of this book can purchaseCD recordingsof actual training sessionsat www.rx4betterhealth.com or (800) 798-6922.

112 BeforeYou Start

and a senseof improved overall health can go a long waytoward convincingan individual to stickwitha treatment program.

Much is written in the diabetes literature about the key role of patient "compliance." Treatmentfailures are often blamed upon "lack ofcompliance." I think it's unreasonable to expect anyone to complywith a treatment plan that explainslittleand, as in the caseof the standard ADA approach, isn't really effective and offers little incentive tocontinue. What we must do isset up a sensible,workableplan that youunderstand and agree with. When I work with my patients in theoffice, I don't just havemystaffhand them a photocopieddiet and expect automatic acceptance. This is something that has to be negotiated, worked out. Do you liketurnips? Great,we can probably fit theminto your diet, but I don't think I've ever eaten one in my life. Call it"physician compliance," but the point is that it's unreasonableto try toforce my personalpreferences on mypatients. Onlywhen one understands and agrees with the plan can we expectcooperation. For cooperation to continue,however, patientshaveto seepositive, rapid results.

Not all people are able to follow a given treatment plan. For example, someone who's been overeating carbohydrate for a lifetime mayfind it next to impossible to begin to followa restricted diet immediately,but we have waysaround this (see Chapter 13). Some absolutelyresist exercise. But for most people we are still able to develop a treatment plan that works. If, for example, someone whose blood sugarshould be controllable with diet and exercise refuses to exercise, I willinstead prescribe medication that lowersinsulin resistance.

YOUR FIRST FEW VISITS

When seeingnew patients, for those who livenearby,my preference isan introductory visit followed later by a series of treatment/trainingvisits lasting 2-3 hours each. The continuity of time is invaluable toshowing rapid results. However, most insurance companies don't liketo pay for lengthy office visits— especially for diabetes training —and so it may be necessaryto break down the initial workup and training into multiple brief visits. Although I don't like to, I may do thiswith local patients; but with patients who livea great distance from myoffice,it's simply not workable to have successive short visits.

At the first visit I always get a drop of fingertip blood to measure thepatient's baseline (initial) HgbA,c. As time goes on and the patient

Establishinga Treatment Plan 113

sticks with the program, the inevitable progression of reduced bloodsugar over the next few months can provide tremendous encouragement.

My preferred procedure for the first few days of treatment is tobreak down visits into three sessions.

Introductory VisitSince blood glucose profiles areso essential to formulatinga treatmentplan, prior to the introductory visit I usuallyask a new patient to procure blood glucosetesting supplies— Glucograf III data sheets andthe other supplies listed in Chapter 3.1 provide guidelines for bloodglucose self-monitoring (like those you haveseen in Chapter 4), andask the patient to learn how to use the equipment so that later,on thefirst treatment/training visit, I can look overone or two weeks' bloodglucose profiles. I alsomaygive the patienta coupleof largebottlessothat a 24-hour urine specimencan be collected for a subsequent visit.

First Treatment/Training VisitIf I haven't done so in the introductory visit, I take a medicalhistoryand begin a physical exam gearedtoward uncoveringlong-term compUcations of diabetes.For patients who havehad diabetes more thanabout five years, I inevitably find a good number of these long-termsequelae (aftereffects), some of whichmaybe reversed by blood sugarnormalization. The exam will include tests described in Chapter 2.Wecheck to ensure the patient has purchased the right supplies. If wehaven't done so already, we provide a supply list (Chapter 3) with appropriate items checked off.

We discuss plans for treatment of medical problems other thanblood glucose control. These may include conditions the patient alreadyknows about, but also anything uncovered by blood testing orby the physical exam. If the patient has already acquired suppliesandbegun measuring blood sugars,I reviewhis or her technique and correct it if necessary.

Second Treatment/Training VisitMany of my patients come from out of town, and so the second visitmaytakeplacethe dayafter the first. Forlocalpatients,however, it willbe approximately a week later.At this visit we finish the physical examination. We also recheck the patient's blood glucose measurementtechnique and his use of the Glucograf form.

114 Before You Start

If I feel that the patient should be taking insulin, I give instructionsfor insulin doses to be taken the night before and the morning of thethird visit. I also providetraining in self-injection (Chapter 16) to patients who haveneverinjectedbefore.For those who areveteran insulinusers, I evaluate self-injection techniqueand correct it if necessary. It'smy experience that most insulin-using patientshave previously beentaught improper techniques for filling syringes and injecting insulin.

To this visit the patient is expected to bring the blood sugardata heor she has collectedoverthe priorweek(s), together with a separatelistof what he/she eats on a typical day. This information enables me toestimateif the patientwill need medication for blood glucose controland tells me about foods the patient likes that might be included inour meal plans. The blood glucose profile also providesa snapshot ofthe patient's status before beginning the new treatment regimen. Wecan review this at a laterdate to evaluate progress. As with each of theother initialvisits,the bulk of our time willbe devoted to training.*

Most important, this is the visit where we negotiate the meal plan(see Chapter 11).

Third Treatment/Training VisitThis visit may take place anytime after the second.We ask the patientto come in fasting and to bring a 24-hour urine collection. At this visitI draw blood for baselinestudies and continue training. I alsoenter allthe "datato remember"at the top of a Glucograf datasheet (Chapter 5). I also use this visit to give verbal instructions and a printedhandout regarding foot care (seeAppendix D).

Patients to be treated with insulin may be kept fasting until supperon the day of this visit in orderto determine if the smallbasal dose oflong-acting insulin that was injected that morning is adequate tomaintain blood glucose at a fixed level. On this day, ifthe patient ariseswith a blood glucose above our target value, she'd have instructions totake atrialdose of fast-acting insulin to bring blood sugardown to thetarget value. If blood sugar on awakening isbelowthe target, she'duseglucose tablets to bringblood glucose up to target. By this means,weconfirm or correctmy estimation ofhow much a given amount of insulin or glucosewill loweror raise the individual'sblood sugar.

* My training program consists essentiallyof the material covered in this book.It's my hope that physicianswho have little time to educate patients will use thisbook to assist in that purpose.

Establishinga Treatment Plan 115

SETTING A BLOOD SUGAR TARGET

Whenever I talkabout blood sugars in thisbook,I'm referringto finger-stick, plasma blood glucose measurements. When I discuss "normal"blood sugar values, I am referring to those found in nonobese nondiabetics — and to those not taken within 3 hours of a high-carbohydrate meal.

In my experience, given the right blood sugar meter, these valueswill be almost exactly the same as you wouldget from plasma measurements of venous blood that your doctor would send to a clinicallaboratory. I've seen finger-stick blood sugars measured on hundredsof nondiabetic,nonobese adults (for example, salespeople who comeinto the office trying to sellme meters— I insist on demonstrations;*or the nondiabetic spouses, parents, or siblings of patients).It usuallyisabout 83mg/dl.In order to simplify, I round offand tellmypatientsthat a normal to shoot for is 85 mg/dl, no matter what age. I haven'thad the opportunity to test a great number of nondiabetic children,but the literatureshows that normalbloodsugars willbe about 85mg/dl, with the potential to be considerably lower.*

With respect to hemoglobin A,c, I have a sophisticated machine inmyoffice that I'vefound correlates almostexactly with measuresfromaclinical laboratory. I therefore check HgbAlc values onevery patientat everyroutine visit, and frequently on nondiabetic relatives. Essentially what I see is that nondiabetics who are notobese have HgbAlclevels in the rangeof 4.2-4.6 percent. I have a number of diabetic patients who, under treatment, now have HgbAlc readings aslow as4.2

*I usedto havesomefun withnondiabetic sales repswhentheycameinto theoffice selling bloodsugarmeters. They'd bedemonstrating a meter, which I wouldcompare to my own meter. I always used their blood because I've had enoughfinger sticks. I'd "guess" their blood sugar. I'd make a show of examining theirskin, then give them a number. It was always about the same, but they didn'tknow that. The number was 83 mg/dl. Inevitably I'd be within ±3 mg/dl.Youknow, of course, that I didn't have anyspecial powers — it wasjust that I'd seenso many random finger-stick readings from nondiabetics, I knew what numberthe nondiabeticwaslikelyto show.t A studypublishedin the New England Journal ofMedicine found that nondiabeticmen with fasting blood sugars of 87 mg/dl or morehad progressively increased risk of developing diabetes than those with values less than 81 mg/dl.Another study of about 2,000healthy men, published in Diabetes Care in January 1999, showedthat overa period of twenty-two yearsthe risk of cardiacdeathwas40 percentgreaterfor thosewith fasting bloodsugarsgreaterthan 85 mg/dl.

116 BeforeYou Start

percent. This is a considerable deviation from the ADA's recommendation of under 6 percent — with no intervention unless levelsexceed7 percent. In my opinion, this is yet another example of "the rape ofthe diabetic."

The ADA recommendation for "tight control" of blood sugars,from its Web site, is as follows:

Ideally,this means levels between 90 and 130mg/dl before mealsand less than 180two hours after starting a meal, with a glycatedhemoglobin level less than 7 percent.

The recommendations go on to state that tight control (what I advocate) "isn't for everyone," which I believe is nonsense. But the ADA'stight control as definedabove isn't verytight at all.I would call it "outof control."

CONVERTING HgbA,c TO BLOODSUGAR VALUES

Many years ago, I reviewed dozens ofHgbAlc values andthousands ofblood sugars from data sheets submitted by my patients and came upwitha formula forconverting HgbAlc to mean (average) bloodsugar.

Myformuladoesnot jibewith mostother formulas, perhapsbecauseothers haven't collectedblood sugars throughout the day running intothe hundreds or even thousands ofpatients covering4-month periods.Theformula isvery simple. An HgbA,c of5percent isequivalent to anaverage blood sugarreading of 100 mg/dl,and every1percent above5corresponds to an additional 40 mg/dl increase in blood sugars.So anHgbAlc of 7 percent would correspond to an average blood sugar of180mg/dl.

Theformula is, in myexperience, useless forHgbAlc values of lessthan 5 percent, and it may not work for average blood sugars greaterthan 300 mg/dl for the simple reason that for a new patient runningblood sugars greater than 300 mg/dl, we rapidly get them down intothe 100s or less. Such new patients don't come in bringing me hundreds of data points in the 300s for me to compute an accurate formula at these values— nor would I ask them to. Many may not bringme any prior blood sugar data on their initial visit.

In February 2002a study published in Diabetes Care reported a formula that is valid for average blood sugars over a much wider range

Establishinga Treatment Plan 117

than mine, includingvalues well above and below 100 mg/dl. It givesresults close to mine in the 100-200 mg/dl range. The formula is:mean plasma glucose =(35.6 x HgbAlc) - 77.3.

So how do we go about settinga target normal value given allthesenumbers? Let's take a look at a type 2 diabetic whose disease can becontrolled by diet and exercise. Here, we'll certainly shoot for bloodsugars of about 83 mg/dl before,during, and aftermeals. It will thenbe up to both me and the patientjointly— if hisblood sugars are, say,in the 90s — to decide whether we want to introduce medications to

further lower blood sugar. Many patients these days are hesitant totake any medication that's been approved by the FDA, despite manysuchmedications' beingquitebenign. If wehave atype 2 diabetic whorequires the insulin-sensitizing drugs like metformin or the thiazoli-dinediones, we certainly canshoot for a target blood sugar of 83mg/dlbefore, during, and after meals, and indeed, I will work with the patient to juggle the medications,usinglong- or short-actingversionsinorderto achieve that target.

Type 2 diabetics who require very small amounts of insulin (say,1-2 units perdose) are atvery lowrisk for hypoglycemia and will usuallyautomatically"turn off" the insulinthey makethemselvesifbloodsugars are too low.Such peopleare also goodcandidates foratarget of83 mg/dl.

When it comes to type 1diabetics, wherevirtuallyallof the neededinsulin is going to be injected, I increase the target to 90 mg/dl, eventhough we know that the mortalityrate — evenin the general, nondiabetic population— is slightly greater for those with fasting or postprandial blood sugars of 90 mg/dT than it is for those with bloodsugars of 83.If at all feasible without frequent hypoglycemic episodes,I will eventuallylower the target to 83 mg/dl. I now use 83 as a targetfor myself.

A targetmay imply corrections to get you to your target. As a rule,if you're a type 2, your blood sugar goes down eventually— maybequickly,maybe over many hours. If you'rea type 1 and injecting significantdosesof insulin, if you make a mistakeon your diet and yourblood sugargoes up, you have to inject additional,calibrated doses offast-acting insulin deliberately to bring down your blood sugar and, ifit's too low, take glucose tablets to raise it.

For a new patient in the very early stagesof type 2 diabetes, I mayseeboth hypo- and hyperglycemia. This is probablybecauseone oftheearly"lesions" of type 2 is difficulty in storing the insulin granules

118 BeforeYou Start

your body makes. So such a person would make insulin for a meal,then make more after the meal. A nondiabetic would store that addi

tional insulin as it's being made, but the early type 2 would releasesome or all of it into the bloodstream as it's generated, thereby bringing blood sugar too low. This explanationalsoaccounts for attenuated(diminished) phase I insulin response—just not having enough insulin stored to cover a meal adequately (another reason to follow alow-carbohydrate diet). Such an individual could experience bloodsugars in the 70sor even mid-60s from time to time, and these individualsmust carry glucose tabletswith them to bring blood sugarsupto their target, usually 83. They don't take injected insulin to bringblood sugar down if it goes too high when they make a mistake, because their bodies willdo that for them, probably faster than injectedinsulin would.

SETTING GOALS OF TREATMENT

On the third visit, it's generally appropriate to prepare a fist of treatment goals. Exactly what are we going to accomplish, how, and overwhat time frame? The patient and I discuss a list of goals to make surethat he or she understands and agrees. The following list is typical ofthe things I want to see any givenpatient accomplish. (Remember, thetraining I provide to my patients is the substance of this book, so ifyou don't entirelyunderstand allof thesegoals right now,don't be discouraged.Mark this chapter and comeback to it when you'vefinishedthe book. By then you should understand the whole philosophy ofmy approach and the goals will make sense. You may also by thattime have developed — if you haven't already— conscious goals ofyour own.)

• Normalization of blood glucose profiles.• Improvementor normalization of the following laboratory tests

that respond to blood glucosecontrol (Chapter 2):hemoglobin A1C thrombotic riskprofilered blood cellmagnesium renal profilelipid profile

• Attainment of idealweight (whereappropriate).• Full or partial reversal of diabeticcomplications, including pain

or numbness in feet, diabetes-related retinal or kidneyproblems,

Establishing a Treatment Plan 119

gastroparesis, cardiac autonomicneuropathy, neuropathic erectiledysfunction, postural hypotension, andsoon. If bloodsugarsare kept normal, someof these improvements willappear withinweeks to years, depending upon the particular problem and itsseverity.

• Reduction in frequency and severity of hypoglycemic episodes(where appropriate).

• Relief of chronic fatigue and short-term memory impairmentassociated with high blood sugars.

• Improvement or normalization of hypertension.• Reductionofdemandupon betacells. If C-peptideis present be

fore starting our program (that is, if the pancreas is producingmeasurable amounts of insulin), glucose tolerance should improve if a regimen is pursued that minimizes the demand uponthe beta cells. This is a very important goal. Remember that fortype 2 patients,smallsacrifices now can preventthe need for 5 ormore daily insulin doses down the road. Beta cell burnout (seepage99) can frequently be prevented.

• Increased strength,endurance, and feeling ofwell-being.

The patient may wish to add some personal goals. The doctorshould respect these if at all possible. For example, I have several patients who arewillingto do whateverI ask,providedI do not put themon insulin. I consider this a reasonable preliminary goal for some,even though it may increase the risk of beta cell burnout. After all, ifwe cannot enlist a patient'scooperation,we achievenothing.

PART TWO

Treatment

The Basic Food Groups

OR MUCH OF WHAT YOU'VE BEEN TAUGHT ABOUT

DIET IS PROBABLY WRONG

In Chapter 1 we discussed how diabetics and nondiabetics mightreactto a particularmeal. Herewe'll talk about how specifickindsof foods can affect your blood sugar.

A curious fact about diet, nutrition, and medication is that while we

can make accurate generalizations about how most of us will react toa particular diet or medical regimen, we cannot predict exactly howeach individual will reactto a given food or medication.

The foods we consume, once you take away the water and undi-gestible contents, canbe groupedinto threemajorcategories that provide calories or energy: protein, carbohydrate, and fat. (Alcohol alsoprovides calories, and will be discussed later in this chapter.) Seldomwill food from one of these groups containsolelyone type ofnutrient.Protein foods often contain fat; carbohydrate foods frequently containsome protein and some fat. The common foods that are virtually 100percent fat areoils,butter, some types of margarine, and lard.

Since our principal concern here is blood sugarcontrol, we'll concentrate on how these three major sources of calories affect bloodsugar. If you're a long-standing diabetic and have followed standardADAteachings foryears, you'll find that much ofwhat you'reabout toread is radically at odds with the ADA's dietary guidelines — and withgood reason, asyou'll soon learn.

When we eat, the digestive process breaks down the three majorfood groupsinto their buildingblocks. Thesebuildingblocks are thenabsorbed into the bloodstream and reassembled into the various

products our bodies need in order to function.

124 Treatment

PROTEIN

Proteins are constructed of building blocks called amino acids.Throughdigestion, dietary proteins are broken downby enzymes inthe digestive tract into their amino acid components. These aminoacids can then be reassembled not only into muscle, nerves, and vitalorgans, but also into hormones, enzymes, and neurochemicals. Theycan alsobe convertedto glucose, but veryslowly and inefficiently.

Weacquiredietaryprotein from a number of sources, but the foodsthat are richest in it — eggwhites, cheese, and meats (including fishand fowl) — contain virtually no carbohydrate. Protein is available insmaller amounts from vegetable sources such as legumes (beans),seeds, and nuts, which also contain fat and carbohydrate.*

Protein and carbohydrate are our two dietary sources of bloodsugar. Protein foods from animal sources are only about 20 percentprotein by weight (about 6 grams per ounce), the rest being fat, water,and/or undigestible "gristle." The liver(and to a lesserdegree,the kidneys and intestines), instructed by the hormone glucagon,* can veryslowly transform as much as 36 percent of these 6 grams per ounceinto glucose* — if bloodsugardescends too low, if serum insulin levels are inadequate, or if the body's other amino acid needs have beenmet. Neither carbohydrate nor fat can be transformed into protein.

In many respects— and going against the grain of a number ofthe medicalestablishment's accepted notions about diabeticsand protein — protein will become the most important part of your diet ifyou are going to control blood sugars, just as it was for our hunter-gatherer ancestors.

If you are a long-standingdiabeticand are frustrated with the careyou've received over the years, you haveprobably been conditioned to

* Phosphate, a by-product of protein digestion, requires calcium in order to beeliminated fromthebody—about 1gramofcalcium forevery 10ouncesof protein foods.If you don't eat much cheese, cream,milk (too high in carbohydrate),yogurt, or bones, all good sourcesof calcium, it would be wise to take a calciumsupplement. This will prevent slow loss of calcium from your bones. I recommend calcium in formulations supplemented with magnesium and vitamin D.+Andother so-called counterregulatory hormones, suchas Cortisol and growthhormone.

$Thisamounts to about 7.5percentof the totalweight of a protein food.Sayyoueat a 3-ounce (85 grams) hamburger, no bun, for lunch — the protein in it canslowlybe transformed by the liverinto no more than 6 grams of glucose.

TheBasicFood Groups 125

think that protein is more of a poison than sugarand is the causeofkidneydisease. I wasconditionedthe sameway— manyyears ago, asI mentioned, I had laboratory evidence of advanced proteinuria, signifyingpotentially fatal kidney disease — but in this case,the conventional wisdom is just a myth.

Nondiabetics who eat a lot of proteindon't getdiabetic kidneydisease. Diabetics with normal blood sugars don't get diabetic kidneydisease. High levels of dietaryprotein do not cause kidney disease indiabetics or anyone else. There is no higher incidence of kidney disease in the cattle-growing states of the United States, where manypeople eatbeefat virtually every meal, than thereis in the stateswherebeef is more expensive and consumed to a much lesser degree. Similarly, the incidence of kidney disease in vegetarians is the sameas theincidence ofkidneydisease in nonvegetarians. Itisthe high blood sugarlevels thatare unique to diabetes, and to a much lesser degree the highlevels ofinsulin required tocover high carbohydrate consumption (causinghypertension), thatcause the complications associated with diabetes.

FAT

The Big Fat LieCallit the BigFat Lie. Fathas, through no realfault of its own, becomethe great demon of the American dietary scene. It is no myth thatmore than half of Americans areoverweight, and the number of obeseAmericans is growing.

Current dietary recommendations from the government, andnearly every "reputable" organization with an opinion, are to eat nomore than 35 percentof calories as fat— which veryfew peoplecanmaintain— and therearesomerecommendations for evenlowerpercentages than that. The low-fat mania in our culture has spawned anincrease in sugar intake. All a candy or cookie has needed is the label"fat free" to send its sales through the roof. The fallacy that eatingfatwill make you fat is about as scientifically logical as saying that eatingtomatoes will turn you red.

This is the kind of fallacious thinking behind the prevailing "wisdom," which maintains that there is an unavoidable link between di

etary fat and high serum cholesterol. And that if you want to loseweight and reduce cholesterol, all you need to do is eat lots of carbohydrate, limit consumption of meat,and cut out fat as much as possi-

126 Treatment

ble. But many contemporary researchers exploring this phenomenonhavebegun to arrive at the conclusion that a high-carbohydrate diet,especially rich in fruit and grain products,is not so benign. In fact, ithasbeen shown — and it is my own observationin myself and in mypatients— that such a diet can increase body weight, increase bloodinsulin levels, and raise most cardiac risk factors.

In an unbiased, clearheaded, and award-winning article in the respected journal Science of March 30, 2001, the science writer GaryTaubes explores what he calls "The Soft Science of Dietary Fat." (A linkto the full text of this article is available at www.diabetes-book.com.)Taubescites the failure of the antifat crusadeto improve the health ofAmericans:

Since the early 1970s, for instance, Americans'average fat intake hasdropped from over40% oftotal calories to 34%;averageserum cholesterollevelshave dropped aswell

Meanwhile, obesity in America, which remained constantfrom the early 1960s through 1980, has surged upward sincethen — from 14% of the population to over 22%. Diabetes hasincreased apace. Both obesity and diabetes increase heart diseaserisk, which could explain why heart disease incidence is not decreasing. That this obesityepidemic occurred just asthe government began bombarding Americans with the low-fat messagesuggests the possibility... that low-fat diets might have unintended consequences — among them, weight gain. "Most of uswould have predictedthat ifwe can get the population to changeits fat intake, with its dense calories,* we would see a reduction in

weight," admits [Bill] Harlan [of the NIH]."Instead, we see theexact opposite."

I urge you to have alook at the article, which will giveyou a notionof the kinds of competing personal, economic, and political intereststhat go into the formulation of"scientific" guidelines.

The U.S. Centers for Disease Control and Prevention (CDC) released datain the year 2004 indicatingthat 66.4 percentofU.S.adultswere overweight and 32.2 percent were obese. Furthermore, the incidence of overweight in children and adolescents aged 2-19 years in-

*Contrary to traditional thinking,a studyrecently publishedin the Journal oftheAmerican College of Nutrition demonstrated that the metabolizable calories infats are about the same as in carbohydrates.

The Basic Food Groups

19JS 1902 1969 1976

Year

Fig 9-1. From 1955to 1990, even as thepercentage ofcalories consumed asfatdeclined, thepercentage ofoverweightAmericans increased by nearly half.

127

1983 1990

creased from 11 percent to 19 percent in the period 1988-94 through2003-04. These statisticsareoccurringeven though people areeatingless fat.

The advent of our agricultural society is comparatively recent inevolutionary terms — that is, it began only about 10,000 years ago.For the millions of years that preceded the constant availability ofgrain and the more recent year-round availability ofavarietyof fruitsand vegetables, our ancestors werehunters and atewhat was availableto them in the immediate environment, primarily meat, fish, somefowl, reptiles, and insects— food that was present year-round, andpredominantly protein and fat In warm weather, some may haveeaten fruits, nuts, and berries that were available locally in some regions and not deliberately bred for sweetness (agriculture didn't exist). If they stored fat in their bodies during warm periods, much ofthat fat was burned up during the winter.Although for the past twocenturies, fruit, grain, and vegetables have, in one form or another,been available to us in this country year-round, our collective foodsupply has historically been interrupted often by famine — in somecultures more than others. The history of the planet as best as we candetermineis one of feast (rarely) and famine, and suggests that faminewill strike again and again asit has in the last few decades in a varietyof places.

128 Treatment

Curiously, what todayseems in our society to be a genetic predisposition toward obesity functioned during the famines of prehistoryas an effective method of survival. Ironically, the ancestors of thosewho todayaremostat riskfor type2 diabetes were, during prehistory,not the sickand dying, but the survivors. If famine struck todayin theUnitedStates, guess whowould survive most easily? The samepeoplewho are most at riskfor type 2 diabetes. For those livingin a harsh environment wherethe availability of food is uncertain, bodies that storefat most efficiently when food is available (for example, by beinginsulin-resistant and cravingcarbohydrate,likemost type 2 diabetics)survive to reproduce.

If you give it some thought, it makes perfectsense: If a farmer wantsto fatten up his pigs or cows, he doesn't feed them meat or butter andeggs, he feeds them grain. If you want to fatten yourself up, just startloading up on bread, pasta, potatoes, cake, and cookies — all high-carbohydrate foods. If you want to hasten the fattening process, consume dietary fat with your carbohydrate. Indeed, two recent studiesshowed that dietaryfat, whenconsumed aspart ofa high-carbohydratediet, was converted to body fat. Fat consumed as part of a low-carbohydrate diet was metabolized,or burned off.

The Insulin/Fat Connection

The primary sourceof body fat for most Americans is not dietary fatbut carbohydrate, which is converted to blood sugar and then, with theaid of insulin, to fat by fat cells. Remember, insulin is our main fat-building hormone. Eat a plate of pasta.Your blood sugar will rise andyour insulin level (if you havetype 2 diabetes or are not diabetic) willalso rise in order to cover, or prevent, the jump in blood sugar. Allthebloodsugarthat isnot burnedasenergy or storedasglycogen isturnedinto fat. Soyou could, in theory, acquire more bodyfat from eatingahigh-carbohydrate "fat-free" dessert than youwouldfrom eatinga tender steaknicely marbledwithfat. Even the fat in the steakismore likelyto be stored if it is accompanied by bread, potatoes, corn, and so on.

The fatty-acid building blocks of fats can be metabolized (burned),stored,or converted by yourbody into other compounds, dependingon what it requires. Consequently, fat is always in fluxin the body,being stored, appearing in the blood, and being converted to energy.Theamount of triglycerides (the storage form of fat) in your bloodstreamat any giventime willbe determinedbyyour heredity, your levelof exercise, your blood sugar levels, your diet, your ratio of visceral (ab-

TheBasicFoodGroups 129

dominal) fat to lean body mass (muscle), and especially byyourrecentconsumption ofcarbohydrate. The slim and fit tend to be very sensitive(i.e., responsive) to insulin and have low serum levels not only oftriglycerides but insulin aswell. But even their triglyceride levels willincrease after a high-carbohydrate meal, as excess bloodsugar is converted to fat. The higher the ratioofabdominal fat (and, to a lesserdegree, total body fat) to lean body mass, the less sensitive to insulinyou'll tend to be. In the obese, triglycerides tend to be present at highlevels in the bloodstream all the time. (This is sometimes exaggeratedduring weight loss because fat is appearing in the bloodstream as itcomes out of storage to be converted into energy.) Not only are hightriglyceride levels a direct cause of insulin resistance, but they alsocontribute to fatty deposits on the walls of yourbloodvessels (atherosclerosis). Research demonstrates that if high concentrations oftriglycerides are injected into the blood supply of the liver of a well-conditioned athlete, someone very sensitive to insulin, she will become temporarily insulin-resistant. (The most important thing tonote here is that insulin resistance, as well as other risk factors for diabeticcomplications, canbe reversed by eating less carbohydrate, normalizing blood sugars, and slimming down, which we'll discuss ingreaterdetail later on.)

If you become overweight, you'll produce more insulin, becomeinsulin-resistant (which will require youto produce yetmoreinsulin),and becomeeven more overweight because you'llcreate more fat andstore more fat. You'll enterthe vicious circle depicted in Figure 1-1.

Consider that steak I mentioned earlier. Asyouknow,the body canconvert protein to blood sugar, but it does so at a very slow rate, andinefficiently. Serum insulinlevels derived from the phase II insulin response or even from insulin injected before a meal may thus be sufficient to preventablood sugar rise from proteinconsumption by itself.Dietary fat cannot be converted to blood sugar, and therefore itdoesn't cause seruminsulinlevels or requirements for injected insulinto increase. Say you eat a 6-ounce steak with no carbohydrate sidedish — this won't require much insulin to keep your blood sugarsteady, and the lower insulin level will cause only a small amount ofthe fat to be stored.

Now consider what would happen if you instead ate a "fat-free"dessertwith exactlythe samenumber ofcalories asthat steak.Your insulin level will jump dramatically in order to cover the sugar andstarches in the dessert. Remember, insulin is the fat-building and fat-

130 Treatment

storage hormone. Since it's dessert, youprobablywon'tbe going out torun a marathon after eating, so the largest portion of your newlycreatedblood sugar won't getburned. Instead much of it will be turnedinto fat and stored.

Interestingly enough,eating fat with carbohydrate canactually slowthe digestion of carbohydrate, so the jump in your blood sugar levelmight thereby be slowed. Thiswouldprobably be relatively effective ifyou're talking about eating a green salad with vinegar-and-oil dressing. But if you're eating aregular dessert, or abaked potato with yoursteak, the slowdown in digestion would not prevent blood sugar elevation in a diabetic.

Despite what the popular media would have us believe, fat is notevil. In fact, many researchers are becomingquite concernedabout thedangerous potential of "fatsubstitutes." Fat isabsolutely necessary forsurvival. Much of the brain is constructed from fatty acids.Withoutessential fatty acids — which, like essential amino acids, cannot bemanufactured by the body and must be eaten — you would die. Fatsubstitutes such as the FDA-approved olestra (sold under the brandname of Olean and present in such products as Frito-Lay WOW!potato chips) bring aboutthe specter of people trying to subsiston ano-fat diet, a diet that could kill them. (Olestra actuallyrobs the bodyof important fat-soluble vitamins and essential fatty acids. The FDAhas required that it contain additives of those vitamins. In test markets, some consumershavebeen made quite ill by the product, whileothers don't see any effect. I don't recommend it — it's at best completely unnecessary.)

Diabetics are affected disproportionately by diseases such as atherosclerosis. This has led to the long-standingmyth that diabetics haveabnormal lipid profiles because they eatmore fat than nondiabetics.*It was likewiseonce thought that dietary fat caused all the long-termcomplications of diabetes. For many years, this was taken asgospel bymost in the medicalcommunity. In truth, however, the high lipid profiles in many diabetics with uncontrolled blood sugar havenothing todo with the fatthey consume.Most diabetics consume very little fat —they've been conditioned to fear it. Highlipid profiles are a symptom

*Alipidprofile isthemeasuremenc ofcholesterol, HDL (good cholesterol), LDL(bad cholesterol), and triglyceride levels in the blood.Somephysicians now considerlipoprotein(a)to be an essential componentof the lipid profile. (See Chapter 2.)

TheBasic Food Groups 131

not of excess dietary fat, but of high blood sugars. Indeed, even inmost nondiabetics, the consumption of fat has little if anything to dowith their lipid profiles.

On the other hand, high consumption of carbohydrate, as we willdiscuss shortly, can cause "nondiabetics" to develop someof the complications usuallyassociated with diabetes.

When I was on a verylow fat, high-carbohydrate diet about fortyyears ago, I had high fasting triglycerides (usually over250mg/dl) andhigh serum cholesterol (usually over 300 mg/dl), and I developed anumber of vascular complications. When I went onto a very low carbohydrate dietand did not restrictmyfat,mylipidsplummeted.Now,in my midseventies, I have the lipidprofile of an Olympic athlete, apparently from eating a low-carbohydrate diet in order to normalizemyblood sugars. That I exercise regularly probably doesn't hurt mylipid profile, either— but I was also exercising when my lipid profilewas abnormal.

Dare your physician. Ask him or her if his or her lipid profile ona low-fat diet can remotely compare to mine, on a high-fat, low-carbohydrate diet:

• LDL— the "bad" cholesterol — 53 (below 100 is considerednormal)

• HDL — the "good" cholesterol— 118 (above 39 is considerednormal)

• Triglycerides— 45 (below 150 is considered normal)• Lipoprotein(a) — undetectable (below 30 is considered normal)

Contrary to popular myth,fat isnot a demon.It's the body'swayofstoring energy and maintaining essential organs such as the brain.Without essential fatty acids, your bodywouldcease to function.

CARBOHYDRATE

I've saved carbohydrate for last because it's the food group that adversely affects blood sugarmostprofoundly. Ifyou'relikemost diabetics— or virtually everyone who fives in an industrialized society —you probably eat a diet that's mostly carbohydrate. Grains. Fruit.Bread. Cake. Beans. Snack foods. Rice. Potatoes. Pasta. Breakfast ce

real. Bagels. Muffins. They look different, but dietarily speaking,they're essentiallythe same.

132 Treatment

If you are already obese, you know and I know that you crave—and consume — these foods and probablyavoid fats. As studies show,you would be betteroffeating the fat than the carbohydrate. Fat alonewill be burned off. A combinationof high-carbohydrate foods and fatwill foster fat storage.

It is, therefore, a myth that Americans areoverweight due to excessive fat consumption. Americans are fat largely because of sugar,starches, and other high-carbohydrate foods.

Accordingto statistics released by the U.S. Department of Agriculture, added sugar consumption hit an all-timehigh in 1999 (the lastyearforwhich statistics wereavailable), atawhopping 158 pounds perAmerican per year, an increase of 30 percentover 1983. The key wordhere is"added." This doesn't account for starches and sugars naturallypresent in food. According to a report from the Oregon Health SciencesUniversity, a 12-ounceStarbucksGrandeCaramelMocha drinkcontains 45 teaspoons of added sugar.

This increase in sugar consumption not coincidentallycorrespondswith the timing of recommendations to eat less fat. It was 1984 whenthe National Institutes of Health (NIH) began advising everyonewithin shouting distance to cut fat intake. It also corresponds quiteneatly with the creation of a whole new, multibillion-dollar industryin low- and nonfat foods, many of which areextremely high in sugar.Formore than ten years, the government had planned to issue areportonce and for alldamning fatasthe demon some scientistswere sure itwas. The problem was, researchers couldn't"reverse engineer"the actual data to make the science fit the assumption. Unfortunately, theprogram to indict fat was left to die aquiet death, and not so much asa press release wasissuedto say, "We were wrong." And so many of usstill don't know the truth. Theywerewrong.

No doubt the popular media have made you aware of the endlessprocession ofbooks and dietsand advertisements for foodsalltoutingthe valueof high"complexcarbohydrate" in the diet.Athletes"carbo-load"beforebig games or marathons. TV and radio commercials extolthe virtues of Brand X sports drink over BrandY because it containsmore "carbos."

As stunning as it sounds — and unbelievable, given the popularmedia's recent love affairwith a high "complex carbohydrate,"low-fatdiet — you can quite easily survive on a diet in which you would eatno carbohydrate. There are essential amino acids and essential fattyacids,but there is no such thing asan essentialcarbohydrate.Further-

TheBasicFoodGroups 133

more, by sticking to a diet that contains no carbohydrate but has highlevels of fat and protein, you can reduce your cardiac risk profile —serum cholesterol, triglycerides, lipoprotein(a), LDL, et cetera—though you'd deprive yourself of all the supposed "fun foods" that wecravemost.* We've allbeen trained to think that carbohydratesareourbest, most benign sourceof food, so how can this be?

What if I, a physician, told you, a diabetic, to eata diet that consistedof 60 percentsugar, 20 percent protein, and 20 percent fat? More thanlikely, you'd think I was insane.I'dthink I was insane,and I would nevermakethis suggestion to adiabetic (norwould I evenmake it to anondiabetic). But this is just the diet the ADA recommended to diabetics fordecades. On the surface, these recommendations seemed to make sense

because of kidney disease, heart disease, and our abnormal Upid profiles. But this is what is known assingle-avenue thinking. It seemed logical to insistthat dietaryintakeofproteinand fat be reduced,becausenoone had looked at elevated blood sugars and the high levels of insulinnecessary to bring them down asthe possible culprits.

So if you eat very little fat and protein, what's left to eat? Carbohydrate.

As I discovered in my yearsof experimentation on myself, and thenin my medical training and practice, the real dietary problem for diabetics is not only fast-acting carbohydratebut also large amounts ofanycarbohydrate. In eithercase, the result ishighblood sugars requiring largeamounts of insulin to try to contain them.

So what arecarbohydrates?The technical answer is that carbohydratesarechains of sugarmol

ecules. The carbohydrates we eat are mostly chains of glucose molecules. The shorter the chain, the sweeter the taste. Some chains are

longer and more complicated (hence,"simple" and "complex" carbohydrates), having many links and even branches.But simple or complex,carbohydrates arecomposed entirelyof sugar.

"Sugar?" you might ask,holding up a slice ofcoarse-ground,seven-grainbread."This is sugar?"

In a word, yes,at leastafter you digest it.With a number of important exceptions, carbohydrates, or foods

derived primarily from plant sources that are starches, grains, and

* You'd also be missing the vitamins and other nutrients contained in low-carbohydrate vegetables, so a zero-carbohydrate diet is not in my ball game.

134 Treatment

fruits, have the same ultimate effect on blood glucose levels that tablesugar does. (The ADA has recognized officially that, for example,bread is as fast-acting a carbohydrate as table sugar. But instead of issuingarecommendation against eating bread, its responsehasbeen tosaythat table sugaris thereforeokay,and canbe"exchanged"for othercarbohydrates. To me, this isnonsense.)Whether you eata pieceofthenuttiest whole-grain bread, drink a Coke, or have mashed potatoes,the effect on blood glucose levels is essentially the same— bloodsugar rises, fast, and in proportionto carbohydrate content.

As noted in the introduction to this chapter, the digestion processbreaks each of the major food groups down into its basic elements,and these elements arethen utilized by the body as needed. The basicelement of most carbohydrate foods is glucose. We usually think ofsimple carbohydrates as sugars and complex carbohydrates as fruitsand grains and vegetables. In reality, most fruit and grain products,and some vegetables, are what I prefer to talk about as"fast-acting"carbohydrates. Our saliva and digestive tractcontainenzymes that canrapidly chop the chains down into free glucose. We haven't the enzymes to break down some carbohydrates, such as cellulose, or "indigestible fiber." Still, our saliva canbreakstarches into the shorterchainson contact and then convert those into pure glucose.

Pasta,which is often made from durum wheat flour and water (butcan alsobe made from plainwhite flour and eggyolks, or other variants), has been touted as a dream food — particularly for runnerscarbo-loading before marathons — but it quickly becomes glucose,and can raiseblood sugarvery rapidly for diabetics.

In the type 2 diabetic with impaired phase I insulin response, ittakes hours for the phase II insulin to catch up with the postprandiallevels of glucose in the blood,and dayafter day, duringthat time, thehigh blood sugars can wreak havoc. In the diabetic who injects insulin, there is a tremendous amount of (rarely successful) guessworkinvolved in finding the proper dosage and timing of insulin to covera carbohydrate-heavy meal, and the injected insulin not only doesn'twork fast enough, it is highlyunpredictable when taken in large dosesin attempts to cover large amounts of carbohydrate (see Chapter 7,"The Laws of Small Numbers").

Some carbohydrate foods, like fruit, contain high levels of simple,fast-acting carbohydrates. Maltose and fructose — malt sugar andfruit sugar — for example, are slower-acting than sucrose — table orcane sugar— but they will cause the sameincrease in blood sugarlev-

TheBask FoodGroups 135

els. It may be the difference between nearlyinstant elevation and elevation in 2 hours, but the elevation is still high, and a lot of insulin isstill required to bring it into line. And, if the insulin is injected, there'sthe further problem of guesswork in timing and dosage. Despite theold admonition that an apple a day keeps the doctor away, I haven'thad fruit since 1970, and I am considerably healthier for it. Somewhole-plantvegetables, that is,those that come mostly from the stalksand leaves, are of value to the diabetic and nondiabetic alike because

they contain considerable amounts of vitamins, minerals, and othernutrients. (The recipe section of this book shows you a number oftastyand satisfying ways to work thesevegetables into your diet.)

As noted previously, most Americans who are obese are overweightnot because of dietary fat, but because of excessive dietary carbohydrate. Much of this obesity is due to "pigging out" on carbohydrate-richsnack foods or junk foods, or evenon supposedhealthy foodslikewhole-grain breadand pasta. It's my beliefthat this pigging out haslittle to do with hunger and nothing at all to do with being a pig.

I'm convinced that peoplewho crave carbohydrate have inheritedthis problem. To some extent,we all have a natural craving for carbohydrate — it makes us feel good. The more people overeat carbohydrates, the more they willbecome obese, evenif they exercise alot. Butcertain people have a natural, ovenvhelming desire for carbohydratethat doesn't correlate to hunger. These people in alllikelihood have agenetic predisposition toward carbohydrate craving, as well as a genetic predisposition towardinsulin resistance and diabetes. (See page185, "The Thrifty Genotype.") This craving can be reduced for manyby eliminating such foods from the diet and embarkingupon a low-carbohydrate diet.

In light of the above, you might guess that I advocate a no-carbohydrate diet. In fact, in the next chapter you'll discover that I include smallamounts of carbohydrate in my meal plan. Backin 1970,asI was still experimenting with blood sugarnormalization, I rememberedthat during the twentieth century a new vitamin had been discovered every fifteen years or so. While theremay be no such thing asan essentialcarbohydrate, it seemed reasonable to conclude that, sinceour prehistoric ancestors consumed some plants, plant foods mightwell contain essential nutrients that were not yet present in vitaminsupplements and had not even been discovered. I therefore addedsmall amounts of low-carbohydrate vegetables (not starchy or sweet)to my personal meal plan. All of a sudden I was eating salads and

136 Treatment

cooked vegetables instead of the bread, fruit, cereal, skim milk, andpastathat I had been eatingon my prior ADA diet. It took a while togetused to salads, but now I relish them. Only recently, in my lifetime,have phytochemicals (essential nutrients found in plant foods) beendiscovered. Phytochemicals are now incorporated into some vitaminpills, but research on the use of isolated phytochemicals is still in itsearly stages. You may haveheard of such phytochemical supplementsaslutein, lycopene,and so on. It would appear that many chemicals—large numbers of which are likelynot even known about yet — worktogether to provide beneficial effects. So at this point, it certainlymakes senseto eatlow-carbohydrate salads and vegetables. (Althoughfruits contain the same phytochemicalsasvegetables, they aretoo highin fast-acting carbohydrate to be part of a restricted-carbohydratediet, as the next chapterwill explain.)

SOME WORDS ABOUT ALCOHOL

Alcohol can provide calories, or energy, without directly raisingbloodsugar, but if you'rean insulin-dependent diabetic, you need to be cautious about drinking. Ethyl alcohol, which is the active ingredient inhard liquor, beer, and wine, has no direct effect on blood sugar becausethe body does not convert it into glucose. In the caseof distilledspirits and very dry wine, the alcohol generally isn't accompanied byenoughcarbohydrate to affect yourbloodsugar verymuch. For example, 100 proof gin has 83 calories per ounce.These extra calories canincrease your weight slightly, but not your blood sugar. Differentbeers— ales, stouts, and lagers — can have varying amounts of carbohydrate, which is slowenough in its actionthat if you figure it intoyour meal plan,it may not raise your blood sugar. Mixed drinks anddessert wines can be loaded with sugar, so they're best avoided. Exceptions would be a dry martini or mixed drinks that canbe made with asugar-free mixer, suchassugar-free tonicwater.

Ethyl alcohol, however, can indirectly lower the blood sugars ofsome diabetics if consumed at the time of a meal. It does this by partially paralyzing the liver and thereby inhibiting gluconeogenesis sothat it can't convert enough protein from the meal into glucose. Forthe average adult, this appears to be a significant effect with dosesgreater than 1.5 ouncesof distilled spirits, or one standard shot glass.If you havetwo 1.5-ounce servings ofginwith ameal,your liver's abil-

The Basic Food Groups 137

ity to convertproteininto glucose maybe impaired. If you're insulin-dependent andyourcalculation of howmuchinsulin you'll require tocover your meal is based on, say, two hot dogs, and those hot dogsdon't get 7.5 percent converted to glucose, the insulin you've injectedwill take yourblood sugar too low. You'll have hypoglycemia, or lowblood sugar.

The problem of hypoglycemia itself isarelatively simple matter tocorrect — you just eat some glucose and your blood sugar will rise.But this gets you into the kind of messy jerking up anddown of yourblood sugar thatcan cause problems. It's best if youcan avoid hypo-andhyperglycemia (high bloodsugar) entirely.

Anotherproblem with alcohol andhypoglycemia isthat if youconsume much alcohol, you'll have symptoms typical of both alcoholintoxication and hypoglycemia — light-headedness, confusion, andslurring of speech. Theonlyway you'll know thecause of your symptoms is if you've been monitoring your blood sugar throughout yourmeal. This isunlikely. So youcould find yourself thinking you've consumed too much alcohol when in fact your problem is dangerouslylowblood sugar. In such asituation, it wouldn't even occur to you tocheck your blood sugar. Remember, that earlyblood sugar-measuringdevice I gotwas developed in order to help emergency roomstaffs tellthe difference between unconscious alcoholics and unconscious diabetics. Don't make yourself an unconscious diabetic. A simple oversight could turn fatal.

Many of the symptoms of alcohol intoxication mimic those of ketoacidosis, or the extreme highbloodsugar andketone buildupin thebody that can result in diabetic coma. The great buildup of ketonescauses a diabetic's breath to have an aroma rather like that of someone

who's been drinking. If youdon't die of severe hypoglycemia, thenyoumighteasily dieof embarrassment when youcome to andyourfriendsare aghast and terrified that the emergency squad had to be called tobring you around.

In small amounts, alcohol isrelatively harmless — oneglass of drywine or beer with dinner — but if you're the type who can't limitdrinking, it's best to avoid it entirely. For thereasons already discussed,and contrary to the guidelines of the ADA, alcohol can be more benign between meals than it is at meals. One benevolent effect of alcohol is that it can enable some diabetics to consume one beer or onesmall bloody Mary (tomato juice mixed with an ounce and a half ofvodka)without raising blood sugar.

10

Diet Guidelines Essential to the

Treatment of All Diabetics

Research into creatingreplacement ceUs for burned-out insulin-producing pancreatic beta ceUs is so promising that it'stemptingto think of a"cure" not in terms of if but when.The

reaUty is,however, less rosy. There may one daybe a cure, but to putoff normalizing your blood sugars until then is simply to ignore thereaUty of your situation. If you're going to controlyour diabetes andget on with a normal life, youwiU have to change yourdiet, and thewhen is now. No matter how mild or severeyour diabetes, the key aspect of aU our treatmentplans for normalizing bloodsugars and preventingor reversing complications of diabetes is diet. In the terms ofthe Laws of SmaU Numbers, the singlelargest"input" you can controlis what you eat.

THE FUNDAMENTAL IMPORTANCE OF A

RESTRICTED-CARBOHYDRATE DIET

The next several pages may weU be the most difficult pages of thisbook for you to accept — as weU as some of the most important.They're fuU of the foods you're going to have to restrict or eliminatefrom your diet if you're going to normalize your blood sugars. Youmay see some ofyourfavorite foods onourNo-No Ust, but before youstop reading, keep in mind a few important things. First, toward theend of this chapter we discuss the foods you can safely eat. Second,whUe you wiU have to eliminate certain foods, there are some genuinely sugar-free and low-carbohydrate alternatives.

One purpose of blood glucose self-monitoring is to learn through

Diet Guidelines Essential to theTreatment ofAllDiabetics 139

yourblood sugar profiles how particular foods affectyou. Blood sugarself-monitoring is the ultimate measure of the effect foods have onyour blood sugar. If you don't beUeve what you'rereading here, checkyour blood sugars every 2 hours afterconsuming food you arecertainmust be benign. Over yearsofexamining profileslike the ones you wiUcreate, I've observed that some people are more tolerant of certainfoods than other people. For example, bread makes my own bloodsugar risevery rapidly. Yet one or two of my patientswith mUdtype 2diabetes eata sandwichof thin breadeverydaywith only minor problems. InevitablyI find this is related to delayed stomach-emptying (seeChapter 22). In any case, you should feel free to experiment with foodand then perform blood sugar readings. It's likely that for many diabetics most or aU of our restrictions wiU be necessary.

Patients often ask, "Can't I just take my medication and eat whatever I want?"It almost seems logical, and would be fine if it worked.But just takingyour medicationandeating whatever you want doesn'twork — because of the Laws of SmaU Numbers — so we have to find

something that does.Many diabetics canbe treatedwith diet alone,and if your disease is

relatively mUd, you could easUy faU into this category. Some patientswho havebeen using insulin or oral agents find that once on our dietthey no longer needblood sugar-lowering medication. But evenif yourequire insulin or other agents, diet wiU still constitute the most essential part of your treatment.

Think smaU inputs. You may recaU from prior chapters that — foreven the nuldest diabetic— the impairment or loss of phase I insulinresponsemakes normalizing blood sugars impossible for at leasta fewhours after a high-carbohydrate meal. Eating even smaU amounts offast-acting carbohydrate raises blood sugar so rapidly that anyremaining phase II insulin response cannotpromptlycompensate. This is trueif you're injectinginsulinor if you're still making your own insulin.

Any sensiblemeal plan for normalizing blood sugartakes this intoaccount and foUows these basic rules:

• First, eliminate aU foods that contain simple sugars. As youshould know by now — but it bearsrepeating— "simple sugar"does not mean just table sugar; that's why I prefer to caU themfast-acting carbohydrates. Breads and other starchy foods, suchas potatoes and grains, become glucose so rapidly that they cancause serious postprandial increases in blood sugar.

140 Treatment

• Second, limit your total carbohydrate intake to an amount thatwiU work with your injected insuUn or your body's remainingphase II insulin response, if any. In this way, you avoid a postprandial blood sugar increase, and avoid overworking any remaining insulin-producingbeta ceUs of your pancreas (researchhas demonstrated that beta ceU burnout can be slowed or halted

by normalizingblood sugars).• Third, stop eating when you no longer feel hungry, not when

you're stuffed. There'sno reason for you to leave the table hungry,but there's also no reason to be gluttonous. Remember theChinese restaurant effect (page97).

• FinaUy, for best results, foUow a predetermined meal plan (seenext chapter).

TESTING FOR STARCH

OR SUCROSE IN FOODS

Sometimes you'U find yourself at a restaurant, hotel, or receptionwhere you cannot predict if foods havesugar or flour in them. Yourwaiter probably has Uttle idea of what's in a givenrecipe,so don't evenask him; his response wiU likely be incorrect. I've found that the easiest way to make certain is to use the Clinistix or Diastix that shouldhave been checkedoff on your supplyUst (Chapter 3). These are manufactured to test urine for glucose. Weuse them to test food. If, for example, you want to determine if a soup or salad dressing containstable sugar (sucrose) or a saucecontainsflour, just put a smallamountin your mouth and mixit withyour saUva. Then spit a tinybit onto atest strip. Any color change indicates the presence of sugaror starch.SaUva is essential to this reactionbecause it contains an enzyme thatreleases glucose from sucrose (table sugar) or from flour in the food,permitting it to react with the chemicals in the test strip. This is how Ifound that one restaurant in my neighborhooduseslargeamounts ofsugar in its bouiUonwhUe another restaurant uses none.*

Solid foods can also be tested this way, but you must chew them

*I use this test on television to showthat even"wholegrain"breads,contrary toclaimsof the ADA, becomeinstant glucose when exposedto saliva.

Diet Guidelines Essential to theTreatment ofAllDiabetics 141

first The Ughtest color on the color chart label of the test strip container indicates a very low concentration of glucose. Any color palerthan this may be acceptable for foods consumed in small amounts.The Clinistix/Diastix method works on nearly aU the foods on ourNo-No Ust exceptmilk products,whichcontain lactose. It wiU alsonotreact with fructose (fruit sugar; alsopresent in some vegetables and inhoney). If in doubt, assume the worst.

NO-NO FOODS: ELIMINATING

SIMPLE SUGARS

Named beloware some of the common foods that contain simple sugars, which rapidly raise blood sugar or otherwise hinder blood sugarcontrol and should be eliminatedfrom your diet.AU grain products,forexample — fromthe flourin"sugar-free" cookies to pastato wheator non-wheat grain products except pure bran — are converted sorapidly into glucoseby the enzymes in saUva and further down in thedigestive tract that they are,as far as blood sugar is concerned,essentially no different than table sugar or even pure glucose. There areplenty of food products, however, that contain such tiny amounts ofsimple sugars that they wiU have a negUgible effect on your bloodsugar.One gram of carbohydratewillnot raiseblood sugar more than5 mg/dl for most diabetic adults (but considerably more for smallchildren). A single stick of chewing gum or a single tablespoon ofsalad dressing made with only 1 gram of sugar certainly poses noproblems. In these areas, you have to use your judgment and yourblood sugar profiles. If you're the type who, once you start chewinggum, has to have a new stick every30 minutes, then you should probably avoid chewing gum. If you have delayed stomach-emptying(Chapter 22), smaU amounts of "sugar-free" chewing gum may helpfaciUtate your digestion.

Powdered Artificial Sweeteners

At this writing, several artificial sweeteners are avaUable. They areavaUable from different manufacturers under different names, andsome, such as Equal and Sweet'n Low, can have brand names underwhich more than one form ofsweetener is sold. Here, to simpUfyyourshopping, are acceptable products currently and soon to be avaUable:

142 Treatment

saccharintablets or Uquid (Sweet'n Low)aspartame tablets (Equal, NutraSweet)*acesulfame-K (Sunett, The Sweet One)steviapowderor Uquid (stevia hasnot been approved in the

European Union)sucralose tablets (Splenda)neotame tablets — when avaUable (newlyapproved by the FDA)cyclamate tablets andUquid (not yet avaUable in the United States)

These are aU noncarbohydrate sweeteners that vary in their avaU-abiUty andcanbe usedto satisfy asweet tooth without significantly affecting blood sugars. But when sold in powdered form, under suchbrand names asSweet'n Low, Equal, The Sweet One, Sunett, Sugar Twin,Splenda, and others, these products usually contain a sugar to increasebulk, andwill rapidly raise blood sugar. They are aU orders of magnitude sweeter tasting than sugar. When you buy them in packets andpowdered form, with the exception of stevia, they usuaUy containabout 96 percent glucose or maltodextrin and about 4 percent artificial sweetener. If you read the "Nutrition Facts" label on granulatedSplenda, for example,it Usts, as such labels must, ingredientsin orderfrom most to least: dextrose (glucose), maltodextrin (a mixture ofsugars), and finally sucralose. Most powdered sweeteners are sold aslow-calorie and/or sugar-free sweeteners because they contain only 1gram of a sugar ascompared to 3 grams of sucrose in a similar paperpacket labeled"sugar." More suitable for diabetics are tablet sweeteners such as saccharin, cyclamate, and aspartame. As noted above, thesame brand name can denote multiple products: Equal is a powdercontaining 96 percent glucose andalso atablet containing aminuscule(acceptable) amount of lactose. Sweet'n Lowpowderis saccharin with96 percent glucose. Stevia powder and liquid (sold in health foodstores) contain no sugar ofany kind and only minute amounts of carbohydrate.

A new"natural artificial" sweetener, caUed tagatose (no brandnameasofthis writing), hasbeen approvedfor sale in the United States. Derived from milk, it'sclaimed to be 92percent assweetassugar, with no

* Many Websites falsely perpetuate the myth that aspartame is toxic because itsmetaboUsm produces the poison methanol. In reality, one 12-ouncecan of anaspartame-sweetened soft drink generates only Vis as much methanol as does aglassof milk.

Diet Guidelines Essential to the Treatment ofAllDiabetics 143

aftertaste and no effect on blood sugars. This last claim — that it hasno effect on blood sugars— remains to be seen.In many cases, what'stermed "no effect" or "negUgible effect" usuaUy has significantenougheffectto make blood sugar control difficult.

Another new artificial sweetener, neotame, is being sold as an additiveby the makers of NutraSweet. It is supposedly8,000times as sweetas table sugar. Its use as a food additiveshould pose no problems, butif it becomes avaUable to consumers as a powder, it wiU probably bemixed with a sugar as in the instances cited above.

Yet another new powdered sweetener, erythritol (Zsweet) is promoted as being 70 percent as sweetas table sugar,but to my taste it ismuch less sweet, so that a considerable amount must be used. Sinceerythritol is a sugar alcohol, it will raise diabeticblood sugars significantlywhen consumed by the tablespoon, as I found necessary.

So-Called Diet Foods and Sugar-Free FoodsBecauseU.S.food-labeling laws in the recent past have permitted andthus encouraged products to be caUed "sugar-free"if they do not contain common table sugar (sucrose), the mere substitution of anothersugar for sucrose has permitted the packagerto deceive the consumerlegaUy. Most so-caUed sugar-free products havebeen, for many years,fuU of sugars that may not promote tooth decay but most certainlywiU raise your blood sugar. If you'vebeen deceived, you're not alone.I've been in doctors' officesthat have candy dishes fuU of"sugar-free"hard candies for their diabetic patients! Sometimes the label wiU disclose the name of the substitute sugar.

Here is a partial list of some of the many sugars you can find in"sugar-free" foods.AU of these wiU raiseyour blood sugar.

carob honey saccharose

corn syrup lactose sorbitol

dextrin levulose sorghumdextrose maltodextrin treacle

dulcitol maltose turbinado

fructose mannitol xyUtolglucose mannose

molasses

xylose

Some, such as sorbitol and fructose, raise blood sugar more slowlythan glucosebut stiU too much and too rapidly to prevent a postprandial blood sugar rise in people with diabetes.

144 Treatment

Other "diet" foods contain either sugars that are alternates to sucrose, large amounts of rapid-acting carbohydrate, or both. Many ofthese foods (e.g., sugar-free cookies) are virtuaUy 100percent rapid-acting carbohydrate, usuaUy flour, so that evenif they wereto containnone of the above added sugars, consumption of a smaU quantitywould easUy causerapid blood sugarelevation.

There are exceptions:

• Most diet sodas — with some glaringexceptions,so always checknutrition labels and look for 0 under carbohydrate.* So-caUedsugar-freeSlice contains40 percent"natural fruit juice"

• Sugar-free JeU-0 brand gelatindesserts — the ready-to-eatvariety, not the powdered mix (see page 161)f

• DaVincibrand sugar-free syrups (seepage 159)

AU of these are made without sugar of any kind. These you need notrestrict. See"So What's Leftto Eat?"later in this chapter.

Candies, Including "Sugar-Free" BrandsA tiny "sugar-free" hard candy containing only 2Vi grams of sorbitolcan raise blood sugar almost 13 mg/dl. Ten of these can raise bloodsugar 125 mg/dl. Since sorbitol, for example, has only one-third thesweetening power of sucrose, the manufacturer uses three times asmuch to get the same effect. This wiU raise blood sugars three timesas much as, although more slowlythan, table sugar.

Honey and FructoseIn recentyearsa number of"authorities" have claimedthat honey andfructose (a sugar occurring in fruits, some vegetables, and honey) areuseful to diabetics because they are "natural sugars." WeU, glucose isthe most natural of the sugars, since it is present in aU plants and aUbut one known species of animal, and we already know what glucose

* Looking for 0 under carbohydrate may not tell you everything you want toknow.Alsolook in the Ust of ingredientsto see if the product contains any of thesugars Usted. If it does, checkyour blood sugarsafter drinking, if you choose todrink them, and see what effectthey haveon you.f Unfortunately, the manufacturers of sugar-free Jell-O brand gelatin recendystarted to add maltodextrin to the powderedversion. I expect that they will soonadd it also to the ready-to-eat version.A suitable substitute would be Knox un-flavored gelatinwith added liquid steviaand your choiceof Da Vincisugar-freesyrup or WaterSensations for flavoring.

Diet Guidelines Essentialto the TreatmentofAllDiabetics 145

can do to blood sugars. Fructose, which is sold as a powdered sweetener, is often derived from corn (a grain) and is a significantingredient in many food products (as in high-fructose corn syrup). Honeyand fructose, "natural" or not, wiU raise blood sugar far more rapidlythan either phase II insulin release, injected insulin, or oral hypoglycemic agents can bring it down. Just eat a fewgrams of honey orfructose and check your blood sugar every 15minutes. You wiU read-Uy prove that "authorities" can be wrong.

Desserts and Pastries

With the possible exception of products marked"carbohydrate— 0"on the nutrition label, virtuaUy every food commonly used fordesserts wiU raise blood sugar too much and too fast. This is not onlybecause of added sugar but also because flour, milk, and other components of desserts are veryhigh in rapid-actingcarbohydrate.

Bread and Crackers

One average sUce of white, rye, or whole grain bread contains 12 ormore grams carbohydrate.The"thin" or "lite"breads are usuaUy cut athalf the thickness of standard bread sUces and therefore contain half

the carbohydrate. So-caUed high-protein breads contain only a smaUpercentage of their calories as protein and are not significantly reduced in carbohydrateunless they are thinly cut. Brownbread, raisinbread, and corn bread aU contain as much or more fast-acting carbohydrate than rye, white, or whole wheat. Some diabetics with severegastroparesis (Chapter 22) can tolerate the inclusion of 1-2 sUces ofthin bread or a few crackers as part of their low-carbohydrate meallimits. Unfortunately, most of us experience very rapid increases ofblood sugar after eating even smaU amounts of such products (bread,crackers, cereals, pastryshells, et cetera) made from anygrain.This includes those made from less common grains, such as barley, kasha,oats, sorghum, and quinoa.

Rice and Pasta

Both pasta and wUd rice (which is actuaUy not a true variety of ricebut another grain entirely) are claimedby some nutrition authoritiesto raiseblood sugar quite slowly. Justcheckyour blood sugar levelsafter eating them and you'Uagain prove the "authorities" wrong. Alternatively, you might try the CUnistix/Diastix test described on pages140-141. Like wUd rice and pasta, white and brown rices also raise

146 Treatment

blood sugar quite rapidly for most of us and should be avoided. Thesame is true of rice cakes.

Breakfast Cereals

Most cold cereals, like snack foods,are virtuaUy 100percent carbohydrate, even those claiming to be "high protein." AdditionaUy, manycontain large amounts of added sugars. Since they are made fromgrain, smaU amounts, even of whole-grain cereals, wiU cause a rapidrise in blood sugar (according to the glycemic index,a measureof howrapidly foods are metabolized into glucose, brown rice actuaUy raisesblood sugar faster than white rice). Even bran flakes are mostlyflour.Ifyouhavebeeneatingbran flakes to improve bowel function,youcansubstitute verysmaU amounts (1 tablespoon) of psyUium husks powder,which is entirelyindigestible fiber. Useonly the sugar-freevarietyof MetamucU or other such products. (You can get the husks powderat a health food store and mix with water. If you don't care for the texture or taste, you can drink it mixed in diet soda.) You can also makeyour own cerealfrom pure bran.

Cooked cereals generaUy contain about 10-25 grams of fast-actingcarbohydrate per half-cup serving. I find that even smaU servingsmake blood sugar control impossible.

Snack Foods

These are the products in ceUophane bags that you find in vendingmachines and supermarkets.They include not just candy,cookies,andcakes, but pretzels, potato chips, taco chips, tiny crackers, and popcorn. These foods are virtuaUy 100 percent carbohydrate and frequentlyhaveaddedsucrose, glucose (the label maysaydextrose), cornsyrup, et cetera. Althoughsome nuts (e.g., macadamia) are relativelylow in carbohydrate, who can sit down and eat only six macadamianuts (about 1 gram of carbohydrate)? It's simpler just to avoid them.

So-Called Protein Bars

Although drugstore and grocery shelves are fuU of bars that claim tobe "protein bars,"most are reaUy nothing more than candy bars with"healthy" packaging. The FDA recently analyzed twenty differentbrands and found that aU but two contained much more carbohydratethan stated on the labels.These were removed from the marketplace,but many more remain. This is another case of when it sounds toogood to be true, it probablyis.

Diet GuidelinesEssential to the TreatmentofAll Diabetics 147

Milk and Cottage CheeseMilk contains a considerable amount of the simple sugar lactoseandwiU rapidly raise blood sugar. Skim mUk actuaUy contains more lactose per ounce than doeswholemilk.One or 2 teaspoonsof milk in acup of coffee wiU not significantly affect blood sugar, but lA cup ofmilk wiU make a considerable difference to most of us. Cream, whichyou have probably been instructed to avoid, is okay. One tablespoonhas only 0.5 gram of carbohydrate. Furthermore, it tastes much betterthan substitutes and has considerably more "lightening power." Thepowdered lighteners for coffee contain relatively rapid acting sugarsand shouldbe avoided if you usemorethan a teaspoonful at a time ordrink more than 1 cup of coffee at a meal. A coffee lightener worthconsidering is WestSoy brand soymilk, which is sold in health foodstoresthroughout the UnitedStates. Although several WestSoy flavorsare marketed,only the ones marked 100% Organic Unsweetened areunsweetened. It comes in plain and vanilla and usuaUy contains5 grams of carbohydrate in 8 ounces.Other unsweetened brands, suchasVitasoy and Yu Natural, areavaUable invarious partsof the country.One catch — soymilk curdles in very hot coffee or tea.

Cottage cheese also contains a considerable amount of lactose because, unlike most other cheeses (hard cheese, cream cheese), whichare okay, it is only partly fermented. I wasunaware of this untU severalpatients showed me records of substantial blood sugar increases afterconsuming a container of cottagecheese. It should be avoided exceptin very smaU amounts, sayabout 2 tablespoons.

Fruits and Fruit JuicesThese contain varying mixtures of simple sugars and more complexcarbohydrates, aU of whichwiU act dramatically on blood sugar levels,which you can prove with a few experiments with blood sugar measurements. Bitter-tasting fruits such as grapefruit and lemon containconsiderable amounts of simple sugars. They taste bitter because ofthe presence of bitter chemicals, not because sugar is absent. Orangejuice,which may be high in vitamin C, also contains about as muchsugar as a nondiet soft drink. Although eliminating fruit and fruitjuices from the diet can initiaUy be a bigsacrifice for manyof my patients, they usuaUy get used to this rapidly, and they appreciate the effect upon blood sugar control. I haven't eaten fruit in almost fortyyears, and I haven't suffered in anyrespect. Some peoplefear that they

148 Treatment

wiU lose important nutrients by eliminating fruit, but that shouldn'tbe a worry. Nutrients found in fruits are alsopresent in the vegetablesyou can safely eat.

In our society, wegeneraUy reserve the name"fruit"for sweetfruits,such as apples, oranges, and bananas, aU of which you should avoid.There are, however, a number of biological fruits (the part of certainplants that contains pulp and seeds) that are benign for the diabetic,such as summer squash,cucumbers (includingmany types of pickle),eggplant, beU and chUi peppers, and avocado. These tend to have largeamounts of ceUulose, an undigestible fiber, rather than fast-actingcarbohydrate. (It's worth noting that ceUulose, found in vegetablesand fruits, is essentially the same fiber that makes up much of theshady elm on the corner. It has undigestible caloriesyour body won'tmetaboUze becausewedon't havethe enzymesto break down the special ceUuose chains of sugarsinto digestible form.)

Vegetables

Beets. Likemost other sweet-tasting vegetables, beets are loaded withsugar.Sugarbeets are a sourceof table sugar.

Carrots. Aftercooking,carrots tastesweeter and appear to raisebloodsugar much more rapidly than when raw. This probably relates to thebreakdown of complex carbohydrates into simpler sugars by heat.Evenraw carrots should be avoided.If,however, you are served a saladwith a few carrot shavingson top for decoration, don't bother to remove them. The amount is insignificant, just like a teaspoon of milk.

Corn. Not a vegetable at aU but a grain, as noted above. NearlyaU ofthe corn grown in the United States is used for two main purposes.One is the production of sweeteners. Most of the sugar in Pepsi-Cola,for example, comes from corn. The other major purpose is animalfeed, e.g., fattening up hogs, cattle,and chickens. Corn for consumption by people,as a"vegetable" or as snackfoods,comesin third. Diabetics should avoid eating corn, whether popped, cooked, or inchips — even 1 gram of corn (a couple of kernels of popcorn) wiUrapidly raise my blood sugarby about 5 mg/dl.

Potatoes. For most diabetics, cooked potatoes raise blood sugar almost as fast as pure glucose, even though they may not taste sweet.

Diet Guidelines Essential to the Treatment ofAllDiabetics 149

Giving up potatoes is a big sacrifice for many people, but it wiU alsomake a big differencein your postprandial blood sugars.

Tomatoes, tomato paste, and tomato sauce. Tomatoes, as youknow, are actuaUy a fruit, not a vegetable, and as with citrus fruits,their tangcanconceal just howsweet theyare. Theprolonged cookingnecessary for the preparation of tomato sauces releases a lot of glucose, and you would do weU to avoid them. If you're at someone'shome for dinner and are served meat or fish covered with tomato

sauce, just scrape it off.The smaU amount that might remain shouldnot significantly affect your bloodsugar. If you are having them uncooked in salad, limit yourself to one sUce or a single cherry tomatoper cup of salad. (See page 394 for a recipe for a low-carbohydrate,tomato-free, ItaUan-style red sauce that can be good over, say, abroUed, sautied, or griUed chicken breast or veal scaUopine.) OnionsfaU into this same category— despitesomesharp flavor, they're quitesweet, some varieties sweeter than others. There are other vegetablesin the alUum famUy that canbe easUy substituted, although in smallerquantities,such as shallotsand elephantgarlic.

Commercially prepared soups. BeUeve it or not, most commercialsoups marketed in this country canbe asloadedwith added sugar as asoft drink. The taste of the sugar is frequently masked by other flavors — spices,herbs, and particularly salt.Evenif there were no addedsugar, the prolonged cooking of vegetables can break the special glucose bonds in the ceUulose of slow-acting carbohydrates, turningthem into glucose. As youknowfrom above, the amount of carbohydrateclaimed on the Nutrition Facts label canvaryconsiderably fromwhat's actuaUy in the can.Addto that the commoninclusion of potatoes,barley, corn, rice,and other unacceptable foods, and you haveaproduct that you should avoid. There are still somecommercial souppossibilities that fit into our scheme. See the corresponding headingon page 154.

Health foods. Of the hundreds of packaged food products that youseeon the shelves of the average healthfoodstore, perhaps 1 percentare low in carbohydrate. Many are sweetened, usuaUy with honey orother so-caUed natural sugars. Indeed, many so-caUed natural foodscanbeveryhighin carbohydrate. Since the healthfood industry shunsartificial (nonsugar) sweeteners like saccharin or aspartame, if a food

150 Treatment

tastes sweet, it probablycontains a sugar. There area few foods carriedby these stores that are unsweetened and low in carbohydrate. You'Ufind some of these Usted later in this chapter.

SO WHAT'S LEFT TO EAT?

It's agoodquestion, andthe same one I asked myselfnearly fortyyearsago as I discovered that more and more of the things that the American Diabetes Association hadbeen tellingme wereperfectly fineto eatmade blood sugar controlimpossible. In the foUowing pages, I'll giveyou abroad overview of the kinds of food my patients and I usuaUyeat. Please remember that with the exception of the no-calorie beverages (including seltzer water and mineral water with no addedcarbohydrate) and moderate portions of sugar-free JeU-O withoutmaltodextrin, there are no "freebies." VirtuaUy everything we eat wiUhave some effect upon blood sugar if enough is consumed.You maydiscover things I've neverheard of that havealmost no effect on yourblood sugar. If so, feel free to include them in your meal plan, butcheckyourbloodsugar every halfhour for a few hours before assuming that they arebenign.

VegetablesMost vegetables, other than thoseUsted in the No-No section, are acceptable. Acceptable vegetables include asparagus, avocado, broccoli,brussels sprouts,cabbage and sauerkraut, cauliflower, eggplant, onions(in smaU amounts), peppers (any color except yeUow), mushrooms,spinach, string beans, summersquash, andzucchini. Asarule ofthumb,% cup of whole cooked vegetables, Vi cup of diced or sUced cookedvegetable, lA cup mashed cooked vegetable, or 1 cup of mixed saladacts upon blood sugar asif it contains about6 grams of carbohydrate.Remember that cooked vegetables tend to raise blood sugar morerapidly than raw vegetables because the heat makes them more digestible and converts some of the ceUulose to sugar. GeneraUy, morecooked vegetables by weight wiU occupyless volume in a measuringcup, so a cup of cookedspinach wiU weigh considerably more than acup of uncooked. On yourself-measurements, note how your favoritevegetables affect your blood sugar. Raw or unmashed vegetables canpresent digestive problems to people with gastroparesis.

Of the foUowing cooked vegetables, eachactsupon blood sugar as

Diet Guidelines Essential to theTreatment ofAllDiabetics 151

if it containsabout 6 grams of carbohydrate in % cup (aU cooked except as noted):

artichoke hearts

asparagus

bamboo shoots

beet greensbeU peppers (green

and red only,noyeUow) (cookedor raw)

bok choy (Chinesecabbage)

broccoli

brusselssproutscabbagecelerycelery root (celeriac)

coUard greensdaikon radish

dandeUon greenseggplantendive

escarole

hearts of palmkohlrabi

mushrooms

mustard greensokra

patty pan squashpumpkinradicchio

rhubarb

sauerkraut

scaUions

snow peas

spaghetti squashspinachstring beanssummer squashturnip greensturnipswater chestnuts

watercress

zucchini

zucchini flowers

In addition to the above, you should keepthe foUowing in mind:

• Onions are high in carbohydrate and should only be used insmaU amounts for flavoring — smaU amounts of chives or shallots can pack a lot of flavor.

• One-halfsmaU avocado contains about 6 grams of carbohydrate.• One cup mixed green salad without carrots and with a single

slice of tomato or onion has about the same impact on bloodsugarsas6 grams of carbohydrate.

• One-quarter cup mashed pumpkin contains about 6 grams ofcarbohydrate. My own opinion is that without some flavoring,pumpkin tastes aboutas appetizing as Kleenex. Therefore I flavorit with much steviaand spice(cinnamon) and warm it to make itabit likepumpkin pie filling. (For othervegetables from this list,suchas turnips, assume that lA cup of the mashed productcontains 6 gramsof carbohydrate.)

Meat, Fish, Fowl, Seafood, and EggsThese are usuaUy themajor sources of calories in themeal plans of mypatients. The popular press is currently down on meatand eggs, butmy personal observations andrecent research impUcate carbohydrates

152 Treatment

No-No's in a Nutshell

Here is a concise Ust of foods to avoid that are discussed in this

chapter.You maywant to memorize it or copyit, as it is worthlearning.

Sweets and Sweeteners

• Powdered sweeteners (other than stevia)• Candies,especiaUy so-caUed sugar-freetypes• Honey and fructose• Most"diet"and "sugar-free" foods (except sugar-free

JeU-0 gelatin whenthe label doesn'tmention maltodextrin, and diet sodas that do not contain fruit juicesor Ust other carbohydrate on the label)

• Desserts (exceptJeU-0gelatinwithoutmaltodextrin — no more than xh cup per serving) andpastries: cakes, cookies, pies,tarts, et cetera

• Foods containing, as a significantingredient, productswhose names end in -olor -ose (dextrose,glucose, lactose, mannitol, mannose, sorbitol, sucrose, xylitol,xylose,et cetera),except ceUulose; also, corn syrup,molasses, maltodextrin, et cetera

Sweet or Starchy Vegetables• Beans:chili beans, chickpeas,lima beans, lentils, sweet

peas, et cetera (stringbeans, snowpeas, and beU andchiU peppers,whichare mostlyceUulose, are okay, asare verylimited amounts of manysoybeanproducts)

• Beets

• Carrots

• Corn

• Onions, exceptin smaU amounts• Packaged creamedspinach containingflour• Parsnips• Potatoes

Diet Guidelines Essentialto the TreatmentofAllDiabetics 153

• Cooked tomatoes, tomato paste, tomato sauce,andraw tomatoes except in smaU amounts

• Winter squash

Fruit and Juices

• AU fruits (exceptavocados)• AU juices (including tomato and vegetable juices—

exceptfor some people,in a smaU BloodyMary)

Certain Dairy Products• Milk

• Sweetened,flavored,and low-fat yogurts• Cottage cheese (except in very smaU amounts)• Powderedmilk substitutesand coffee Ughteners• Canned milk concentrate

Grains and Grain Products

• Wheat, rye,barley,corn, and lesser-known,"alternative"grains, such as kasha,quinoa, and sorghum

• White, brown, wUd rice, or rice cakes

• Pasta

• Breakfast cereal

• Pancakes and waffles

• Bread,crackers,and other flour products, including"whole grain" breads

Prepared Foods

• Most commerciaUy prepared soups• Most packaged"health foods"• Snack foods (virtuaUy anything that comes wrapped

in ceUophane, including nuts)• Balsamic vinegar (comparedto winevinegar, white

vinegar, or cider vinegar,balsamic contains considerable sugar)

154 Treatment

rather than dietaryfat in the heart disease and abnormal blood Upidprofiles of diabetics and even of nondiabetics. If you are frightenedofthese foods,you can restrict them, but deprivingyourself wiU be unlikely to buyyouanything. Appendix AdetaUs the current controversyand the shakyscience behind the present,faddish high-carbohydratedietary recommendations, and lays out my concerns and opinions.Eggyolks,by the way, are a major source of the nutrient lutein, whichis beneficial to the retina of the eye. Organic eggs contain largeamounts of omega-3 fattyacids, whichare good for your arteries.

Tofu, and Soybean Substitutes for Bacon, Sausage,Hamburger, Fish, Chicken, and SteakAbout half the calories in these products come from benevolentvegetable fats, and the balance from varying amounts of protein andslow-acting carbohydrate. They are easy to cook in a skiUet or microwave. Protein and carbohydrate content should be read from thelabels and counted in your meal plan. Their principal value is forpeople who are vegetarian or want to avoid red meat. Health foodstores stock many of these products. For the purpose of our mealplans, as described in the next chapter, remember to divide the gramsof protein listed on the packageby 6 in order to get"ounces" of protein(seepage 171).

Certain Commercially Prepared and Homemade SoupsAlthough most commercial and homemade soups contain largeamounts of simple sugars,you can learn how to buy or prepare low-or zero-carbohydratesoups (seesuggestions below).Manybut not aUpackaged bouillon preparationshave no added sugar and only smallamounts of carbohydrate.Checkthe labelsor use the Clinistix/Diastixtest, observing the special technique described on pages 140-141.Plain consomme' or broth in some restaurants may occasionaUy beprepared without sugar. Again, checkwith Clinistix/Diastix.

Homemade soups, cooked without vegetables, can be made verytasty if they are concentrated.You can achieve this by barelycoveringthe meat or chickenwith water whUe cooking,rather than fiUing theentire pot with water, as is the customaryprocedure.Alternatively, letthe stock cook down (reduce) so you get a more concentrated, flavorful soup. You can also use herbs and spices, aU of which have negligible amounts of carbohydrates, to enhance flavor. See "Mustard,Pepper, Salt, Spices, Herbs," page 160. Clam broth (not chowder) is

Diet Guidelines Essential to theTreatment ofAllDiabetics 155

usuaUyverylowin carbohydrate.In the UnitedStatesyou can alsobuyclam juices (not Clamato), which contain only about 2 grams of carbohydrate in 3 fluid ounces. CampbeU's canned beef bouiUon andconsomme' contain only 1gram carbohydrateper serving.CoUege Innbrand canned chickenbroth contains no carbohydrate.Most bouiUoncubesare also lowin carbohydrate; read the labels.

Cheese, Butter, Margarine, and CreamMostcheeses (other than cottagecheese) contain approximately equalamounts of protein and fat and smaU amounts of carbohydrate. Thecarbohydrateand the protein must be figured into the meal plan, as IwiU explain in Chapter 11. For people who want (unwisely) to avoidanimal fats, there are some special soybean cheeses (not very tasty).There's also hemp cheese, which I knownothing about. Cheese is anexceUent source of calcium. Every ounce of whole milk cheese contains approximately 1 gram carbohydrate, except cottage cheese,which contains more. GeneraUy speaking, where dairy products areconcerned, the lower the fat, the higher the sugar lactose, with skimmilkand "no fat"cheeses containing the most lactoseand the least fat,and butter containing no lactose and the most fat.

Neither butter nor magarine in myexperience wiU affect your bloodsugar significantly, and theyshouldn'tbe a problem as far asweight isconcerned if you're not consuminga lot of carbohydrate along withthem. Margarine and most vegetable oUs contain trans fatty acids,which are now considered unhealthy for the heart. Butter is now a"healthy"fat. Organiccoconut oU isperhaps the healthiest and tastiestoU for cooking and salads. Since it is soUd at room temperature, itshould be warmed sUghtly for salads. It can be found on the Internetand in health food stores. Onetablespoon of cream hasonly0.5gramcarbohydrate — it would take 8 tablespoons to raise my blood sugar20 mg/dl.

The cheese puffsI describe in the nextchapter (page178)are lowincarbohydrate and can be used instead of bread to make sandwiches.

Yogurt

Although personaUy I don't enjoyyogurt, many of my patients feeltheycannot survive without it. Forour purposesthe plain wholemilkyogurt, unflavored, unsweetened, and without fruit, is a reasonablefood. A fuU 8-ounce container of plain, Erivan brand, unflavoredwhole milk yogurt contains only 11 grams of carbohydrate and 2

156 Treatment

ounces of protein. You can even throw in some chopped vegetablesand not exceed the 12 grams of carbohydrate limit we suggest forlunch. Do not use nonfat yogurt. The carbohydrate goes up to 17grams per 8-ounce container.Yogurt can be flavored with cinnamon,with DaVincibrand sugar-free syrups,with bakingflavor extracts,orwith the powder from sugar-freeJeU-0 brand gelatin (if the packagedoesn't list maltodextrin as an ingredient) without affecting the carbohydratecontent. It canbesweetened with stevia Uquid or powderorwith Equal or Splenda tablets that have been dissolved in a smaUamount of hot water. Erivan brand yogurt is avaUable at health foodstores throughout the United States. If you read labels, you may findbrands simUarly low in carbohydrate in your supermarket; two suchbrands are Stonyfield Farm and BrownCow Farm. Always be sure touse only the whole-milk and not the low-fat products.

SoymilkThere are many soy products that can be used in our diet plan, andsoymilkis no exception. It's a satisfactory Ughtener for coffee and tea,and one of my patients adds a smaU amount to diet sodas. Othersdrink it as a beverage, either straight or with added flavoring such asthose mentioned for yogurt. PersonaUy, I find the taste too bland todrink without flavoring, and I much prefer cream dUuted with water.When used in smaU amounts (up to 2 tablespoons/1 ounce), soymilkneed not be figuredinto the meal plan. It wiU curdle if you put it intovery hot drinks.

As noted in the No-No foods section, of the many brands ofsoymilkon the market,WestSoy offers the onlyunsweetened ones I'vebeen able to find,although other unsweetened brands are avaUable invarious parts of the country.

Soybean FlourIf you or someone in your home is wiUing to try bakingwith soybeanflour, you wUl find a neat solutionto the pastry restriction.One ounceof full-fat soybean flour (about lA cup) contains about 7.5 grams ofslow-acting carbohydrate. You couldmakechicken pies,tuna pies,andevensugar-free JeU-0 piesor pumpkin pies.Justremember to includethe carbohydrate and protein contents in your meal plan.

Soybean flour usuaUy must be blended with egg to form a battersuitable for breads, cakes,and the like.Creating a blend that works re-

Diet Guidelines Essential to theTreatment ofAllDiabetics 157

quires either experience or experimentation. Some recipes using soyflour appear in Part Three, "YourDiabetic Cookbook."

Bran Crackers

Of the dozens of different crackers that I have seen in health food

storesand supermarkets, I havefound only three brands that are trulylow in carbohydrate.

• G/G Scandinavian Bran Crispbread, produced by G. GundersenLarvik A/S, Larvik, Norway (distributed in the United States byCel-Ent, Inc., Box 1173, Beaufort, SC 29901, phone [843] 525-1437). Each9-gram slice containsabout 3gramsof digestible carbohydrate.If this product isnot avaUable locaUy, you can order itdirectly from the importer. One case contains thirty 4-ouncepackages. They are also avaUable from Rosedale Pharmacy,(888) 796-3348.

• Bran-a-Crisp,produced by SaetreA/S, N1411, Kolbotn, Norway(distributed in the United States by Interbrands, Inc., 3300N.E.164thStreet,FF3, Ridgefield, WA 98642). Each8.3-gramcrackercontains about 4 gramsof digestible carbohydrate. Bran-a-Crispmay be ordered directly from Interbrands, Inc., by phone ore-maU if you cannot find it locaUy. Phone: (843) 524-9444;e-maU: sales@branacrisp.com; Web site: www.branacrisp.com; ororder from Rosedale Pharmacy.

• Wasa Fiber Rye. These crackers are avaUable in most supermarkets in the United States and in some other countries. One

crackercontainsabout 5 gramsof digestible carbohydrate. Manyof my patients feel that this is the tastiestof these three products.Do not use other Wasa products,as they contain more carbohydrate.

Although some people eat these without a spread, to me theytastelike cardboard. My preference is to enjoy them with chive-flavoredcream cheese or butter. Crumbling two G/G crispbreads into a bowland coveringthem with cream or cream diluted with water can createbran crackercereal. AddsomeEqual or Splenda tablets (dissolved in abit of hot water) or someUquid stevia sweetener and perhapsa bakingflavor extract (banana flavor, butter flavor, et cetera), or one of the DaVinci sugar-freesyrups.

If eaten in excessive amounts, bran crackers can cause diarrhea.

158 Treatment

They should be eaten with Uquid. They are not recommended forpeople with gastroparesis (delayed stomach-emptying),since the branfibers can form a plug that blocksthe outlet of the stomach. The carbohydrate in thesecrackers isveryslowto raiseblood sugar.They aregreatfor people whoneeda substitute for toast at breakfast.

Note: In the UnitedStates, labeling regulations requirethat fiberbeUsted as carbohydrate. Therearemanydifferent kindsof fiber, solubleand insoluble, digestible and undigestible, and so,because there is norequirement to distinguish in labeling between them, these listingscan complicate computation of carbohydrate content. Usethe carbohydrate amounts that I have listed above instead of thoselisted on thepackagelabels.

Toasted Nori

When my friend Kanji sent me a beautifuUy decorated canister fromJapan, I was mostimpressed andintrigued. You canimagine mydismaywhen I removed the coverand found seaweed. Mydismaywasonly temporary, however. I reluctandy opened one of the ceUophane envelopesand puUed out a tissue-thin sUce. Myfirst nibblewasquitea surprise—it was deUcious. When consumed in smaU amounts, I found, it had virtuaUy no effect upon blood sugar. Onceaddicted, I combedthe healthfood stores searching for more. Most of the seaweed I tried tastedlikesalty paper. EventuaUy, a patient explained to methat Kanji's seaweed isa special kind caUed toasted nori. It contains smaU amounts of additional ingredients that include soybeans, rice, barley, and red pepper. Itis avaUable at most health food stores,and is a very tasty snack. Fiveorsixpieces at a timehave hadno effect uponmybloodsugar. TheClinistix/Diastix test showed no glucose after chewing. A standardsUce usuaUy measures VA x V/i inches and weighs about 0.3 gram. Since theproduct contains about 40 percent carbohydrate, each strip wiU haveonly 0.12 gram carbohydrate. Larger sheets of toasted nori should beweighed in order to estimate their carbohydrate content.

Sweeteners: Saccharin, Aspartame, Stevia, Splenda,and CyclamateI carrya package of Equal (aspartame) tablets with me, particularlywhenI goout to eat. Cyclamate isnot currently avaUable in the UnitedStates, but maybe returning. Aspartame is destroyed by cooking andis much more costly than saccharin, which has a bitter aftertaste, butit wiU work for sweetening hot coffee or tea. I find that using one

Diet Guidelines Essential to the Treatment ofAllDiabetics 159

Vi-grain saccharin tablet for every Equal tablet rather than two saccharin tablets or two Equal tablets eliminates saccharin's aftertaste andkeeps costs down. Equal tablets are avaUable in most pharmacies andmany supermarkets. Although Equal tablets contain lactose, theamount is too small to affectblood sugar.

Acesulfame-K is a newartificial sweetener beingmarketed in tabletform outside the United States by Hoechst, AG, of Germany. It is notdegraded by cooking. It is added to some "sugar-free" foods in theUnited States under the brand name Sunett, and is combined withglucose in the packaged powder caUed TheSweet One,whichyou obviously should avoid. There are, however, some questions about itscausingcancer, so there maybe better choices. Other noncaloric tabletsweeteners wiU be appearing on groceryshelves in the United Statesinthe future. Stevia, mentioned earUer, is an herbal sweetener and hasbeenavaUable in health foodstores for manyyears. It is not degradedby cookingand is packaged in tablet, powder, and Uquid forms. TheUquid must be refrigerated to prevent spoiling. Stevia hasnot yetbeenapproved in the European Union because of fears that it may causecancer. Studies of this"possibUity" are under way.

Splenda (sucralose) tablets are avaUable now in some parts of theUnitedStates, overseas, and on the Internet. Theyare benign in spiteof containing minuteamountsof lactose. In powdered form,Splenda,like the others except stevia, isprincipaUy a mixture of sugars to provide bulk and should be avoided.

No-Cal Brand SyrupsThese artificiaUy sweetened liquidflavors aresoldbysomesupermarkets in the northeastUnited States. (They aredistributed by CadburyBeverages, Inc., Stamford, CT 06905-0800.) The avaUable flavors includestrawberry, raspberry, black cherry, chocolate, and pancake/waffle topping. This product contains no calories, no carbohydrate, noprotein,and no fat. It takes a bit of imagination to put it to good use.Forexample, I usedto spike mycoffee withthe chocolate flavor, or myteawithfruit flavors. I put the pancake/waffle topping on myeggs inthemorningafterheating it in a skiUet. In recent years, however, to mytaste, the chocolate flavor has deteriorated, so I no longeruse it.

Da Vinci Gourmet Sugar-Free SyrupsSimUar in concept to No-Cal syrups but in myopinionmuch tastier,this product is avaUable from several Web distributors, including

160 Treatment

www.davincigourmet.com, and from Rosedale Pharmacy. Da Vincicurrentlyproduces morethan fortyflavors. Internetprices rangefrom$7.49 to $8.95 for a 750 ml bottle. Flavors include banana, blueberry,caramel, cherry, chocolate, coconut, cookie dough, pancake, peanutbutter, and watermelon. I like to sometimes mix the toasted marsh-maUow syrup into my morning omelet. For a list of distributors,phoneDaVinci Gourmet, Ltd., at (800) 640-6779. Theproductiscertified kosher. Da Vincialso seUs syrups that are not sugar-free, so besure to specify sugar-free whenordering.

Water Sensations

Sweetened with sucralose and avaUable in several fruit flavors, thisflavorconcentrate is sold in boxesof foU packets,which makes it idealfor travel. It can be used to flavor water, seltzer, and yogurt and canbe added to tequUa to make a sugar-free margarita. For detaUs visitwww.watersensations.com or www.rx4betterhealth.com.

Flavor Extracts

There are numerous flavor extracts often used in baking that you canuse to make your food more exciting. They usuaUy can be found insmaU brown bottles in the bakingsupplyaisles of supermarkets. Readcarbohydrate content from the label. UsuaUy it's zero and thereforewon't affectyour blood sugar.

Mustard, Pepper, Salt, Spices, HerbsMost commercial mustards are made without sugar and contain es-sentiaUy no carbohydrate. This canreadUy be determined for a givenbrand by reading the label or by using the Clinistix/Diastix test. Pepper and salt have no effect uponblood sugar. Hypertensive individuals with proven salt sensitivity should, ofcourse, avoid salt andhighlysalted foods (seepage454).

Mostherbs and spices have verylowcarbohydrate content and areused in such smaU amounts that the amount of ingested carbohydratewiU be insignificant. Watch out, however, for certain combinationssuch as powdered cinnamon with sugar. Just read the labels. By theway, I mix powdered cinnamon with powdered stevia and creamcheese and eat it off the platewith bitesof smokedsalmon.

Low-Carbohydrate Salad DressingsMost salad dressings areloaded withsugars and other carbohydrates.The ideal dressing for someone who desires normal blood sugars

DietGuidelines Essential to the Treatment ofAllDiabetics 161

would therefore be oU and vinegar, perhaps with added spices, mustard, and foUowed by grated cheese or even real or soybacon bits.There arenowavaUable some commercial salad dressings withonly1gram carbohydrate per 2-tablespoon serving. This is low enough thatsuch a product can be worked into our meal plans. Be careful withmayonnaise. Mostbrands are labeled "carbohydrate — 0 grams," butmay contain up to 0.4 grams per tablespoon. This is not a lot, but itadds up if you eat large amounts. Some imitation mayonnaise products have 5grams ofcarbohydrate per2-tablespoon serving. I personaUy use coconut oU and vinegar on my salads, but I like to mix thevinegar with DaVinci sugar-free raspberry syrup.

Nuts

Although aU nuts contain carbohydrate (as weU as protein and fat),they usuaUy raise blood sugar slowly and can in smaU amounts beworked into meal plans. As with mostother foods, you wiU want tolook up yourfavorite nuts in one of the books listed in Chapter 3 inorder toobtain their carbohydrate content. Byway ofexample, 10 pistachio nuts (smaU, not jumbo) contain only 1 gram carbohydrate,whUe 10 cashew nuts contain 5grams ofcarbohydrate. Although a fewnuts may contain little carbohydrate, the catch is in the word "few."Very few ofuscan eatonly a few nuts. Infact, I don'thave a single patient who can count out a preplanned number of nuts, eat them, andthen stop. So unless you have unusual wiUpower, beware. Just avoidthemaltogether. Also beware of peanut butter, another deceptive addiction. One tablespoon of natural, unsweetened peanutbutter contains 3grams ofcarbohydrate, andwiU raise mybloodsugar 15 mg/dl.Imagine theeffect on blood sugar of downing 10 tablespoons.

Sugar-Free JeU-0 Brand GelatinThis is one of the few foods that in smaU amounts wiU have no effectupon bloodsugar if you get the kind that is indeed sugar-free. I havefound it to betruethat in my area "sugar-free" actuaUy contains somemaltodextrin, which is a mixture of sugars and wiU raise yourbloodsugar. The ready-to-eat variety in plastic cups does not thus far contain maltodextrin —or at least thatwhich I've found on mygrocery'sshelves. Check thelabels. Truly sugar-free JeU-O or other truly sugar-free brands ofgelatin are fine for snacks anddesserts. AVi-cup servingcontains no carbohydrate, no fat, and only1 gramof protein. Just remember not to eat so much that you feel stuffed (see "The Chinese

162 Treatment

Restaurant Effect," in Chapter 6). You can enhance the taste by pouring a littleheavycreamoveryour portion. One of my patients discovered that it becomeseventastier if you whip it in a blender with creamwhen it hascooled, justbeforeit sets. Of the manyflavors of sugar-freeJeU-0 that are avaUable, I likeapple, Hawanan pineapple, and watermelon. Unfortunately,very fewsupermarkets seem to carry the appleand Hawanan pineapple flavors, and I wonder if they stiU exist.

If the only"sugar-free" JeU-0 you can find contains maltodextrin,try adding some Uquid stevia and Da Vinci sugar-free syrup to Knoxunflavoredgelatinas a tasty substitute.

Sugar-Free Jell-0 PuddingsAvailable in chocolate, vaniUa, pistachio, and butterscotch flavors,these make a nice dessert treat. Unlike JeU-0 gelatin, they contain asmaU amount of carbohydrate (about 6 grams per serving), whichshould be counted in your meal plan. Instead of mixing the powderwith milk, use water or water plus cream. Every 2 tablespoons ofcream wUl add 1 gram of carbohydrate.

Chewing GumGum chewing can be a good substitute for snacking and can be ofvalue to people with gastroparesis becauseit stimulates salivation andsaUva contains substances that facUitate stomach-emptying. The carbohydrate content of one stick of chewing gum varies from about 1gram in a stickof sugar-free Trident or Orbit (tastes better) to about 7grams per piece for some Uquid-fiUed chewing gums. The 7-gramgum wiU rapidly raise mybloodsugarbyabout 35mg/dl. The carbohydrate content of a stick of chewing gum can usuaUy be found onthe package label. "Sugar-free" gums aU contain smaU amounts ofsugar— the primary ingredientof Trident"sugarless" gum issorbitol,a corn-basedsugaralcohol. It alsoincludes mannitol and aspartame.Isometimes use a chewing gum called XlearDent. It contains 0.72grams of the sugarxylitol perpiece. XyUtol isan antimetabolite (metabolicpoison) forbacteria and prevents tooth decay whenchewed regularly. It may be obtained by phoning (877) 599-5327 or on theInternet at www.xlear.com.

Very Low Carbohydrate DessertsPart Three of this book consistsof low-carbohydrate recipes,preparedand testedby chefs. It includeseasyrecipes for somelow-carbohydrate

Diet Guidelines Essential to theTreatment ofAllDiabetics 163

desserts that are truly delicious. Morelow-carb desserts can be foundin my book The Diabetes Diet, Little,Brown, 2005.

Coffee, Tea, Seltzer, Mineral Water, Club Soda, Diet SodasNone of these products should have significant effect upon bloodsugar. The coffee and tea may be sweetened with Uquid or powderedstevia, or with tablet sweeteners such as saccharin, cyclamate, sucralose (Splendatablets),steviatablets, and aspartame (Equaltablets).Remember to avoid the useof more than 2 teaspoons of cow's milk asaUghtener. Tryto usecream (which hasmuchless carbohydrate, tastesbetter,and goesmuch further). Readthe labels of "diet"sodas,as a fewbrands contain sugar in the form of fruit juices. Manyflavored mineralwaters, bottled "diet" teas, and seltzers also contain added carbohydrateor sugar, as do manypowdered beverages. Again, readthe labels.You can also try adding your flavor choice of Water Sensations or DaVinci sugar-free syrupsto seltzer to create your own diet soda.

Frozen Diet Soda PopsMany supermarkets and toy stores in the United States seU plasticmoldsfor making yourownicepops.If these arefilled with sugar-freesodas, youcancreate a tastysnack thathasno effect upon bloodsugar.Do not use the commerciaUy made"sugar-free" or "diet"icepops thatare displayed in supermarket freezers. They contain fruit juices andother sources of carbohydrate.

Alcohol, in Limited AmountsEthyl alcohol (distiUed spirits),aswediscussed on pages 136-137, hasno direct effect upon blood sugar. Moderate amounts, however, canhave a rapid effect upon the Uver, preventing the conversion of dietaryprotein to glucose. IfyouarefoUowing a regimen that includes insulinor a pancreas-stimulating oral hypoglycemic agent, you'redependentupon conversion of protein to glucose in order to maintain bloodsugar at safe levels. The effects of small amounts of alcohol (i.e., Wiouncesof spirits for a typical adult) are usuaUy negligible. Most conventional American beers (Ught lagers), in spiteof their carbohydratecontent, don't seem to affectblood sugar when only one can or bottleis consumed.Darker beers,such as ales, stouts, and porters, can contain considerably more carbohydrate, and since beer does not haveNutrition Factslabeling, findingthe true carbohydrate content can bedifficult. "Lite"beerswiU generaUy have the leastcarbohydrate.

164 Treatment

INCREASE YOUR AWARENESS OF

FOOD CONTENTS

Read Labels

VirtuaUy aU packaged foods bear labels that reveal something aboutthe contents. The FDA now requiresthat labelsof packagedfoods listthe amount of carbohydrate, protein, fat, and fiber in a serving. Besure, however, to note the sizeof the "serving." Sometimes the servingsize is so smaU that you wouldn't want to be bothered eating it.

Beware of labels that say"Ute," "Ught," "sugar-free,""dietetic," "diet,""reduced-calorie,""low-calorie," et cetera. Counts of calories are onlygoing to teU you so much, and "low fat" is going to teU you nothingabout carbohydratecontent."Fat-free" desserts maybe the most dangerous of aU. Even ifyou're losing weight, carbohydrate intakewiU impede your efforts much more than fat wiU (see Chapter 9). Forexample,I've found that it's impossible to put weighton veryslim patients foUowing low-carbohydrate dietsby givingthem 900extra calories a day in the form of 4 ounces of olive oU. Two recent studiessupport this — but only if carbohydrate is verylimited.They showedthat when carbohydrate is low, the fat is metaboUzed, not stored."Low-fat"and "fat-free"foods frequently but not always contain morecarbohydrate than the foodsthey replace. The onlywayyou can determine the carbohydrate content is to read the amount stated on the label. But even this can be deceptive.For example, one popular brand of"sugar-free" strawberry preserves has a label that states, "Carbohydrate — 0."Yet anyone can see the strawberries in the jar, and common sense would teU you that strawberries contain carbohydrate. Sodeceptive labeling occurs and, in my experience, is fairly prevalent inthe "diet" food industry.

Use Food Value Manuals

In Chapter 3,severalbooks are listed that show the carbohydrate contents of various foods. These manuals are recommended but not es

sential tools for creatingyour meal plan. The guidelinesand advicesetforth in Chapters 9-11 of this book, plus perhaps the recipes in PartThree and in TheDiabetes Diet, are aU you reaUy need to get started.

If you want the potential for considerable variety in your meals,getaU the books Usted in Chapter 3. The best of these is TheNutriBaseComplete Book ofFood Counts. Food Values ofPortions Commonly Used

Diet Guidelines Essential to the Treatment ofAllDiabetics 165

has been the dietitian's bible for more than fifty years. It is updatedeveryfewyears.Besure to use the index at the back to locate the foodsof interest. Notethat on every page in the mainsection, carbohydrateand fat content are listedin the samecolumn. The carbohydrate content of a food always appears below the fatcontent.Do not get the twoconfused. Also, be sure to note the portion sizein aU these books.

The USDA's nutrient database is a very handy resource and offers software for use on PCs and handheld PDA computers that wiUenableyou to find nutrition informationon just about any food youchoose. The Nutrient Data Laboratory home page can be found atwww.ars.usda.gov/main/site_main.htm?modecode=12354500.

VITAMIN AND MINERAL SUPPLEMENTS

It is common practice to prescribe supplementary vitaminsand minerals for diabetics. This is primarily because most diabetics havechronicaUy high blood sugars and therefore urinate a lot. Excessiveurinationcauses a loss of water-soluble vitamins and minerals. If youcankeep your bloodsugars lowenough to avoid spilling glucose intothe urine (you can test it with Clinistix/Diastix), and if you eat redmeat at least once or twice a week, and a variety of vegetables, youshould not require supplements. Note, however, that major dietarysources of B-complex vitamins include "fortified" or supplementedbreads and grains in the United States. If you're foUowing a low-carbohydrate diet and therefore exclude these from your meal plan,youshouldeat somebeansprouts,spinach, broccoli, brussels sprouts,or cauUflower eachday. Ifyoudo not like vegetables, youmight takeaB-complex capsule or a multivitamin/mineral capsule each day. Seepage 179 for a discussion of calcium supplementation for certainpeoplewho foUow high-fiber or high-protein dietsor usemetformin.

Supplemental vitamins and minerals shouldnot ordinarUy be usedin excess of the FDA's recommended daUy requirements. Large dosescan inhibit the body's synthesis of some vitamins and intestinal absorption of certain minerals. Large doses are also potentiaUy toxic.Doses of vitamin C in excess of 500 mg daUy may interfere with thechemical reaction on your blood sugar strips.Asa result,your bloodsugar readings can appear erroneously low. Large doses of vitamin Ccan actuaUy raiseblood sugar and evenimpair nerve function (as candoses of vitamin B-6 in excess of 200mg daUy). Vitamin E has been

166 Treatment

shown to reduce one of the destructive effects of high blood sugars(glycosylation of the body's proteins), in a dose-dependent fashion—up to 1,200 IU (international units) per day. It has recently beenshown to lower insulin resistance. I therefore recommend 400-1,200IU per day to a number of my patients.Besure to use the forms of vitamin E known as gamma tocopherol or mixed tocopherols, not thecommon alphatocopherol, whichcaninhibit the absorptionof essentialgamma tocopherol from foods andat high doses hasactuaUy beenshown to increase risk of cardiac death.

CHANGES IN BOWEL MOVEMENTS

Anewdiet oftenbringsabout changes in frequency and consistency ofbowelmovements. This is perfectly natural and should not cause concern unless youexperience discomfort. Increasing the fiber content ofmeals, as with salads,bran crackers, and soybean products, can causesofter and more frequent stools.More dietary protein can cause lessfrequent and harderstools. Calcium tablets can cause hard stools andconstipation, but this is usuaUy offset if they contain magnesium.Normal frequency of bowel movements can range from 3 times perdayto 3timesperweek. Ifyounotice anychanges in yourbowel habitsmore or lessthan these frequencies, discussthem with your physician.

HOW DO PEOPLE REACT TO

THE NEW DIET?

Mostof mypatientsinitiaUy feel somewhat deprived, but alsogratefulbecause they feel more alert and healthier. (See the chapter "Beforeand After" for reactions of some patients to the new diet.) I faU intothis category myself. Mymouth waters whenever I pass a bakeryshopand sniff the aroma of fresh bread,but I am also gratefulsimply to bealiveand sniffing.

11

Creating a Customized Meal Plan

Now that you have the essentials of what you should eat andwhat youshould avoid, it'stime to take you through thestepsof customizing a meal plan that wiU getyouon yourway to

blood sugar normalization.

A NOTE BEFORE YOU EMBARK

UPON THE DIET

If youfound yourself thinking asyou went through the No-No foodssection of the prior chapter that aU of this information goes againstconventional thinking — you're right. Nodoubtasyouembark uponameal and treatment plan to normalize your bloodsugars, weU-mean-ing but Ul-informed friends and relatives wiU urge you to try more"fun" foods, or toeat less fat andmore "complex" carbohydrates. I suggest thatyouread Appendix A, which provides some possible explanationsas to whyconventional wisdom mayhave taken a wrongturn.

GENERAL PRINCIPLES FOR TAILORINGA MEAL PLAN

If you useblood sugar-lowering medications such as insulin or oralagents, the first ruleof meal planning isdon't change yourdiet unlessyourphysician first reviews the new meal planand reduces yourmedications accordingly. Most diabetics who begin our low-carbohydratediet show animmediate anddramatic drop inpostprandial blood sugar

168 Treatment

levels, as compared to blood sugars on their prior,high-carbohydratediets. If at thesametimeyourmedications are not appropriatelyreduced, your bloodsugars candrop to dangerously low levels.

The initial mealplanshouldbe geared toward blood sugar control,and also toward keeping you contentwith what you eat. Sowith thosethingsin mind, if I were to sitdownwith you to"negotiate" yourmealplan, I wouldneedto have before me aGlucograf data sheet (Chapter 5) showing blood sugar profiles and blood sugar-lowering medications (if any) takenduring the preceding week. I also would ask fora Ust of what and when you eat on a typical day. This informationwouldgive me anidea of what youlike to eat andwhateffect particular doses of blood sugar-lowering medications have on your bloodsugars. I also must know your current weight and about any otherfactors — such as delayed stomach-emptying and medications forother ailments — that might affect your blood sugar. In negotiatingthe mealplan, I'd try wherever possible to incorporate foods you like.

We wiU discuss weight reduction in Chapter 12. Changes for thispurpose can be madeafter observing the effects of the initial diet for amonth or so.

If you've trieddieting to lose weight orto control yourbloodsugar,you may have foundthat simplycutting backon calories according topreprinted tables or fixed calculations can be frustrating andcanevenhavethe opposite effect. Say you have a supperthat's too smaU to satisfy you. Later you're so hungry you feel you must have a snack. Ifyou're likemost people, yoursnack wUl likely be snack food, abowlofcereal, or some fruit — that is,something loadedwith carbohydrate—so you end up with high blood sugars and more calories than youwould haveconsumed if you'd started with a sensible meal. My experience is that it's always best to start with a plan that aUows you to getup from the table feeUng comfortable but not stuffed.

If you've ever foUowed the oldADA"exchange" system for preparingdiabetic mealplans, you'U find thatkeeping track of grams of carbohydrate and ounces of protein food (we always estimate carbohydrate ingrams and protein foods in ounces) requires considerably less effortNot onlyisit easier thanthe exchange approach, it's moreeffective, because it places the focus on the nutrientsthatactuaUy affect blood sugar.

Since aU of my patients bringme glucose profiles, overthe years it hasnot been very difficult to develop guidelines for carbohydrate consumptionthatmakebloodsugar control relatively easywithout causingtoo great a feeling of deprivation, even for those tryingto lose weight.

Creatinga CustomizedMealPlan 169

Mybasicapproach in negotiating a mealplan is that I first set carbohydrate amountsforeachmeal. ThenI askmypatientto teU mehowmany ounces of protein we should add to make him/her feel satisfied.(I actuaUy show them plasticsamplesof protein foods of various sizes,to help them estimate amounts.) Forexample, I usuaUy advise patientsto restrict their carbohydrate intake to no more than 6 gramsof slow-acting carbohydrate at breakfast, 12 grams at lunch, and 12 grams atsupper.* Few peoplewouldbe wiUing to eatless than theseamounts ofcarbohydrate. (These guidelines also apply to chUdren.) There is nosuch thing as an essential carbohydrate for normaldevelopment, despite what the popular press might have you beUeve, but there mostcertainly are essential amino acids (protein) and essential fatty acids.As mentioned in Chapter9, the main reason I don't suggest that youavoid aU carbohydrate is that there are many constituents of vegetables — such as vitamins and minerals, but also manyother nonvita-min chemicals (phytochemicals) —that are only recently becomingunderstood but that are nonetheless crucial to diet and cannot be obtainedthroughconventional vitamin supplements. Thisisparticularlytrue for whole-plant and leaf varieties. FoUc acid — so-caUed becauseit isderived fromfoUage — isessential to aU mannerof development,but strictlyspeakingis neithervitamin nor mineral.

IdeaUy, yourblood sugar should be the same after eating as it wasbefore. If blood sugar increases by more than 10 mg/dl after a meal,evenif it eventuaUy drops to your targetvalue, either the meal contentshould be changed or blood sugar-lowering medications should beusedbefore you eat.Contrary to ADA guidelines, it has recently beenshown that postprandial, or after-meal, blood sugars are more likelythan fasting bloodsugars to cause cardiovascular damage.

SLOW-ACTING CARBOHYDRATE

Distinctions are often made between "complex" and "simple" carbohydrates, with foods suchasmultigrain breads or pastatouted as"fuUof complex carbohydrates." This is essentiaUy a meaningless distinc-

* It'snot at aU necessary to consume carbohydrate of any type for breakfast. Ifyoudo,theonlykindI recommend isin theform ofacceptable vegetables (whichcan work well in, for example,an omelet) or the bran crackersmentioned in theprevious chapter.

170 Treatment

tion, if not a fooUsh one. There are fast-acting carbohydrates —starches and sugars that break down rapidly and have a consequentrapid effect on blood sugars — and there are slow-acting carbohydrates. GeneraUy, slow-acting carbohydrate comes from whole-plantvegetables (andothers listed on page 151). They are predominantly indigestible fiber accompanied by some smaU amount of digestible carbohydrate and vitamins, minerals, and other compounds, but haverelatively Uttle effect on blood sugars.

The foods in the foUowing Ust areslow-actingcarbohydrate foods.These can constitute the buUdingblocks of the carbohydrate portionofeachmeal.Ofcourseyou needn't limit your foods to these — manyother such buUding blocks can be created. Read labels on packagedfoods, consult nutrition tables for carbohydrate values of foods youlike, checkyourbloodsugars, and find out which foods work for you.

Equivalent in blood sugar effect to approximately 6 grams ofcarbohydrateper serving

• 6 Worthington Stripples or Morningstar Farms Breakfast Strips(meatless soybacon) (also contains 1ounce protein)

• 3 Morningstar Farms Breakfast Links (meatless soy sausage)(also contains 2 ounces protein)

• Vh Bran-a-Crisp crackers• 2 G/G crispbreads• 1Wasa Fiber Rye cracker• 4!/2 ounces Brown Cow Farmor Stonyfield Farmwhole-milk un

flavored yogurt (8 ounces contains 11 grams carbohydrate and 1ounce protein)

• 1cup mixed salad with oU-and-vinegar (not balsamic) dressing• % cup cooked whole slow-acting carbohydrate vegetable (or lA

cup mashed or Vi cup slicedor diced) from list on page 151• 1 serving Jett-0 sugar-free pudding made with water or water

and 1 tablespoon cream• Vi medium avocado (3 ounces)

Equivalent in blood sugar effect toapproximately 12grams ofcarbohydrate per serving

• 1cup mixed salad with oU-and-vinegar (not balsamic) dressing,plus% cup cooked wholevegetable (or V4 cup mashedor Vi cupsliced or diced) from list on page 151

Creatinga CustomizedMealPlan 171

• 1 cup mixed salad prepared with 4 tablespoons packaged dressing (if each tablespoon contains 1.5 grams of carbohydrate)

• 8 ounces BrownCow Farm or StonyfieldFarm whole milk unflavored yogurt (contains 11 grams of carbohydrate plus 2 ouncesprotein)

These Usts sUghtly exaggerate the carbohydrate content of salad andcooked vegetables, but because of their bulk and the Chinese restaurant effect, the net effect upon blood sugaris approximately equivalent to the amounts of carbohydrate shown. To this slow-actingcarbohydrate, we'd add an amount of protein that, in your initialopinion, would aUow you to leave the table feeling comfortable butnot stuffed.

PROTEIN

Aswith carbohydrate, it isnecessary to keepthe sizeofthe protein portion at a particular meal constant from one day to the next, so if youeat 6 ounces at lunch one day, you should have 6 ounces at lunch thenext. This is especiaUy important ifyou'retakingblood sugar-loweringmedications. If you're using tables of food values and need to convertgrams of protein to ounces of a protein food, keep in mind that forthese meal plans, 6 grams of protein is the equivalent of 1 ounce ofan uncooked protein food. To estimate by eye, a portion the size of adeck of playingcards weighsabout 3 ounces (red meats weigh about3.7 ounces because of their greater density).

In order to maintain muscle mass,most people should consume atleast 1-1.2 gramsof protein per ldlogram of idealbody weight.*Athleteswitt requireconsiderably more, aswiU growing chUdren.

Protein foods with virtually no carbohydrate

• Beef, lamb, veal

• Chicken, turkey, duck• Eggs• Most cold cuts (bologna, salami, et cetera)• Fish and shellfish (fresh or canned)

* This would amount to 11.5-14 ounces of protein daily for a nonathletic individual whose ideal body weight is 155pounds.

172 Treatment

• Most frankfurters

• Pork (ham, chops,bacon, et cetera)• Most sausages

Proteinfoods with a smallamount ofcarbohydrate(1 gramcarbohydrateper ounceofprotein)

• Cheeses (other than cottagecheese and feta cheese); the gram ofcarbohydrateper ouncefound in most cheeses should usuaUy beincluded when computing the carbohydrate portion of a meal

Soyproducts (up to 6 gramscarbohydrate per ounceofprotein —checknutrition label on package)

• Veggie burgers• Tofu

• Meatless bacon

• Meatless sausage• Other soysubstitutes (for fish, chicken, and so on)

If you have a rare disorder caUed famUial dyslipidemia, where dietary fat actuaUy can increase LDL, restrictions on certain types ofdietary fats contained in some protein foods may be appropriate.

THE TIMING OF MEALS AND SNACKS

Mealsneed not foUow a rigidlyfixed time schedule,provided, in mostcases, that you do not begin eatingwithin 4 hours of the end of theprior meal. This is so the effect of the first meal upon blood sugarwon't significantly overlap that of the next meal.For those who injectinsulin before meals, it's very important that meals be separated by atleast 5 hours ifyou want to correctelevated blood sugarsbeforeeating(seeChapter 19).This isalsoideaUy but not always true of snackscovered by insulin.

Snacks are permitted for some diabetics but certainly not required.The carbohydrate content of snacksmay dupUcate but should not exceed that aUocated for lunch or supper. So if you ate lunch at noon,you might tolerate a snack that didn't exceed 12 grams of carbohydrate at about 4 p.m. You would then eat supper at about 8 p.m. Snacksare discussed in greater detaU later in the chapter.

Creatinga CustomizedMealPlan 173

If you do not take insulin, you need not be restricted to only threedaUy meals if you prefer four or more low-carbohydrate meals on aregularbasis. The timing,again, should ideaUy be at least4 hours afterthe end of the prior meal or snack.For most type 2 diabetics,it may beeasier to control blood sugar,with or without medication, after eatingseveral smaUer meals than aftereatingonlyone or two largemeals.

Remember that there are no diabetes-relatedprohibitions on coffeeand tea, either plain or with limited cream (not milk) and/or tablet(not powdered, except for stevia) sweeteners.*

Now, let's attempt to translate our guidelines into some practicalexamples.

BREAKFAST

With or without blood sugar-lowering medications it is usuaUy moredifficult to prevent a blood sugar rise after breakfast than after othermeals. Therefore, for the reasons discussed under "The Dawn Phe

nomenon" in Chapter 6,1 usuaUy suggest half as much carbohydrateat breakfast as at other meals. Your body wiU probably not respondas weU to either the insulin it makes or to injected insulin for about3 hours after you get up in the morning because of the dawn phenomenon.

It is wise to eat breakfast every day, especiaUy if you're overweight.In my experience,most obese people havea history of either skippingor eating very httle breakfast. They then become hungry later in thedayand overeat. Nevertheless, for most of us, any meal can be skippedwithout adverse outcomes, provided, of course, that insulin or anyother blood sugar-lowering medication taken specifically to coverthat meal is also skipped.

A typical breakfast on our meal plan would include up to 6 gramscarbohydrate and an amount of protein to be determined initiaUy byyou. There are numerous possible sources of appetizing ideas for thecarbohydrate portion of your breakfast. The best place to start is withwhat you currently eat, as long as it's not on the No-No list (seepages152-153).You can also sample recipes from Part Three or from mybook The Diabetes Diet. You can experiment with foods in the "So

* Remember that 10cups of coffee, each with 2 tablespoons cream, can raise theblood sugar of a 140-pound type 1 diabetic by 50 mg/dl.

174 Treatment

What's Left to Eat?" section, on pages 150-163. There are many soybean products, such as the foods mentioned on page 154. Despite restrictions, with aUttle creativity you can findanynumber of satisfyingthings to have for breakfast.

Suppose that, like many of my new patients, you'vebeen eating forbreakfasta bagelloadedwith creamcheese and 2 cups of coffee withskim milk and Sweet'n Low powdered sweetener (totaling about 40grams of rapid-acting carbohydrates altogether). As we negotiate, Imight propose that you substitute other sweeteners for the Sweet'nLow and 1 ounce WestSoy soymilk (0.5 gram carbohydrate) for theskim milk in each cup of coffee (or use cream). Then I'd recommendthat instead ofabagel you eata Bran-a-Crisp cracker (4 grams carbohydrate) with 1 ounce of cream cheese (1 gram carbohydrate plus 1ounce protein). This adds up to about 6 grams of carbohydrate. Fi-naUy, I'd suggest that you adda protein food to your mealto make upfor the calories and"filling power" that disappeared with the bagel.

Let's sayyou decide you'U eat eggs for breakfast (or egg whites orEgg Beaters, although for most of us on alow-carbohydrate regimen,neither ofthese is necessary for cholesterol control).I'd askhow manyeggs it would take to make you feel satisfied after giving up the bagel.You might want to makea vegetable omelet instead of eating one ofthe carbohydrate foods mentioned above. If you're unnecessarUyafraid of egg yolks, you might use organic eggs or eggwhites. If youfind egg whites bland, you could add spices, or soy or Tabasco sauce,or some mushrooms or a smaU amount of onion or cheese, or chUi

powder, or even cinnamon with stevia, to enhance the taste. One ofmy current personal favorites for flavoring isa"chUi sauce" made fromBetter Than BouiUon ChUi Base. This packs a nice chUi punch withveryUttle carbohydrate (according to the label, 1gram ofcarbohydrateper 2 teaspoons), and works quite weU on eggs or other foods, depending on your tastes. (I like to make chUi burgers with it — whichyoucouldcertainly have for breakfast.) This product, akind of mushypaste, comes in a smaU glass jar atmost supermarkets or from Superior QuaUty Foods, 2355 E. Francis St., Ontario, CA 91761 (e-maU:service@superiortouch.com; on theWebatwww.superiortouch.com).

Some years ago, I tried to help my patients who felt they had to havecold cereal include a smaU amount in their breakfast meal plan, butblood glucose profiles showed consistently that this just didn't work.Grain products, with the exception of the bran products I've mentioned, contain too much fast-acting carbohydrateto aUow us to keep

Creating a Customized MealPlan 175

blood sugarunder control, and so we'vehad to eliminate breakfastcerealsentirely.An alternativemight be the bran crackercerealdescribedon page 157.

The good news is that there are lots of other tasty, filling thingsto eat.

If you don't want eggs, you might try some smoked fish, tuna fish,or even a hamburger. I have one patient who eats two hot dogs forbreakfast — her favorite food. The quantity of fish or hamburgerwould be up to you, but it would have to be kept constant from oneday to the next. You can either weigh the protein portion on a foodscale or estimate it by eye.The rule of thumb is, again, that a portionof poultry or fish the size of a standard deck of playing cards wiUweigh about 3 ounces (3.7 ounces for redmeat).One egg has the approximateprotein content of 1ounceofmeat, poultry,or fish plus upto 0.6 gram carbohydrate.

You cantake any of the foods in the 6 grams of carbohydrate Ust onpage 170and add protein to them (cheese, eggs, et cetera) to make asatisfying breakfast. You can have less than 6 grams carbohydrate oreven no carbohydrate, provided the amount is unchanged from dayto day.

LUNCH

FoUow the same guidelines for lunch as forbreakfast, with the exception that the carbohydrate content may be doubled, up to 12grams.

Say, forexample,that you and your friends go to lunch everydayatthe "greasy spoon"around the corner from work and areserved onlysandwiches.You might try discarding the sUces of bread andeating thefilling — meat, turkey, cheese, or other protein food — with a knifeand fork. (If you choose cheese, remember to count 1 gram carbohydrate per ounce.) You could alsoorder a hamburger without the bun.And instead of ketchup, you could use mustard, soy sauce, or othercarbohydrate-free condiments. You then might add Mb cups cookedwholevegetable from the Ust on page 151 (12 grams carbohydrate) or2 cups of salad with vinegar-and-oU dressing (12 grams of carbohydrate) to round out your meal.

If you want to create a lunch menu from scratch, use your foodvaluebooks to look up foods that interestyou. If you like sandwiches,one double cheese puff as described later in this chapter under the

176 Treatment

"Snacks" heading wiU be about the size of a large slice of bread.They're sturdy enough that you could make a sandwich from two ofthem. Just make sure to account for the protein and carbohydrate inthe cheese.

The foUowing buUding blocks may be helpful in giving you astart.

Forthe protein portion, one ofthefollowing

• A smaU can of tuna fish contains 3V4 ounces by weight in theUnited States. If you're packing your lunch, these can be quiteconvenient if you like tuna. The next larger size can contains 6ounces.The tastiest cannedtuna I've tried is made by Progresso,packedin oliveoU.

• 4 standard sUces of packaged pasteurized process Americancheese (process cheddar in the U.K.) weigh about 2% ounces.This wUl contain about 3 ounces of protein and 3 grams of carbohydrate.

Forabout 12gramscarbohydrate, oneofthefollowing

• VA cups whole cookedvegetables (from the list on page 151).• 2 cups mixed green salad, with 1 sUce of tomato and vinegar-

and-oil dressing. Sprinkling bacon or soy bacon bits or gratedcheesewill havenegligible additionalblood sugareffect.

• V/i cups salad, as above, but with 3 tablespoons of commercialsalad dressing (other than simple vinegar-and-oU) containing 1gram of carbohydrate per tablespoon. Check the label.

You might decide that 2 cupsof salad with vinegar-and-oU dressingis fine for the carbohydrate portion ofyour lunch.You then should decide how much protein must be added to keep you satisfied. One person might be happy with a 3xA-o\xnce can of tuna fish, but anothermight require 2 large chicken drumsticks or a packet of lunch meatweighing 6 ounces. For dessert, you might want some cheese (in theEuropean tradition) or perhaps some sugar-free JeU-O gelatin (if itcontains no maltodextrin) coveredwith 2 tablespoons ofheavy cream.You might consider some of the dessertsdescribed in PartThree or inThe Diabetes Diet. The possible combinations are endless; just useyour food value books or read labels for estimating protein and carbohydrate. Some people, after having routinely eaten the same thingfor years, discover that their new meal plan opens up culinary possi-

Creatinga CustomizedMeal Plan 177

bUities they neverknewexisted. Our patients,asweU as readers,are always looking for recipes, so if you come up with a recipe that youthink is particularly good, pleasefeelfreeto share it on the Website forthis book. You can either go directly to www.diabetes-book.com/recipes/recipes.shtml or choose the "Recipes" link and foUow the directionsfor submission. The simplerecipe format used in Part Threemust be foUowed precisely for it to be acceptable.

SUPPER

Supper should foUow essentiaUy the sameapproach as lunch. There is,however, one significantdifference that wiU especiaUy apply to thosewho are affected by delayed stomach-emptying (gastroparesis) andtake insulin. As we've discussed briefly, this condition can cause unpredictable shifts in blood sugar levels because food doesn't alwayspass into the intestines at the same rate from meal to meal. The difficultywith supper is that you can end up with unpredictably high orlow blood sugars whUe you are sleeping and unable to monitor andcorrect them. Sustained exposure to high blood sugars whUesleeping — evenif they are normalized during the day— can lead tolong-term diabeticcompUcations. Forcertainaffected people,a viableapproachto this problemis to facUitate stomach-emptying by replacing salads with cooked vegetables (from our list) that are low in insoluble fiberand reducing protein content. For these people,the amountof protein at supper would be less than that eaten at lunch — just theopposite ofwhat has become customary for most Americans. A morecompleteanalysis of this problem appears in Chapter 22.

If you like cookedvegetables (from our Ust) for supper, rememberthat most can be interchanged with salads as near equivalents —%cup of cookedwholevegetable (or lA cupmashedor V4 cup sUced ordiced) and 1 cup of salad each havethe blood sugar effectof about 6grams carbohydrate.

If you like wine with dinner, choose a very dry variety and limityourself to one 3-ounce glass (see pages 136-137 for further detaUs).Asnoted on page 163,one beer mayactuaUy turn out to have no effectupon your blood sugar. Still, don't drink more than one if you takeinsulin or use one of the oral agents that stimulate insulin secretion(sulfonylureas; remember that our program prohibits use of theseagents).

178 Treatment

SNACKS

For many people with diabetes, snacks should be neither mandatorynor forbidden. They do, however, pose a problem for people who takefast-acting insulin before meals. Snacks should be a convenience, torelieve hunger if mealsare delayed or spacedtoo far apart for comfort.If your diabetes is severe enough to warrant the use of rapid-actingblood sugar-loweringmedicationbeforemeals, such medication mayalso be necessarybefore snacks.

The carbohydrate limit of 6 grams during the first few hours afterarising and 12 grams of carbohydrate thereafter that appUes to mealsalso appUes to snacks.Besure that your prior meal has been fuUy digestedbeforeyour snackstarts (this usuaUy meanswaiting4-5 hours).This is so that the effects upon blood sugar wUl not add to one another.You needn't worry, however, if the snackisso sparse (say, a bit oftoasted nori) as to have negUgible effects on blood sugar. Sugar-freeJeU-O gelatin (without maltodextrin) can be consumed pretty muchwhenever you like,provided you don't stuff yourself and provoke theChinese restaurant effect. As a rule, snacks limited to smaU amounts of

protein wiU have less effect upon blood sugar than those containingcarbohydrate. Thus 2-3 ounces of cheese or cold cuts might be reasonable snacks for some people.

Among my patients,a common favorite snack,which has a negUgible amount of carbohydrate, is homemade microwave cheese puffs.They're simple and convenient to make. Get some freezer paper fromthe grocery — not waxed paper. It has a duU side and a shiny side.Place a sliceof American cheese (process cheddar in the U.K.) on theshiny side of a piece of the freezer paper, then pop it into themicrowave for 1-2 minutes, depending on how powerful your microwave is. The cheese wiU bubble up and puff quite nicely, but let itcool a Uttle before attempting to remove it from the paper. CooUngcan be accelerated by putting it into the freezer for 30 seconds.

Two slicesside by side in the microwave wiU make a double cheesepuff. Two of these are suitable for a sandwich. I have put mayonnaise on one and mustard on the other and ham or turkey and cheesein between. Cheese puffs can also be substituted for toast at breakfast.

Ifyou'rebeingtreatedwithonlylonger-acting bloodsugar-loweringagents, the question of random or even preplanned snacking is bestanswered by experimentation using blood sugar measurements.

Creatinga CustomizedMeal Plan 179

OTHER CONSIDERATIONS

Meal and Medication AdjustmentsAlthough your blood sugars wiU respond best if you adhere to our restrictions on carbohydrate, you'U find that you have considerable leeway when it comes to planning the amount of protein for each meal,provided that you don't havegastroparesis or another digestive disorder and inject insuUn. At the initial meal-planning session with yourphysician or other health careprovider, you mayestimatethat you wiUrequire perhaps 6 ounces of protein to satisfyyour appetite at lunch.When you actuaUy try eatingsuch a lunch,you mayconclude that thisamount ofprotein is either too much or too Uttle for your satisfaction.This can readUy be changed,provided that you first adviseyour healthcare provider, so that dosageof any blood sugar-lowering medicationyou take may be adjusted accordingly. Once a comfortable amount ofprotein has been establishedfor a meal,it should not changefrom dayto daybut, likethe carbohydrate, be held constant The predictabiUtyof blood sugar levels under this regimen depends, in part, upon thepredictabiUty of your eatingpattern.

Carbohydrate or Protein JugglingManypatients ask me if they can jugglecarbohydrateor protein fromone meal to another, keeping the totals for the day constant Such anapproach doesn't work, for reasons that should be obvious by now,and can be downright dangerous if you're taking medications thatlowerblood sugar.Many patients who visit me for the first time afterreading this book have totaUy ignored this very important point andhavefound it impossibleto achieve stableblood sugars.

Calcium Concerns

Somepeoplewho foUow my dietaryguidelines consumeconsiderableamounts of fiber. Slow-acting carbohydrate foods that are especiaUyhigh in fiber include salads, broccoU, cauUflower, bran, and soybeanproducts. Fiberbinds dietarycalcium in the gut, causing a reductionof calciumabsorption and potentialdepletionof bone mineral,whichcontains 99.5 percent of our calcium reserves. The phosphorus present in proteins also may bind calcium sUghtly. Since I discourage theuse of milk and certain milk products (except cheese, yogurt, andcream), which are good sources of dietary calcium, the potential forbone mineral depletionmayindeedbe real. This is a special problem

180 Treatment

for women, who tend to lose bone mass at an increased rate aftermenopause. I recommend a calcium supplement to anyone who follows our diet and doesn't use cheese, yogurt, or cream, especiaUywomen. Sincesome women rapidly lose calcium from their bones after menopause,it makes sense to buUd up calcium storesearlierin Ufe,and to offset high-fiber and high-protein diets with extra calcium.Calciumsupplementation,by the way, is most important for growingteenagers who foUow low-calcium diets. Calcium supplements withvitamin D, magnesium, and manganese are more effective, as theseaid calcium uptake by bone — and the magnesiumhelps counter thepotentiaUy constipatingeffect of calcium takenby itself. Calciumsupplementation also facUitates weight loss by sUghtly elevating yourmetaboUc rate, but that doesn't mean that the more you take, the moreweight you'U lose. Nor does it meanthat if you are in the minority ofdiabetics who are trying to gainweightyou should avoidcalcium.

I recommend calcium citrate because it is weU absorbed in the gutand inhibits the formation of kidney stones. One study of calciumsupplementation suggests the equivalent of at least1,000 mg for every10 ounces of protein consumed. Calcium supplements are best takenwith each meal. Calcium tablets taken at bedtime are often effective

in reducing the frequency of nocturnal muscle cramps in the legs.Sedentary and thin people lose more bone calcium over a lifetimethan do physicaUy active people. Exercise buUds bone just as it buUdsmuscle.

SOME PROTOTYPE MEAL PLANS

The guidelines setforth in this chapter should beadequate for you tocreate yourownmeal plan, but I don'twantto leave youwithanyuncertainty as to how it is done. I have, therefore, Usted below 3 days'worth of breakfasts, lunches, and suppersto give you an idea of how Ido it. These meals should serve as a starting point. You may want tooverhaul them entirelyto reflect your favorite foods. If, for example,you prefer canned salmon to frankfurters, just substitute a smaU can{SlA ounces) of salmon for the two 1.7-ouncefrankfurters in the lunchof Day One.

The carbohydrate contentof eachmealreflects our 6-12-12 guide-fines. If you're going to maintain normalbloodsugars, then whateveramounts of carbohydrate youusemust remainrigidand reaUy should

Creatinga CustomizedMeal Plan 181

reflect maximum but constant amounts. (SmaU chUdren should theo-reticaUy consume less, but this may pose problems of compliance.)That said, however, exceeding or diminishing carbohydrate aUoca-tionsby 1-2 gramsper mealfor adultswiU not makea greatdifferencein your blood sugars — remember the Laws of SmaU Numbers. Asidefrom theseconstraints, you are otherwise limitedonlybyyour imagination.The protein content of meals, on the other hand, is completelyup to you, provided that you don't take insuUn and have a digestivedisorder. For the foUowing examples, I've arbitrarUy assumed certainamountsof protein that maybe too muchor too little to satisfy yourdesires; you wiU want to experiment to determine your own preferences. Remember, however, that protein, likecarbohydrate, should bekept constant from one dayto the nextfor anygiven meal.

Let's assume that you've negotiated a mealplan,and the amounts ofassigned carbohydrate and amounts of protein that you think wiU satisfyyou are as foUows:

Breakfast: 6 grams carbohydrate, 3 ouncesproteinLunch: 12grams carbohydrate, 4 ouncesproteinSupper: 12grams carbohydrate, 5 ounces protein

Note that none of the nine meals to foUow adds up precisely totheseguideUnes for total carbohydrate and protein,yet aU of them arequite closeand thus acceptable. Notealsothat I usuaUy don't list beverages. This is simply because most acceptablebeveragescontain neither carbohydrate nor protein and may therefore be ignored in ourcomputations. Remember, however, that every tablespoon of creamfor your coffee or tea contains0.4gramsof carbohydrate.

Day One

Breakfast

Mushroom Omelet with Bacon(page398)

1 Bran-a-Crisp with butter

TOTAL

Lunch

Green CabbageCole Slaw(page 406), 1 serving

1 G/G crispbread with mustard or butter

2 frankfurters

TOTAL

Carbohydrate Protein

(grams) (ounces)

3.1 2.8

i& LQ

7.1 3.8

5.8 _

3.0 0.2

_LQ M

11.8 3.6

182

Supper

% cup mbced saladwith oil,vinegar, and spices

2 tablespoons crumbledbluecheese on salad

Pan-FriedSwordfish with GingerScallion Butter

(page 422)

TOTAL

Day Two

Treatment

4.0 -

0.4 0.7

JA 4£

12.0 5.5

Breakfast

Carbohydrate(grams)

Protein

(ounces)

Low-carbohydrate pancakes(page401)

2 sausage patties,1ounce each

Lunch

TOTAL

7.0

7.6

1.4

3.4

2 cups saladwith vinegar-and-oil dressing,

sprinkledwith gratedcheese 12.0 0

1 small can tuna (3V4 ounces) mixed with

1 tablespooneachmayonnaise and choppedcelery 0.3 3.25

1 sliceAmerican cheese (place on top of tuna

and heat in microwave for tuna melt) 0.67 0.67

12-ounce bottle Blatz Cream Ale Assume 0 Assume 0

total 12.97 3.92

Supper

Quiche Lorraine (page437),%serving

ChocolateSouffle (page440)

Day Three

TOTAL

9.2

.2d

12.1

2.7

Lfi

4.5

Carbohydrate Protein

Breakfast (grams) (ounces)

2 ounces smoked Nova Scotia salmon — 2.0

2 G/G crispbreads 6.0 0.5

2 cheese puffs (page 178) U. LI

TOTAL 7.3 3.8

Creatinga Customized Meal Plan

Lunch

Avocado Spread(page435), 1serving

Half a red or green bell pepper,cut into strips

3Vi ounces hamburger meat

1 tablespoonBacos brand soybaconbits

(kneadinto hamburgerbeforecooking)

TOTAL

Supper

1 medium artichoke, boiled, served with melted butter

4Vi ounces any meat, fish,or poultry,cookedas you like -

TOTAL

6.6 0.4

3.8 -

- 3.5

-24 Q£

12.4 4.4

12.4 0.5

~ 4,5

12.4 5.0

183

To any one of these meals you could add as a dessert a serving ofsugar-free JeU-0 brand gelatin (without maltodextrin), which wouldnot appreciably affect your carbohydrate aUocations. Again, you arelimited only by your imagination, and there are countless differentmealsyou cancreate that addup to no more than 6 or 12gramsofcarbohydrateand 3,4,5, or more ouncesof protein.

12

Weight Loss — If You're Overweight

Weight loss can significantly reduce your insulin resistance.You may recaU from Chapter 1 that obesity,especiaUy abdominal (truncal, or visceral) obesity, causes insulin resis

tance and thereby can play a major role in the development of bothimpaired glucose tolerance and type 2 diabetes. If you havetype 2 diabetes and are overweight, it is important that weight loss become agoal of your treatmentplan.Weightreduction canalso slowdown theprocess of beta ceU burnout by making your tissues more sensitive tothe insulin you stiU produce,aUowing you to require (and therefore toproduce or inject) lessinsuUn.

It may even be possible, under certaincircumstances, to completelyreverse your glucose intolerance. Long before I studied medicine, Ihad a friend, Howie, who gained about 100 pounds over the course ofa few years. He developed type 2 diabetes and had to take a largeamount of insulin (100 units daUy) to keep it under control. Hisphysician pointed out to him the likely connection betweenhis diabetes and his obesity.To my amazement, during the foUowing year, hewas ableto lose 100pounds. At the end ofthe year, he had normal glucose tolerance, no need for insulin, and a new wardrobe. This kind of

success may only be possible if the diabetes is of short duration, but itis certainlyworth keeping in mind — weight losscan sometimes workmiracles.

Beforewe discuss weightloss, it makessenseto considerobesity,because if you don't understand why and how you are overweight orobese, it wiU be somewhat more difficult to reverse the condition.

WeightLoss — If You*re Overweight 185

THE THRIFTY GENOTYPE

When I see a very overweightperson, I don't think, "He ought to control his eating."I think, "He has the thrifty genotype."

What is the thrifty genotype?The hypothesis for the thrifty genotype was first proposed by the

anthropologistJames V. Neel in 1962 to explain the high incidenceofobesityand type 2 diabetesamong the Pima Indians of the southwestern United States. Evidence for a genetic determinant of obesity hasincreased overthe years. Photographs of the Pimas froma centuryagoshowa leanand wirypeople. Theydid not knowwhatobesitywasandin facthad no word for it in their vocabulary.

Their foodsupplydiminished in theearlypart of the twentiethcentury, something that had occurred repeatedly throughout their history. Now, however, they weren't faced with famine. The Bureau ofIndianAffairs providedthem with flourand corn,and an astonishingthing happened. Theselean and wirypeopledeveloped an astronomicalincidence of obesity— close to 100 percentof adult Pima Indianstoday aregrossly obese, witha staggering incidence of diabetes. Todayhalf of adult Pimas in the United States are type 2 diabetics, and 95percent of those are overweight. Since publication of the first editionof thisbook,manyPimachUdren have become obese, type2 diabetics.AsimUar scenario isnowplaying out across thecountryin the generalpopulation. The pace may be slower,but the result is simUar.

Whathappened to the Pimas?* How didsuch apparently hardyandfit people become so grossly obese? Though their society was at leastin part agrarian, they lived in the desert, where drought was frequentand harvests couldeasUy faU. Duringperiodsof famine, those of theirforebears whose bodies were not thrifty or capable of storingenoughenergy to survive without food died out. Those who survived werethose who couldsurvive longperiods without food. Howdid theydoit?Although it may be simpUfying somewhat, the mechanism essen-tiaUy works like this: Those who naturaUy craved carbohydrate andconsumed it whenever it was avaUable, even if they weren't hungry,would have made more insuUn and thereby stored more fat. Add tothisthe additional mechanism of thehigh insulin levels caused byinherited insulin resistance, and serum insulin levels would have be-

*For more information on the Pimas, visit http://diabetes.niddk.nih.gov/dm/pubs/pima/index.htm.

186 Treatment

come greatenough to induce fat storage sufficient to enable them toUve through famines. (See Figure 1-1.) Truly survival of the fittest—providedfamines would continue.

A strain ofchronicaUy obese micecreated in the early 1950s demonstrates quitevividlyhowvaluable thrifty genes canbe in famine. Whenthese mice areaUowed an unlimited food supply,they baUoon and addasmuch ashalf again the body weightofnormal mice.Yet deprivedoffood, these mice can survive 40 days, versus 7-10 days for normalmice.

More recent research on these chronicaUy obese mice providessome tantalizingly direct evidence of the effecta thrifty genotype canhave upon physiology. Innormal mice, ahormonecaUed leptinisproduced in the fat ceUs (also a hormone human fat cells produce, withapparently simUar effect). The hormone tends to inhibit overeating,speed metabolism, andact as amodulator of body fat. A genetic"flaw"causes the obese mice to make a lesseffective form of leptin. Experiments showed that when injected with the real thing they almost instantly slimmed down. Notonlydidtheyeat less but theylostas muchas 40percent of their bodyweight, their metabolism sped up,andtheybecame much more active. Many were diabetic, but their loss ofweight (andthe change in the ratio of fat to lean body mass) reversedor even "cured" their diabetes. Normal mice injected with leptin alsoate less,became more active, and lost weight, though not as much. Research on humans hasnot advanced sufficientlyto provide conclusiveevidence that the mechanism is the same in obese humans, but re

searchers beUeve it is at least equivalent and probably related to morethanone gene, andto different gene clusters in different populations.

In a fuU-blown famine, the Pima Indian's abUity to survive longenough to find food isnothing shortof ablessing. Butwhen satisfyingcarbohydrate craving issuddenly justamatter of going to the groceryor malting bread, whatwas once an asset becomes a very serious liability.

Although current statistics estimate slightly more than 60 percentof the overaU population of the United States as chronicaUy overweight, there isevengreater reason to beconcerned, because the number has been increasing each year. Some researchers attribute risingobesity in the United States at least in part to increasing numbersofformer smokers. Others attribute it to the recent increasein carbohydrate consumptionby those tryingto avoid dietary fat. Whatever thereasons, overweight andobesitycanlead to diabetes.

Weight Loss—IfYou're Overweight 187

The thrifty genotype has its most dramatic appearance in isolatedpopulations like the Pimas, which have recently been exposed to anunlimited foodsupplyafter miUennia of intermittent famine. The FijiIslanders, for example,wereanotherlean,wiry people,accustomed tothe rigors of paddUng out against the Pacific to fish. Theirdiet,high inprotein andlowin carbohydrate, suitedthem perfectly. After the onsetof the tourist economythat foUowed World War II,their diet changedto our high-carbohydrate westerndiet, and they too began (and continue) to suffer from a high incidence of obesityand type 2 diabetes.The same is true of the AustraUan Aboriginesafterthe Aboriginal Service began to provide them with grain. Ditto for South African blackswho migrated from the bush into the big cities. Interestingly, a studythat paidobese,diabetic South African blacks to go back to the countrysideand return to their traditional high-protein, low-carbohydratediet found that they experienced dramatic weight lossand regressionof their diabetes.

It's clear that thrifty genotypes work in isolated populations tomake metabolism supremelyenergy-efficient, but what happenswhenthe populations have unrestricted access to high-carbohydrate foods?

It would appear that the mechanism of the thrifty genotypeworks something like this: Certain areas of the brain associated withsatiety— that sensation of being physicaUy and emotionaUysatisfiedby the last meal— may have lower levels of certain brain chemicalsknown asneurotransmitters. A number of years ago,Drs. Richard andJudith Wurtman at the Massachusetts Institute of Technology (MIT)discovered that the level of the neurotransmitter serotonin is raised in

certain parts of the hypothalamus of the animal brain when the animal eats carbohydrate, especiaUy fast-acting concentrated carbohydrate like bread. Serotonin is a neurotransmitter that seems to reduce

anxiety as it produces satiety. Other neurotransmitters such as dopamine, norepinephrine, and endorphins can also affect our feelings ofsatiety and anxiety. There are now more than one hundred knownneurotransmitters, and many more of them may affect mood in response to food in ways that are just beginning to be researched andunderstood.

In persons with the thrifty genotype, deficiencies of these neurotransmitters (or diminished sensitivity to them in the brain) causesboth a feeling of hunger and a mUd dysphoria— often a sensation ofanxiety, the opposite of euphoria. Eating carbohydrates temporarilycausesthe individual to feelnot only lesshungry but alsomore at ease.

188 Treatment

A frequent television sitcom scenario is the woman just dumped byherboyfriend who plopsdown on the couchwith a pieor half a gaUonof ice cream, a spoon, and the intention of eating the whole thing.She's not reaUy hungry.She's depressed and trying to make herself feelbetter.She's indulgingherself, we think, rewarding herselfin away forenduring one of life's traumas, and we laugh because we understandthe feeling. But there is a very real biochemical mechanism at workhere.She craves the sugar in the pieor the icecreamnot because she'shungry but because she knows, consciously or not, that it reaUy wiUmake her feel better. Contrary to popular belief, the fat in the icecream or in the crust of the pie doesn't make much of a difference. It'sthe carbohydrate that wiU increase the levelof certainneurotransmitters in her brain and make her feel better temporarily. The side effectof the carbohydrate is that it also causes her blood sugar to rise andher body to make more insulin;and, as she sits on the couch, the elevation in her serum insulin level wUl facUitate the storage of fat.

On television the actress may never get fat. But for the real-lifewoman, high serum insulin levels from eating high-carbohydratefoodswiU cause her to crave carbohydrate again. If she is a type 1diabeticmakingno insulin, she'U have to inject alot of insulinto getherblood sugar down,with the sameeffect— more carbohydrate cravingand buUdingup of fat reserves.

GETTING IT OFF AND KEEPING IT OFF

There may be many mechanisms by which the thrifty genotype cancause obesity. The most common overtcause of obesityis overeatingcarbohydrate, usuaUy over aperiod of years. Unfortunately, thiscanbea very difficult type ofobesity to treat.

If you're overweight, you're probably unhappy with your appearance, and no less with your high blood sugars. Perhaps in the pastyou've tried to foUow a restricted diet, without success. GeneraUy,overeating foUows two patterns, and frequently they overlap. First isovereating at meals. Second is normal eating at mealtime but withepisodic"grazing." Grazing canbe anything from nibbling and snackingbetween mealsto eating everything that doesnot walk away. Manyof the people who foUow our low-carbohydrate diet find that theircarbohydratecravingceases almost immediately,possiblybecauseofareduction in their serum insulin levels. The addition of strenuous ex-

Weight Loss—IfYou're Overweight 189

ercise sometimes enhances this effect. Unfortunately, these interventions don't work for everyone.

Medications

If you're a compulsive overeater, if you just can't stop yourself fromeating,and are addicted to carbohydrate, you may not be able to adhereto our dietwithoutsomesort of medical intervention (see Chapter 13). Carbohydrate addictionisjust asrealasdrug addiction,and inthe case of the diabetic, it can likewise have disastrous results. (In actual fact, excess body weight kiUs more Americans annuaUy from itsrelated complications than aU drugsof abuse combined, including alcohol.)

Youneed not despair of never losing weight, however. I have seen anumber of "diet-proof" patients over the years get their weightdownand blood sugars under control. Over the last several years, medicalscience has gained a much more sophisticated understanding of theinteractions ofbrain chemicals (neurotransmitters) that contribute toemotional states such as hunger and mood. Many relatively benignmedications have been successfuUy applied to the temporary treatment of compulsive overeating. There is no doubt that when usedproperly, many appetite suppressants are quite effective in helpingpeopleto loseweight.Ifyou simplycannot loseweight,it may be helpful to discusswith your physicianmedicinesthat maybe ofuse to you.I haveused more than 100different medicationswith my patients andhave found many of them to be of great value for treating carbohydrate addiction.

There is, however, a catch to this method. Over the years, I havefound that none of these medicationsworkscontinuaUyfor more thana few weeks to a few months at a time, a fact that many if not mostmedical and diet professionals may be unaware of.

I developed a reasonably successful method for prolonging effectiveness ofsome by rotating them weekly, so that from one weekto thenext a different neurotransmitter would be caUed into action to provide the sensation of satiety. I found that about eight different medications, changed every week for eight weeks, and then repeating thecycle, would perpetuate the effect for as long as people continued totake them. At one point this looked to be a very promising means tohelp get weight off and keep it off. I even acquired a patent for thetechnique. Over time, however, I found severalsignificant reasons notto continue pursuing this route. The most insurmountable of these

190 Treatment

was that it was just too difficult formostpeople to foUow theirnormalregimen of diabetes medications whUe at the same time changingtheirregimen ofappetite suppressants from week toweek. Add to thatthedifficulty ofworking with a patient over a number ofweeks just tofindeight medications thatworked for themand could be rotated.

What I did discover during aU this trial and error wereseveral effectivemethodsof curbingovereating. The results mypatientshave hadwith them aresosignificant that I've devoted thewhole nextchaptertothem.

Reducing Serum Insulin LevelsAnother group of type 2 diabetics has a common story:"I was neverfat until after my doctor started me on insulin." UsuaUy these peoplehave been foUowing high-carbohydrate diets and so must inject largedoses of insuUnto effecta modicum of blood sugar control.

InsuUn, remember, is the principal fat-buUding hormone of thebody. Although a type2 diabetic maybe resistant to insuUn-facUitatedglucose transport (frombloodto ceUs), that resistance doesn't diminish insulin's capacity for fat-buUding. In other words, insulin can begreat at makingyou fat eventhough it maybe, for those with insulinresistance, inefficient at lowering your blood sugar. Since excess insulin is a cause of insuUnresistance,the more you take, the more you'Uneed, and the fatter you'U get.This is not an argument against the useof insulin; rather it supports our conclusionthat high levels of dietarycarbohydrate — which, in turn, require large amounts of insulin —usuaUy makeblood sugarcontrol (and weightreduction) impossible.

I have witnessed, over and over, dramatic weight loss and bloodsugar improvement in peoplewhohavemerelybeen shown how to reduce their carbohydrate intake and therefore their insulin doses. Although this is contrary to common teaching,you need only visit thereader reviews of earUer editions of this book to read the simUarexperiences of many readers.*

Several oral insulin-sensitizing agents, which we wUl discussin de-taU in Chapter 15,can alsobe valuabletools for facUitating weight loss.They work by making the body's tissues more sensitive to the bloodsugar-lowering effectof injectedor self-madeinsulin. As it then takes

* At www.amazon.com, www.amazon.co.uk, and www.diabetes-bookcom.

Weight Loss—IfYou're Overweight 191

less insulin to accomplish our goal of blood sugar normalization,you'U have less of this fat-building hormone circulating in your body.I have patients using these medications whoarenot diabetic, and theywork in a simUar way: the body is more sensitive to insulin, so it needsto produceless, and there is,again, less of it presentto build fat. Onemayalso have less of a sense of hunger, and less lossof self-control.

Increasing Muscle MassThe above suggests whatwehave beenadvocating aU along— a low-carbohydrate diet. But what do you do if this plus one of the abovemedications does not result in significant weight loss? Another stepis muscle-buUding exercise (Chapter 14). This is of value in weightreduction for several reasons. Increasing lean body weight (musclemass) upgrades insulin sensitivity, enhancing glucose transport andreducing insulin requirements for blood sugar normalization. Lowerinsulin levels facilitate lossof stored fat. Chemicals produced duringexercise (endorphins) tend to reduce appetite, as do lower serum insulin levels. Peoplewho have seen results from exercise tend to investmore effort in looking even better (e.g., by not overeating, and perhaps exercising more). They know it can be done.

HOW TO ESTIMATE YOUR REAL

FOOD REQUIREMENTS

Now suppose you have been foUowing our low-carbohydrate diet,have been conscientiously "pumping iron,"and are, in effect, "doingeverythingright."What else can you do if you have not lost weight?WeU, everyone has some level of caloricintake belowwhich they wiUlose weight. Unfortunately, the "standard" formulas and tables commonly used by nutritionists set forth caloricguidelines for theoreticalindividuals ofa certain age,height, and sex,but not for real people likeus. The only way to find out how much food you need in order tomaintain, gain,or loseweight isbyexperiment.Here is an experimental plan that your physician may find useful. This method usuaUyworks, and without counting calories.

Beginby setting an initial target weightand a reasonable time framein which to achieve it. Usingstandard tables of"ideal body weight" isof little value,simplybecause they give a verywide target range.This

192 Treatment

is because some people have more muscle and bone mass for a givenheightthan others. The highend of the ideal weight for a given heighton the MetropoUtan Life Insurance Company's table is 30 percentgreater than the lowend for the same height.

Instead, estimateyour target weight by looking at your body in themirror after weighing yourself. (It pays to do this in the presence ofyour health care provider, because he/she probably has more experience in estimatingthe weightof your body fat.) If you can grab hand-fuls of fat at the underside of your upper arms, around your thighs,around your waist, or overyour beUy, it is pretty clear that your bodyis set for the next famine. Your estimate at this point need not be terribly precise, because as you lose weight your target weight can bereestimated. Say, for example, that you weigh200 pounds.You and yourphysician may agree that a reasonable target would be 150 pounds. Bythe time you reach 160pounds, however, you may have lost your visible excess fat— so settle for 160 pounds.Alternatively, if you stillhavefataround your beUy when you getdown to 150 pounds, it won't hurtto shoot for 145 or 140 as your next target, before making anothervisual evaluation. GraduaUy you home in on your eventual target, using smaller and smaUer steps.

Once your initial target weight has been agreedupon, a time framefor losing the weight should be established. Again, this need not be utterly precise. It's important, however, not to "crash diet." This maycause a yo-yo effect by slowing your metabolism and making it difficult to keep off the lost bulk. Bear in mind that if you starveyourselfand lose 10 pounds without adequate dietary protein and an accompanyingexercise regimen, you may lose5 pounds of fatand 5 poundsof muscle. If you gain back that 10 pounds from eating carbohydrateand stiU are not exercising, it may be all fat. After crash dieting, onceyou've reachedyour target, you may go right back to overeating. I liketo have my patients foUow a gradual weight-reduction diet thatmatches ascloselyaspossible what they'U probably be eatingafter thetarget hasbeen reached. In other words, once your weighthas leveledoff at your target, you stayon the samediet you foUowed whUe losingweight — provided, of course, that you don't continue losingweight.This way you've gotten into the habit of eating a certain amount, andyou stick to this amount, more or less, for life.

To achieve this, weight loss must be gradual. If you are targeted tolose 25 pounds or less, I suggest a reduction of 1 pound per week. If

Weight Loss — IfYou're Overweight 193

you're heavier, you maytry for 2 pounds perweek. If just cuttingthecarbohydrate results in a more rapid weight loss, don't worry— justenjoyyour luck.This hashappenedto a number of my patients.

Weighyourselfonceweekly— stripped,ifpossible, on the samescale,andbeforebreakfast. Picka convenient day, andweighyourselfon thesame day each week at the same time of day. It's counterproductiveand not very informativeto weighyourselfmore often. SmaU, normalvariations in body weight occur from day to day and can be frustrating if you misinterpret them.* GeneraUy speaking, you won't lose orgain apound ofbody fat in aday. Continue on your low-carbohydratediet, with enough protein foods to keep you comfortable.

Let's say that your goal is to lose 1 pound everyweek.Weigh yourselfafterone week. If you'velost the weight, don't change anything. Ifyou haven't lost the pound,reduce the protein atanyone mealby one-third. For example, if you've been eating 6 ounces of fish or meat atdinner, cut it to 4 ounces. Youcan pickwhichmeal to cut. Checkyourweight one week later. If you have lost a pound, don't change anything. If you haven't, cut the protein at another mealby one-third. Ifyou haven't lost the pound in the subsequent week,cut the proteinbyone-third in the one remaining meal. Keep doing this, week by week,until you are losingat the target rate. Never add back any protein thatyou have cut out, even if you subsequently lose 2 or 3 pounds in aweek.*

If you'vemanaged to lose at least 1 pound weekly for many weeksbut then your weight levels off, this is a good time for your physicianto prescribe the special insulin resistance-lowering agents describedin Chapter 15. Alternatively you can just start cutting protein again.Continue this until you reach your initial target or until your visualevaluation of excess body fat teUs you that further weight loss isn'tnecessary. The average nonpregnant, sedentary adult with an idealbody weight of 150 pounds requires about 11.5 ounces of high-quaUty protein food (i.e., 69 grams of pure protein) daUy to preventprotein malnutrition. It is therefore unwise to cut your protein intake

*This is especially true for many menstruatingwomen,who retain more waterduring the weekbefore their periods.tThis may not work for girls or women with polycystic ovarian syndrome(PCOS). TheymayfaU to loseweightevenon a near-starvation diet (seeAppendix E).

194 Treatment

much below this level (adjusted for your own ideal body weight). Ifyou exercise strenuouslyand regularly, you mayneed much more thanthis in order to buUdyour muscles. Growing chUdren also need moreprotein. Once you've reachedyour target weight,do not add back anyfood. You wiU probably have to stay on approximately this diet formany years, but you'U easUy becomeaccustomed to it. If you requiredone of the appetite-reducing approaches described in the next chapter, do not discontinue it.

SOME FINAL NOTES

Reduce Diabetes Medications While Cutting Proteinor Losing WeightWhUe you'relosingweight, keepchecking blood sugarsat least4 timesdaUy, at least2 daysa week. If they consistently drop belowyour targetvalue for even a few days, advise your physician immediately. It wiUprobably be necessary to reducethe dosesof anyblood sugar-loweringmedications you may be taking. Keeping track of your blood sugarlevels as you eat less and loseweight is essential for the prevention ofexcessively low blood sugars.

Increased Thrombotic Activity During Weight LossDuring weight loss, many people unknowingly experience increasedclumping of the smaU particles in the blood (platelets) that form clots(thrombi). This can increase the risk of heart attack or stroke. Yourphysician may thereforewant you to take an 80 mg chewable aspirinonce daUy during a meal to reduce this tendency. The aspirin shouldbe chewed midwaythrough a meal to reduce the possibUity of irritation to the stomach or intestines.Rinseyour mouth with water or dietsoda after chewing aspirin to prevent inflammation ofyour gums. Alternatively, instead of aspirin you can use vitamin E in the form ofgamma tocopherol or mixed tocopherols. The dosing would be 400mg one to three times daUy depending upon your size. It need not betaken during meals,as it won't irritate your gastrointestinal tract.

Elevated Serum Triglycerides During Weight LossWhen you're losingweight, fat is "mobUized" for oxidation— i.e., tobe burned — and it wiU appear in the bloodstream as triglycerides. Ifyou see elevatedserum triglyceride levels as you're losing weight, it's

Weight Loss — If You're Overweight 195

not something to worry about. Your triglyceride levels wiU drop assoon as weight loss levelsoff.

Supplemental Calcium May HelpThere is evidence that dietary calcium and to a lesser degree calciumsupplements (1,000-3,000 mg daUy) mayfacUitate weight lossby inhibiting the accompanying slowdown in metaboUsm that mayoccurwhenyouloseweight. If usedfor thispurpose, the supplementshouldnot contain vitamin D,as it wiU counteract the effect on weight loss.

13

How to Curb CarbohydrateCraving or Overeating

USING SELF-HYPNOSIS OR LOW-RISK MEDICATIONS

The diet plan described in this book should make it possible forvirtuaUy any diabetic to achieve normal blood sugars. Thereare, however,three exceptions. The first, as I've mentioned, is

the presence of gastroparesis, or the partial paralysis of the stomach,and other ailments that can impair stomach-emptying. These may include hiatal hernia, stomach or duodenal ulcers, a "tonic" (tight)stomach, gastritis, duodenitis, and scleroderma, among others. Thenext is infection. The third is the inabUity to control food intake, butespeciaUy carbohydrate intake. Because of the thrifty genotype, weshould expect to find this condition in many type 2 diabetics. Indeed,about 25 percentofmy type 2 patients find it extremelydifficult to remain on a low-carbohydrate diet — or indeed any kind of structureddiet. Typical scenarios include snacking when bored, eating bread inrestaurants for no better reason than that it's on the table, and eatingeverythingon your plate regardless ofanyactual hunger if you happento be givena too-large portion,often at restaurants. Others may eat awhole pint, and some even aquart,of icecreameverynight, often becausethey feel they have nothing elseto do. At least 10 percent of mytype 1diabetic patients have suchproblems, but their problems, whenthey occur, have a more devastating effect on blood sugars. These arethe people who rapidly develop retinopathy, numb feet, kidney dysfunction, and so on.

Several years ago, I recaUed how, in medical school, I had beentaught a technique for self-hypnosis in order to avoid faUing asleepwhen we had boring speakers and the lights were turned off. I wondered if perhaps the same technique might be helpful to those patientswho just couldn't seem to stick to a low-carbohydrate diet or any

How toCurb Carbohydrate Craving orOvereating 197

other. I decided to get in touch with the physician, Herbert Spiegel,MD,who had taughtme autohypnosis.

Remarkably, he was stUl in the same office at the same telephonenumber asmore than twenty years before. To my amazement, he toldme that he routinely used this technique to treat people with eatingproblems. Put this under the category of reasonably important discoveries I had missed. In fact,with his son, David, he had even writtena book, Trance and Treatment: Clinical Uses ofHypnosis. It includes achapter on just this subject. Since then, I've referred many patients tohim to learn this technique, and we've had success in helping peoplebreak the cycle of carbohydrate addiction. (Dr. Spiegel uses thismethod for altering a number of different behaviors, not just weightloss or the propensity ofelderly medical students to snore duringsoporific lectures.)

The whole cycle of going into a hypnotic state, giving yourself amessage, and coming out of the state takes initiaUy about 1 minute.Once you have some experience, it only takes about20 seconds to complete. The technique only works if you're hypnotizable. A quaUfiedmedicalhypnotist quite readUy can determine whether you area suitable subject. One of the things the specialist looks for ishow high youcan roU up your eyes as you attempt to look toward the top of yourhead.AdditionaUy, the techniquewUl only work if you perform autohypnosis at least10times daily (for a daUy total ofabout 3Vi minutes).The section below,which is adaptedwith permission from Dr.Spiegel'sbook, is the handout that our eminent consultant, Dr.Spiegel, gives tohis patients with eating problems. This handout is a reminder ofwhatthey've been taught in his office.

A METHOD OF SELF-HYPNOSIS*

Sit or lie down. At first, being in a quiet place can help. Toyourself, count to three.At one you are goingto do one thing, attwo, you wiU do two things, at three, you wiU do three things.

* Reproduced (with minor modifications by me) from Trance and Treatment:Clinical Uses ofHypnosis, by Herbert Spiegel, MD,and DavidSpiegel, MD,American Psychiatric Press, 1987.

198 Treatment

1. Without moving your head, look upward toward youreyebrows, attthe way up.

2. Close youreyeUds andtake adeep breath.3. Exhale; let your eyesrelax and let your body float.

As you feel yourselffloating, you permitone hand orthe other tofeel like a buoyant baUoon and aUow it to float upward. As itdoes, your elbow bends and your forearm floats into a verticalposition. Sometimes you may get a feeling of magnetic puU onyourhand asit goes up.When yourhandreaches thisvertical position, it becomes a signal for you to enter a stateof meditationand increase your receptivity.

In this state of meditation, you concentrate on this feeling ofimaginary floating and at the same time concentrate on thesethree messages:

1. Formy body, overeating is a poison.2. I need my body to live.3. I owe my body this respectand protection.

In the beginning, do these exercises as often as 10 differenttimes a day,* preferably every 1-2 hours. At first, the exerciseshould take about a minute, but it will come more rapidly withpracticed

As you meditate, reflect on the impUcations of these criticalpoints and then bring yourself out of this state of concentrationby counting backwards in this manner: Three, get ready; two,with your eyeUds closed, roU up your eyes (do it now); and one,let your eyeUds open slowly. Then, when your eyesare back intofocus, slowly make a fist with the hand that is up and, as youopen the fist slowly, your usual sensationand control returns. Letyour hand float downward. This is the end of the exercise, butyou retaina general, overaU feeling of floating.

By doing this exercise (at least) 10 different times each day,you can float into this stateof buoyant repose. Give yourself anisland of time. Twenty seconds, 10 times a day, in which to use

* I have some patients who must do this 15 times daUy, including once beforeeach meal.

t Requiringonlyabout 20seconds eachtime.

Howto Curb Carbohydrate Craving orOvereating 199

this state of extra receptivity to reimprint these three points. Reflect upon it, then float backto yourusual state ofawareness andget on with what you ordinarUy do.

CamouflageNow, suppose an hour or two passes and you want to do the exercise. You don't have the privacy and you don't want to attractattention. Here's the wayto camouflage. There are two changes.First, you close your eyes and then roU your eyes up, so that theeye roU is private. Second, instead of your hand coming up asdone in the hypnosis session [with the hypnotist], let it come upand touch your forehead. To an outsider, the exercise looks asthough you are in deep thought. In 20 seconds you can shiftgears, establish this extra receptivity, reimprint the criticalpoints, and shift back out again.

You might be sitting at a desk,a table, or may be in a conference,in which case you leanoveron your elbowwith your handalready on your forehead, you closeyour eyes,roU them up, andshift into the brief meditative state.

By doing this basic or camouflaged exercise every day, everyone or two hours, you estabUsh a private signal system so that youare ever alert to the messages you are sending yourself and thecommitment you are making to yourselfand your good health.

HOW TO DO IT

It is possiblebut unlikely that you wiU be ableto master this techniquewithout training from a professional medical hypnotist. Sufficienttraining should be possibleto accomplishin a singleoffice visit with adoctortrained in medical hypnotism.I stress the necessity ofusingtheservices of a doctor because I have had patients who, upon visitingnonphysician hypnotherapists, were convinced (you might even sayconned) that many officevisits werenecessary, and spent considerablesums but faded to learnthe technique. (If the word"hypnotism" auto-maticaUy conjures up images of charlatans and carnival sideshows inyour mind, this may be a reason.)

You should be able to locate a competent medical hypnotist byphoning the department ofpsychiatry at the nearest medicalschoolor

200 Treatment

teaching hospital. Ask for the secretary/assistant to the chairman ofthe department, and then ask who their top MD hypnotherapist is.Your insurance may or may not cover the visit, depending on yourplan, but it almost certainly wUl not pay for a nonphysician hypnotherapist.

When youvisit the MD hypnotherapist, bringeither this book or aphotocopy of the above paragraphs so that he/she wUl know exactlywhatyou are seeking. If youUve withina reasonable distance of NewYork City, Dr. Spiegel's office is located on East Eighty-eighth Streetand his office phone number canbe located in the Manhattan directory.He is the hypnotherapist to whom I refer my patients.

In Trance and Treatment he is very emphatic on the foUowing:

AcceptresponsibUity for Your Eating Behavior. It is very temptingto blameyoureating behavior on your parents, yourwife,themayor,Watergate, the moon, the tides. As soon asyou seethe absurdity of that you wiU realize that of aU the things you do in Ufe,there is nothing in which you are more clearly 100 percent responsiblethan your eatingbehavior. Reflecton the fact that mostof the things you do in life haveto take into account other considerations or other people, but in your eating behavior you arein business for yourself.

I should note that Dr.Spiegel's three points, or messages, were developed for the treatment of obeseovereaters, not necessarUy diabetics but certainly people at higher risk for developing type 2 diabetes.For many ofmy patients, his three points hit the mark. For others, thepoints they want to stress are more closely attuned to their personalsituations, and you can customize your approach asweU. I haveonepatient who is simultaneouslylosingvision and kidney function. Thispatient's personal points are to curb overeating in order to preserveeyesight and to stayoff dialysis. Another teUs herself that she doesn'twant to be like the ladywho Uved across the street from her when shewas a kid — the woman was diabetic and had both her arms and legsamputated. Another patient is a fund-raiser — his points areattunedto the greater likelihoodof people making donationsto someone whois slim and trim rather than obese. Makes sense.

Some people havea difficult time remembering to hypnotize themselves every 1-2 hours, so for these people, I recommend an alarm

HowtoCurb Carbohydrate Craving orOvereating 201

watch (which youcanpurchase quite reasonably) thatcanbesetto gooffevery hour. Getonethathas a vibration mode ifyoudon't wanttobe beeping regularly,* and you can use the camouflage technique ifyour situation requires it.

For those who learn how to hypnotize themselves and do it 10-15times a day, I've found that the success rate for curbingcarbohydratecraving is about 80 percent. For those who hypnotize fewer than 10times a day, the success rateisessentiaUy zero. I cannotoveremphasizethevalue of engaging in autohypnosis when yousitdownat a table fora meal, especiaUy if you're in a restaurant and have not yet ordered.I have patients who are walking around with normal blood sugarsonly because they have been successful using this technique. It hasthe added benefit of having no toxicity whatsoever, and it might beused to change other behaviors (smoking, biting fingernaUs, andso on).

There is, however, a major problem with autohypnosis. I find thatmany patients either refuse to try it or eventuaUy stop doing it, evenwhen itworks. The foUowing section offers asolution toovereating thatpeople have beenmorethanwiUing to pursue andcontinue to use.

WHAT IF YOU CANNOT BE HYPNOTIZED

OR OBJECT TO AUTOHYPNOSIS?

I have a simple, patented technique that has had a very high successrate for those of mypatients who otherwise have great difficulty controlling carbohydrate intake. I have been prescribing it for severalyears but cannotyetbe certain that it wUl work indefinitely. It relatesto the"runner's high" that people often experience during and afterexercise, but it doesn't require running.

You may already know that very strenuous, prolonged physicalexercise and climactic sexual activity cause the brain to produce endorphins, also known as the body's own opiates because they are produced internaUy (or endogenously —so they're known in medical

*An excellent source for such products is e-PUl, LLC, 70 Walnut Street,Welles-ley, MA, (800) 549-0095, orwww.medicalwatches.com. I recommend their PagerVibrating Multi-Alarm ($75.95). It will give asmany alarms asyoudesire if usedin the "repeat countdown" mode.

202 Treatment

circles as"endogenous opiates") and bind to receptors in the brainthat bind actual opiates, such as morphine and codeine. Endorphinscause a pleasant, relaxed feeling, simUar to that of narcotics, but to amUder degree andwithout producing atolerance.* You may havenoticed that seriousrunners and many professional athletestend to prefer protein foods, don't crave carbohydrate, and don't become fat aslongas theycontinue theirsport. Itwouldseem that theirendorphinsprevent overeating andcarbohydrate craving without losing their effect over time asdo traditionalappetite suppressants.

This technique involves a medication caUed naltrexone, which wasoriginaUy introduced as a treatment for narcotics addicts because ofits abUity, in large doses, to prevent addicts from getting highon narcotics. In large doses, naltrexone wiU block the brain's receptor sitesfor endorphins, rendering them ineffective. However, when taken insmaU doses, it also appears to raise endorphin levels in the brain.

A verysmaU dose of naltrexone taken atbedtime appears to blockendorphin receptors for about 8hours. Thebrain maycompensate forthis by making more endorphins than usual that then keep workingthroughoutthe foUowing day, when receptors are no longer blocked.

I've found that a smaU doseofnaltrexoneused in this way isvery effective in controUing carbohydrate addiction and overeating in general forabout73 percent of thosewho have tried it. Furthermore, justlike the endorphinsmadeby athletes, naltrexone, thus far in my experience, seemsto work for a prolonged period— perhaps indefinitely.

I've had only five patients who discontinued naltrexone because ofuncomfortable side effects. These effects included tiredness, headache,and difficulty concentrating on complex tasks. Such problems alwaysoccur afterthe firstdose or adosage increase. When they occur,I musteither lower the dose or discontinue the medication.

Onepatient whosnacked between dinner and bedtime also hadinsomnia. Since naltrexone made him tired, we were able to use it to

treathis insomnia and his snacking simultaneously.Naltrexone is suppUed in 50 mg tablets. For the low dose that I

prescribe, I use a compounding chemist to put naltrexone powderinto smaU capsules — usuaUy about 4.5 mg.f

* In medical terms, "tolerance" refers to declining efficacy over time, so thathigher andhigher doses are required to produce thesame results.fThe compounding chemists that most of my patients use are RosedalePharmacy, phone (888) 796-3348, and Rockwell Compounding Associates,

How to CurbCarbohydrate Craving orOvereating 203

Although in the pastI've prescribed naltrexone atvariousdosesandat different times of the day, I changedthis to 4.5 mg at bedtime at thesuggestion of Dr. Bernard Bihari, who has prescribed it for ailmentsother than overeating. This dosing method indeed appears to be themost effective.

Side effects that some patients have caUed to my attention includeoccasional headaches or a feeling of mental confusion that impairsconcentration on difficult tasks.These effectsareunacceptable, and soI may start my patients on a very low dose — 0.5 mg capsules— andincrease the amount of each dose until we reach an effective level. One

must keep in mind, however, that smaUer doses are often more effective than larger ones.

As with the other suggestions in this book, ask your physician togive naltrexone a try. He should payparticular attention to the package insert warningsagainst overdosing. For other remarkable uses forlow-dose naltrexone, visit the Web site www.lowdosenaltrexone.org.

I have patented this mode of using naltrexone,in order to encourage its distribution by pharmaceutical companies in low doses. Suchcompanies arenot interested in sellingproducts that arenot protectedby patents.

Another product has curbed overeating in about 65 percent of thepatients for whom I've recommended it. This is hoodia, a nonprescription extract ofa South African cactus. The brand I prefer is caUedHoodiaXtra, 1,000 mg. It is avaUable online at www.hoodiaxtra.comand www.diabet.es911 .net. Other brands, usuaUyin smaUerdoses, maybe purchased at health food stores, Rosedale Pharmacy, and at othersites online. Since hoodia begins working within 30-60 minutes, itshould be taken about 1hour before an anticipated need. Thus, if youusuaUy overeat at dinner and then snack thereafter, you might take1-3 capsules before dinner and another 1-3 after dinner. Somesources of hoodia supply a timed-release version. It is most effectivewhen taken on arising and again6-8 hours later.

I have seen no adverse side effects from this product, but I havenever used it in chUdren.

(914) 925-2304. (Compounding chemists are pharmacists with special trainingin the precise mixing of pharmaceuticals and over-the-counter medications.They can prepare capsules,powders,liquids,and evenointments, just as all pharmacists did when I was a child. There are many compounding chemists in theUnited States and elsewhere.Most require a physician's prescription.)

204 Treatment

Because demand for hoodia now exceeds the supply, many phonyformulations are being marketed, especiaUy on the Internet. Tosecurea reliableproduct, you would be wise to use a known brand supplierand a product without additivesthat may dUute its strength.

I believe that carbohydrate craving is truly an addiction. This addiction can be reinforcedby consumption of foods on our No-No list(pages 152-153). So once you have discontinued them, I recommendnever trying them again or you wiU likelyrelapse. Even a smaU tastecan cause you to faU off the wagon — just as for smokers, alcoholics,and other drug addicts.

AN EXCITING NEW CLASS OF DRUGS

CALLED INCRETIN MIMETICS TO

FIGHT OVEREATING

You may recaU from our discussion of the Chinese restaurant effect(page 97) that intact pancreatic beta ceUs make a hormone caUedamylin. Amylin productionisbroughtabout in response to a meal,bygut hormones caUed incretins. Since diabetics do not have beta ceUsthat function adequately, they make Uttle or no amylin and thereforemay not experience the degree of satiety that nondiabetics do. Theyare therefore more likely to remain hungry after a meal and thus toovereat at meals and snack between meals.

Perhaps the most excitingclassof drugs to hit the market in manyyearsactuaUy solves this problem.Productsin this categoryare caUedincretin mimetics (IMs) — that is, they imitate the effects of incretinsor of amylin. What is so special about them is that in my experiencethey reaUy work, and they do so for about 90 percent of users, a veryhigh degree of success. At present these products are sold to lowerblood sugar after meals. Our appUcation to overeating is thereforeconsidered"off label" but is permitted by the FDA if prescribedby aphysician.

The most effective IMs,at this writing,must be administered by injection one or more times daUy. The good news is that the needles aretiny, so these injections are painless if you foUow our injection technique (Chapter 16). A once-weekly version wiU be avaUable shortlyand an oral version (Januvia) is now on the market. But start now withthe injections because the benefits are so great.

How to Curb CarbohydrateCravingor Overeating 205

For example, I sawa newpatient recently who weighed 286pounds(130 kUograms) andhadan HgbAlc of6.9 percent when we first met.I started her on an IM, and over a period of sUghtly less than a monthand a half (44 days), her weight came down to 258 pounds (117.3 kUograms) andherHgbAlc dropped to 5.2 percent. Thus shelostan average of nearly 3A pound per day and her three-month moving averageblood sugars dropped from 176 mg/dl to 108 mg/dl. Her highestblood sugar of the final week of this period was 95 mg/dl. Since thefirst dose of the new medication, she has been able to foUow our low-

carbohydrate meal plan without hunger,cravings, or any snacking.The recently developed incretin mimetics faU into three categories:

Amylin analogs. The onlyone beingmarketedin late 2006is pram-lintideacetate, brand name Symlin. It ismarketedbyAmyUn Pharmaceuticals, Inc. It is chemicaUy simUar to amylinand performs the samefunctions in the body. It is only avaUable for injection.

GLP-1 mimetics. GLP-1 is one of the hormones secreted into the

bloodstream by the intestines that teU the beta ceUs of the pancreas tosecrete amylin, insuUn, and glucagon. GLP is an abbreviation for"glucagon-like peptide."The only version currently on the market isexenatide (Byetta),jointly marketed by AmyUn Pharmaceuticals, Inc.,and EU LUly and Company. It too is only avaUable for injection.

DPP-4 inhibitors. DPP-4 is an abbreviation for dipeptidyl peptidase-IV,the enzyme that the body uses to destroy GLP-1.Administration of its inhibitor opposes the destruction of naturaUy producedGLP-1. This circumvents the need for injecting a GLP-1 mimetic.Merck and Company is now sellinga tablet that can be taken oraUy—sitagliptin phosphate (brand name Januvia). I question whether it wUlbe as effective for diabetics (whomakelittleor no amylin) as for nondiabetics. I am currently testing it for lowering blood sugars aftermeals.

HOW DO WE USE THE

INCRETIN MIMETICS?

The only classof IMs that wiU be effective for curbing the appetite ofpeople who havevirtuaUy no beta ceUs (type 1diabetics) is the amyUn

206 Treatment

analogs (i.e., pramlintide), sincethe other agentsonly serve to teU existing beta ceUs to make more amylin.Therefore it makes sense to useonly this class forthose ofus who make no insuUn.

There is one catch, however. Most type Is havehad high blood sugars for more than five years and are therefore likely to have at leastsome degree ofgastroparesis, ordelayed stomach-emptying. Since oneof the actionsof amylin (and therefore the other incretin mimetics) isto slow stomach-emptying, gastroparesis is likely to worsen. As explainedin Chapter22,severe gastroparesis canmake blood sugar control impossible. If I am faced with a type 1 diabetic who has mUd tomoderate gastroparesis but who also snacks on carbohydrate orovereats, I must then decidewhich wiU disturb his blood sugarsmore,the eatingbehavioror the gastroparesis. This canbe a tough caU, butthe decisioncanbe facUitated with the helpof the R-Rstudy describedin that chapter. Any physician contemplating this problem should certainly readthat chapter.

I have one very obese patient who only overeats at restaurants andparties. He has moderate gastroparesis. I therefore have him takingSymlin only beforeeating out. Fortunately, this strategy is working.

VirtuaUy any prescription medication has a potential for adverseside effects, and the IMs areno exception. Since they do slow stomach-emptying, their most common adverse effectis gastrointestinal disturbances such asnausea, constipation,stomachaches, and even diarrhea.It is therefore wise to start aU ofthem at alow dose and work up slowlyif necessary.

Manufacturers of IMs currently on the market saythey must be injectedabout 1hour beforebreakfast and supper. I suggest that exceptions should be made for those who overeat only between supper andbedtime, or only at supper, andso on. In suchcases, I prescribe the IMabout 1 hour before the overeating or snacking usuaUy occurs. Forthose who only snack in the lateafternoon and otherwise stick to ourmeal plan,I'd prescribe it for useabout 1hour beforethe usualtime ofafternoon snacking. Strangely, some users find that pramlintide mustbe injected 2-3 hours before the targeted time for it to be effective.Therefore timing of injectionsis a matter of trialand error.

It is likely that in the near future long-acting injectable IMs wUl beavaUable that need be taken only once weekly.

RecaU from page 98 that amylin also reduces the body's productionof or sensitivity to glucagon — the major culprit in the Chineserestaurant effect. Between the reduced overeating and the reduced

How to CurbCarbohydrate Cravingor Overeating 207

glucagon effect,blood sugars can be much lower after meals — evendangerously low if you takeblood sugar-lowering medicationsof anykind. It is therefore necessary that your physician loweryour dosesofthese agents at the time you start any incretin mimetic.

How much should doses be lowered? To some extent it comes down

to experimentation. I usuaUy start by lowering premeal medicationsby about 20 percent. I then may look at blood sugars the next day tosee if dosing of these medications should be increased or decreased.

Adjusting Doses of Pramlintide (Symlin)Pramlintide is suppUed in rubber-stoppered vials, like insulin, butonlyhalf the size (5 ml). EachmiUUiter contains600meg of the drug.It is injectedwith a standard insulinsyringe, so 1"unit" on the syringecontains 6 meg. I usuaUy start patients who weigh less than 150pounds on 2-4 units taken 1 hour before their usual episodes ofovereating or snacking. So if someone only overeats at supper, shewould inject about 1 hour before supper. If he snacks between 9 p.m.and midnight, he'd injectat 8 p.m. and, if necessary, again at 10p.m. Ifsomeone overeatsonly when eating out, he'd inject about 1 hour before he anticipatesarrivingat the restaurant and not on other days. Ifshe snacks aU day long, she might inject on arising and every 3-4hours thereafter.

If someone gets adverse side effects, we'd cut back to a lower doseuntil side effects diminish, and then increase each dose lh unit perweek until either cravings vanishor sideeffects reappear. If no adverseeffects appear initiaUy, doses might each be increased by 2 or 4 unitsuntil cravings cease. Heavier people might start at higher doses withlarger increases.

If doses total 120units over the courseof a daywithout a major effect on appetite, I would assume that the medication is ineffective.

Adjusting Doses of Exenatide (Byetta)Untilwehave a once-weekly doseof Byetta, it wiU be necessary to focus dosing on the times of daywhen overeating or snacking occurs.This means starting with the 5 meg prefiUed syringe (orange label)and injectingabout 1 hour beforetimes of snackingor overeating occur. Study the packageinsert carefuUy to learn how to inject with thisspecialdevice,which the manufacturer refers to as a pen. (Avideo tutorial is avaUable on the manufacturer'sWeb site,www.byetta.com.)

If you overeat only at one meal, inject about 1 hour before that

208 Treatment

meal. If 5 meg helps partiaUy, the dose can be increased to 10 meg byeither injectingtwo 5 meg doses or 1 dose from the 10meg (blue label) pen. If the eating problem occurs several times daUy, 5-10 megshould be injected 1hour prior to eachtime of the daywhen the problem eating usuaUy occurs.The maximum daUy dosageof exenatide is20 meg.

MY PREFERENCE

If we ever get a once-weekly dose of exenatide or if Januvia helpsovereating, I wiU certainlyconsiderthem because of their easeof use(assuming, also, that they are as effective). In the meanwhUe, I preferthe pramlintide (SymUn) because the amounts injected can be adjusted in smaU increments and multiple daUy doses are faciUtated,even though that is contrary to instructions on the package insert.Also, the pramlintide is much more likely to work for people withminimal or absent beta ceUs.

Afterreading the draft of the aboveparagraph, I haveprescribedfora few patients a new product that stimulates the intestines to secretetwo hormones, GLP-1 and cholecystokinin (CCK). We've already discussed GLP-1. CCK, like amylin, works directly upon the brain tobring about satiety. Although this newproduct isdouble-barreled,it isnot as effective as injected pramlintide. The new product containspinolenic acid, a polyunsaturated fatty acid that's derived from pinenuts. It is sold as a supplement caUed Natural Appetite Control, by theLife Extension Foundation. It is worth trying for people who distrustproducts approved bythe FDA, but so far I'veseenno appetite reductions after minimal trials. Dosing is 1-3 softgels about 30 minutes before times of anticipated overeating or snacking. The cost is $28 perbottle if purchased singly, $19 per bottle if purchased in groups offour.Toorder,phone (800) 544-4440 or visitwww.lifeextension.com.

Of all the medications mentioned in this chapter,the IMs certainlywork for more people than the others. If it turns out that they remaineffective after years of use by the same individual, I wiU certainly caUthem miracle drugs.

Recent studies in animals have shown IMs to foster beta ceU regeneration. I'm sure that this won't cure diabetes,but it may further enhance the abUity of diabeticsto control and normalize blood sugars.

Howto Curb Carbohydrate Craving orOvereating 209

CAN ANY OF THESE TREATMENTS

PERMANENTLY STOP OVEREATING?

1 have seen patients using autohypnosis, low-dose naltrexone, andevenjust low-carbohydrate dietswho,after one year, found that theyno longer had cravings for carbohydrates or excess food, even whenthey discontinued hypnosis or naltrexone. This is probably akin tosome studies of depressed patients treated with certain antidepressants: after a period of time, the antidepressants may no longer beneeded.MetaboUc brain scans sometimes showan apparentlypermanent normalization of brain function in selected regions. For aU weknow, this may applyas weU to the incretinmimetics.

One of my pramlintide patientsfound that it ceased workingafter2 months of use. She discontinued it for one week and restarted at a

lower dose. The lowerdoseis stillworking after2V2 months.In any event, the improvement in blood sugars and concomitant

weightlossare major incentives to give these methods a try.

IF THE STOPPER ON THE SYMLIN VIAL

IS TOO HARD

Some Symlin users have complained that the stoppers on some oftheirSymlin vials have beensohard that the needle of their insuUn syringe is duUed after one fiUing with Symlin. They also have complained that on some vials, the needle actuaUy becomes permanentlybent when one attempts to puncture the vial.

Amylin Pharmaceuticals isplanningto comeout with an improvedstopper,but approvalof this product by the FDA maydelaythe releaseby several years from the time of this writing. The company is alsoplanning to come out with a Symlin pen simUar to the pen used forByetta. This is not reaUy a solution to the problem,since the pen wiUonly inject fixed doses instead of the variable doses that we seek.

Thisleaves uswith twooptionsforcircumventing the problem.Thefirst is to puncture the stopper in the verycenter, where the rubber isthinnest. The needle should be perpendicular to the surface of thestopper and should not puncture it at an angle. If this technique doesnot solve the aforementioned problems, then it wiU be necessary to

210 Treatment

transfer your Symlin to empty vials that are more suited to use withinsulin syringes.

Empty, sterUe insulin vials are avaUable at no charge from mostpharmacies. They are also avaUable from EU LUly and Company.Yourphysician can prescribe these empty vialstogetherwith a 5 cc syringewith a IVi-inch,23 gauge needle for transferring the Symlin from theoriginal vialto anew 10ccinsulinvial. The technique for transferringthe SymUn is very simple. Puncture an empty vial with the 23 gaugeneedle and drawout 5 cc of air. Injecthalf the airinto the SymUnvial.With the vial upside down and the needleweU below the surfaceoftheUquid, draw out about2.5ccof SymUn. Then injectthe restof the airinto the Symlin vialand drawout the remaining2.5cc of Symlin.

You now can inject the 5 cc of Symlin into the empty, sterUe vial. Ifyou wish, you canrepeat the above procedure with a second 5 cc SymUn vial, transferring its contents to the same empty 10 cc insuUn vialthat you used previously.You can,forexample,transferthe contents often Symlin vialsto five 10cc insulin vials.

UPDATES ON FORTHCOMING

APPETITE SUPPRESSANTS

Anyone can purchase a subscription to Obesity Meds and ResearchNews at www.obesity-news.com, or by phoning (703) 960-5513 orfaxing (703) 960-7462. This is the best update source that I know offor news on upcoming and newly approvedmedications.

14

Using Exercise to Enhance

Insulin Sensitivity

Strenuous, prolonged exercise is the next level of our treatmentplan after diet, and should ideaUy accompanyany weight-lossprogram or treatment for insulin resistance (as in type 2 dia

betes). Before we go into our specific recommendations for exercise,aU of which should be approved by your physician prior to puttingthem into practice,it's important that you understand the benefits exercisecan bring.

WHY EXERCISE?

WhUe many peoplemaybeginexercising out ofasenseof responsibU-ity — the way chUdren eat vegetables they don't like — the main reason they keep exercising is that it feels good. Whether it's the intensecompetition of a fast and furious basketbaU game, or cycling alone inthe countryside,exercise bringsmany rewards — physical, psychological, and social.

People who aren't diabetic and exercise strenuously and regularlytend to Uve longer, are healthier, look healthier and younger, havelower rates of debUitating and incapacitating Ulnesses such as osteoporosis, heart disease, high blood pressure, memory loss of aging—and the Ust goes on. OveraU, peoplewho exercise regularly arebetterequipped to carry on day-to-day activities as they age.

Many type 1 diabeticshavebeen Ul for so long with the debUitatingeffects of roUer-coaster blood sugars that they are often depressedabout their physical health. Numerous studies have established a linkbetween good health and a positivemental attitude. If you'rea type 1

212 Treatment

diabetic,asI am, strenuous exercise wiU not improve your blood sugarcontrol as it wiU for type 2s (which we'U discuss shortly), but it canhave a profound effect on your self-image. It's possible, if you keepyourbloodsugars normal andexercise regularly andstrenuously, to bein betterhealththan yournondiabetic friends. Also, it'sbeen my experience that type 1diabetics who engage in a regular exercise programtend to takebetter care of theirblood sugars and diet.

Think of exercise as money in the bank — every 30 minutes youput intokeeping in shape today wUl not onlyleave youbetter off rightnow, it wiU paycontinuing dividends in the future. If going up thestairs yesterday leftyouhuffingandpuffing, in awhUe you'll bound upthe steps. Your strength wUl likely make you feel younger, possiblymore confident. There isevidencethat exercise actuaUy does make youlook younger: even the skinof those who exercise regularly tendsnotto ageasrapidly.

After working out for a few months, you'U look better, and peoplewUl mention it. With this kind of encouragement, you may be morelikelyto stick to otheraspects of our regimen.

Although most of us who engage in bodybuUding exercise can experience increases in muscle mass and strength, the degree to whichwe respond is in part geneticaUy determined. With very simUar exercise regimens, somepeople wiU show dramatic increases in both musclebulk andstrength; others wUl showneither. Mostof usUe betweenthese two extremes. There areeven people who gain strength but notlarge muscles, andothers who can buildlarge muscles without gettingmuch stronger. If you don't develop big muscles or great strength,you wiU stiU enjoy the other benefits from the weight training described here.

It has longbeen known that strenuous exercise raises the levels ofserumHDL (good cholesterol) andlowers triglycerides in the bloodstream. Recent studies suggest that bodybuUding exercise (anaerobicrather than aerobic exercise) also lowers serum levels of LDL (badcholesterol).There is even evidence that atherosclerosis (hardening ofthe arteries) may be reversible in some individuals by such major improvements in serum Upid profiles. I'm weU over seventy, I exercisestrenuously on adaUy basis, I don't eat fruit, I've hadtype 1diabetes forsixty years, and I have two eggs for breakfast every day. Where's mycholesterol? It'sin averyhealthyrange that nondiabeticsone-third myage rarely attain (page 131). Part of thatisdueto mylow-carbohydratediet, but part of it is due to my daUy exercise program.

UsingExercise to Enhance InsulinSensitivity 213

Frequentstrenuous exercise hasbeen shown to reduce significantlythe Ukelihood ofheartattack, stroke, andblockage ofbloodvessels bylowering serum fibrinogen levels. Long-term strenuous exercise lowers resting heart rate and blood pressure, further reducing the risk ofheart attacks and stroke.

Weight-bearing, resistance, and impact exercise slow the loss ofbone mineral associated with aging. Ever hear the slogan "Use it orlose it"? In a very realsense, ifwe don't use our bones, we lose them.

Although exercise does make weightcontrol easier, it does not directly — atleast not as muchas wemaywish— "burn fat." Unless youworkout at verystrenuous levels for several hours each day, exerciseisn't going to have a significant direct effect upon your body fat. Theeffects of exercise are broader andmore indirect. Oneof thegreat benefits is that many people find that when they exercise, they have lessdesire to overeat. The reasons for this are probably related to the release in the brain of neurotransmitters suchas endorphins. (As notedin the previous chapter, endorphins are "endogenous opiates" manufactured in the brain. They can elevate mood, reduce pain, and reducecarbohydrate craving. Brain levels of endorphins are reduced in poorlycontroUed diabetes.*) It might be said that in the samewaythat obesity leads to further obesity, fitness leads to further fitness.

Even though your fat won't "melt away," exercise, particularly ifyou're atype 2 diabetic, isstill of value in aweight-reduction programbecause muscle buUding reduces insulin resistance. Insulin resistance,remember, is linked to your ratio of abdominal fat to lean bodymass.The higher your ratioofabdominal fatto muscle mass, the moreinsulin-resistant you're likely to be.Asyou increase yourmusclemass,your insuUn needswiU be reduced — and having less insulin presentin yourbloodstream wUl reduce the amount of fat you pack away. Ifyou remember my old friend Howie from Chapter 12, his insulin resistance dropped dramatically when helost 100 pounds and radicaUychanged his ratio ofabdominal fat to lean body mass.

Long-term, regular, strenuous exercise also reduces insulin resistance independently of its effect upon muscle mass. This makes youmore sensitive to your own and injected insulin.As a result, your in-

* Plasma endorphin levels can be measured by most commercial laboratories. Ifyouarecuriousabout your level, just askyourphysician to order plasmabetaendorphin prior to startingan exercise program or a regimen of naltrexone andagain a fewweeksor months later.

214 Treatment

sulin graduaUy becomes more effective at lowering blood sugar. Ifyou inject insulin, your dosage requirements wiU drop, and the fat-buUding effects of largeamounts of insulin wiU likewise drop. In myexperience, daUy strenuousexercise wiU, overtime,bringabout a steady,increased level of insuUn sensitivity. This effect continues for abouttwo weeksafter stopping an exercise program. Awareness of this is especiaUy important for those of us who inject insulin and must increaseour doses after two weeks without our usual exercise. If you goout of town for only a week and cannot exercise, your increased insulin sensitivity wiU probablynot suffer.

Although increased muscle bulk also increases insulin sensitivity,independently of the aboveeffect, this isverygradual and may requiremany months of bodybuUding beforeits separateblood sugar effectsbecome noticeable.

HOW DOES EXERCISE DIRECTLY AFFECT

BLOOD SUGAR?

Exercise does affectblood sugar,and for that reason it can make yourefforts at blood sugar control sUghtly more difficult if you're taking insulin or sulfonylurea blood sugar-lowering medications.* The benefits, however, are so great that if you're a type 2 diabetic, you'd befooUsh not to get involved in an exercise program.

Foryears, guidelines for the treatment of diabetes haverepeated thehalf-truth that exercise always lowers blood sugar levels. In reaUty,physical exertion can indeed lowerblood sugar via increased numberand mobilization of glucosetransporters in muscle ceUs. Certain conditions, however, must be present: exertion must be adequately prolonged, serum insulin levels must be adequate, blood sugar must notbe too high, and for most of us, exercise should not be performedwithin 3 hours of arisingin the morning (seepage 216).

Moderate to strenuous exercise such asswimming,running, weightUfting, or tennis — as opposed to more casualexercise, such as walking — causes an immediate release of "stress," or counterregulatory,hormones (epinephrine, Cortisol, et cetera).These signal the Uver and

* AsI will explain in Chapter 15,1 recommendagainst the use of sulfonylureasand similar medications.

UsingExercise to Enhance Insulin Sensitivity 215

muscles to return glucose to the bloodstream by converting storedglycogeninto glucose.The nondiabetic response to the additional glucose is to release smaU amounts of stored insulin to keep blood sugarsfrom rising. Blood sugartherefore wUl not increase. If a type 2 diabeticwithout phaseI insulin responsewereto exercise fora fewminutes, hisblood sugar might increase for awhUe, but eventuaUy it would returnto normal, thanks to phase II insulin response. Thus, briefstrenuousexercise can raise blood sugar, whileprolonged exercise can lower it. Forthis reason, Dr.EUiot P. Joslin told a group ofus (in 1947): "Don't runa block for a bus, run a mUe."

When insulin is nearly absent in the blood, the glucose released inresponse to stress hormones cannot readUy enter muscle and Uvercells. As a result,blood sugar continues to rise, and the muscles mustrely upon stored fat for energy. On the other hand, suppose that youhave injected just enough long-acting insulin within the previous 12hours to keep your blood sugar on target without exercise, and thenyou run a few mUes. You wiU have a higher serum insuUn level thanneeded, because exercise facUitates the action of the insulin alreadypresent.Blood sugarmay thereforedrop too low.The same effect mayoccur if you are using sulfonylureas, a class of oral hypoglycemicagents. Furthermore, if you haveinjectedinsulin into tissue that over-Ues the muscle being exercised, or perhaps into the muscle itself, therate of release of insulin into the bloodstream may be so great as tocause serious hypoglycemia. Nondiabetics and type 2s not on insulinor sulfonylureascan automaticaUy turn down their insuUnin responseto exercise.

It may be unwise for you to exercise if your blood sugar exceedsabout 170 mg/dl. This number varies with the individual and themedications taken. This is because elevated blood sugars wiU tend torise even further with exercise. This effect wiU be less dramatic if

you're making a lot of insulin, and is most dramatic for a type 1 diabetic who doesn't take extra insulin to prevent the blood sugarelevation. I have one type 1 patient who keeps her blood sugarsessentiaUynormal.She stUl makesalittle insulinanddislikes insulin injectionssomuch that she works out everydayafterlunch to save herselfa shot tocover the lunch. In her case, the exercise plus the smaU amount of insulin she stiU makes together work very weU.

One greatbenefit ofregular, strenuous exercise in type 2 diabetes,asmentioned earlier, is that it can bring about a long-term reduction ofinsulin resistance, by increasing muscle mass. Long-term muscle de-

216 Treatment

velopment, therefore, can faciUtate blood sugar control and weightloss. It also reduces the rate ofbeta ceUburnout, because the increased

ratio of muscle mass to abdominal fat reduces insulin resistance and

thus reduces the demand for insulin production.

THE DAWN PHENOMENON AND EXERCISE

Several of my type 1 patients must take additional fast-acting insulinwhen they exercise in the morning, but not when they exercise in theafternoon. This is a dramatic exampleof how the dawn phenomenonreduces even injected serum insulin levels. In the afternoon theirblood sugardrops with exercise, but in the morning it actuaUy goesupif they do not first inject some rapid-acting insuUn.

RESTRICTIONS ON EXERCISE

Despite the benefits that exercise can have, an exercise program thatisn't sensibly put togethercan have disastrous results. Even if you thinkyou're perfectiyfit,your physicianshould be consulted before you proceed. Keep in mind that there are certain physical conditions that mayrestrict the type and intensity of exercise you should attempt. Yourcurrent age,your cardiac and muscle fitness, the number of years you'vehad diabetes,the average level of your blood sugars,whether or not —and how much — you'reoverweight, and what sort of diabetic complicationsyou havedeveloped: aU thesemust be considered to determinewhat kind of exercise you should undertake,and at what intensity.

Before You Start

FoUowing are severaldifferentaspectsof your health you should consider and discusswith your physicianbeforeembarking upon an exercise program.

Heart. Everyone over the ageof forty, and diabetics over the age ofthirty, should be tested for significant coronary artery disease beforebeginning a new exercise program. At the veryleast,an exercisingelectrocardiogram, stress echocardiogram (my preference),or stress thallium scan is usuaUy advised. An abnormal test may not necessarUy

Using Exercise to Enhance Insulin Sensitivity 217

rule out exercise, but it may suggest restraint or close supervisionwhUe exercising. Again, seek your doctor's advice before starting anynew exercise program.

High blood pressure. Although long-term exercise helps to lowerresting blood pressure, your bloodpressure can risewhUe you are exercising. Ifyou're subject to wide pressure swings, theremaybe riskofstroke and retinal hemorrhages during strenuous exercise. Again, firstcontact your physician.

Eyes. Before beginning anyexercise program, you should have youreyes checked bya physician, ophthalmologist, or,ideaUy, a retinologistexperienced in evaluating diabetic retinal disease (retinopathy). Certain typesof retinopathy are characterized bythe presence of neovascularization, or very fragUe newbloodvessels growing from the retinainto the vitreous gel that overUes it. If you strain too much,assume ahead-down position, or landhardon yourfeet, these canruptureandhemorrhage, causing blindness. If yourphysician or ophthalmologistidentifies such vessels, you'U probablybe warned to avoidexercises requiringexertion of strongforces (e.g., weight Ufting, chinning, pushups,sit-ups) and sudden changes of motion (e.g., running, jumping,falling, diving). Bicycling and surface swimming are usuaUy acceptable alternatives, but first check withyourphysician.

Fainting. A form of nerve damage caUed vascular autonomic neuropathy (caused by chronically high blood sugars) can lead to lightheadedness and even fainting during certain types of exertion (seepage 341), such as weight Ufting and sit-ups. Such activities shouldtherefore be embarked upon graduaUy and onlyafter instruction byyour physician.

If you take blood sugar-lowering medications. If you take insulin or oral hypoglycemic agents, it is wise to makesure your bloodsugars are stabilized before you begin a strenuous exercise program.As previously noted, exercise can have significant effects upon bloodsugars and introduce another variable that can confuse anyone reviewing your blood sugar data. It's much easier to readjust your dietand/or medications to accommodate physical activity after blood sugars are under control.

218 Treatment

Sympathetic autonomic neuropathy. If you're unable to sweatbelowyourwaist, there isa possibUity that prolonged exercise maycauseundue elevation of your body temperature.

Proteinuria. Elevated levels of urinary protein are usuaUy exacerbated by strenuous exercise. This in turn can accelerate the kidneydamage that youmayalready have.

Ongoing Concerns for Exercising DiabeticsFoUowing is a Ust of aspects of healthyoushouldconsider on an ongoingbasis asyou pursueyour exercise program.

Recent surgery. A history of recent surgery usuaUy warrants restraint or abstinence until you receive clearance fromyour surgeon.

Blood sugar changes. Even after blood sugars are reasonablyweUcontroUed, illness, dehydration, and eventransient blood sugar valuesover170 mg/dlare reasons foryouto refrain from exercise. Formanypeople, bloodsugars above 170 mg/dl wiU increase furtherwithexercise, due to the production of stress hormones that wediscussed previously.

Blood sugars below target values. Ifyoutakebloodsugar-loweringmedications, do not exercise if blood sugar is belowyour target value.Bring it up to targetfirst withglucose (see thenextsection, and Chapter 20,"How to Prevent and Correct LowBlood Sugars").

Possible foot injury. If you've had diabetes for a number of years,thereisa goodchance thatyourfeet areespeciaUysusceptible to injurywhUe exercising. There are several reasons for this:

• The circulation to your feet maybe impaired. With a poor bloodsupply, the skin is readUy damaged and heals poorly. It also ismore likely to be injuredby freezing temperatures.

• Injuryto nerves in thefeet caused bychronicaUy highbloodsugars leadsto sensoryneuropathy, or diminished abUity to perceivepain, pressure, heat,cold, and so on. Thisenables blisters, abrasions, and the like to occur and continue without pain.

• The skin of the feet can become dry and cracked from anotherform of neuropathy that prevents sweating. Cracks in heels arepotential sitesof ulcers.

Using Exercise to Enhance Insulin Sensitivity 219

• A third form of neuropathy, caUed motor neuropathy, leads towasting of certain muscles in the feet. The imbalance betweenstronger and weakermuscles leadsto a foot deformity verycommon among diabetics, which includes flexed or claw-shapedtoes, high arches, and bumps on the sole of the foot due toprominence of the heads of the long metatarsalbones that leadto the toes.Theseprominent metatarsal headsare subject to highpressure during certain types of weight-bearing exercise. Thiscan lead to caUuses and even skin breakdown or ulcers. The

knuckles of the claw-shaped toesaresubjectto pressurefrom theupper surface of your shoes or sneakers. The overlying skin cantherefore blister and ulcerate.

• Another form of neuropathy makes it difficult to perceive jointpositionin the feet. This, in turn, canleadto orthopedicinjuries(e.g., bone fractures) whUe running,jogging, or jumping.

AU of this implies that the feet must be carefuUy protected duringexercise. Your physician or podiatrist shouldbe consulted before youstart any new exercise, as some restrictions may be necessary. Evenprolonged swimming can cause maceration of the skin. You shouldalso be thoroughly trained in foot care. Please seeAppendix D,"FootCare for Diabetics."

You or a famUy member should examine your feet daUy for anychanges, abrasions, pressurepoints, pink spots,blisters,and so on. Besure to checkthe soles of your feet, usinga hand mirror if necessary. Ifyoufindanychanges, seeyour physician immediately. Bring withyouaU the shoes and sneakers that you currently use, so that he can trackdown the cause of the problem. Atthe very least he mayrecommendthe use of flexible orthotic inserts and wide, deep toe box sneakerswhUe exercising. No attempt shouldever be madebyanyone (including podiatrists) to remove calluses, as this is probably the most common cause of ulceration.

FOR DIABETICS WHO USE BLOOD

SUGAR-LOWERING MEDICATIONS:

COVERING EXERCISE WITH

CARBOHYDRATE

People who do not take medications that lower blood sugar are usuaUy able to "turn off" their insulin secretion in response to a drop in

220 Treatment

blood sugar brought about by exercising. You cannot, however, turnoff sulfonylurea hypoglycemic agents or injected insulin once you'vetaken them. (This is one of the reasons I never prescribe sulfonylureasand simUar products.) To prevent the occurrenceof dangerously lowblood sugars, it is wise to coverthe exercise with glucose tablets (e.g.,Dextrotabs; see page326) in advance of a drop in blood sugar.

Some type 1 diabetics try to use"treats," such as fruit or candy, tocover an anticipatedblood sugar drop. I don't ordinarily recommendthis approach, because it's not as precise as using glucose tablets. Myexperience with patients who've taken raisins or grapes or candies tocover their exercise has been that they suffer subsequent elevatedblood sugars. Say you eat an apple. It wiU contain some fast-actingsugars that enterthe bloodstream almostimmediately. It wiU also contain other, slower-acting sugars that may take several hours to havetheir fuU effect upon blood sugar. On the other hand, as we wiU discussbelow,certainsustainedactivities — such ascross-country skungor physical labor formany hours— cankeep your blood sugar dropping aU day. For those, you'll need something longer-acting to helpkeep you from becoming hypoglycemic.

To discover how much carbohydrate you shouldtake foragivenexercise session requires some experimentation and the help of yourblood sugar meter.One valuable guideUne is that 1 gram of carbohydrate wUl raise blood sugar about 5 mg/dl for people with bodyweights in the range of 140 pounds. A chUd weighing 70 poundswould experience double the increase, or 10 mg/dl per gram, and anadult weighing 280 poundswould probably experience only half thisincrease (2.5 mg/dl).

My own preference is Dextrotabs, each ofwhich contains1.6gramsof glucose. Other brandsof glucose tablets are avaUable at most largepharmacies anddiabetes maU-order suppUers (see Chapters 3 and 20).If you weigh 150 pounds, one Dextrotab wiU raise your blood sugarabout 8 mg/dl. Sincethese glucose tablets start raising blood sugar inabout 3 minutes and finish in about40 minutes, they'reideal for relatively brief exercise periods.

Let's run through a hypothetical example to demonstrate howyou'd go about determininghow many tabletsyou ought to take. Let'sassume you weigh 170 pounds and 1 Dextrotab wiU likely raiseyourblood sugarabout 7 mg/dl.You'vedecided to swim (or playtennis) foran hour.

Using Exercise to Enhance Insulin Sensitivity 221

• First, check yourbloodsugar before starting (you should alwayscheck blood sugar before starting to exercise). If it's below yourtarget value,takeenough Dextrotabs to bring it up to target. Wait40 minutes for them to finish working. If you don't come up toyour target, you may be too weak to exercise effectively. Recordyour blood sugar levelupon starting. (I urge the use of Glucograf data sheets for recording aU exercise-related blood sugars.)

• When you begin such activity — the first time you exercise afterbeginning our regimen — take 1 Dextrotab, and then 1 againevery 15 minutes thereafter.

• Halfway into your activity, checkblood sugar again, just to makesure it's not too low. If it is, take enough Dextrotabs to bring itbackup, andcontinuethe exercise. If it'stoo high,you may needto skip the next few tablets, depending upon how high the value.

• Continue the exercise and the tablets (depending upon bloodsugarlevels).

• At the end ofthe exercise period, measure bloodsugar again. Correct it with glucose tablets if necessary. Remember to write downaU blood sugarvaluesand the time when eachtablet was taken.

• About an hour after finishing your workout, checkblood sugaragain. This is necessary because it may continue to drop for atleast 1hour after finishing. Bring it backup with glucose tabletsif necessary. (Very intense or prolonged exercise maykeepbloodsugarsdropping for as long as 6 hours.)

• If you required, say, a total of 8 tablets altogether, this suggeststhat in the future you should take 8 tablets spread out over thecourse ofyourworkout. If youonlyrequired 4 tablets, then you'dtake 4 tablets the next time. And so on. For some exercise programs you may need no tablets.

• Repeat thisexperiment on occasion, because youractivitylevel israrely exactly the same for every exercise period. If you required3 tablets the first time and 5 tablets the second time, take theaverage, or 4 tablets, the next time. If your activity level increases — sayyou'vebeen playing with a slowtennis partnerandyou find another who makes yousweat yourbutt off— you mayfind it necessary to increase the number of glucose tablets.

Thereare some activities where coverage with aslower-acting formof carbohydrate may be appropriate, and it's here, perhaps, that you

222 Treatment

could use the "treats" I would normally discourage. For example, Ihave two patients, both on insulin, who are housepainters. Neitherworks every day, and the hours of work vary from day to day. Theyrarelywork for less than 4 hours at a time.The painter in Massachusetts finds that half a blueberrymuffineveryhour keepshis blood sugars level, whUe the painter in NewYork eats a chocolate chip cookieevery hour.

Somepatients find that their blood sugars drop when they spend afew hours in a shopping maU. I teU them to eat a sUce of bread (12gramscarbohydrate) whentheyleave their car. The bread wiU start toraise blood sugar in about 10minutes,and wUl continue to do so forabout 3 hours. The cookies and blueberrymuffinscontain mixtures ofsimpleand complex sugars, so theystart working rapidlybut alsocontinue to raise blood sugar for about 3 hours. I discourage the use offruits, which can raise blood sugar lesspredictably. If your exercise isnot going to continue for many hours, coverit with glucose — not afun food — if you want predictableresults.

Beware, however. If you havea history of craving carbohydrate, funfoods are likely to exacerbate the problem, making the addiction impossibleto control.

Whatever your plan for coveringexercise with carbohydrate, alwayscarry glucose tablets with you! If you have gastroparesis, you may dobetter with a Uquidglucosesolution (see page 377).

WHAT FORM OF EXERCISE IS

BEST FOR YOU?

As you are by now aware, insulin resistance, which is the hallmarkoftype 2 diabetes, is enhanced in proportion to the ratio of abdominalfat to lean body mass.One of the best ways to improve this ratio in order to loweryour insuUn resistance is to increase your lean body mass.Therefore, for most type 2 diabetics, the most valuable type of exerciseis muscle-buUding exercise. (It'sgoodfor type Is too,becauseit makesyou feel better, look better, and can improve your self-image.) Therealso is cardiovascular exercise, which benefits the heart and circulatorysystem, and wiU be discussed later in the chapter.

First, what is muscle-buUding exercise? Resistance training, weighttraining (weight lifting), or gymnastics would aU qualify. If doneproperly, weight lifting has many attributes that make it superior to

Using Exercise to Enhance Insulin Sensitivity 223

theso-caUed aerobic exercises. Aerobic exercise isexercise mUd enoughthat your muscles are not deprived of oxygen. When muscles exerciseaerobicaUy, theydon't increase muchin mass and theydon't requireasmuch glucose for energy. Anaerobic exercise deprives the muscles ofoxygen; it tiresthem quickly and requires nineteentimesas much glucose to do the same amount of work as aerobic exercise. When youperform anaerobic exercise, your muscles break down for the first 24hours, but then they buUdup over the next 24 hours. I have little oldladies performing weight-Ufting exercise. They're never going to looklike Arnold Schwarzenegger — it's physicaUy impossible becausewomen haven'tthe hormonesfor it — but they feel much better andare certainly strongerbecause of it. Theyalso buUd enough muscletoreduce their insulin resistance.

Butwhatabout aerobic exercise, suchasjogging or outdoor biking?I don't think it's as valuable for diabetics — or for anyone reaUy, forreasons weshaU discuss. StiU, I usuaUy suggest that mypatientsengagein activities that theywiU enjoyand wiU continueto pursue in a progressive fashion. Progressive exercise is exercise that intensifies over aperiod of weeks, months, or years. Below are Usted various characteristicsof an appropriate exercise program:

• It should comply with any restrictions imposed by your physician.

• The cost should not exceed your financial limitations.• It should maintain your interest, so that you'U continue to pur

sue it indefinitely.• Thelocation shouldbeconvenient, andyoushouldhave the time

to workout at least every other day. DaUy activity is very desirable.

• It should be of a progressivenature.• It should ideaUy buUd muscle mass, strength, and endurance.• The same muscle groups should not be exercised anaerobicaUy

two days in a row.

AEROBIC AND ANAEROBIC EXERCISE

You've often heard of aerobics, and now you've seen me mention"anaerobic" several times. What makes one of these types of exercisebetter for diabetics than the other?

224 Treatment

Our musclesconsistoflong fibers that shorten,or contract,when theyperformwork likeUfting aloador moving the body.AU muscle fibers requirehigh-energy compoundsderived from glucose or fatty acids in order to contract. Some muscle fibers utilize a process caUed aerobicmetabolism to derive high-energy compounds from smaU amounts ofglucose and large amounts of oxygen. These fibers can move Ught loadsfor prolonged periods of time, and are most effective for "aerobic" pursuits, such as jogging, race walking, aerobic dancing, tennis, nonsprintswimming,moderate-speed bicycling, andsimUar activities. Other muscle fibers canmove heavyloads but only forbrief periods. They demandenergyat avery rapid rate, and so must be able to produce high-energycompounds faster than the heart can pump blood to deUver oxygen.They achieve this by a process caUed anaerobic metabolism, which requires large amounts of glucose andvirtuaUy no oxygen.

This is of interestto diabetics fortwo reasons. First, the blood sugardrop during and after nearly continuous anaerobic exercise wiU bemuch greater than after a simUar periodof aerobic exercise because ofthis requirement for large amounts of glucose. Second, as your bodybecomes accustomed to this requirement, it wUladjust to the stressesyou put on it and more efficientlytransport glucose into your muscleceUs. As muscle strength and bulk develop, glucose transporters inthese ceUs wiU increase greatly in number. Glucose transporters alsomultiply in tissues other than muscle, including the liver. As a result,the efficiencyofyour own (or injected) insulin in transportingglucoseand in suppressing glucose output by the liverbecomes considerablygreater when anaerobic exercise is incorporated into your program.

In relatively short order, you wiU develop greater insulin sensitivityfor lowering blood sugar. SimUarly, your requirements for insulin(that which you create or inject) wiU diminish.The overaU drop in insulin in yourbloodstream wiU reduce yourbody'sabilityto hold on tostored fat, thus further lowering insulin resistance.

Think here of the Pimas. Not only did they gain access to an almostunlimited food supply,they also went from a strenuous existence,onethat naturaUy incorporated both aerobic andanaerobic activity, to onethat was almost entirely sedentary. Thus their circumstances werechanged utterly from what you might caU the biological expectationsof their bodies. Of course, it's not just the Pimas who are sedentary.When you understandhow to meet yourbody'sevolutionaryexpectations, you can begin to bring it back into balance.

Anaerobic metabolism producesmetabolic by-products that accu-

Using Exercise to Enhance Insulin Sensitivity 225

mulate in the active muscles, causing pain and transient paralysis —fora few seconds, youjust can'tcontractthat muscle again. Since theseby-products are cleared almost immediatelywhen the muscles relax,the pain likewise vanishes upon relaxation, as doesthe paralysis. Youcan identify anaerobic exercise by the local pain and the accompanyingweakness. This painisUmited to themuscles being exercised, goesaway quickly when the activity stops, and does not refer to agonizingmusclecramps or to cardiacpain in the chest. Anaerobic activities caninclude weight Ufting, sit-ups, chinning, push-ups, runningup a steepincline, uphitt cycling, gymnastics, using a stair climber, and so forth,provided that these activities are performed with adequate loadsandat enough velocity to cause noncardiac pain or transient discomfort(not heart attack, but the pain of"no pain,no gain").

BODYBUILDING: NEARLY CONTINUOUS

ANAEROBIC EXERCISE

Continuous anaerobic activity, as you can weU imagine, is reaUy impossible. The pain in the involved muscles becomes intolerable, andtheweakness that develops with extreme exertion leaves youunable tocontinue. Nevertheless, youcanapproach thisgoal byusingthespecial"inverted pyramid" technique described on page 228.

BodybuUding, or resistance exercise — which includes weight Ufting,sit-ups, chinning, and push-ups — focuses on one muscle groupat a timeand then shifts the focus to anothermuscle group.Ifyou usethe inverted pyramid technique you can achieve nearly continuousanaerobic activity, but on a rotating basis. After you finish exercisingcertain of your abdominal muscles bydoing sit-ups, for instance, youswitch to push-ups, which focus on various arm and shoulder muscles. From there, yougoto chinning. SimUarly, different weight-liftingexercises also focus on different muscle groups. Anaerobic exercisealso can increase the benefits of exercise in stimulating heart rateandthereby exercising the heart. To maintain an elevated heart rate, youswitch immediately from one anaerobic exercise to another, withoutresting in between.*

I personaUy preferthis typeof activity for type 2 or obesediabetics

*This type of cardiac exercise is not nearly as effective in raising heart rate asthose described under"Cardiovascular Exercise," page 230.

226 Treatment

because — as I have said before and wiU say again — the buildup ofmuscle mass lowers insuUn resistance and thereby facUitates bothblood sugar control and weightloss. A number of my patients engagein bodybuUding exercises, includingmen and women oversixtyyearsof age. Theyare aU verypleased with the results.*

Sincethe pubUcation of the firstedition of this book, there has beena change in our societyin the recognition of the importance of thiskind of exercise. Asignificant benefitis its abUity to help increasebonedensity. Bones, likemuscles, tend to be only as strong as they need tobe. When you strengthen your muscles, you're also exercising yourbones — your muscles, afteraU, areattachedto your bones;when theycontract, your bones move on their joints. If your bones weren't asstrong as the muscles attached to them,they'dsnap.

Some Suggestions for a Bodybuilding RoutinePlease refer back to "Restrictions on Exercise," page 216.These restrictions and cautions apply especiaUy to bodybuUding.

Even if you have room in your home, and the finances, to equipyour ownprivate gym, I usuaUy recommend that people go to an outsidegym or health club to learn the different exercises before beginning an anaerobic exercise program. Then, if you want to buydumbbeUs or a weight-lifting machinefor useat home, that's fine.Butit's important to learn good technique and good form first.You canalso consult books on the subject,but at least a fewsessionssupervisedby an experiencedinstructor is best.

Equipment. Foryourupperbody, you're goingto haveto useweights.I don't recommend that you Uft barbells— they can be dangerous,and you therefore must have assistance if you're using them — but Ido recommend dumbbeUs and weight-Ufting machines,which for themost part are quite safe to use.* Whether you're using dumbbeUs at

*A number of years ago, a report from the human physiology lab at Tufts University reported that onlytwelve weeks of weight trainingtripledthe strength ofmalesubjects ages 60-96.Thiswas believed to improve their qualityof life significandy. Subsequent studiesshowed similareffects in women.f A number of inexpensive multiexercise machinesare on the market that utilizethick rubber bands instead of weights. Beware of these: since you have to stopand change the bands to change resistance, they do not permit true anaerobictraining. Hydraulic and pneumaticmachines that utilize rotary knobs to adjustsettingsare usuallyexcellent but often quite cosdy.

Using Exercise to Enhance Insulin Sensitivity 227

home or in the gym, they should be soUd cast iron, usuaUy paintedblack enamel or gray. They're inexpensive — usuaUy 50-75 cents apound, so a 10-pound dumbbeU costs about $5-$7.50. Don't usedumbbeUs consisting of a bar with plates on either end that can beadded or removed. These can be dangerous — the plates frequentlysUde off— and they alsodefeatthe wholemethod that I advocate (see"Technique," below).

Exercises. Ifyou're going to a health club or gym to learn the ropes,I suggest that you learn fifteen upper body exercises, and as manylower body exercises as are avaUable. Upper bodywould be for thearms, hands, shoulders, flanks, chest, abdomen, andback. Ifyou're going to the gym every day, which I recommend, you'd do your upperbody exercises on oneday, andlower body exercises the next. Why alternate days? Becauseof the muscle breakdown over the first 24 hoursafter exercise and the need for time to rebuUd. So on the second day,whUe you're doing your lower body exercises, your upper body muscles are rebuUding.

As you can guess, there are more muscle groupsthat work in moreways in the upper body than in the lowerbody, so there are fewer sensible lower bodyexercises. If you're using a treadmiU, a stair, a bike,anda cross-country ski machine aU in thesame day, you're exercisingmore or less thesame lower body muscles witheach apparatus, whichisn't sensible. The other types of lower body exercises that involveweight lifting are few in number: leg presses, knee curls, toe presses,and knee extensions. Some gyms have machines to exercise yourlegsasyouspreadthem apart or squeeze them together, but in aU, thereareat most six legexercises commonly avaUable.

Asa consequence, I always add some other exercises on the days Ido lower bodyexercises: grip strengthening, side bends (which exercise the sidemuscles), and sit-ups or crunches, asweU aswhat's caUedcardiovascular exercise (page 230). Theinstructor at yourhealth clubwiU be able to help you with aU of these.

Form. To get the most out of your weight-Ufting exercises, it's important to have as close to perfect form as possible. This means thatyou isolate and useonlythe muscles targeted by a particularexercise.You shouldn't, forexample, use yourback muscles to help perform anarm exercise. You should also Uft slowly, saygraduaUy over about 7seconds, and let theweight downvery slowly overabout 15seconds, so

228 Treatment

that the entire individual repetition takes about 25 seconds — or aslongasyoucantolerate. This tends to bemucheasier on jointsandhasbeen shown to be a higher quahty of exercise. Do not fuUy flex or extend your muscles while weight lifting. Instead, stop just before youwould reach the endpoint of any motion. This is where having goodinstruction can pay off. Your instructor can critique your form andhelpyou select the right equipmentfor each exercise.

Technique: The Inverted Pyramid SystemFirst, a word ofwarning: Don't embark upon this technique until youhave demonstrated perfect form for each exercise. This wiU ensuremaximum benefit and minimize the possibiUty of muscle strain.

The most productive way to performan anaerobic exercise is to tirea particular group of muscles as quickly as possible and keep themtiredduringthe course of theexercise. Thismaysound a Uttle strange,given that we're aU accustomed to the idea that some athletes workinprecisely the opposite manner —warming up slowly and building toa fast finish. That maybe fine for a sprint,but we're not talking aboutracing here, we're talking about buUding muscle mass. By placingmaximumdemands on yourmuscles at first, youput yourselfinto theanaerobic (or oxygen-deprived) stateright off.Then bygraduaUy progressing to Ughter weights, you force your muscles to workcontinuouslyin the anaerobic stateand thereby buUd them.Thisiswhat I caUthe inverted pyramidapproach to weight Ufting, and for the purposeof buUding muscle mass, it's far superiorto the old system.

Many weight lifters foUow a regimen that requires 10 repetitions("reps") of a Uft, foUowed bya rest, another10reps, another rest, andanother 10reps. The restbetween each setof repsaUows the heart toslow, replenishes oxygen to the muscles, and thereby defeats our central goals. AnaerobicaUy, you mustcontinuaUy keep yourmuscles deprived of oxygen and force them to develop newmetabolic pathwaysthat demand less oxygen. The ideais quaUty, not quantity, and it's mybeUef that youcanaccomplish a morethorough and sensible workoutin 30 minutesthan youcanin an hour and a halfof conventional, lessstrenuous aerobic activity.

I use the invertedpyramidsystem, so caUed because I start out withas much resistance as I can handle, and then ease up.

This is how it works: Let's say you're performing curls. These involve sitting at the edge of a bench or chair and flexing your arms atthe elbows with weights in each hand. You start with the heaviest

Using Exercise to Enhance Insulin Sensitivity 229

weights that you can lift 3-4 times without losing good form. By thetime you've lifted them, say, 4 times, your muscles are tired and youcan't lift them anymore. You immediately lift the next Ughter weightsand do as many reps as you can (say, 3-4), and so on down throughUghter andUghter weights untilyouget to atotal of about20reps. Youmight find that you can getout 21, ormaybe youcan onlymanage 19.That's fine. The idea is that after the first few repetitions, yourmusclesare tired and they're working whUe they'retired,which is what stimulates muscles to buUd more mass.

Exceeding 20 reps by much maybe unwise. This isbecause anaerobicexercise does damage to muscle fibers, and wewant such damageto be minimal so that fuU repair wiU have occurred within2 days, orbefore you exercise thatmuscle group again.

Once you've done your reps for a particular muscle group, youdon't needto do that exercise again untU the dayafter tomorrow. Youimmediately go on to the next exercise. In this way, you can accomplish considerablymore in a shorter time frame.

The same system applies to anexercise like sit-ups. Whether you'redoing sit-ups withyour legs straight, bent, orwithoneof those sit-upboards, youstart off with yourhands behindyourhead. If you can't doasingle sit-up with hands behind your head, try it with hands atyoursides or even pressing them on the floor. With practice you'U eventu-aUy be strong enough to put your hands behind yourhead. If you'rereaUy experienced at sit-upsand have strong abdominal muscles, youholdaplate — a flat weight — behind your head.You do as manyrepetitions as you can. Maybe you'U onlyget5-6, maybe only 2-3. Immediately putdown your weight if you're holding one, ortake your handsfrom behindyourheadand fold them across yourchest. Nowstartdoingthe same sit-ups in this fashion. You do as manymore reps as youcan, then put your hands at your sides and do as many more additional repetitions as you can. If you get very experienced and findyourself doing40ormore sit-ups, it can getprettyboringandis also awaste of time. When you find yourself doing dozens of sit-ups, youcan get an inclined board or a Roman chair, which is like a sit-upboard but is raised about four feet off theground and permits youtobegin with your head belowyour waist. Again, you foUow the sametactic. You can also get an abdominal crunch machine with variableresistance (not those with removable weights that take time tochange). They're the best, but they're expensive. Again, you'd start athigh resistance andwork down for a total of about 20 reps. It is hu-

230 Treatment

manly possible to do more than 4,000 sit-ups at one session, butwhat's the point unless you're trying to impress someone or set arecord? Sitting up over a 7-second period and coming down slowlyover 15 or more seconds is actuaUy more effective for exercisingyourmuscles than doing 3 or 4 or more sit-ups in the same time period,and wiU significantly reduce the total number of sit-ups you can dobefore muscle exhaustion.

CARDIOVASCULAR EXERCISE

Cardiovascular exercise is widelyassociated in the public mind withwhat the popular press calls aerobicexercise. However, aerobic exerciseas many people practice it — a leisurely jog, a relaxing bike ride,mUd caUsthenics, evena brisk walk—is reaUy of only limited benefitto your cardiovascular system, doesn't buUd muscles, and has relatively little impact on yourstamina and capacity. Thekind of cardiovascularexercise I recommend to my patients (and foUow myself) isverystrenuous, operates intermittently in the anaerobic range, and ac-compUshes tremendous things. Forexample, manyyears ago, before Ibecamea physician, I usedto goto diabetes conventions. Therewasalways a group of doctors whowould getup in the morning,don theirrunning togs, and go running.These were peoplewho ran everyday.I'm not a runner; I work out in the gym everyday. But I do a particular cardiovascularworkout on a recumbent exercise bicyclethat I wiUexplain. I would go out with these doctors on their runs. After a fewmUes, peoplewouldstart droppingout. EventuaUy, I'd be the onlyoneleft— and then I'd go another five mUes and come back. Clearly, although I was older than mostof these people, and not a runner,I hadmuch more stamina. The stamina was created by this anaerobic cardiovascular exercise.

Exercise Harder, Exercise BetterCardiovascular workouts can be performed on a treadmiU, a stairclimber, or bicycle. If you're female, I'd recommend a treadmiU, becauserunning impactsyour feetand thus helpsincrease bone densityin your legs. However, if done to excess or with inadequate arch supports, the impact can injureyour knees. If you'remale, I recommenda recumbent bicycle rather than the standard upright bike; it's muchmore comfortable for men because the seat is luce an ordinary chair.

Using Exercise to Enhance Insulin Sensitivity 231

IdeaUy, your machine should haveameter that reads the amount ofwork that you're doingin calories (or joules) perminute asweU astotal calories (or joules), but certainly youcan get a good workoutwithjust a mUeage meter. It is important to wear a pulse meter.The brandthatI like bestiscaUed Polar; it costs about $60, and youwear asensoraround your chest withawristwatch-type readout. If youbelong to ahealth clubthat hasa treadmiU with a pulse meter in the handlebars,youwon'thave to put oneon your chest, but some sortof pulse meteris essential. The degree of workout you're getting is measured by howfast your heart works. If youget evaluated byacardiologist before youstartyour exercise program, you should askhim or her what your initial target pulse rate oughtto be.Over time,youcanincrease it.

There's a formula thatweuseto specify atheoretical maximum attainable pulse rate: we take 220 and subtract from it your age. So ifyou're sixtyyears old, you'd have atheoretical maximumpulse rate of160 — that is, in theory, you shouldn't be able to exercise at a fasterpulse rate. Your doctor wiU decide based on your overaU health andfitness level what percentage of this would beagood initial target ratefor you— say, 75-80 percent of maximum. Rarely would a doctorstart you out at 85 percent of maximum or higher if you were not inshape. EventuaUy, you may find that you can get up to and beyondyour theoretical maximum — I can exercise at 160 even though mytheoretical maximumis 148.1 can do this without having a heart attack in partbecause I've been exercising strenuously for forty years.Don't expect — even after years of this kind of exercise — to getyourheart rate up to or even near your theoretical maximum,or to yourtarget, right after youbegin thiskind of workout. It takes time. I get tomy target pulse rate at the end of about 10 minutesof trying.

To do a reaUy effective anaerobic/cardiovascular workout, you usethe same principles as youuse lifting weights. Start out by selecting asafe, comfortable speed andsetting the resistance of yourmachine tothe point where your muscles are so tired after about 20 seconds thatyou can'tgoany further. As soon as you reach this point, lower the resistance setting sUghtly and keep going. For treadmiUs, the resistancewiU be the angle at which you're running uphiU. So if you're using atreadmiU, you needto be able to setthe incline of yourtreadmiU fromthe handlebars — you don't want to get off,reset the angle, then getback on.You'U lose yourrhythm, regain someof the oxygen in yourmusclesand heart,and defeatthe point of the workout.

As with the weights, you lower the resistance a Uttle at a time, and

232 Treatment

each time you lowerit, shoot for 20seconds of exercise untUyou can'tgoanymore. Nearly fromthebeginning you're wipedout,yetyoukeepdoing it at lower and lower resistance. This is a realworkout.

Your goalwiU be to get your heart rate up to (but not above) thetraining level recommended by your physician. If you can't reach therecommended rate when you can barely notice the resistance of yourmachine,increase your speeduntil you get to your pulse target.Try tomaintain this rate for up to 5 minutes.

A major goal of cardiovascular exercise is to enhance your heartrate recovery time, i.e., to shorten it. (Cardiologists now beUeve thatthe fasteryour heart rate slows from your target to near resting rate,the better your cardiacfitness.) Aminimal testof recovery wouldbe toslow your heart rate by 42 beats per minute from your maximumwithin 2 minutes of slowing your feet until you are barelywalking orpedaling. Todo this you sprint at top speedfor 2-5 minutes and thendrop to a veryslowspeedfor 3-5 minutes,and then sprint again,overand over.

When you think you've had enough,lowerthe resistance to zerobutkeep your legs moving veryslowly until your pulsehas returned to avalue about 30 percent above your starting point. This slowexercisepumps blood back to your heart from your legs, thereby greatly reducing the hazard of a postworkoutheart attack.

I recommend that rather than timing your workout, you look at thecalorie counter on the machine, if it has one, and decide on a particular number of calories that you want to shoot for. Calories are a measure of work done and therefore a reasonable gauge ofyour workout.Minutes or even mUes don't take effort into account. I aim for about

200calories. When it getsup to that range,I caU it quits. But the pointof this kind of exercise isn't weightloss, so don't start looking at thecaloriecounter thinking that if you burn 200more caloriesyou'U loseanother pound — exercise just doesn't work that way. IncidentaUy, Ihave a retired patient who actuaUy has the time and the stamina tocontinue intermittent sprinting for an hour.

AN IMPORTANT CAUTION

If you're doing cardiovascular exercise of this type,you haveto be verycareful,especiaUy if you're a long-term diabetic,or a recent-onset diabetic over the ageof forty,or havea famUy history of coronary disease.

Using Exercise to Enhance Insulin Sensitivity 233

One rule isthatyouneverfinish acardiovascular workout and stop cold.I had an overweight nondiabetic cousin who started jogging when hewas about fifty years old. He was in his second month of exercising,not doing anything more than jogging with friends. One day, afterthey stopped jogging, he dropped dead of a heart attack. He and hisjogging buddies were in the habit of stopping cold after their run tochat. Stopping cold isan extremely bad idea — if people are going todrop dead of heart attacks from running orbiking, it's mostoften immediately after the exercise thatthis happens. Why?

WhUe you're exercising, your heart isbeating veryrapidly because itand your legs require a lot of blood. By pumping your legs up anddown, you're pumping blood from your legs back to your heart. Themuscles thatare demanding alotof blood are both in yourlegs andinyour heart, but theblood's getting pumped back to your heart byrunning. If you stop cold, your muscles are stiU going to demand alot ofblood — they've been depleted of oxygen and glucose — and gravityisgoing to help themget theblood. The problem is, they're no longerpumping theblood back to theheart. Suddenly your heart isdeprivedand, if your coronary arteries are narrowed by atherosclerosis, you'reset up for a heart attack.

Whether you're on a treadmiU, bike, or stair climber, cut the resistance setting to zero and proceed ataveryslow pace after yourworkout until your heart rate slowly comes down to no higher than about30 percent above your initial starting rate. If your resting pulse is 78,you don't want to stop your biking, walking, or step cUmbing untUyour heart rate is 101 or below.

PROGRESSIVE EXERCISE

As your strength and endurance increase for any exercise, it wiU becomeprogressively easier to perform. If it becomes too easy, youwon'tget any stronger. The key to getting progressively morestrength andendurance is to make the exercise progressively more difficult. Thiscanbe done for almostanyactivity.

If youare Ufting weights, for example, every few weeks (ormonths)you can add a very smaU weight (say a separate 2^-pound plate) tothe weight stack for anyexercise. When doing a cardiovascular exercise, you might try to increase your maximum heart rate by, say, 2beats per minute every 2months, byincreasing your resistance setting

234 Treatment

or your speed. A swimmer canassign a fixed time period,say30 minutes, fordoing laps. The goal wouldbe to graduaUy increase the number of laps. Thus, aftera month you might increase your speed to get15V2 lapsinsteadof 15lapsin 30minutes, and so on. Of course,a waterproof wristwatch would be helpful.

Evenwalking can evolveinto both an enduranceand a bodybuUding activity. AU you need is awristwatch, a few Ughtweight dumbbeUs,and a pedometer. The pedometer is a small gadget from a sportinggoods store that you cUp onto your belt. It measures distance bycounting your steps. Suppose you wish to setaside 30minutes per session for walking.You begin by walking at a leisurelypace for 15 minutes and then returning at the same pace. Record your distance fromthe pedometer.Thereafter, try to walkat least that distance in the sametime period.After ten sessions, you might try to increase distanceby 5percent over the same time. If you increase distance by this amountevery ten sessions, you'U eventuaUy find yourself running. You canthen graduaUy increase your running speedin the same fashion.

Supposeyour doctorhastold you not to run because of a bad kneeor fragUe retinal blood vessels. Limit your speed to a fast walk, butstart swinging your arms a Uttle bit. Over time, try swinging themhigher and higher. When you think they are going so high that youlook siUy, start with the dumbbeUs. You might begin with a pair of1-pound dumbbeUs and short swingsof the arms.Wear gloves if thedumbbeUs feel cold.Again,graduaUy increase the distance you swing.When you eventuaUy feel you look siUy, try 2-pound dumbbeUs. Aftera yearor two, you may be goingat avery fast walk,swinging 5-pound(or even heavier) dumbbeUs. Imagine what your physique wiU looklike then. You'U alsoprobably feel younger and healthier.

The exercises I've mentioned above are by no means the only ones.There are countless different ways you can exercise — voUeybaU,snowboarding, surf-kayaking, cross-country skiing,you name it. Themost important considerations are keeping within the restrictionsyour physician might place on your activity, and discovering what youlike to do best — and sticking with it. After that, aU you have to do ismonitor and correct your blood sugars, record the exercise on yourGlucograf form, and keep exercising in a progressive fashion. Thepayoff— longer life,lowerstress, weight lossif you'reoverweight, andbetter overaU health — is usuaUy worth the time and effort.

15Oral InsuHn*Sensitizing Agents,Insulin~Mimetic Agents,and Other Options

Ifdietandexercise are notadequate tobring your bloodsugars under control, the next level of treatment to consider is oral bloodsugar-lowering medication, commonly known as oral hypo

glycemicagents (OHAs).There are three categories of OHAs, those that increase sensitivity

to insulin, those whose action resembles that of insuUn, and those thatprovoke your pancreas to produce more insulin. The first group isknown as insulin sensitizers (or ISAs, for insulin-sensitizing agents);the second are the insulin mimetics (or IMAs, for insulin-mimeticagents), which act like insulinbut do not buUd fat. FinaUy, there arethe original OHAs, like sulfonylureas.

I only recommend the insuUn sensitizers and insulin mimetics, forreasons that wiU become plain in shortorder. (Some drug companieshave combined pancreas-provoking OHAs with insulin sensitizers, amoveI strongly chaUenge. TeU yourdoctor you do not want anyproduct containing an agent that works by causing the pancreas to makemore insulin.This includes the old sulfonylureas and the new,simUardrugs caUed megUtmides and phenylalanine derivatives/)

For people who stUl have sufficient insuUn-producing capacity, insulinsensitizers alone may provide the extra help they need to reachtheir blood sugar target. Some insulin-resistant individuals who pro-

*In addition to causing beta cell burnout,sulfonylureas also impaircirculationin the heart and elsewhere by closing ATP-sensitive potassiumchannels that relaxbloodvessels. Theyhave beenshown to increase aU causes of mortaUty, including deaths from heart diseaseand cancer.

236 Treatment

duce Uttle or no insuUn on their own may find a combination of insulin sensitizersand insulin mimetics usefulin reducing their doses ofinjected insulin.

There are three ISAs currentlyon the market, and at this writing IprescribeaU three of them — metformin (Glucophage), rosigUtazone(Avandia), and piogUtazone (Actos). RosigUtazone and piogUtazonehave simUar effects upon blood sugar,so it servesno purpose for oneindividual to use both.

A note: Sincebrand names vary from country to country, I wiU useonly the generic names in my discussion of drugs in this chapter. Inmy experience, however, not all genericmetforminsmatch the effectiveness ofGlucophage.

Some of the OHAs on the market are not insulin-sensitizing or-mimetic. Instead, they provokethe pancreasto produce more insulin.For several reasons, this is considerably less desirable than taking amedicationthat sensitizes you to insulin.First,the pancreas-provokingOHAscan causedangerously lowblood sugar levels (hypoglycemia) ifused improperly or if meals are skipped or delayed. Furthermore,forcing an already overworked pancreas to produceyet more insulincan lead to the burnout of remaining beta ceUs. These products alsofacUitate beta ceU destruction by increasing levelsof a toxic substancecaUed amyloid.FinaUy, it has been repeatedly shown in experiments —and I have seen it in my own patients — that controlling diabetesthrough blood sugar normaUzation can help restore weakened ordamaged beta ceUs. It makes absolutely no sense to prescribe or recommend agents that wiU cause them renewed damage. In a nutsheU,pancreas-provoking drugs are counterproductive and no longer haveanyplacein the sensible treatment of diabetes.

As it's far more productive to talk about good medicine, I wiU leavepancreas-provoking OHAsin the past,whereeventhe newerones belong, and from here on out discussonly insuUn sensitizersand insulinmimetics. Then, at the end of the chapter, I wiU look at possible newtreatment options for three specialcircumstances.

INSULIN-SENSITIZING AGENTS

The great advantage of insulin sensitizers is that they help to reduceblood sugar by making the body's tissues more sensitive to insulin,

OralInsulin-SensitizingAgents, Insulin-Mimetic Agents, andOtherOptions 237

whether it's the body's own or injected. This is a benefit that can'tbe underestimated. Not only is it a boon to those trying to get theirblood sugars under control, but it's also quite useful to those who areobese and simultaneously trying to get their weight down. By helpingto reduce the amount ofextra insulin in the bloodstream at any giventime, these drugs can help aUeviate the powerful fat-buUding properties of insulin. I have patients who arenot diabetic but have come tome for treatment of their obesity. Insulin sensitizers have been a realplus to the weight-lossefforts of some because of their abiUty to cur-taU insulin resistance. Their major shortcoming is that they're ratherslow to act — for example, they wiU not prevent a blood sugar risefrom a meal if taken an hour before eating, as some of the betaceU-pushing medications wiU. As you wiU learn,however, this can becircumvented.

Some obese diabetic patients come to me who are injecting verylarge dosesofinsuUnbecausetheir obesity makes them highly insulin-resistant. These high doses of insulin faciUtate fat storage, and weightloss becomes more difficult. Insulin sensitizers make these patientsmore sensitive to the insulin they're injecting. In a typical case I had apatient taking 27 units of insulin at bedtime, even though he was onour low-carbohydrate diet. After he started on metformin, he was ableto cut the dose to about 20 units. This is still a very high dose, but themetformin faciUtated the reduction.

Insulin sensitizers have also been shown to improve a number ofmeasurable cardiac risk factors, including blood clotting tendency,lipid profile,Upoprotein(a), serum fibrinogen,blood pressure,C-reactive protein, and even abnormal thickening of the heart muscle. In addition, metformin hasbeen found to inhibit the destructive binding ofglucose to proteins throughout the body— independent of its effectupon blood sugar. It has been shown to reduceabsorption of dietaryglucose, and also improves circulation, reduces oxidative stress, reduces blood vessel leakage — in the eyes and kidneys — and reducesthe growth of fragUe new blood vessels in the eyes. It has also beenshown to improve satiety in women near menopause. Thiazolidine-diones such asrosigUtazone and piogUtazone can slowthe progressionof diabetic kidney disease, independent of their effectson blood sugars. These medications can also down-regulatethe genesthat cause fatstorage, and they havebeen found to delayor prevent the onset of diabetesin some high-risk individuals.

238 Treatment

INSULIN-MIMETIC AGENTS

In addition to the insulin sensitizers, there are some substances sold in

the United States as dietary supplements that are effective for helpingto control blood sugars. Many studies in Germany have demonstratedthis effectfrom R-alphalipoicacid,or ALA. A 2001 study showed it towork in muscle and fat ceUs by mobilizing and activating glucosetransporters — in other words, it works like insulin, or is an insulinmimetic. German studies have also shown that its effectiveness in

mimicking the effects of insulin is greatly enhanced when used withequivalent amounts of evening primrose oU, another dietary supplement. ALA can reduce the body's natural levels of biotin, so it shouldbe taken in a preparation that contains biotin (see footnote below).ALA and eveningprimrose oU are no substitute, however, for injectedinsulin — they are at best a fraction as potent. Still,their combined effectiveness is significant.

AdditionaUy, ALA is perhaps the most potent antioxidant on themarket and has certain cardiovascular benefits simUar to those

claimed for fish oU. Many of the cardiologistswho were taking vitamin E for its antioxidant properties ten yearsago are now taking ALA.I've been taking it myself for about eight years. When I began, Ipromptly found that I had to lower my insuUn doses by about one-third. R-ALA and evening primrose oU do not appear to mimic oneimportant property of insulin— they don't appear to facUitate fatstorage. They are both avaUable without prescription from somehealth food stores and from some pharmacies.* They have the potential to cause hypoglycemia in diabetics who inject insulin if theydon't adjust their insulin dosages accordingly. I havenever seen themcause hypoglycemia, however, when they are not used with injectedinsulin.

Other German studies have shown dramatic improvements indiabetic neuropathy (nerve damage) when alpha Upoic acid is ad-

*Although conventionalALA is widely available, R-ALA is more effective. Asofthis writing, the principal manufacturer in the United States isGlucoreU Inc.,ofOrlando, Florida,phone (866) 467-8569, www.insulow.com. Their product In-sulowcontains 100mg R-ALA per capsule, plus 750meg (0.75mg) biotin. Insu-low is also available from RosedalePharmacy.

OralInsulin-SensitizingAgents, Insulin-MimeticAgents, andOtherOptions 239

ministered intravenously in large doses over several weeks. Given itsantioxidant and likely anti-inflammatory properties, this isn't thatsurprising. But it faUs under the category of "Don't Try This atHome."

AlphaUpoic acid,likehigh-dose vitaminE (the form caUed gammatocopherol) and metformin, can impede glycosylation and glycationof proteins, both of which cause many diabetic compUcations whenblood sugars are elevated.

I usuaUy recommend two 100mg tablets every 8 hours or so, withone 500 mg capsule of evening primrose oU at the same time. If aninsulin-resistant patient is already taking insulin, I wUl start her onhalf this doseonce daUy and observe bloodglucose profiles and lowerinsulin dose as I raise alpha Upoic acid and evening primrose oU.Again, it's aU trial and error.

WHO IS A LIKELY CANDIDATE FOR

INSULIN-SENSITIZING OR INSULIN-

MIMETIC AGENTS?

GeneraUy speaking, these agents are natural choices for a type 2diabetic who despite a low-carbohydrate diet cannot get his weightdown or his blood sugars into normal ranges. The blood sugar elevation may be limited to a particular time of the day, it may be during the night, or it may entaU a sUght elevation aU day. We base ourprescription on the individual's blood sugar profiles. If even on ourdiet, blood sugar exceeds 300 mg/dl at any time of the day, I'll immediately prescribe insulin and won't even attempt to use theseagents, except to eventuaUy reduce doses of injected insulin. If yourblood sugar is higher upon arising than at bedtime,we'dgive you thesustained-release version of metformin at bedtime. If your bloodsugar goes up after a particular meal,we'd give you a relatively rapidacting insulin sensitizer (rosigUtazone) about 2 hours before thatmeal. Since food enhances the absorption of the thiazoUdinediones,wemight give it with the meal. If bloodsugars are sUghtiy elevated aUdaylong,wemight use alphaUpoic acidand evening primrose oU onarising, postiunch, and postdinner. It should be noted, however, thatthe ISAs are considerably more effective than IMAs at loweringbloodsugars.

240 Treatment

GETTING STARTED: SOME

TYPICAL PROTOCOLS

Let'ssayyou're a type 2 diabeticand through weight loss,exercise, anddiet, you pretty much have your blood sugars within your targetrange. StiU, your blood sugar profiles show a regular elevation in themornings after a low-carbohydrate breakfast, probably due to thedawn phenomenon.

Of the medications I've described here, the most rapid to start acting is rosigUtazone, which, although it reaches peak levels in thebloodstream in about an hour, probably achieves its fuU effect afterabout 2 hours. Soyou might takea starting dose of 4 mg upon arisingand then eat breakfast 1-2 hours later. If this is only partly effective,the dose can be increased to two 4 mg tablets or one 8 mg tablet (themaximum recommended daUy dose). If this is somewhat effective, but2 hours after breakfast your blood sugars are still above target, youmight add an extended-release dose of metformin before you go tobed. This type of metformin achieves its peak blood levels after about7 hours. A starting point would be one 500 mg tablet at bedtime. Ifthis stiU doesn't get your blood sugars into target range, then youcould increase the dose graduaUy, perhaps by one more tablet at bedtime for a week and so on, until you reach a maximum of 4 tablets anight or you hit your target. I always recommend the least possibledosage— partly due to the Laws of SmaU Numbers,but also becauseof the reduction of likelihood for potential side effects. With metformin, if you buUdup your dosageslowly, it lessensthe possibUity ofgastrointestinaldiscomfort that about one-third of users of the older,more-rapid-acting version experience.

In some cases, blood sugar levels either increase overnight or increase during the first 2 hours after you arise. The latter situation ismost likely due to the dawn phenomenon. Either situation may respond to timed-release versions of metformin (Glucophage XRin theUnited States) with or without ALA plus evening primrose oU, aUtaken at bedtime, using the doses described above. If need be, piogUtazone may also be added at bedtime. Tabletsof piogUtazoneare soldin 15 mg and 45 mg doses.The maximum daUy dose is 45 mg.

Another possibUity that wouldwarrant oral medicationwould be ifyour blood sugar levels increasedafter lunch or dinner. Wecould possiblycover the problem meal with rosigUtazone by taking it 1-2 hoursbefore eating.

OralInsulin-SensitizingAgents, Insulin-MimeticAgents, andOtherOptions 241

TABLE 15-1

RECOMMENDED ORAL AGENTS FOR BLOOD

SUGAR CONTROL

Maximum

U.S. brand Available (effective)Agent Type name dosages dally dosage

Metformin InsuUn Glucophage 500,850, 2,500mgfsensitizer and generic 1,000 mg*

Metformin InsuUn Glucophage XR 500 mg 2,000mg1extended sensitizer and genericrelease

RosigUtazone Insulin

sensitizer

Avandia 4,8mg 8mg

PiogUtazone InsuUn

sensitizer

Actos 15,30,45 mg 45 mg

R-alpha Upoic InsuUn Insulow 100 mg 1,800 mgacid (ALA) mimetic

with biotin

Evening InsuUn Many 500 mg 3,000 mgprimrose oil mimetic recommended

(EPO) booster

for every300 mg

ofALA

*Alsoavailableas a Uquid.f Forreasons not apparent to me,the manufacturer's recommendation for maximum daily dosing is lessfor extended-release metformin than for the standard version.

WILL THESE MEDICATIONS CAUSE

HYPOGLYCEMIA?

Sulfonylurea and the newer gUtazar OHAs carry the very real possibUity of causing dangerously low blood sugars, which is one of thereasons I never prescribe them. However, this is only remotely likelywith the insulin-sensitizing and insulin-mimetic agentsUsted above.Noneof them interferes with the self-regulating system of a pancreasthat can stiU make its own insulin. If your blood sugardrops too low,

242 Treatment

your body wiU most likelyjust stop making insulin automaticaUy. Sulfonylureas and simUar drugs, on the other hand, because they stimulate insulin production whether the body needs it or not, can causehypoglycemia.

Although the manufacturer and the scientific literature claim thatmetformin does not cause hypoglycemia, I did havea patient who experiencedhypoglycemia. Shewasveryobese but onlyverymUdly diabetic, and I was giving her metformin to reduce insulin resistance tofacUitate weight loss. When I put her on metformin, her blood sugarswent too low (but not dangerously) — down into the 60s.

So there may be some very sUght risk of hypoglycemia with theinsulin sensitizers or insulin mimetics,but this is not at aU comparable to the great risk with the sulfonylureas and simUar medications.One warning,however. The body cannot turn off injected insulin, soif you are taking insulin plus anyof theseoral agents,hypoglycemia ispossible.

WHAT IF THESE AGENTS DON'T BRING

BLOOD SUGARS INTO LINE?

If theseagentsare not adequateto normalizeblood sugarscompletely,chances are there is something awry in the diet or exercise portion ofyour treatment program. The most likely culprit for continued elevatedblood sugarsis that the carbohydrate portion of your diet is notproperly controUed. So the first step is to examine your diet again tosee if that's where the problemUes. With many patients, this is a matter of carbohydrate craving. If this is the case and your carbohydratecraving is overwhelming, I'd recommend that you rereadChapter 13and consider pursuing one of the techniquesdescribedthere. If diet isnot the culprit, then the next thing — no matter how obese or resistant to exercise you might be — would be to try to get you started ona strenuous exercise program. If even this doesn't do the trick, we'Ucertainlyuse injectedinsulin.

It's also worth keeping in mind that infection or illness can seriouslyimpairyour efforts at bloodsugarnormalization. If your bloodsugarlevels areway out of lineeven with the useof insulin, youmightalso consider talking to your physician about potential underlying infection, especiaUy in the mouth (see pages 100-101).

OralInsulin-SensitizingAgents, Insulin-MimeticAgents, andOtherOptions 243

DISADVANTAGES OF INSULIN SENSITIZERS

AND INSULIN MIMETICS

AlthoughinsuUn mimeticsand insuUn-sensitizing agentsare some ofthe best tools we havefor controUing blood sugars,they are not without their difficulties. Sincealpha Upoic acid and evening primrose oUare not prescription drugs in most countries (Germany is a notableexception), they are not covered by most health insurance. AlphaUpoic acid is not inexpensive; at this writing,a supply of 180Insulow100mg tablets costs about $30.

ALA reduces body stores of biotin, a substance that aids in the utilization of protein and a varietyof other nutrients, so when you takealpha Upoic acid,you might be wiseto takebiotin supplements also—unless you are taking Insulow,which alreadycontains biotin. Yourbiotin intake should theoreticaUy equal about 1 percent of your alphaUpoic acidintake,so ifyouare taking1,800 mgALA per day, in theoryyouwouldtakeabout 18mg of biotin.Mostof mypatientswho usealpha Upoic acid don't take more than about 15mg biotin per day, andthey experienceno apparent adverse effects. Most preparations comeonly in 1 mg strengths.

Metformin has a very low side-effects profile, with the exceptionof gastrointestinal distress — queasiness, nausea, diarrhea, or a slightbeUyache — in as many as a third of the people who try the non-extended-release version. Most people who experience such discomfort, however, find that it diminishes as they become accustomed tothe medication. Only a very few patients can't tolerate it at aU. (Somepatients, particularly obese people who are anxious to achieve theweight loss that metformin can facUitate, wiU ignore any initial gastrointestinal distress and use an antacid drug such as Pepcid or Tagamet for reUef. Others, who may only experience relatively mUddiscomfort, are wiUing to tolerate it for a few weeks just to get thingsroUing.) Rarecasesof diarrhea have been reported long after the startof metformin therapy. They were reversed by discontinuation of themedication. I havenot observedgastrointestinal sideeffects associatedwith the use of thiazolidinediones or extended-release metformin.

Metformin's predecessor, phenformin, was, in the 1950s, associatedwith a potentiaUy life-threateningcondition calledlacticacidosis. Thisoccurred in a smaU number of patients who were already sufferingfromheart faUure or advanced Uver or kidney disease. AlthoughI have

244 Treatment

read of only a few instances of lactic acidosis associated with metformin, the FDAadvises against using it in individualswith these conditions. Metformin has been reported to lowervitamin B-12 stores inabout one-third of users. This effectcanbe preventedby taking a calcium supplement (see page 179).*

The two thiazoUdinediones currently avaUable in the United Statesboth have potential for minor problems. PiogUtazone is cleared fromthe bloodstream by the liver, utilizing the same enzyme it utilizes toclear many other common medications. The competition for this enzyme can leave dangerously elevated blood levels of some of thesedrugs. If you are taking one or more of these competing medications,such as some antidepressants, antifungal agents, certain antibiotics,and others, you should likely not be using piogUtazone. You shouldcheck the package insert for potential drug interactions and talk toyour physicianand pharmacist.

RosigUtazone and especiaUy piogUtazone can cause a smaU amountof fluid retention in some people.The consequenceof this is a dilutionofredblood ceU count andmUd swelling in the legs. I'veseenanumberof such cases. There can alsobe a smaU weight gaindue to the retainedwater, not to fat. This water retention has been associated with a few instances of heart faUure in individuals taking one of these medicationsplus insulin. In the UnitedStates, the FDA hastherefore recommendedthat doses of these agents not exceed 4 mg and 30 mg per day, respectively, for peoplewho inject insulin. I havetreated many insulin userswith them and haveseen sUght swelling ofthe legsin some cases. Whenthis occurred, I discontinued the medication immediately. There alsohave been very rare cases of reversible Uver damage associated withboth rosigUtazone and piogUtazone.* A study reported in EndocrinePractice in 2001 showedasignificant increase in serum triglyceride levels for users of rosigUtazone but not piogUtazone. On the other hand,piogUtazone hasbeen shownto improveUpid profiles (LDL, HDL,andtriglycerides), whUe rosigUtazone cancause a sUght impairment.

* A deficit ofvitamin B-12 can increase serum levels of the renal disease risk fac

tor homocysteine. It would therefore be wise for your physician to check yourserum homocysteine everysix months whileyou are using metformin.*Even though reports of Uver toxicityare far fewer than with some commonlyused medications such as niacin and the so-caUed statins, it's a good idea forusers of these insulin sensitizers to have their blood tested for liver enzymesannuaUy.

Oral Insulin-SensitizingAgents, Insulin-Mimetic Agents, andOther Options 245

Because of the possibUity of fluid retention, neither medicationshould be used by patients with significant cardiac, lung, or kidneydisease, or with any degreeof heart failure.

I usuaUy start people on rosigUtazone to avoid potential competition for clearance by the liver with other drugs another physicianmight prescribe in the future.

USING MULTIPLE AGENTS

Metformin works principaUy by lowering insuUn resistance in theliver. It also impairs, somewhat, theabsorption ofcarbohydrate bytheintestine. Thiazolidinediones principaUy affect muscleand fat, and toa lesser degree the liver. Thus, if metformin does not fuUy normalizeblood sugars, it makessense to add one of the thiazoUdinediones —and vice versa. Since rosigUtazone and piogUtazone workbythe samemechanisms, it makes little sense to use both in the same individual.The FDA suggests that doses of piogUtazone not exceed 30 mg daUywhen taken with metformin.

Since ALA and eveningprimrose oU work as insulin mimetics, it iscertainly appropriate to add these to any combination of the otheragents.

OTHER CONSIDERATIONS

Thethiazolidinediones do not have theirfuU bloodsugar-lowering effects on thedaytheyarestarted. PiogUtazone achieves its fuU potencyafter a few weeks, and rosigUtazone mayrequire up to twelve weeks.

When bloodsugars aremuch higher than the targets that I set,bothmetformin and the thiazoUdinediones can cause the pancreas to increase its insulin production in response to glucose. Because of thelower bloodsugars that wesee, thiseffect becomes insignificant.

Vitamin A supplementation has been shown to lower insulin resistance (as does vitamin E)* in doses of about 25,000 IU daUy. Sinceslightly higher doses of vitamin AarepotentiaUy very toxic, and dosesas low as 5,000 IU can cause calcium loss from bone, I would consider

*Vitamin Eshouldonlybe usedin theforms called gamma tocopherol or mixedtocopherols.

246 Treatment

only moderate doses of its nontoxic precursor, beta carotene, for thispurpose.

Studies have shown that magnesium deficiency can cause insuUnresistance. It would therefore be a sensible idea for physicians to testtype 2 diabetics for red blood ceU magnesium (not serum magnesium) levels. If the level is low, magnesium supplementation shouldhelp. I recommend a product caUed slow-mag in smaU dosesthat canbe increased if the test remains low after one month. Excessive doses

cancausediarrhea. Sinceredblood ceU magnesium is not a perfect indicator of blood magnesium stores, and since magnesium supplements are benign to peoplewith normalkidneys (except fordiarrhea),it is appropriate to use magnesium supplements as a test to see ifblood sugars decUne. Doses as high as700 mg daUy are common foradults.

SimUarly, zinc deficiency can cause diminished production of leptin, a hormone that impedes overeating and weight gain. Such deficiencycan also impair functioning of the thyroid gland. It is thus wisefor aU type 2 patients to ask their physicians to test their serum zinclevels and to prescribe zinc supplementation if warranted. FoUow-upserum zinc levels should be measured to ensure that normal levels are

not exceeded.

Compounds ofthe heavymetalvanadiumhavebeen shown to lowerinsulin resistance, reduce appetite, and possibly also act as insuUn-mimetic agents.They are quite potent in lowering blood sugars, butthere's a catch.Vanadium compounds work by inhibiting the enzymetyrosine phosphatase, which is essential to many vital biochemicalprocesses in the body. The possibUity is quite real that this inhibition can be damaging. Since clinical trials in humans have not exceeded three weeks in duration, long-term freedom from adverse effects has yet to be documented. Some users of vanadium compoundshave experienced gastrointestinal irritation. Although vanadyl sulfateis widely avaUable in health food stores as a dietary supplement andhasbeen used foryears without anyreports of adverse effectsin medicaljournals, I tentatively recommend that it be avoided until more isknown.*

Except by commercial pilotswho must avoidinsuUn (seepage247).

OralInsulin-SensitizingAgents, Insulin-MimeticAgents, andOtherOptions 247

ACARBOSE: FOR PEOPLE WHOSE

CARBOHYDRATE CRAVING CANNOT

BE CONTROLLED

In theory at least, there are individuals who do not respond to any ofthe measures recommended in Chapter 13for the control of carbohydrate cravingand overeating. Thesepeoplecan be helped slightly by aproduct caUed acarbose (Precose). Acarbose is avaUable as 25 mg, 50mg, and 100 mg tablets to inhibit action of enzymes that digeststarches and table sugar,* thereby slowing or reducing the effects ofthese no-no foods upon blood sugars. It is interesting that the ADArecommends eating starches and sugars and then the simultaneoususe of acarbose to prevent their digestion.

The maximum recommended daUy dose of acarbose is 300 mg. It isusuaUy taken at the time of carbohydrate consumption. Its major adverse effect, in about 75percent of users, isflatulence (predictably), soit is wise to taper up the dose graduaUy. It should not be used for patients with any intestinal disorders (e.g., gastroparesis). I have neverhad the need to prescribe it.

PHLEBOTOMY: A LAST RESORT FOR SOME,BUT IT MAY WORK

Commercialairline pUots with diabetes are currently facedwith regulations in the United States that threaten loss of Ucense (and UveU-hood) if they inject insulin. Certainlythese people should try aU of theoral agents recommended above, as weU as a low-carbohydrate dietand strenuous exercise. They should also consider vanadyl sulfate,magnesium, and the other supplements listed under "Other Considerations" on page 245.

There is yet another potentiaUy powerfulway of lowering insuUnresistance for people with this problem. It's been demonstrated thatmen whose body iron stores placed them in the top 20 percent ofthe nonanemic population had much greater insuUn resistance thanthose in the bottom 20 percent. Furthermore, their insulin resistance

*The enzymes are alpha-glucosidase and pancreatic amylase.

248 Treatment

dropped dramaticaUy when they donated enough blood every twomonths to keep them in the bottom 20 percent.I've actuaUy seen thiswork on my own patients.A good measure of total body iron is theserum ferritin test. Sincesome blood banks wiU not accept blood donations from diabetics, it may be necessary to visit a hematologist fora phlebotomy (removalof blood from a vein) everytwo months. It islikely that most insurance planswUl paythe hematologist's fee.

Women are much lesslikely than men to havehigh normal ferritinlevels.

AND ONE MORE OPTION

The recent avaUabUity of the firstDPP-4 inhibitor (seepage205) provides one more option for those who refuse to take injections. Thisnew product, sitagUptin (Januvia) comes in piU form — 25, 50, and100mg.The maximum adult dosefor peoplewithout kidney impairment is 100 mg once daUy. It wiU significantly reduce the effect ofglucagon upon blood sugar during and after meals (Chinese restaurant effect). It can be used as part of a three-way combination withmetformin and a thiazolidinedione.

16

Insulin: The Basics of SelMnjection

Asyou may have learned from the preceding chapter, certainoral agents, such as ISAs and insuUn mimetics, are valuablefor controlling blood sugars but can only go so far. If you're

taking the maximum effective doses of oral agents and your bloodsugars remain elevated — in spite of diet, exercise (where feasible),and weight loss — injected insulin wiU be essential to bringing yourbloodsugars down to yourtarget range.*

Although many patients initiaUy balk at the idea of injecting insulin, you should look at this as an opportunity, not a curse, becauseinsulin injections will increase the likelihood that you can bring about apartial recovery ofyour pancreatic beta cell function. This is especiaUytrueif youare aslimtype 2 orarecently diagnosed type 1.

If you're afraid of insuUn because youimagine thatonceyou start,you'U never beable to stop, you've faUen victim toacommon myth.InreaUty, injected insulin is the best means we have at this writing forpreventing beta ceU burnout.

The Biostator GCIIS, an "artificial pancreas," was a device devel-

*Investigators in Buffalo, New York, have demonstrated that injected insuUn appears to lower the production of inflammatory substances and increase levels ofanti-inflammatoryagentsin obeseindividuals. Since inflammationincreases theUkeUhood of atherosclerosis, chronic useof insuUn injections can lower riskofcardiac disease, peripheral vascular disease, andstroke, independent of itseffectsuponblood sugar. Injected insulin also facUitates thedilation (opening) ofcoronary and other arteriesthat maybe constricted in many diabetics and even innondiabetics. It also has been found to improve the absorption of oxygen byblood flowing through the lungs.

250 Treatment

oped in the 1970s when the average insulin-usingdiabetic took a single, daily, industrial dose of insulin. The device may still be available.In any case, its initials stood for "glucose-controlled insulin infusionsystem." That's exactly what it aimed to do — infuse insulin as a pancreas would, based on blood glucose levels. It attached to the patientthrough two intravenous connections, one that measured blood sugars constantly and another that deliveredglucose or insulin to correctblood sugars to 90 mg/dl virtually instantaneously. Although it wasnot practical for home use (it had a staff of two— one to operate themachine and one to service it — and rented for tens of thousands of

dollars a month), it did useful research, the most important element ofwhich was that it showed that beta cell burnout could be reversed or

halted, even by relatively short exposure to normalized blood sugars.How?

Many years ago, Gerald Reaven, MD, author of Syndrome X, conducted a study with thirty-two diabetics, half of them female, half ofthem male.One at a time,he put them into the hospital and had themattached to the Biostator for two weeks. His staffchecked HgbA,c onarrival, at discharge, and every three months thereafter. They foundthat HgbA,c plummeted during the two-week treatment period, butthe most important thing they found was that when the subjects wentback to their ordinary lives and their poor diets, their HgbAJC measures took an average of two years to return to their high, pretreat-ment values.

Considerable beta cell recoveryclearlyoccurred after just two weeksof normal blood sugars. In fact, it took two years to undo those twoweeks of healing. I'm not inviting you to normalizeyour blood sugarsfor two weeks and then go back to your old diet. My intent is todemonstrate the value of using insulin, and the value of normalizedblood sugars. We might envision that a mild diabetic still has threetypes of beta cells, active, dying, and dead.Myown beta cells are likelyall of the last variety— dead. I've mentioned it previously, but if I'dhad the kind of treatment upon my diagnosis more than sixty yearsago that I advocate today, I might still have a significant number ofworking beta cells. If you have some beta cell function left, you canprobably increase it by normalizing your blood sugars.

If the prospect of injecting yourself horrifies you, don't let it. Manypeople assume injections must be painful, but they needn't be. Ifyou've alreadybeen using insulin for years and find the shots painful,the likelihood is you were taught to inject improperly.

Insulin: The Basics ofSelf-Injection 251

HOW TO GIVE A PAINLESS INJECTION

Ifyouhave type 2 diabetes, sooner or lateryou may require insulin injections, either temporarily (as during infections) or permanently.This is nothing to be afraid of, even though many people with longstanding type 2 diabetes spend literally years worrying aboutit. I usually teach all my patients how to inject themselves at our first orsecond meeting, before there's any urgency. Once theygive themselvesa sample injection of sterile saline (salt water), they find out howeasyand painless it can be, and they are spared years of anxiety. If you'reanxious about injections, after you read this section please ask yourphysician or diabetes educatorto allow you to try a self-administeredinjection (without the insulin).

Insulin is usually injected subcutaneously. This means into a layerof fat under theskin. The regions ofthe body thatare likely to containappropriate deposits of fat are illustrated in Figure 16-1. Examineyour body to see if you have enough fat at the illustrated sites to comfortably grab a big hunk between your thumband first finger.

Most diabetics are erroneously taught to inject into their thighs inspite of the obvious: most thighs have inadequate fat for satisfactoryinjections. The net result is that the injection ends up going into muscle instead of fat and the timing of the insulin issped up inappropriately.

Fig. 16-1. Potential sitesfor subcutaneous injections.

252 Treatment

To showyou how painless a shot can be,your teacher should self-administer a shot to illustrate that no pain is felt. Your teacher shouldnext give you a shot of saline or "throw" the needle into your skin toprove thepoint.Now it's time foryou to give yourself an injection, usinga syringe that's already empty or has been partly fiUed foryouwithabout 5 "units" of saline.

1. First,with your "nonshooting"hand, grab as big a chunk of skinplus underlying fat as you can hold comfortably. If you have anice roll of fat around your waist, use this site. If not, select another site from those illustrated in Figure 16-1. Nearly everyonehas enough subcutaneous buttocks fat to inject there withoutgrabbing any flesh. Just locate a fatty site by feel. To inject intoyour arm, use the top of a chair, theoutside corner of two walls,or the edge of a doorway to pushthe loose flesh fromthe backofyour arm to a forward position that you can easily seeand reachwith the needle.

2. Hold the syringe like a dart, with the thumb and first two or threefingers of either hand.

3. Now comes the most important part. Penetration must be rapid.Never put the needle against the skin and push. That's themethod still taught in many hospitals, and it's often painful. Ifyou can find only a small amount of flesh to hold, the needleshould pierce the skin at a 45-degree angle, as in Figure 16-2,oreven better, use one of the new insulin syringeswith a short needle (5/i6 inch). If youcan grab a heftyhandful,you should plungethe needle straight in, perpendicular to the skin surface, or at

Torry Eppridge

Fig. 16-2. Ifyouare skinny, pierce theskin at a 45-degree angle, oruseashort (Vi6-inch) needle.

Fig. 16-3.Ifyou're chunky, pierce theskin at anyanglebetween 45 degrees

and 90 degrees.

Insulin: TheBasics of Self-Injection 253

anyangle between 45degrees and 90degrees, as shown in Figure16-3.

4. The stroke should begin about 4 inches from your target to givethe moving needle a chance to pick up speed. Pretend you'rethrowing a dart — but don't let go of the syringe. Move your entire forearm and give the wrist a flick at the end of the motion.You shouldn't get hurt. The needle should penetrate the skin forits entire length.

5. As soon as it's in, push the plunger all the way down to injectthe fluid. If the demonstration syringe is empty, then don'tbother to push the plunger. Now promptly remove the needlefrom the skin.

There's no need to practice injecting oranges, as has been taught inthe past. If you're going to practiceanything,you might first practice"throwing" a syringe, with the needle cover on, at your skin.

All you need do is experience one rapid stick to realize that speedmakes it painless. Never has it taken more than a moment for me toget a patient to self-inject. I'vehad grownmen in tears at the prospectof injecting insulinwhosoondiscover that it'seasy and painless and ofconsiderable value in treatment. It doesn't demand much skill, andcertainly doesn't require bravery.

HOW TO SELECT AN INSULIN SYRINGE

In recent years, a number of new insulin syringes have appeared onthe market in the United States. Although they are all sterile, plastic,and disposable, some are better than others.The important features toconsiderare describedbelow. Refer to Figure 16-4, which identifies theparts of a typical insulin syringe that you might find at your localpharmacy.

The Scale

When selecting a syringe, the printed scale is the most importantfeature, because the spacing of the markings determines how accurately you can measure a dose. Think Laws of Small Numbers: accuracyand consistencyof dose are both highlyimportant.

Insulindoses are measured in "units." One unit of our most-rapid-acting insulin will lower my blood sugar by 60 mg/dl. One unit will

254 Treatment

lower the bloodsugar of a 45-pound chUd byabout 160 mg/dl. Someofmyslim adultpatients with mUd type 2diabetes find that 1unitwUldrop themby80mg/dl. Clearly, an error of onlyV4 unit canmake thedifference betweena normal blood sugar and hypoglycemia for manyof us. My insuUn-using patients never injectas much as 8 units in asingle dose. It would therefore be ideal to have a long, slender syringewith a total capacity of 10unitsand markings for every lA unit spacedfarenough apartthat V& unitcan beaccurately estimated visuaUy. Thenumberson the scale shouldbe easy to read. Thelinesshouldbe dark,but no thicker than Vn unit. Such a syringe, unfortunately, does notexist quite yet.

A currently avaUable preferred syringe is Ulustrated below. Notethat the scale line nearest to the needle is longer than the other lines.This is the zero line. It overUes the end of the gasketwhen the plungerispushedin fuUy. It isnot the 1-unit line. Theupperscale in Figure 16-4displays whole units; the lower scale shows halfunits.

7^Needle

Gasket Barrel

I 1 _iTiffWrnjirrn 1111ilrni ih 111 il~t°-

Zero Line Scale

tPlunger

Fig. 16-4. Apreferred insulin syringe, calibrated in half-unit increments (enlargedimage).

The Rubber GasketThis is the dark-colored piece of synthetic rubber at the end of theplunger nearest the needle. It indicates a given dose by its positionalong thescale. Thebestgasket has asurface that's flat andnot conical,as some are, so that doses can be read without confusion. Note: theendof the gasket that isnearest theneedle isthe endthat shouldbesetat the dose.

The NeedleThe needle should be %-%6 inch long. Longer needles may go toodeeply into thin people. UntU 1996 aU disposable insulin syringessold in the United States had V^-inch needles. Syringes with shorter

Insulin: The Basics ofSelf-Injection 255

(5/i6-inch) needles are nowavaUable. With these syringes you usuaUyneed not "grab a hunk of flesh" or inject at a 45-degree angle unless,likeme,youhaveveryUttle fat at the injection site. Justthrow it in. Donot, however, use short needles for intramuscular injection, as described on page 309.

Needle thickness is specified bygauge number, just as for naUs andwire. The higher the gauge number, the thinner the needle. With avery thin gauge, even penetrating the skin too slowly may not hurt.Withtoo thin a gauge, theneedle mightbendor breakwhen puncturing tough skin.The idealcompromise between thinnessand strengthis probably31 gauge, whichis nowwidely avaUable.

The Point

Theneedle pointsof disposable insulin syringes currently soldin theUnited States arequitesharp. Advertising that claims special sharpnessfor a particularbrand is usuaUy exaggerated.

FILLING THE SYRINGE

My technique for filling a syringe with insulin differs from what isusuaUy taught,but it hasthe advantage ofpreventing the developmentof air bubbles in the syringe. Although it is not harmful to inject airbubbles below your skin, their presence in the syringe interferes withaccurate measurement of smaU doses.

General TechniqueThis step-by-step approach maybe foUowed foraU clear insuhns. Onlyoneinsulinnowon the marketiscloudy. It iscaUed NPHin the UnitedStates and isophane overseas. Ifyouusecloudy insulin, be sureto readthesection that foUows thisonebefore proceeding.

1. Take the cap(s)offyour syringe.2. Drawroom air into the syringe bypidling the plungerbackuntU

the end of the rubber gasket nearest the needle is set at the doseyou intend to inject. If the gasket has a dome or conical shape,thedose should besetat thewidest partofthegasket, not at itstip.

3. Puncture the insulin vial with the needleand inject the air intothe vial. This seemingly useless step has a purpose. If you were

256 Treatment

not to inject air to replace the insulin you withdrew,after manyfiUings a vacuum would eventuaUy develop in the vial, whichwould makesubsequent fiUings difficult.

4. Invertthe syringe and vialand hold them verticaUy, as shown inFigure 16-5, then rapidly puU back on the plunger until the barrel is filled with insulin weU beyond your dose (e.g., to about 15units if your dose is to be 5 units).

5. Slowly push the plunger in, stiU holding verticaUy, until the appropriate part of the rubber gasket reaches the desired dose.

6. Continue to hold syringe and vial vertically as you remove thefilled syringe and needle from the vial.

Filling a Syringe with Cloudy InsulinOne intermediate-acting insuUn (NPH) issoldtodayin vials that containa clear Uquid and a gray precipitate. The gray particles tend to setderapidly from theUquid when thevial isleft undisturbed. Theymustbere-suspended uniformly intheUquid immediatelypriortoevery use. FaUureto do this wiU result in inconsistent effects upon blood sugarsfrom oneshot to another. The way to secure a uniform suspension is to shake thevial. Many years ago, egg white-based vaccines were of a syrupy consistency and tended to form a permanent foam when shaken. This isnot thecase with today's water-based insulins. Yet most textbooks — and eventhe American Diabetes Association — still teU nurses and doctors to roU

the vial between the hands and not to shake it. This misinformation is un

fortunate, because wedon'tgetconsistent results when vials are roUed.When fiUing a syringe with a cloudy insulin, observe the following

procedure to ensurean even suspension.

1-3. Remove cap(s) from syringe, drawair into it, and inject the airinto the vial as described in steps 1-3 on pages 255-256.

4. Before drawingout anyinsulin,whUe stiU holding the vial andsyringe in one hand, vigorously shake them back and forth6-10 times as shown in Figure 16-6. Holding the upward-pointing syringe and vial vertically, rapidly draw back theplunger immediately after shaking to fill the syringe with insulinweU beyond yourdose. Do not delay, as the grayparticleswUl settle very rapidly.

5-6. StiU holding verticaUy, slowly push plunger in until desireddose is reached, then remove needle and filled syringe fromvial (seesteps 5-6, above).

Insulin: The Basics ofSelf-Injection

Fig. 16-5. Filling the syringe, holdingvial and syringe vertically.

Fig. 16-6. Shaking a vialofcloudyinsulin before drawing outthe dose.

ON THE REUSE OF DISPOSABLEINSULIN SYRINGES

257

The annual cost of sterUe disposable insulin syringes can beconsiderable, especiaUy if you take multiple daUy injections. You may becometempted to reuse your syringes, especiaUy if your medical insurancedoesn't reimburse you for the cost. (Many medical insurance poUciesinthe United States do at least partiaUy cover this expense.) AlthoughIhaven't encountered any infection caused by asingle person reusinghis own syringes, I have encountered the problem of polymerizationof insulin.*

Many ofmypatients pass through astage when they routinely reusetheir syringes several times, to save money orto enable themto travelwith only asmaU supply. These patients never use the same syringe fortwo different types of insulin, so we can't say that one insulin iscontaminating another. Inevitably, Iget atelephone caU with the message,

*Apolymer isa large molecule made up of identical smaUer molecules boundtogether.

258 Treatment

"My blood sugars are high and I can't get them down." I ask, "Bringyour clear insulin to the phone. Is it crystal clear, like water?" Inevitably the reply is, "No, it's slightly hazy." Insulin that becomes hazyhas been partially deactivated by polymerization and will not adequately control blood sugars. This is not found bypeople who do notreuse their syringes.* Of course, I advise such patients to immediatelyreplace all insulin vials, whether long- or short-acting, that have beenused to fill reused syringes. Replacement of the vials always cures theproblem. Naturally, syringes should not subsequently be reused.

What ifyou encounter a situation whereyou only haveone syringetolast for a weekand haveno wayof getting new ones? Flush the syringewith air several times after each use to clear out any remaining insulin.When filling the syringe, do not inject air into the insulin vial (step 3),and don't inject the excess insulinback into the vial (step 5). Just drawthe needle from the vial and squirt the excess into the air.This way, youwon'tcontaminate yourvial with the minute amountofold insulin thatmay remain in the needle or syringe. If you have a second unused syringe, youcanuseit justto inject air intoyourvials, making certain theneedle does not come into contact with the insulin in the vials.

If for financial reasons you really must reuse your syringes, the following procedure should help minimize contamination with polymerized insulin. You will, at the minimum, need three syringes, butfour would be better.

• Set aside one syringe for each of the different insulins you may beusing. Put a small piece of adhesive tapeon each syringe, markedwith the abbreviated name of the insulin (see page 269).

• Use your insulin vials for a week without injecting air into them.Squirt any excess insulin from each filling into a sink or waste-basket, not back into the vial.

• At the end of a week, remove the plunger from an unused syringe. Stand the vial stopper up on a flat surface and push theneedle of the unused syringe into the stopper of the vial.Withinseconds, the vacuum in the vial will suck in enough air throughthe needle to replace the vacuum.

* The reason for this is that the minute amount of insulin remaining in a usedneedlewillbecomepolymerized (inactivated) within a few hours. If it is injectedback into the vial, it will eventuallyact as a seed for the polymerization of muchof the insulin in the vial.

4

Insulin: TheBasics of Self-Injection 259

• PuU theneedle outofthestopper, reinsert theplunger, andrecapthe "air" syringefor use the next week.

WHAT IF YOU INJECT SEVERAL DIFFERENTINSULINS AT THE SAME TIME?

As discussed in Chapter 19, "Intensive Insulin Regimens," you mighthave to inject several different insulins at thesame time. For example,when you arise in the morning, you might inject an ultrarapid insulin (e.g., Uspro) to bring down a sUghtiy elevated blood sugar,then a rapid-acting insulin (regular) to cover your breakfast, then along-acting (basal) insulin (i.e., detemir or glargine). Take the most-rapid-acting (lispro), then the rapid-acting (regular), and last thelong-acting, one injection after another, aU using the same syringe.You cansafely do thisbecause the insulin has not hadenough time topolymerize in theneedle (this takes several hours). Ifyour long-actinginsulin is glargine, however, don't use the same syringe. Just a smaUamountof Uspro or regular in theneedle mayeventuaUy cause the insulin in thevial ofglargine to turncloudy andlose some ofitsactivity.This is very important.

Don't mix different insulins together, either in thesame syringe orin thesame vial, as this wiU result ina new insuUn with new, inappropriate timing.The onlyexception wouldbe to slowdown the action ofregular insulin when dealing with gastroparesis.

MUST YOUR SKIN BE WIPED

WITH ALCOHOL?

Most textbooks and instruction sheets that teach insulin injection orfinger stickingadvisethat the skin should be "sterilized" with alcoholbefore puncturing with a needle. Alcohol wUl not sterilize your skin.Atbest it wiU clean offdirt. My patients and I have given miUions ofinjections and finger sticks without using alcohol. Noneof us has becomeinfected asa result. Certainly it'sa sensible idea to cleanoffvisibledirt first, but you can do thiswith simple soap and water on therare occasions that it may be necessary. I often inject myself rightthrough myshirtor trousers (butnot through the trouser pockets).

260 Treatment

DISPOSAL OF USED SYRINGES

A Cost-Free MethodI recommend the foUowing cost-free, safe method for disposing ofused syringes. Again, this is contrary to the recommendations ofthe ADA.

1. Recap the needle.2. Putthecapped syringe intoalarge plastic bottle such asthatused

for bleach,bottled water, seltzer, or soft drink. Alternativelyuse alarge coffee can.

3. When the container is fuU, replace the cover or cap and preventits removalby applying duct tape.

4. Put the container into your trash* or take it to your physician,hospital, or pharmacy for pickup bythe special disposal servicethat they might use.

5. Ifyouareinahotel or restaurant, don'tput used syringes in theirtrash containers unless you firstput them with needle recappedin an opaque plastic bag, sealed with tape or knotted closed.*Their cleaning people wiU not appreciate seeing loose syringes.In an airplane, recap the needle and put the syringe in the trashbin in the lavatory.

A High-Tech MethodIt's now possible to meltneedles offinsulin syringes. If you are especiaUy conscientious about our environment or would enjoy using abriUiant technological device, you might try the Disintegrator Plus.This is a smaU device in a plastic box measuring about 6 x 3Vi x 2xhinches (15.24 x 8.9x 6.35 cm) and powered bya buUt-in rechargeablebattery. It seUs for$49 atCVS (cvs.com) andfor$79 ifpurchased fromthe manufacturer.

To operate the device you merely insert the needle intoa hole andpress ontheactivating button for 3seconds. The needle wiU disappear,

*Somecommunities forbidthe disposal of suchcontainers in local garbage. It iswise to contact your garbage coUection department foradvice. You canalso visitwww.safeneedledisposal.org to access a national database of local regulations inthe United States.f I save plastic grocery bags forthis purpose andalways pack a few empty oneswhen I travel.

Insulin: The Basics ofSelf-Injection 261

melted into a tiny metal blob that is stored inside the instrument. Youcan then drop the plastic syringeinto your ordinary trash container.

The stored metal blobs can be removed aftera month or so by unscrewing a small screw in a hatch on the bottom and pouring themout. This may take 30 seconds.

Disintegrator Plus is distributed by Perfecta Products, Inc., ofNorth Lima, Ohio, phone (800) 319-2225. It's fun to use and keepsneedles off our beaches.

REMOVING BLOODSTAINS FROM CLOTHING

Nowadays, most of us will inject through thin clothing (shirts, stockings, trousers) when it's inconvenient to undress. This can cause aproblem on the rare occasion that the needle encounters a small bloodvessel. A drop of blood can appear at the puncture site and stain yourclothing. Finger punctures sometimes bleed more freely than youexpect, so that upon squeezing you mayget a squirt in the eye, or bloodon your tie, if you're not careful.

The answer to bloodstains on clothing is hydrogen peroxide solution. Hydrogen peroxide isvery inexpensive and is soldin allpharmacies. Purchase several small bottles. Keep a bottle of peroxide handyatevery location where you measure blood sugars. Carry a small bottlein your luggage when you travel. Once a bottle has been opened, thesolution remains stablefor perhaps sixmonths,so you might want tohave a backup bottle available.

You can make bloodstains disappear very simply withoutbleachingthe dyes in your clothing. It'sbestif you treat thestain while the bloodis still wet,as dried blood bleaches veryslowly. If you allowthe bloodto dry, it may take 20 minutes of rubbing to get rid of the stain. Poursome peroxide on a handkerchief and rub it into the stain.The peroxide will foam when it contacts blood. Keep applying and rubbing until the stain has vanished.

SPECIAL DEVICES FOR "PAINLESS"

INJECTIONS

Many devices have been advertised with the claim that they inject insulin "without pain." Since most diabetics have not been taught the

262 Treatment

high-speed painless injection technique described in this chapter,manyof these special, spring-driven devices aresoldeveryyear. Ifyourinjections are already painless, it makes Uttle sense to usethem.

Other "painless" devices, caUed jet injectors, use very precise construction to inject a high-pressure jet of insulin, penetrating the skinwithout a needle. These injectors do not require a separate syringesince theymust be loaded directly with insulin, using special adaptersthat plug into the insuUn vial. Although the conceptis veryenticing,sprayinjectors posesomeproblems. First, they're veryexpensive, costingfrom$300 to $600 in theUnited States. Although thisisa substantial initial investment, the cost can be recovered over the course of ayear or two if you're giving yourself lots of injections withdisposablesyringes. Your insurance plan maynot payfor a jet injectorbut wiUmost likelypay for disposable syringes.

They'renot as convenient asdisposable syringes because they mustbe taken apart and sterilized in boiling, deionized water everyone totwo weeks. Also, the adapters for the insulin vials sometimes leakwhen the vialsare carried in a purse or bag.

You wiU require considerable training and experimentation withpressure settings in orderto give yourself a properjet injection. Thiscan delaygettingyour blood sugars normalized. You mayalso experience sUghtiy more pain than you would with a speedily injected shotfrom a conventional syringe, and there'sa high incidenceof blackandblue marks on the skin and minor bleeding and even loss of smaUamounts of insuUn at the puncture sites.

Despite these drawbacks, jet injectors do have two unique advantages, aside from reducing the number of syringes you must disposeof.Firstis that youwUl require aboutone-thirdless insulin, since theshots are better absorbed. Second, if you use fast-acting insuUn tolower elevated blood sugars, it wiU work even faster. But not fasterthan an intramuscular injection (page 307). FinaUy, jet injectorsshould not be used for longer-acting insulins.

INSULIN PENS

Several manufacturers are advertising "insuUn pens." These are syringes into which smaU cartridges of insulin canbe loaded. They areintended to reUeve you of the burden of carrying a vial of insulin ifyou have to injectaway fromhome.None of thosemarketedas of this

Insulin: The Basics ofSelf-Injection 263

writing canbe setat quarter-unit increments, and only one of thosesold in the United States can be set at half-unit increments. Mosttherefore cannot provide the fine-tuning ofblood sugars that ourregimens require. Stay away from themunless youareveryobese and require large doses of insulin. Withlarge doses, an error of Vi or Va unitis insignificant.

Thecartridges used for insulin pens areless than one-thirdthe sizeof standard insuUn vials and are consequently more convenient tocarryin a pocket or purse. You canpuncture thecap withtheneedle ofa standard insulin syringe andslowly draw out insulin. Donot injectair or reinject insulin into these cartridges.

17

Important Information AboutVarious Insulins

Ifyou start using insulin, you ought to understand how itseffectscan be controlled. It can do some remarkable things, but it mustbe handled with respect and knowledge. Much of the information

in this chapter is based upon my experience with my own insulinneeds and with those of mypatients. Asin much of this book, you willlikely note that some statements contradict traditional teachings andmanufacturers' literature.

AVOID INSULINS THAT

CONTAIN PROTAMINE

There are a confusing number of brands and types of insulins beingmarketed today — andeven more areon theway. Insulins maybecategorized by how long they continue to affect blood sugars after injection. There are most-rapid-acting, rapid-acting, intermediate-acting,and long-acting insulins. Until recently, the rapid-acting insulins appeared clear, like water, and the other insulins appeared cloudy. Thecloudiness is caused by an additive that combines with the insulin toform particles that slowly dissolve under the skin. The one remainingintermediate-acting insulin, called NPH, is modified with an animalprotein caUed protamine. Insulins that contain protamine may stimulate the immune system to make antibodies to insulin. These antibodies can temporarily bind to some of the insulin, renderingit inactive.Then, unpredictably, they can release the insulin at a time when it'snot necessarily needed. This effect, although small,impairs the meticulous control of blood sugars that we seek.Protamine can present an-

Important Information AboutVarious Insulins 265

other, more serious problem ifyou ever require coronary angiographyfor the study of arteries that feed your heart (a common procedurenowadays). Just before such a study, you would be given an injectionof the anticoagulant heparin to prevent the formation of bloodclots.When the procedure isover, protamine is injected intoa blood vesselto"turn off" the heparin. This can cause severe aUergic reactions, evendeath, in a smaU percentage of people who have previously beentreated withinsulin containing protamine. Thus, even if an insulin ismarketed as a "human" insulin, its effects upon antibody productionmay besignificant if it contains the animal protein protamine.

As you may guess, I strongly oppose the use ofinsulins containingprotamine. In theUnited States, theonly oneiscaUed NPH(elsewhereit may be caUed isophane insulin). NPH or mixtures of NPH andother insulins are widely avaUable and should beavoided. People whorequire very smaU doses of insuUn, such as chUdren, may be besttreated with dUuted insulin (page 272) for accurate dose measurement. Unfortunately, there isnodUuting fluid made for glargine, oneofour two remaining long-acting insulins.* I therefore amnowreluctantly obUged to prescribe three daUy doses of dUuted NPH on rareoccasions. More commonly, however, I'U dUute thelong-acting insulindetemir with saline, as described onpage 272.

A Ust of the insuUns that I consider possibly suitable appears onpage 269.

STRENGTHS OF INSULIN

Thebiological activity of insulin is measured in units. At smaU doses,2 units of insulin should lower blood sugar exactly twice as much as1 unit An insulin syringe is therefore graduated in units,and the oneshown in Figure 16-4 is also caUbrated in half-units. The lines are farenough apart so that even Va unit can be reasonably estimated. The syringe we recommend is designed for a concentration of 100 units per

*My favorite long- and intermediate-acting insulins, ultralente and lente,were taken offthemarket in2006 because they were less profitable to themanufacturers. DUuting fluids were available for these insulins. Although theAmerican Diabetes Association made no protest when these discontinuations wereannounced, there iscurrendy anuproar over this intrusion uponpatient care inthe U.K.

266 Treatment

cc, and candispense up to 3/io cc, or 30units. Theinsulin's strength isdesignated U-100, meaning"100 units per cc." Inthe United States andCanada, this is the only insulin concentration sold, so you need notspecify thestrength when you purchase. Other insulin strengths, suchas U-40 and U-80, are sold in other countries, and the scaleson the syringes in these countries are designed for these other strengths. Aspecial strength, U-500, isavaUable toyour physician intheUnited States,upon request from the manufacturers, for special appUcations. The syringes for U-40 andU-80 strengths are notsold in theUnited States.

Ifyou travel overseas and happen to lose or misplace your insulin,you may beunable tosecure the U-100 strength locaUy. You can makethe best of this by purchasing U-40 or U-80 insulin, together withU-40 or U-80 syringes. You should draw yourusual doses in units intothe newsyringes with the newinsulin.

CARING FOR YOUR INSULIN

Insulinisstable until the expiration dateprintedon the label, if refrigerated. Aslight loss of potency may occur if insulin is stored at roomtemperature longer than30-60 days. This isespeciaUy trueof glargine(Lantus) insuUn, which maylose a significant amountof potencyafter60days at room temperature. It isbest stored in a refrigerator.*

Insulin can becomepartiaUy deactivated with or without a changein its appearance, leading to unexpectedly elevated blood sugars.When I receive a distress caU from a patient who has had higher thanusualbloodsugars forseveral days, I aska number of questions in order to determine the source of the blood sugar elevation. Have therebeen dietary indiscretions? Is there a possible infection? Or mighttheinsulin be somewhat deactivated, perhaps by reuse of syringes (page257)? Even sUght cloudiness ofa clear insulin isa certain sign of deactivation. Sois the appearance of visible clumps within, or a gray precipitate on the waU of, a vial of NPH insuUn (normaUy cloudy) thatwiU not disappear whenit'sshaken. Deactivation of insulin, however,may notbe possible to distinguish simply bylooking. Ifdietor infection seems unlikely to be the source of the blood sugar elevation, I

*The manufacturer of Lantus isoverly cautious and recommends that it be discarded at 30 days after initial use — even if refrigerated. This is a very profit-effective directive.

Important Information About Various Insulins 267

therefore advise my patient to discard aU insulin currently in useandto utilize fresh vials, evenif the insuUn looksokay.

Here are some simple rules for routine care of your insulin:

• Keep unusedinsulin in arefrigerator untU you are ready to useitfor the first time. Vials in current use maybe keptat roomtemperature for convenience, but Lantus (and possibly detemir andgluUsine) isbest stored in the refrigerator.

• Never aUow insulin to freeze. Even after it thaws out, it may nolonger possess its fuU strength. If you suspect it mayhave frozen,discard it.

• If yourhome reaches temperatures above 85°F (29°C), refrigerateaU your insulinwhen not in use. If your insulinhasbeen exposed to temperatures in excess of 99°F (37°C) for more than 1day, discard it.

• Do not reuse your insulin syringes (page 257).• Do not put insulin in prolonged sunUght or in closed, unat

tended motor vehicles, glove compartments,or car trunks. Theseareas can become overheated on a sunny day, even in winter. Ifyou inadvertently leave insulin in a hot vehicle, discard it. Thisrule also appUes to blood sugar test strips.

• Donot routinely keep insulin close to yourbody, asin shirtpockets.• If you keepyourcurrently usedinsuUn out ofthe refrigerator, af

ter it warms to room temperature use a felt-tipped marker tomark the datewhen the vialwas first removed from the refrigerator. Coverthe marking with clear tape to prevent erasure. DiscardaU vialsof glargine, gluUsine, and detemir whenever 30-60days haveelapsed foUowing the marked date.

• When you invertyourinsulin vial to fill yoursyringe, observe thelevel of insuUn. When the level drops belowthe loweredgeof thelabel on the inverted vial, discard the vial. This is especiaUy necessarywith normaUycloudy insulins (NPH) becausethe concentration of active particles may change asyou use it up.

• If you plan to travel to anarea withwarmclimate where you maynot be able to refrigerate your insulin,consider a product caUedFrio, mentioned in Chapter 3,"Your DiabeticTool Kit." This is asmaU fabric waUet with peUets sewninto the lining. It's avaUablein five sizesin the United Kingdom and two in the United States.When the waUet is soaked in water for 15 minutes,the peUets wiUform a gel. As the water in the gel slowly evaporates through the

268 Treatment

pores of the wallet, it will keep insulin at a safe temperature without recharging for at least 48hours at a surrounding air temperature of 100°F (38°C).

HOW INSULIN AFFECTS YOUR BLOOD

SUGARS OVER TIME

It's important for you to know whenyour insulinwUl begin to affectyour blood sugar and whenit will finish working. This information isprinted on the insert in the insulin package. The published information, however, maybe inaccuratefor patientson our regimen.The reason for this is that we use very small doses of insulin, while mostpublished data are based upon much larger doses. As a rule, largernonphysiologic doses tend to start workingsooner and finish workinglater than smaller doses. Furthermore, the action time of an insulin

wiU vary somewhat from one person to another and from smaller tolarger doses. Nevertheless, Table 17-1 is a reasonable guide to the approximate startingand finishing times of the insulins we recommendwhen used in physiologic (as opposed to the usual industrial) doses.Your response may not follow a typical pattern, but at least this tablecan serve as a starting point.

Insulin action wiU be speeded considerably if you exercise the region of your bodyinto which you injected. As a consequence, it maybe,for example, unwise to inject long-acting insulin into your arm on aday that you lift weights or into your abdomen on a day that you dosit-ups.

A NOTE ABOUT MIXING INSULINS

In a word, Don't.

Twodifferent insulins should never be mixed — with the singleexception of the specific situation discussed on page 378. Otherthan that, mixingof insulinshas no usefulpurpose, even though itis advocatedby the ADA and even though you can purchase mixtures that are marketed by pharmaceutical companies. Mixing along-acting insulin with a rapid-acting one results in an insulinthat no longer has either the long- or rapid-acting properties.

Important Information About Various Insulins

TABLE 17-1

APPROXIMATE ACTION TIMES OF

PREFERRED INSULINS

269

Action time after injection*

Generic name

of insulin Abbreviation

U.S. brand

name DesignationAction

starts

Action

ends

Aspart* A Novolog Most-rapid-

acting

20 minutes 6-7 hours

Lispro* H Humalog (but assume

Glulisine G Apidra 5 hours)

Regular,or

crystalline1

R Humulin R

Novolin R

Rapid-acting 45 minutes 8-10 hours or

more (but

assume 5 hours)

NPH***

(cloudy)

N Humulin N

Novolin N

Intermediate-

acting

2-3 hours 12 hours if

injected in the

morning; 8 hours

if injected at

bedtime

Detemir* D Levemir Long-acting Slowlyover

4 hours

18 hours if

injected in the

morning; 8-9

hours if injected

Glargine LAN Lantus at bedtime

(apparent)

* Doses exceeding 7 unitswill usually start sooner, last longer, and act less predictablythan smaller doses. See page 304.f Aspart isnotquite as rapid in itsaction as lispro or glulisine.*Canbe diluted forusebychildren (see page 272).** Doses of NPH that exceed 7 units mayhave a peakof actionat about 8 hours after injection.

ABBREVIATED DESIGNATIONS FOR THE

VARIOUS INSULINS

When you're filling in the information on your Glucograf datasheets, it will be more convenient for you and your doctor if you usethe abbreviated designations shown in the "Abbreviation" column ofTable 17-1 — A, H, G, R, N, D, or LAN — instead of the full names.

270 Treatment

Since it's implied, you also needn't write out the word "units" whennoting insulin doses. Seven units of regular insulin would abbreviateas "7 R," and so on. If you forget these abbreviations, they are printedin the upper right corner of your Glucograf III data sheet.

ARE THE PREFERRED INSULINS

EQUALLY POTENT?

If we ignore the differences in timing, 1 unit of each of these insulinswill havethe same effect upon blood sugaras 1 unit of any of the others, with the striking exception of lispro, glulisine, and aspart. Theseinsulins are about 50 percent more potent than regular, the only remaining rapid-acting, true human insulin.

DO YOU NEED A PRESCRIPTION

FOR INSULIN?

Yes and no. Aspart, lispro, glulisine, detemir, and glargine require aprescription from your doctor in the United States. NPH and regularmay be purchased without a prescription in most states. Local regulations are subject to change.

WHY DO WE USE THE LONGER-ACTING

INSULINS?

Glargine and detemir, the clear longer-acting insulins, serve a purposedifferent from that of the rapid-acting insulins. Indeed, for our regimenstheyhave but oneprincipal task — to keep bloodsugarfrom risingwhile fasting (see the discussions of gluconeogenesis and the dawnphenomenon, pages 92-93). They are our basal insulins. They're notintended to preventthe bloodsugarriseaftereating. Furthermore, theyare not used to lower a blood sugar that is too high — they work tooslowly for this. A secondary purpose of longer-acting insulins in mildtype 2 diabetes is to help delay or prevent beta cell burnout.As you'llsee later, we may use a rapid-acting insulin to cover meals, whether ornot the longer-acting insulins are used to cover the fasting state. Whichinsulin to use, and when, depends upon blood sugar profiles.

ImportantInformationAbout Various Insulins 271

Now, why might we use both the intermediate-acting insulin(NPH) and the long-acting ones (detemir, glargine)? Won't just onetype or the other suffice? Which one to use depends upon blood sugarprofiles. If yourblood sugartypically rises between noon and bedtimeondays thatyou skip all your meals, you'll need glargine or detemir onarising in themorning. We use these andnot NPH in the daytime because they last longer and will usually carryover until a bit past bedtime. On the other hand, we may use one or, in rare cases, two of theseinsulins at bedtime, to cover the overnight fasting state. When one isneeded at bedtime, we usually try the longest-acting first. Glargineand detemir are especially valuable if the dawn phenomenon is prolonged or ifyou sleep longer than 8 hours. Ifour initial dose ofa long-acting insulin is not adequate, we may increase it. Sooner or later,however, we may find that late-morning blood sugars are going toolow, due to the higherdose. We might thenswitch over to NPH at bedtime, to concentrate action during the sleep period.One must be careful, however, not to give too much NPH at bedtime, because largedoses may cause blood sugars to drop in the middle of the night. Inpractice, I prescribe intermediate-acting insulin for fewer than 1 percent of my insulin-using patients. There are other rare uses of NPHdiscussed elsewhere in this book.

WHEN DO WE USE RAPID-ACTING

INSULIN?

If you're a type 1 diabetic — or a type2 diabetic who is following ourdiet and using oral medication and still experiencing bloodsugar increases after one or more meals — injecting regular (R), lispro (H),glulisine (G), or aspart (A) insulin prior to these meals is indicated. Bysheer coincidence, the 5-hour (assumed) minimum action time ofregular corresponds approximately to the time most of us require todigest fully a mixed meal of protein and carbohydrate, and to experience the final effect of the meal upon blood sugars. Regular insulinshould usually be injected 45 minutes before a meal, so that it starts towork just as we start to eat.

The beta cells of some type 2s, however, mayenjoy enough of a restfrom oneor twosmall doses ofglargine or detemirthat theycan producesufficient insulin to cover meals. Since everyone isdifferent, your insulinregimen must be custom-tailored to normalize your personal glucose

272 Treatment

profile. All this takes more effort onthe partofyour physician than justtheprescription ofone or two daily shots ofalong-acting insulin.

Because of theirvery rapidaction, lispro and glulisine are also theinsulins that weuseto lower a highbloodsugar. Since elevated bloodsugars are the cause of the long-term complications of diabetes, wenaturallywantto see themcome down to normal asfast aspossible. InChapter 19, we will teach you how to rapidly get high blood sugarsdown to your target, using G or H insulin. If your doctor finds thatyourblood sugars are rarely elevated or appear to rapidly dropdownon theirown,then it maynot benecessary to useadditional insulinforthis purpose.

DILUTING INSULIN

Many type 2 diabetics, mild type 1diabetics, and small children withtype 1diabetes require suchsmall doses of injected insulinthat dosagecannot be measured accurately enough with any of the syringescurrentlyon the market. Forsuchpeople, 1unit might lower bloodsugarby more than 120 mg/dl (versus only10mg/dlfor a veryobese type 1or a very obese insulin-requiring type 2 adult). A measurement errorof Va unit would therefore be equivalent to more than 30 mg/dl. Tosolve this problem we dilute the insulin. This is very easy. Yourphysician or pharmacistcansecure, at no charge, emptysterile insulinvialsfrom the insulin makers. The manufacturers will also provide, at nocost, the appropriate diluting fluids for some of the insulins you use.As if this writing, there are no diluting fluids for aspart, glargine, orglulisine insulins, so these cannot be diluted for children. I have recently discovered, however, that 0.9percent sterile injectable saline solution can be used to dilute detemir insulin.* Thus we again have along-acting insulin that can be diluted for small people, and are nolonger obliged to rely on 3 shots of NPHinsulin spread over the dayfor those who require dilution.

If your pharmacist is unwilling to performthe dilution for you,either find a pharmacy with a compounding chemist or do it yourself asfollows:

* The saline, in 10, 20, and 50 ml vials with rubber stoppers, is available at anypharmacyupon the prescription of a physician.

Important Information AboutVarious Insulins 273

1. Have clear instructions from yourphysician as to how much insulin and how much diluting fluid should be put into a vial. Ifyour doctor writes "dilute 2:1" (say "two to one"), this means 2parts of diluent, or diluting fluid, for every 1 of insulin, and soon. He may want to give you a few sterile 3 cc syringes* for thispurpose.They will contain about ten times asmuch asthe 25- or30-unit syringe you use for injections. Using the larger syringewill speedup the preparation of yourvials.

2. Each vial can hold only 10 cc of fluid. You should write downhow many cc's of diluting fluid and insulin you will need, remembering that the sum of the two cannot exceed 10 cc. Thus,if yourdoctor tells youto dilute your insulin 3:1, you might use6 cc of diluent and 2 cc of insulin.

3. All diluting fluids should be crystal clear, like water. Make surethatthe label of thediluting fluid youare using specifies thatit isfor the insulin you wantto dilute. The diluting fluid for lispro isthe same asthat for NPH. Regular (R) insulin has its own diluting fluid. As of this writing, none has been made available forglargine (LAN), aspart (A), orglulisine (G) insulins. Thedilutingfluid for detemir (D) insulin is 0.9 percent saline.

4. Pierce the empty vial with the needle of your3 cc syringe. Drawout airto the doseof diluent you wish to transfer(1,2, or 3 cc,etcetera).

5. Move the needle and syringe to the diluting fluid vial and injectthe air. Invert syringe and vial and hold vertically while youslowly withdraw the predetermined amount of fluid. Keep thetip of the needle near the stopper of the vial to avoid drawing inair. Be sure to expel anybubbles in the syringe.

6. Inject the diluent into the empty vial from which you took theair, and withdraw more airif you willbe delivering more fluid.

7. Repeatsteps4,5, and 6 until the amount of diluent that you hadwritten down is in the originallyempty vial.

8. Drawanother 1,2, or 3 ccof air(dependingupon how much insulin you will be transferring) from the vial you've been fillingwith diluent, but this time inject the airinto the insulin vial. Invert syringeand vial and,holdingvertically, drawout the predetermined amount of insulin. Keep the tip of the needle near the

Theyshouldbesupplied with relatively wide-bore (21-23gauge) needles.

274 Treatment

stopper of the vial to avoid drawing in air. (If you're workingwith NPH [cloudy] insulin, remember to shake the insulin vialvigorously 6-10 times immediatelybefore withdrawing thedose;seeFigure 16-6, page 257.)

9. Inject theinsulin into the vial towhich diluent hadbeen added.10. Repeat steps 8 and 9 until thedesignated amount of insulin has

been added to the diluent.

11. Using a permanent-ink felt-tip marker, label the newly dilutedinsulin vialwith the expiration date that appears on the insulinvial, the typeof insulin(usethe designation ND,HD,DD, or RDto indicate that the insulin has been diluted), and the ratio ofdiluent to insulin used (2:1, 3:2, 4:1, or whatever it happens tobe). Cover yourwriting with clear tape to prevent it from rubbing off.

12. Put the vialof diluted insulin in the refrigeratorfor storage untilits first use.

I've seen many people, includingdoctors,nurses,and pharmacists,become confused about how much diluted insulin to inject.With thatin mind, we will run through a coupleof examples to showyou howsimply this canbe computed.

Example 1. Your doctor wants you to inject 2V4 units of an insulinthat has been diluted 1:1. For every 2 parts of liquid in the syringe,only 1part, or half, is insulin. To get 2lA realunits of insulin,you willhave to inject twice as many diluted units (2 x 2V4 = 4V£) as they'remeasured on the scaleof the syringe— which is easier to estimate, especially with the newsyringes that arecalibrated every Vi unit.

Example 2. Your doctor wants you to inject 1V4 units of an insulinthat has been diluted 4:1. This time, for every 5 parts of liquid only 1part is insulin,sowemust multiply realunits by 5 to set our dose: 5 x1V4 = 5% = 6V4 units on the syringe.

I don't really expect my patients to computethe diluted units theymust take. In the caseof the secondexampleabove,I would askyou totake 6V4 diluted units. If this werelispro insulin, I'd write "6+ HD" onyour data sheets in the usual doses boxat the top of the form.

ImportantInformation AboutVarious Insulins 275

LISPRO, ASPART, AND GLULISINE:NEW ULTRARAPID INSULINS

These three insulins were developed bythree different manufacturersto overcome regular insulin's inability to rapidly cover fast-acting dietary carbohydrates. They cannot, however, circumvent the Laws ofSmall Numbers relating to large amounts of dietary carbohydrate.Since fast-acting carbohydrate foods (bread, pasta, fruit, and so on)usually contain large amounts ofcarbohydrate, the hazards of usingsuchfoods and covering themwithlarge amounts of insulin will stillexist. Furthermore, these foods will still raise blood sugar faster thanthenew insulins can lower it for people with normal digestion.

There are some applications of these insulinsthat the manufacturers may not have considered. For instance, if it is inconvenient to takeregular insulin 40-45 minutes before a meal, you can take aspart,glulisine, or lispro 20 minutes before the meal. They should be fastenough to cover small amounts of slow-acting carbohydrate withoutthe 40-45-minute delay. This can bevery valuable when youeat out,as you will learn in Chapter 19. Also, insulin users who previouslyused regular insulin to lower an elevated blood sugar will benefit byusing lispro or glulisine. They will get blood sugar down more rapidly.This, too, will bediscussed in Chapter 19. Note that studies show lisproto actsomewhat more rapidly than aspart.

NONINJECTABLE INSULINS

Although several insulinsthat do not require injection are and willbeon the market, noneareof use for theprecise control of bloodsugarsthatweseek. Some arebriefly discussed at the endof Chapter 19.

18

Simple Insulin Regimens

This chapter andthe next describe anumberof specific insulinregimens. As you read, please refer backto Table 17-1 in thelastchapter for descriptions of the various insulins and their

speed of action — for instance, long-acting insulin will be eitherglargine or detemir.

The particular regimen that suitsyou willdepend to a considerabledegree upon your blood sugar profiles. Your physician must decidewhether you need long-acting insulin to cover the fasting state, short-acting insulinto cover meals, orboth. In eitherevent,he or shewill requireblood sugar profiles and related data, covering asmany days ashe/she designates, priorto everyoffice visit or telephone call for fine-tuning of doses. Remember that "related data" includes the times ofmeals,whether you overate or underate, the times of exercise (including seemingly inconsequential activity such as shopping), times anddosesofblood sugar medications, infectionsor illnesses you may havehad,when and how many glucose tablets were taken to correct a lowbloodsugar — in short, anything thatmighthave affected yourbloodsugar. Bedtime blood sugar readings are especially important information, because an increase or decrease overnight should mostcertainly affect the determination of yourbedtime dosage of longer-acting insulin.

To give you some examples of how we might use insulin to bringyourblood sugar levels into target range, let's consider the followingblood sugar profile scenarios.

Simple Insulin Regimens 277

SCENARIO ONE: FASTING BLOOD SUGARS

ARE HIGHER THAN BEDTIME BLOOD

SUGARS

Let's say you're taking the highest useful dosage ofaninsulin-sensitizingagent (ISA) at bedtime. Your fasting (i.e., before-breakfast, empty-stomach) blood sugars are stillconsistently higher than your bedtimeblood sugars. Because of this, you probably require long-acting orintermediate-acting insulin atbedtime. Before we'd startyouon insulin,however, we'd examine your data sheet carefully in order to makecertain that you finished your last meal ofeach day at least 5hours priorto your bedtime blood sugar measurement. No oneshould be given along-acting insulin to cover an overnight blood sugar increase causedby a meal unless delayed stomach-emptying (Chapter 22) ispresent.

Forpeople who customarily sleep 8hours or longer, we usually startwitha long-acting insulin; wemay(rarely) start withan intermediate-acting insulin for people who sleep 7 hours or less. If youlike to sleepmore than 8 hours on weekends, it's wise to use a long-acting insulinrather than an intermediate-acting one every night, instead of tryingto switch between one and the other.

Because of the dawn phenomenon (page 93), a result of rapid removal of insulin from the bloodstream by the liver near the time ofarising in the morning, it's wise to take the bedtime dose of long-acting insulin no more than 9 hours before the morning dose. Thebedtime insulin will usually appear to have lost much of its action9 hours after the injection but will start working again after about3 hours — when the dawn phenomenon ceases.

Estimating the DoseYour physician may want to use this simple method for estimatingyour starting bedtime insulin dose. Generally, 1unit of regular, NPH,or long-acting insulin* lowers blood sugar 40mg/dl fora 140-pound,nonpregnant adult whose pancreas produces no insulin. Since yourbeta cells may still beproducing some insulin, we'd abide bythe Lawsof Small Numbers and cautiously assume initially that 1 unit of any

*Aspart, glulisine, and lispro areabout 50 percent more potent than the otherinsulins. For the other insulins I recommend, as noted in the previous chapter,except forthespeed with which it acts, aunitofoneinsulin isequivalent toa unitof any of the others.

278 Treatment

insulinwouldlower you80mg/dl, just sowewouldn'tbringyou dangerously low and riskovernight hypoglycemia.

Wewould then proceedas follows:First, we'd lookat yourblood sugar profiles. The first number we

want is the minimum overnight blood sugar increase over the pastweek. We'd subtract your bedtime blood sugars from your fastingblood sugars and take the difference from the night with the lowestrise. For this calculation, bedtime must be at least 5 hours after finishing supper. For small children, we accomplish this byasking parents toget apainless "tushy stick" using the Vaculance (see page 69) while thechild is sleeping.

The second number we want is the maximum amount that we'd expect 1 unit of long- or intermediate-acting insulin to lower yourovernight blood sugar. To get this number, we'd take the maximumanticipated blood sugar drop from 1 unit. Since our initial conservative rule of thumb is that 1 unit of glargine, detemir, or NPH willlower a 140-pound type 2's blood sugar by80mg/dl, we would divide140 byyour weight inpounds and then multiply the result by 80 mg/dl. If your weight is 200 pounds, the equation would look like this:(140 -5- 200) x 80= 56. So yourinitial estimated bloodsugar dropwillbe 56 mg/dl from 1 unit.

Letus assume, for example, that your lowest overnight blood sugarrise in thepast week was 73 mg/dl. We'd take 73 mg/dl anddivide itbythenumber you derived from theabove equation, or 56.Your trialbedtimedose of long- or intermediate-acting insulin would be 73 -§- 56=1.3 units. This isyour starting bedtime dose. Rounding offthedose tothenearest Va unitgives you Wa units, which you can abbreviate onyourdata sheetas 1+ (oneplus) LAN (or D or N), or just over1 unit.

Fine-Tuning the DoseThatwas pretty easy, but itwas onlyastarting point. Most probably thisdose won't beperfect —likely toolow orpossibly even alittle toohigh.To fine-tune thebedtime insulin, youmerely record bedtime and fasting blood sugars for the first few days after starting theinsulin. If theminimum overnight blood sugar rise was less than 10 mg/dl, you'vehit theproper dose onthefirst try. Iftherise was greater, your physicianmay want you to increase thebedtime dose byas little asVa unit everythird night, until theminimum overnight rise isless than 10 mg/dl.

Even oneovernight hypoglycemic episode canbe quite frightening,especially ifyou live alone. Such anevent can easily turn you offto in-

Simple Insulin Regimens 279

sulin therapy, so it's wise to take some simple precautions to ensure itdoesn't happen. On the nightthat you take yourfirst shot (and on thefirst night of any increase in dosage), set your alarm clock to ring 6hours after your bedtime injection. When the alarm sounds, measureyour bloodsugar, and correct it to your targetvalue if it's too low (seeChapter 20). Even onelow blood sugar event suggests that thebedtimedose should be reduced, or that if you're taking intermediate-acting(NPH) youshouldpossibly beswitched to a longer-acting insulin.

With the possible exception of growing teenagers, people with delayed stomach-emptying, or the obese, most of us usually require lessthan 8 units of long- or intermediate-acting insulin at bedtime. As thedose of NPH is increased above 7 units, its action tends to peak 6-8hours after the bedtime injection. This may be a great advantage, because it offsets the dawn phenomenon, or it may cause the problemjust mentioned — hypoglycemia several hours before arising.

Detemir and glargine in doses greater than 7 units, instead of peaking, tend to last longer. This maybe responsible for blood sugars thatare too low in the late morning, or even in the afternoon. There are atleast twoways to prevent this. First, you can split the insulin into twoor more approximately equal doses. Theseshould be injected at bedtime, but into different sites. If your required dose is 9 units, youmight inject4 units into your arm and the other 5 into your abdomen.You may recall that largedoses are not absorbed with consistent timing or total action, so two or more smaller injections have the advantage of making the absorption of both doses more predictable. Thesame syringe can be used for the second, third, and so on.

If this method doesn't do the trick for you, your physician may askyou to inject two separate insulins: one intermediate-acting and theother long-acting. Hewould customize the relative proportions experimentally. We never mix the two insulins together in one syringe.

SCENARIO TWO: BLOOD SUGAR RISES

DURING THE DAY, EVEN IF MEALS ARE

SKIPPED

If your blood sugar rises during the day even though you're takingmaximal doses of one or more ISAs before meals, it's time for you andyour physician to perform another experiment.

This time youwant to determine if meals have causedyour increase

280 Treatment

or if blood sugar increased independently. It's very unusual, by theway, for fasting blood sugars to rise during theday ifyou don'trequireinsulinat bedtime, usually to compensate for the dawnphenomenon(which, aswe've said, isthetendency in many diabetics forbloodsugars to go upovernight, andperhaps for upto3hours after arising). Inorder to determine when and how much your blood sugar is risingduring the day:

• Startyour daywitha bloodsugarmeasurement.• Ifyou're taking an ISA in themorning, continue with yourpres

ent dose.

• Checkblood sugars again 1hour afterarising.• Do not eat breakfast or lunch, but plan on a late supper — at

least 12 hours after this second morning blood sugar measurement.

• During the day, continue to check blood sugars approximatelyevery 4 hours, and certainly 12 hours after the second morningtest.

• If, evenwith a maximal doseof your ISA, your blood sugar risesmore than 10 mg/dl during the 12-hour period — without anydrops along the way —you probably should be taking a long-acting (that is, basal) insulin when youarise in themorning.* Werarelyuse an intermediate-acting insulinin the morning,sinceitprobablywon't last until bedtime.

This dose of basal insulin is calculated the same way we calculatedthe bedtime dose in the first scenario. Because fasting twice in oneweek is unpleasant, we may try to waitanotherweek before performingthisexperiment again to see if our basal dose isadequate. Furtherexperiments in subsequent weeks may benecessary forfine-tuning ofthe insulin dose.

MONITORING YOUR INSULIN REGIMEN

Once you take insulin, it is essential that you and your family be familiarwith the prevention of hypoglycemia (lowblood sugar).Tothisend,youand thosewholive or workwithyoushouldreadChapter20.

*See page 284 for our introduction to the concepts of basal and bolus insulindosing.

Simple Insulin Regimens 281

It should notbe necessary tomeasure blood sugar every day for therest ofyour life ifyou are taking only longer-acting insulin as describedin this chapter and you are strictly following our dietary guidelines.Nevertheless, it'swise to assign oneday every week or two formeasuringbloodsugaron arising, rightbefore and 2 hours after meals, andat bedtime, just to make sure that your insulin requirements are notincreasing or decreasing. If any ofyour blood sugars are consistentiy10 mg/dl above or below yourtarget, advise yourphysician.*

It's essential thatyou also measure blood sugar before andafter exercising. If, in your experience, your blood sugar continues to dropone or more hours after finishing your exercise, blood sugar shouldalsobe checked hourly until it levels off.f

As youshall read in Chapter 21, it isimportant whenever yousufferan infectious illness to secure daily blood sugar profiles and reportthem to your physician.

Many patients and physicians routinely increase the basal morningdose if before-breakfast blood sugars are repeatedly elevated. This isthewrong dose to change. It's thebedtime dose that controls fastingblood sugar, and therefore that dose should be adjusted accordingly.After fine-tuning ofbedtime and,ifnecessary, morning doses oflong-acting insulin,your pancreatic betacells mayrecover enoughfunctioneventually to prevent a blood sugar rise after meals. This frequentlyturns out to be the case. If, however, you still routinely experience ablood sugar riseof more than 15mg/dl 1or 2 hours after anymeal,ormore than 10 mg/dl 5 hours after anymeal, you'll probably requirepremeal injections of a rapid-acting insulin, as described in the nextchapter.

OTHER CONSIDERATIONS

Weather-Related Changes in Insulin RequirementsSome people experience a sudden decline in their insulin requirementswhen a longperiodof cool weather (e.g., winter) isabruptlyinterrupted by significantly warmer weather. This phenomenon can be

*See page299if you've forgotten howwearrive at a bloodsugartarget.*Insulin users mustalways check blood sugar before they drive andhourly whiledriving. Ditto for operating potentially dangerous machines. Scuba diversshould probably checkblood sugarsevery 20-30 minutes.

282 Treatment

recognized by blood sugar well below target when the weather suddenly becomes warmer. Insuch individuals, insulin requirements willrise aswinter occurs and dropin the summer.* Thereason for thiseffect is speculative, but may relate to the increased dilation of peripheral blood vessels during warm weather and resultant increaseddelivery of glucose and insulin to peripheral tissues. Whatever thecause, keep careful track of your blood sugar whenever the weatherwarms suddenly, since potentially severe hypoglycemia can result ifinsulin dosages are not adjusted.

Air Travel Across Time Zones

Long-distance travel that requires youto shiftyourclock by2hoursorless shouldn't have a major effect upon your dosing of ISAs or basalinsulins covering the fasting state. It should certainly have no effectupon the use of fast-acting insulin or insulin-sensitizing agents intended to cover meals. A problem does arise when travel shifts thetime frame by 3 or more hours and you're taking different doses oflong-acting medication in the morningand at bedtime. Thesituationbecomes particularlycomplexif you travelhalfway around the world,so that day and night are reversed.

When the time shift amounts to 2 hours or less, you need only takeyour morning medication upon arising in the morning and your bedtime medication at bedtime. One solution to handling larger timeshiftsis to effect a gradualtransition,using3-hour intervals over a period of days. Todo this,you must keeptrack of the time "back home."If,for example,you'retraveling east,so that the time backhome is earlier,on your first dayaway you would takeboth of your doses3 hourslater on the "back home" clock. On the second day, you would takethem 6 hours later,and so on. Thus, if your new location to the east ofhome is in a time zone 6 hours later than it was at home, it would takeyou 2 days to achieve a full transition.You woulddo just the oppositewhen traveling west. Thisprocedurecanbe inconvenient becauseit requires that you set an alarmclock for absurdhours just to takean insulin shot or a pill — and then, you hope, go back to sleep.

Several of mypatients routinelysave themselves this kind of annoyancewhen they travel. Attheir destinations, theycontinue to take their

* Some diabetics who also havethe diseaselupus erythematosus may experiencejust the opposite — lower insulin requirements in cold weather and higher requirements in warm weather.

Simple Insulin Regimens 283

morningdose when they arise in the morning andtheirbedtimedosewhen they go to bed. They check their blood sugars every 2 hourswhile awake andlower them,if too high, using the method describedin Chapter 19. If their bloodsugars drop too low, they raise them using themethod described in Chapter 20. Frankly, this istheapproachI use myself. Neither I nor my patients have gotten into trouble thisway. This carefree approach can cause problems if the bedtime dose isconsiderably different from the morning dose. If this is the case, thegradual transition of3 hours perday is certainly safer.

Splitting Larger Doses of InsulinMy patientsand I haveobserved that aslarger doses of insulin are injected, the effects upon blood sugar become less predictable. This isdue in part to day-to-day variations in absorption of large injections.After some trial and error, I arrived at a cutoff point of 7 units as thelargest singleinjection I would want an adult to take (smaller for children). Therefore, if an insulin-resistant patient requires 20 units ofglargine at bedtime, I askhim to take 3 separate injections in 3 separate sites of7 units,7 units,and6 units,all usingthe samesyringe.

19

Intensive Insulin Regimens

Alltype 1diabetics but themildest should betreated with rapid-acting insulin before meals as well as long-acting insulin inthe morning and at bedtime to cover the fasting state. This

roughly mimicsthe way that a nondiabetic's body releases insulin tomaintainnormalblood sugars. Generally, the nondiabetic body whenfasting has a constant, relatively low level of insulin in the bloodstream. This is the baseline, or basal, insulin level to prevent gluco-neogenesis, the conversion of protein stores (muscles, vital organs)into glucose. Without it, theywould"melt into sugar water," asthe ancients observed when diabetes was first described in writing.

During the fasting state (sleeping, between meals), the pancreasstoresthe insulin it creates in preparation for the next time the body isexposed to food, while maintaining the low basal release rate. Uponeating and for the first 5 or so hours thereafter, the body receiveswhat's known asa bolus of insulin — a greater rateof release — untilthe glucose derived from meals is stored in the tissues (Figure 1-2,page 45).As you mayrecall from Chapter 6, the body has counterreg-ulatory hormones that keep blood sugar from dropping too low sothat one doesn'tbecomehypoglycemic. So for those of us who makelittle or no insulin,essentially whatwe're trying to do with rapid- andlong-acting (and, in some cases, intermediate-acting) insulins is tocreate a rough approximation of a steady basal rate and an appropriate bolus rate.

If you are a type 2 diabetic and preprandial (before-meal) useof ISAs does not prevent your blood sugars from routinely increasingby more than 10 mg/dlatanytime priorto the next meal,it'sprob-

Intensive Insulin Regimens 285

ably time for you to use a rapid-acting insulin —lispro (H), aspart(A), glulisine (G),or regular (R) — before meals.*

Much of this chapter consists ofguidelines for computing insulintiming and doses invarious situations. They are essentially pretty simple calculations, and your physician or health care provider can andindeed should make themforyou. I have included themhereforseveral reasons. First, you should understand the information that goesinto customizing a dose ofinsulin, so that you know there's nomysteryinvolved. Second, ifyouunderstand howthese calculations work,you can also more clearly seewhat incorrect insulin doses look like,and, we hope, avoid them. Finally, despite the dramatic findings oftheDiabetes Control andComplication Trial, many physicians andhealthcare professionals arestill underthe false impression that normalizedblood sugars are dangerous or impractical or impossible. My hope isthatby providing these calculations, I can help you help your healthcare provider provide you with better health care.

Ifyou're not the"math type," you can certainly skip thecalculations,but do not skip the entire chapter. Herein lies importantinformationaboutadjusting yourinsulin dosages or timing to accommodate common variations in your daily routine, suchas eatingout, and how toadjust your insulin if you skip a meal or have a snack. (Later in thischapter, youwill learn why I rarely advocate snacking.)

DO YOU REQUIRE RAPID-ACTING

INSULIN BEFORE EVERY MEAL?

Theuse of rapid-acting insulin priorto every meal or snack may helpto preserve the function of anybeta cells that youmaystillhave. Nevertheless, you might not feel terribly enthusiastic about multiple dailyinjections. It'spossible, however, thatyoumay only require insulin before some meals and not others. Several of my patients, for example,maintainnormalbloodsugars byinjecting rapid-acting insulinbefore

*Clinical trials have shown aspart andglulisine to have virtually the same potency as lispro but somewhat slower timing of action, and more rapid actionthan regular (R) insulin. I have tried all of the new analog insulins and haveelected to useregular and glargine for mypersonal bolusand basal insulins, respectively, andlispro forlowering elevated blood sugars.

286 Treatment

breakfast andsupperandtaking an ISA 2 hoursbefore lunch.Onepatient injects before breakfast andsupper, and has no medication before the small lunch she eats prior to her workout at the gym. Theultimate determinant of when you require preprandial rapid-actinginsulin isyour glucose profile. Ifblood sugar remains constant beforeandafter every meal except supper, thenyouneed rapid-acting insulinonlybeforesupper.

You may recall, from our discussion of the dawn phenomenon inChapter 6, that bothyour own and injected insulins appear to be lesseffective whenyou wake up in the morning. This is why virtually allthe people I've seen who require any premeal bolus insulin must atleast have a dose before breakfast.

THE RAPID-ACTING INSULINS: LISPRO (H),ASPART (A), AND GLULISINE (G) VERSUSREGULAR (R) FOR COVERING MEALS

Please reread the section entitled "Lispro,Aspart, and Glulisine: NewUltrarapid Insulins," on page275.

Clearly, when compared to regular insulin, lispro has both advantages and disadvantages. Figure 19-1 illustrates the reasonfor a minordilemma. As you can see, Humalog, or lispro, has a high early peaklevel in the blood, and then after 2 hours its leveldrops below that ofregular. Attempting to match this peak with the action of carbohydrate upon blood sugar is verydifficult for several reasons. I won't gointo them all, but consider the following:

• The timingand shapeof the peakwill varyfrom one injectiontothe next.

• They willalsovarywith the sizeof the dose.• The appearanceof carbohydrate in the blood willvary over time

and from meal to meal.

• The flatter peak of regular insulin is easierto match with slow-actingcarbohydrate than is the sharp peakof H, A,or G with either slow-or fast-acting carbohydrate.

On the other hand, for most of us, regular must be injected about45 minutes prior to a mealin order to start workingas the meal startsto raise blood sugar. Lispro will start working about 20 minutes afterinjection.This short time intervalmakes for great convenience if you

Intensive InsulinRegimens

3.0-,

•^ 2 5-

y 2.0 qo

o

I 1.5 4toc

I 1.0 •:

| 0.5 A

w 0.0 J

Humulin R (n=10)Humalog (n=10)

(Mean Dose 15.4 U)

i •'• 'Ii•••1111•11111•111111111111111111111111111!

0 60 120 180 240 300 360 420 480Time (minutes)

287

'Baseline insulin concentration was maintained by infusion of0.2mll/min/kg human insulin.

Fig. 19-1. Serum insulin levels and action times ofrapid-acting insulins: HumulinR(regular) versus Humalog (lispro). Note that the "industrial-sized" mean dose,15.4 units, isfar larger than the physiologic doses recommended in this text.

don't know precisely when your meal will beserved, as when diningout (see below). With thisin mind, Iusually recommend thatpatientscover meals with regular whentime permits, but takelispro when timeis tight. I will usually, therefore, refer to regular as the premeal bolusinsulin. This does not rule outthe use of lispro, aspart, orglulisine, orlispro plus regular, for situations tobediscussed ina few pages.

There are yetadditional complexities to using the three analog insulins.* First of all, their effect uponblood sugar is not as consistent,at least for me and my patients, as that of regular. Second, as mentioned earlier, these are, in our experience, 50 percent more potentthan regular, so that their doses must be only two-thirds the dose ofregular for thesame neteffect upon blood sugar.

From here on, for the sake ofbrevity, I'll usually refer only tolisprowhendiscussing the most-rapid-acting insulins.

*Onlytwoof the insulins wediscuss (regular and NPH) have the samemolecular structure as human insulin. All the others have slightly different structuresand are therefore called "analog" insulins, not "human"insulins.

288 Treatment

HOW MANY MINUTES BEFORE A MEAL

SHOULD REGULAR INSULIN BE INJECTED?

Our goal is to minimize or totally prevent anyblood sugar increaseduring or after meals. To achieve this, you must take your shot farenoughin advance so that the insulin begins to lower blood sugarasyourfood starts to increase blood sugar. Yet you should not take it sofar ahead of the meal that blood sugardrops faster than digestioncankeep upwithit.The best time to inject regular, formost ofus,isabout45 minutesbefore eating. The most commonexception wouldoccurif you have gastroparesis, or delayed stomach-emptying. Our approaches to the diagnosis of this condition and to appropriate timingof preprandial insulin ifyouhave it aredescribed in Chapter 22.

Determining When to InjectThe following experiment should be useful in determining how longbefore a meal youshould inject yourregular insulin. This test can beconclusive onlyifyourstarting bloodsugar isnearnormal— perhapsbelow 140 mg/dland level for at least the prior 2 hours.

First, inject regular insulin 45 minutes before your planned mealtime. Now,measure blood sugars25,30,35,40,45 minutes, and so onafter the shot.

The pointin time when your blood sugar has dropped 5 mg/dl determineswhenyou shouldstart eating. If this point occursat 25 minutes,don't evenbother to measure further, just start to eat. If no dropis seen at 45 minutes, then delay the meal and continue checkingblood sugar every 5minutes until you see atleast a5mg/dl drop. Thenbegin your meal. It shouldn't be necessary to repeat this experiment,unless your preprandial dose of regular is changed by 50 percent ormore at some future date.

Ifyourstarting blood sugar ishigher than140 mg/dl when youperform this experiment, the lack of precision in blood sugar measurementand insulin sensitivity maybe greater thanthe 5mg/dl dropthatwe're looking for. Just put offtheexperiment untilyourbloodsugarisnearer to normal. In the meantime, assume the 45-minute guideline.

Is There Room for Error?

Suppose after performing the above experiment you find that yourregular insulin should be injected 45 minutes before eating —which

Intensive Insulin Regimens 289

is the case for most ofus. How far off can you be without getting intotrouble?

Eating 5minutes early orlate makes nosignificant difference. Ifyoueat 10 minutes too soon, your blood sugar may rise during the meal,butit probably will return to its starting point by the time we assumethe regular finishes acting, about 5hours after injecting. This isnotserious, especially if it occurs only occasionally. If blood sugars go upsignificantly with every meal over many years, you would probably beat risk for long-term complications of diabetes. If you eat 15 or 20minutes too soon, your blood sugar may go so high (say 180 mg/dl)thatyoubecome slighdy resistant to theinjected insulin. Ifthisoccurs,your blood sugar will not drop all the way to thepremeal level whenthe regular finishes its action. Ifit happens often, your risk for developingthe long-termcomplications of diabetes will increase.

What ifyou delay your meal by 10 or 15 minutes beyond the propertime after your shot? Now you're asking for trouble! Regular starts towork slowly, but its effect on blood sugar accelerates over the first 2hours or so. Even a delay of 10 minutes can send your blood sugardropping more rapidly than a low-carbohydrate meal can raise it.This, of course, can be hazardous.

USING A MOST-RAPID-ACTINGINSULIN WHEN DINING OUT

Part of the pleasure of eating out is having someone else serve yousomething you can't make at home, but the difficulty for the insulin-taking diabetic isthatyou're served ontheir schedule, notyours. Hostesses, restaurants, and airlines —as well intentioned as they maybe— rarely serve you at the time they promise. For nondiabetics,waiting may beannoying. For those ofus who are diabetic, annoyanceis compounded with danger. When planning your premeal bolus insulin shot, you cannot afford to rely on the word of your hostess,waiter, or airline staff. I've been taking premeal bolus regular insulinfor more than thirty-five years and have been "burned" more timesthanI care tocount. Now thatwe have lispro, I inject adose when I seethe waiter approaching my table with the first course. If I suspect thatthe main course will be delayed, I'll split mydose in halfand take thesecond half when the waiter arrives with the main course. You should

290 Treatment

do the same. A transient blood sugar elevation is a small price to payfor the assurance that youwill not experience severe hypoglycemia because the meal was delayed. If you eat a low-carbohydrate meal veryslowly, even a transient blood sugar increase can beavoided.

As lispro is 50 percent more potent than regular, its dose shouldonly be two-thirds thedose of regular for the same meal.

Nowadays, most airlines serve meals only onoverseas flights. Unlessyou are traveling first class, or possibly business class, you will probably have no choice as to meal content. It is therefore wise to bringalong yourown food — or at least theprotein portion,such ascannedfish or meat or even some cheese. Usually you will be served slow-acting carbohydrate in theform of salad or vegetables. Again, this isatimeforusing a most-rapid-acting insulin such as lispro 0-20 minutesbefore you begin to eat.

By the way, never order "diabetic" meals when traveling by air. Asof this writing, airlines are still serving as "diabetic" meals a high-carbohydrate diet loaded with simple sugars. Thesalads in these mealsmay even contain fruit. My trick is to preorder "seafood" or evenkosher mealswhen I reserve my flight. This ensures that I get reasonable portions of protein. Unfortunately, many airlines do not serveseafood for breakfast. On airlines that serve nothing but drinks and abag of peanuts, youmayactually be betteroff. You can packyour ownbrown bag breakfast or lunch, stick to your diet, and time exactlywhen you're going to take yourshot and eat your food.

One warning: If you have gastroparesis, never inject a most-rapid-acting insulin for a meal, as it will work faster than your stomach canempty the food. Use regular insulin.

OTHER MEALTIME CONSIDERATIONS

Must Meals Be Eaten at the Same Time Every Day?Eversince the introduction of long-acting insulin in the late 1930s,diabetics have been advised that they must have meals and snacks at thesame times everyday. Thisvery inconvenient rule still appears in current literaturedescribing the treatmentof diabetes. Prior to our useoflowdoses of long- or intermediate-acting insulins to cover the fastingstate, mostphysicians prescribed 1or 2large daily doses of long-actinginsulin to cover both the fasting state and meals. (Most still do.) Suchregimens never succeed in controlling bloodsugars, and hypoglycemia

Intensive Insulin Regimens 291

is an ever-present threat. Patients are told to eat meals and severalsnacks atexactly the right times, to offset the continuous blood sugardrop caused bythe long-acting insulin.

But if, as outlined in this chapter, we now cover our meals withrapid-acting insulin, we're free to eat whenever we want, provided wetake ourshot beforehand. We can also skip a meal ifwe skip theshot.When I was in medical training and worked 36-hour shifts, I sometimes skipped breakfast andate lunch at3a.m. Onsome days I didnoteat at all. This worked out fine because I followed the flexible insulinregimen described here.

What If You Forget to TakeYour Regular 45 Minutes Before Eating?Ifit's now less than 15 minutes before apredetermined mealtime (e.g.,your lunch break at work), take lispro instead of regular.

Ifyou ate your meal after forgetting your regular insulin, take lisproinstead —immediately—but don't forget that theamount of lisproshould beonly two-thirds your usual dose of regular.

HOW TO ESTIMATE PREPRANDIAL

DOSES OF REGULAR INSULIN

We know that for type 1 diabetics who make no insulin at all, 1 unit ofregular insulin usually lowers blood sugar 40 mg/dl ina 140-pound adult.We also know that 1gram of carbohydrate raises blood sugar 5 mg/dl.Thus 1unitregular usually covers 8grams ofcarbohydrate.We also knowthat1unitofregular insulin covers approximately Wi ounces ofprotein.

There arevariables, however. These figures apply onlytopeople whoproduce none of their own insulin and who are not insulin-resistant.Doses must betailored to theindividual, soifyou're obese, pregnant,or a growing child, you may require more insulin than these guidelines suggest. On the other hand, ifyour beta cells are still producingsome insulin, you may need considerably less insulin than indicatedhere. I have patients who require only one-quarter ofthese amounts ofinsulin.

Another variable in figuring a proper dose of regular is our oldfriend the dawn phenomenon. The regular insulin you inject beforeeating will be perhaps 20 percent less effective at breakfast than atother meals, eventhough it comesfrom the samevial.

292 Treatment

The biggest factor is, ofcourse, what you eat. Since we cannot knowexactly how regular insulin will affect you until you begin to use it,your initial trial doses before meals must be based upon your preciselyformulated meal plan. With that, we can make a reasonably safe initialestimateof howmuch insulinyou're likely to need.

It's noteasy for your physician tobalance outall these variables andcome up with just the right doses of regular insulin on the first attempt. Because of this, we try, for safety's sake, to underestimate yourinsulin needs initially, andthen gradually to increase your preprandialdoses after checking subsequent blood sugar profiles. This is yetanother example oftheLaws ofSmall Numbers inaction. Because ofthecomplexity ofthis task, let us examine how your physician might proceed with two very different scenarios.

SCENARIO ONE

You're a type 1 diabetic and are switching to our regimen from an outdated regimen ofl or2 large daily doses ofintermediate- orlong-actinginsulin. Remember thatmany type 2 diabetics eventually lose nearly allbeta cellfunction andthen, in effect, have type 1diabetes. So this scenariowould applyto these people too.

Assume that the meal plan you negotiated with your physician isthe following:

Breakfast: 6 grams carbohydrate, 3 ounces proteinLunch: 12gramscarbohydrate, 4V£ ounces proteinSupper: 12grams carbohydrate, 6 ounces protein

Because wewant to play it safe and staywith the lowest possible insulin doses, wewillfor the moment ignoreanyeffect of the dawn phenomenon upon your breakfast dose, as well asthepossibility of insulinresistance due to obesity. Our approximate calculations, based on thenumbers mentioned above for a 140-poundadult, are as follows:

To cover carbohydrate: number of grams •*- 8 = units of regularinsulin

To cover protein: number of ounces -s- 1.5 = units of regularinsulin

Intensive Insulin Regimens 293

Breakfast

• 6 grams of carbohydrate * 8 = 3A unit of regular insulin (whichyou'd note on your data sheet as 1~ [1 minus] R)*

• 3 ounces of protein •*- 1% = 2 units of regular (2 R)• Total trial dose for breakfast will be2% units of regular (3~ R)

Lunch

• 12 grams of carbohydrate v8=l'/2 units of regular (1 Vz R)• 4Vi ounces of protein -s- Wi = 3 units of regular (3 R)• Total trial dose = 4Vi units of regular {iVi R)

Supper

• 12 gramsof carbohydrate -4-8=1% units of regular (1% R)• 6 ounces protein + Vh= 4 units of regular (4 R)• Total trial dose = 5% units of regular (5!/2 R)

Your physician will probably want to lower these doses if yourpancreas is making any insulin (as shown either by his or her educatedguess or by the C-peptidetest, page 54).

It's virtually certain thatyour trial doses will beabit toohigh or toolow. In other words, your blood sugars may either rise or drop aftersome or all of these meals. It is most likely, however, that your postprandial blood sugars will not be dangerously low, unless you havegastroparesis. If you're insulin-resistant, you will likely need more insulin on the second try.

Both you andyour physician will want toget your blood sugars intoline asrapidly aspossible. So you'll probably beasked to fax, phone, orbring inyour blood sugar profiles during the second day (and perhapssubsequent days) of this intensive insulin regimen for fine-tuning ofdoses. Remember that the important blood sugar measurements forfine-tuning your doses of premeal insulin are 5 hours after each doseof regular, aspart, glulisine, or lispro, as we assume this is the time ittakes for the insulin to finish working. Let's assume that on the firstday your blood sugar profile lookedlike this:

*Note thatwe use thesymbols +and" to indicate thata dose isjustabove or justbelow the nearest whole unit on asyringe scale. So 1" means 3A unit and 3+ means3V4 units.

294 Treatment

5 hours after breakfast:increased70 mg/dl5 hours afterlunch:decreased 20 mg/dl5 hoursafter supper: increased 25mg/dl

Clearly, our initial insulin doses were abit off and require adjustmentto prevent further increases ordecreases ofmore than 10 mg/dl.These changes are easy, if you remember that for most 140-poundadults who makeno insulin (type 1diabetics), 1unit of regular lowersblood sugar by 40 mg/dl. If you weigh 100 pounds, 1unit of regularwill lower you about 56 mg/dl, or(140 +100) x 40 mg/dl. If you weigh180 pounds, 1unitof regular will lower you about 30 mg/dl, or(140 +180) x 40 mg/dl. We will assume, for this exercise, that your weight isclose enough to 140 pounds to use the 40 mg/dl drop from 1 unitof regular. Type 2 diabetics might do better by using Table 19-1, onpage 303.

Now let's look again at the hypothetical blood sugar profiles andworkout thechanges in preprandial regular thatwill be necessary:

Change in doseBlood sugar Change * rounded off to

Meal change 40mg/dl nearest V* unit

Breakfast +70 mg/dl +1.75 +13/4RLunch -20 mg/dl -0.5 -V*RSupper +25 mg/dl +0.625 +V6R

We now fine-tune our premeal bolus of regular insulin by makingthe above changes to the original trial doses.

Meal Trial dose Change New dose

Breakfast 23/4R +1% 4V*R

Lunch 4V£R -Vi 4R

Supper 5V4R +V4 6R

That was pretty easy. Remember, however, that thecontent of yourmeals, in termsof grams of carbohydrate andounces of protein, mustbekeptconstant from oneday to thenext, because your insulin doseswill not be changing every day. If you're consistently hungry after aparticular meal, you can increase theamount of protein at that meal,but you must then have the extra protein every day. When you raise

IntensiveInsulin Regimens 295

the protein portion ofyour meal, you look at your blood sugar profiles(or your physician does) to see how much your blood sugar goes up,and increase your dose of regular insulin for that meal accordingly. Donot increase your carbohydrates beyond 6 grams for breakfast, 12grams for lunch,and 12 grams for supper — the Laws ofSmall Numbers dictate that the resultant rise andrequirement for excess insulinwill cause real problems with your blood sugar normalization attempts.

Scenario Two

You have type 2 diabetes and are following our diet. You've been takingan ISA in the morning and/or at bedtime. Your blood sugars are finewhen you skip meals, butthey go up after meals, even with the maximaldoses ofyourISA.

Since you're not a type 1diabetic and are making some insulin ofyour own, we cannot use the simple rules that apply to those whomake essentially no insulin.Wehave toassume that your beta cells stillmake a portion of the insulin needed to cover your meals, yetwedonot know the magnitudeof that portion. Furthermore, wedon't knowhowmuch your insulin resistance will affect your injected insulin requirements. So we see how mucha meal will raise yourblood sugarswithout premeal bolus regular insulin. We then use this blood sugarincrease as a guide for the doses you will be needing. We do not usethis method withtype Isbecause their blood sugars mightgo sohighwithout insulin as to cause the dangerous condition known as ketoacidosis.

Further fine-tuning of preprandial regular insulin might be performed by reviewing your blood sugar profiles over aweek. If you'vebeen taking a premeal ISA, as assumed in this scenario, you probablyhave already collected blood sugar profiles that show howmuchyourblood sugar increases after each meal. Ifthese profiles cover only 1day,okay. If theycover aweek, better. Wewant to start youwiththe lowestreasonable insulin doses, sowepickthesmallest bloodsugar increasesthatwe can find for each meal, and then adjust your preprandial insulin accordingly. To find theincrease before you begin taking regular,subtract the preprandial blood sugar from the 3-hour postprandialblood sugar measurement (we wait 3 hours to allowthe effect of themealto be nearits highest level).

On pages 277-278, weshowed youhowto compute astarting doseof long- orintermediate-acting insulin tocover overnight blood sugar

296 Treatment

rises. We can use the samesimple formula to calculate initial doses ofregular insulin to cover meals. But for safety's sake, and to obey theLaws of Small Numbers, we're deliberately going to keep the trialdoses on the low side.We'll use as a guide the blood sugar data youcollected while you were taking your ISA, even though we may discontinue the ISA sometime after you startusingpremeal bolus regularinsulin.

To finish this example, letus assume thatyour3-hourpostprandialincreases in blood sugar over the past weekcanbe summarized as follows:

Smallest increase afterbreakfast: 105 mg/dlSmallest increase afterlunch: 17mg/dlSmallest increase aftersupper: 85 mg/dl

Now we must estimate the premeal bolus doses of regular insulinthat would approximately offset these increases. You may rememberthat our preliminary formula in estimating trial doses of glargine insulin is that 1unit of insulin will lower a 140-pound, insulin-requiringtype 2 diabetic's blood sugar by 80 mg/dl.Your physician maywanttobe even more conservative and assume that 1 unit will lower yourbloodsugar by 90mg/dl. We nowonlyneed to divide the above postprandial blood sugar increases by 90 to get the trial doses of premealbolus regular insulin, as in the following table:

Rounded off to

Blood sugar Increase * nearest V* unit forMeal increase 90 mg/dl trial dose of R

Breakfast 105 mg/dl 1.17 MRLunch 17mg/dl 0.18 V*RSupper 85 mg/dl 0.94 1R

As in the previous scenario, you will need to take periodic bloodsugar measurements to monitor the effect of the insulin. If after oneday on the trial doses of premeal bolus regular insulin, yourpostprandial blood sugars still go up by more than 10 mg/dl at 5 hours, yourphysician mayask you to increase the appropriate preprandial dosesby V4 unit. (Note that we now look at5-hour blood sugars instead of3-hour values, becausewe assume injected regular insulin requires 5hours to finish working.) If your postprandial blood sugar elevations

IntensiveInsulin Regimens 297

hardly respond to the Vfc-unit increase, your physician maychoose 1-unit increases. We rarely increase an initial preprandial dose in stepsgreater than 1 unit because of the danger of hypoglycemia.

The above trial-and-error procedure should be repeated untilyour5-hourpostprandial blood sugars donot consistently change from thepreprandial values by more than 10 mg/dl up or down. This all assumes that the carbohydrate and protein contents of your meals remain constant.

WHAT ABOUT SNACKS?

Ifyou've ever been on oneof theconventional regimens that utilizes 1or 2 large daily doses of longer-acting insulin, you're probably familiarwith mandatory snacks. These are required, usually midway betweenmeals and at bedtime, in the hopesof offsetting the continuous bloodsugar-lowering effect of large amounts of insulin, hopefully preventing dailyepisodesof hypoglycemia.

Our regimen, as you know, uses such lowdoses of glargine or de-temir insulins that blood sugars tend to remain level during the fasting state. With our regimen, there is no need for mandatory snacks!This does not mean that you must wait until the next meal before eating if you're hungry. Theoretically, you can eat a snack almost anytime,provided that you cover it with regularinsulin,just asyou woulda meal. There are, however, some guidelines to remember.

Snacking GuidelinesTryto avoid snacks during the initial fine-tuning stage of your insulindoses.This is especiallytrue of bedtime snacks.Snacksand their dosesof regular insulin canconfuse the issue ofwhat caused what change inblood sugar. If, for example, you wake up with a high or low fastingblood sugar, did the problem originate in your bedtime dose of intermediate- or long-acting insulin, or in the dose of regular that you tookfor the snack?

Anytime you snack, try to wait untilyour prior meal has been fullydigested, and the dose of regular insulin for that meal has run itscourse, about 5 hours after the preprandial regular. Suppose you wereto eat a snack 2 hours after a meal and then were to check your bloodsugar 5hoursafter the regular you took to cover the snack; youwouldhave no wayof tellingwhether it wasthe meal or the snack, and the re-

298 Treatment

spective doses of regular insulin, thatwere responsible for anyincreaseor decrease in your blood sugar.

If yousnack, don't eat "snack food." Try to snack on a food such asasingle serving of sugar-free Jell-0 gelatin (without maltodextrin) orthree small sheetsof toastednori, that is, something that will not significantly affect your blood sugar and will not have to be covered withinsulin. Most snacksother than these muddy the waterswhen you'retrying to analyze data. If you really make no insulin you shouldn'tsnack, because yourbloodsugar depends almost entirely on whatyoueat and inject. Snacking interferes with meticulous blood sugar control. Full type Is who do snack will have to refrain from correctinghigh blood sugars until 5hours after thebolus injection of regular orlispro for the snack. If you make some insulin and your routine injected doses have been fine-tuned, blood sugar corrections after asnack maynot be needed, as youmaybe able to make enough insulinto prevent slighdy elevated blood sugars (or "turn off" insulin productionif bloodsugars are heading too low). Butif you makelittleorno insulin, youwill still need to inject the correct dosage prior to thesnackto cover it, andto checkyourblood sugar levels 5 hours later tomake sure they do not differ from your target.

For these reasons, most of my patientsdo not snack on foods thatwill affect blood sugars. If you do snack, the same carbohydrate limitthatapplies to meals should also beapplied to snacks. If youconsume12 grams of carbohydrate for lunch and for dinner, 12 grams of carbohydrate would be the upper limit for carbohydrate for any singlesnack. Lesser amounts of carbohydrate for a snack— asthe Laws ofSmall Numbers wouldsuggest — willnaturally poselesser problems.

Ifyou're hungry several hours after ameal, checkyourblood sugarbefore snacking. Hunger mayreflect hypoglycemia, reflecting in turn toomuch insulin, and shouldbe treated with glucose tablets asindicated inChapter 20 anda possible reduction of insulin dosage the next day. Animportant rulefor alldiabetics: When hungry, check blood sugar.

Estimating the Dose of Regular Insulin for a SnackThere areseveral different approaches to this problem.

The simplestisto decide in advance that youwilleat for your snackexacdy halfthe amount of carbohydrate and protein thatyou eat forlunch or supper. Remember that fat has no direct effect on bloodsugar, soyouneedonlyconsider thecarbohydrate and protein. Coverthe snack with exacdy half the dose of regular that you take for the

Intensive Insulin Regimens 299

meal you selected. If your snack is one-third or one-quarter of yourselected meal, then you'd naturally take one-third or one-quarter yourusual dose of regular for this meal — rounded off to the nearest V4unit. You should inject the regular insulin as far in advance of thesnack as you would for a meal. In a pinch, you can take lispro insteadof regular and wait 20 minutes instead of, say, 45 minutes beforesnacking. But for this insulin, take only two-thirds of the dose that youwould take for regular.

If you select a snack containing carbohydrate and/or protein that isnot in the same proportion as one of your meals, use the computational method outlined on pages 292-297 for regular meals. To test thevalidity of your computations, skip lunch and lunch insulin and takethe snack and snack insulin instead. Check your blood sugar beforetaking the snack insulin, and then check it again 5 hours after eating.This will help you determine the dosage correction to make when younext decide to do the same experiment (perhaps a few days later, asyou may not wish to skip lunch two days in a row). You may want totry this several times to be sure of the dose. Thereafter, you won't haveto skip lunch in order to have a snack.

If you've decided that your snacks will consist only of a smallamount of protein (say, less than 3 ounces) and no carbohydrate, youcan take your regular insulin 20 minutes before eating instead of 45minutes before. This is because protein is converted to glucose muchmore slowly than is carbohydrate. Be sure to keep the protein and/orcarbohydrate content of your snack(s) the same from one day to thenext, as you probably won't want to do more experiments to determine doses of insulin.

Last but not least, blood sugars will beeasierforyou to control ifyoudon't snack at all, or if you makeyour snacka small amount of sugar-free Jell-O (without maltodextrin) instead of real food. It is importantto remember thatfor covering a meal or snack, the dose of most-rapid-acting insulin (lispro) should always be only two-thirds the equivalentdose of regular.

WHAT SHOULD YOUR TARGET

BLOOD SUGAR LEVEL BE?

In my experience, random blood sugars of nonobese, nonpregnant,nondiabeticadults tend to clusterclosely around 83mg/dl (4.6mmol/1).

300 Treatment

Children tend to run slighdylower. About 1hour aftera high-carbohydrate meal, many nondiabetics may have considerably highervalues. This, however, isnot"natural," because for mostof humanhistorypriorto the development of agriculture about 10,000 years ago, high-carbohydrate mealswerenot usually available. Americansnow eat anaverage of morethan 150 pounds of added sugar peryear, somethingthat the average human would not have experienced in a lifetime10,000 years ago. Nowadays fast-acting carbohydrate accounts for thelargest part of energy consumption. So if we ignore elevated bloodsugars that may be encountered shordy after high-carbohydratemeals,a"normal"valuewould be 83 mg/dl, perhaps even lower.

Several recent studies have demonstrated that risk for both cardiac

and all othercauses of death increases as bloodsugars or the equivalentvalues of HgbAlc exceed about 75 mg/dl.

With the above information in mind, for type 2 diabetics who useno or very little injected insulin, I seekblood sugars of 80-85 mg/dl(4.4-4.7 mmol/1). Since type Is and type 2s who inject nontrivialamounts of insulin cannot turn off injected insulin as their bloodsugars drop, there always exists the possibility of going too low (hypoglycemia). I therefore throw in a smallsafety factor and asksuch individuals, at leastinitially, to shoot for a targetof 90 mg/dl (5 mmol/1).As you will learn in the next section, we try to correct blood sugarswhen they areaboveor belowa target. Sincewe follow alow-carbohydrate diet, our targetremainsthe samebefore,during, and aftermeals,as it probablywas for our distant ancestors.

Under certaincircumstances we will set a higher target:

• If someone's blood sugars prior to starting our regimen werevery high, she/he will experience the unpleasant symptoms ofhypoglycemia at blood sugars that are well above our 85 or 90mg/dl. Thus if a new patient has had most blood sugars in thevicinity of 250mg/dl,we might initially setatarget of 140 mg/dl.We would then lower this target slowly overa periodofweeks.

• Sincethe initialcalculations of insulin doses may be too high, inspite of the precautions described earlier, it is wise to have a substantial safety factor. Thus one might set an initial target of 120mg/dl and then slowlylowerthis to 90 over a period ofweeks after it becomes apparent that no blood sugars less than 70 mg/dlhave been encountered. This safety factor may also protect pa-

Intensive Insulin Regimens 301

tients who at first make mistakes, because it is difficult to followeverything taught herein perfecdywhen starting out.

• Some insulin users, for whatever reason, are not meticulous infollowing what they have learned in this book or in my orifice —most commonly the dietary guidelines. These folks will inevitably experience roller-coaster blood sugars, although to amuch lesserdegree than in the past. Here again it is safer to use atarget well above 90 mg/dl. A similar problem is encounteredwith people who experience unpredictable exercise, such as laborers and small children.

• Insulin pump users experience much greater uncertainty of insulin absorption than do those who inject. We therefore find itnecessary to shoot for a higher than normal blood sugar, just toreduce the likelihood of severehypoglycemia.

• Lastbut not least are those with gastroparesis (see Chapter 22).Here the unpredictable variations in blood sugars are greatenough that a higher long-term target is frequendy necessaryinorder to avoid very lowvalues.

RAPID CORRECTION OF ELEVATED

BLOOD SUGARS: CALCULATING

THE DOSE OF LISPRO

Sooner or later a dietary indiscretion, an infection, morning exercise,acute emotional stress,or evenerrors in estimatingmeal portions maycause your blood sugar to rise substantially over your target value. Ifyour beta cellsare still capable of producing moderate amounts of insulin, your blood sugar may drop back to target within a matter ofhours. On the other hand,you maybe likeme and makelittleor no insulin,or you maybe veryresistant to your owninsulin.If anyof theseis the case,your physicianmay want you to inject lispro, glulisine, oraspart whenever your blood sugar goestoo high.* (Asyou've probablynoted, doses of insulin used to bring down elevated blood sugars areoften referred to as"coverage.") Because these work faster than regular

* Because lispro is somewhat fasteracting than aspart, I prefer the lispro for correctingelevatedblood sugars.

302 Treatment

insulin, they are much preferred for this purpose. (If you are presentlycovering elevated blood sugars with regular insulin, use care whenswitching to lispro — see "Some Final Considerations RegardingLispro, Aspart, and Glulisine Insulins," page 312.) To do this properly,you must first know how much Vi or 1 or 5 units of lispro insulin willlower your blood sugar; it's usually 50 percent more than regular will.

This requires yet another experiment.Wait until you have a blood sugar that is at least 20 mg/dl above

your target (but this should not be an elevated measurement taken onarising — the dawn phenomenon can muddy the result of the experiment). To make sure that your prior mealtime bolus dose has finishedworking, this blood sugar should be measured at least 5 hours afteryour last dose. Besure that you have taken your morning basal dose ofglargine or detemir. For this test, skip your next meal and the insulinbolus that covers it.

Now refer to Table 19-1, which suggests the amount that 1 unitof lispro might lower your blood sugar, for the purpose of this trialonly. The left-hand column represents the sum of your daily doses ofdetemir/glargine or NPH that you are taking just to keep your fastingblood sugars level (your basal doses). The middle column shows theamount that 1 unit of lispro will probably lower your blood sugar. Theright-hand column showsthe amount that 1 unit, as read on a syringe,would likely lower blood sugar using a dilution of 3:1. (See page 273for diluting instructions.) Again, this table isonly approximate. Its onlypurpose is to suggest how much lispro (H) you might try for this experiment. The column for diluted insulin is for those few individuals(children, for example) who find that a little goes a long way.

After recording your elevatedblood sugar,determine the amount oflispro insulin suggestedby the table to bring your blood sugar down toyour current target. Let's assume that the sum of the dosesof detemir/glargine/NPH that will just keep your blood sugars level (if no meals)is 9 units. Then, by interpolating between lines in the table, 1 unit oflispro will probably lower your blood sugar about 54 mg/dl. Let's further assume that your blood sugar at the time of this experiment is 175mg/dl and that your target is 100 mg/dl. You therefore would like tolower your blood sugar 75 mg/dl. Dividing 75 by 54 yields 1.38 unitslispro. Rounding down to the nearest quarter-unit, VA units of Hshould lower you about 1.25 x 54 = 68 mg/dl. This is certainly closeenough, so you would inject \lA units.

Intensive Insulin Regimens 303

TABLE 19-1

SUGGESTED TRIAL EFFECT OF 1 UNIT LISPRO (H)

IN LOWERING BLOOD SUGAR

1 unit H (fullstrength) might lowerblood sugar

Total daily basal doseof undiluted long-actingand intermediate-actingInsulin*

1 unit H (3:1 dilution)might lowerblood sugar

2 units 240 mg/dl 13.3 mmol/F 60 mg/dl 3.3 mmol/1

3 180 10 45 2.5

4 120 6.7 30 1.7

5 96 5.3 24 1.3

6 80 4.4 20 1.1

7 68 3.8 17 0.9

8 60 3.3 15 0.8

10 48 2.7 12 0.7

13 37 2.1 9 0.5

16 30 1.7 7.5 0.4

20 24 1.3 6 0.33

25 19 1.1 5 0.27

*If you have gastroparesis and must take more longer-acting insulin at bedtime inorder to cover overnight emptying of your stomach, instead of using your bedtimedose to arrive at this number, substitute double your morning long-acting dose anddon't add in the bedtime dose.

Reminder: mmol/1, or millimolesper liter, is the standard international measure ofblood glucose level (1 mmol/1 = 18 mg/dl).

Check and record your blood sugar again 4,5, and 6 hours after theshot.* The lowest value will not only tell you how much your bloodsugar dropped but also how long it took. For most of us, we assumethat the lispro/aspart/glulisine finishes working in about 6 hours. Ifyour lowestvalue occurs at or after 6 hours, you should in theory waitat least this long in the future before checkingyour blood sugars to see

* Note that this experiment requires that you refrain from eating for 5 hours after your last shot of regular and then another 6 hours after the lispro, for a totalof 11 hours. With luck,you'll have to do this onlyonce in your life.

304 Treatment

if the extra shot of lispro really brought you down to target. Let's saythat the 1V4 units of lispro in the above examplebrought your bloodsugar from 175 down to 81 mg/dl after 5 hours, and it did not dropfurther at6 hours.Nowyou've learned that 1XA units H willloweryourblood sugar by 94mg/dl (or 175 - 81).Divide 94mg/dl by 1.25 (unitsof lispro/aspart/glulisine) to find that 1unit H willactually loweryourblood sugar 75 mg/dl. Whatever this value turns out to be, write itdown on your Glucograf data sheet in the box l unit willlower blood sugar. In this case, we have learned that our initial es

timate that 1unit would lower you 54 mg/dl wasoff by about 39 percent.This canhappen, andthis is precisely whywedo this experiment.

If at any point during this experimentyour blood sugar drops 10mg/dl or more below your target, immediately correct to target withglucosetablets,asdetailedin the next chapter. This will offset the hazard of hypoglycemia. On your data sheet, record the number of glucose tablets that you used. After you have read the next chapter, youwill understandhow knowingthe number oftablets willenable you tocomplete the above calculation without terminating or repeating theexperiment.

As statedat the beginningof this chapter, it shouldn't be necessaryfor you to perform any of the abovecalculations on your own. This isthe job of your health care professional, who can use our table andshould havemuch more experience than you. He or she might want totry a simple option. For example, your doctor might instruct you tomeasureyour 6-hour,posdunchblood sugar and,if it'sover 180 mg/dl,to inject 1unit oflispro(H) and seehow far your blood sugar drops inanother 6 hours (without eating again). This will tell you approximately how much 1 unit will loweryour blood sugar.

WHEN TO COVER HIGH BLOOD SUGARS

Once you know how much 1 unit of lispro will lower your bloodsugar, you're in a positionto bringdown yourblood sugar rapidlyif itgoesmuch aboveyour target. All you need to do is to inject the properdose.Within hours, your blood sugar will probablyreturn to target,unless for you small doses of lispro work more slowly, or unless youhave a very high blood sugar and take more than 7 units (split intosmallerdoses,eachno greater than 7 units). These extra doses arewhatis known ascoverage. Once your insulin doses have been fine-tuned, it

Intensive InsulinRegimens 305

should rarelybe necessary for you to cover with more lispro than willlower you 60 mg/dl, unless you overeat, have an infection, or sufferfrom gastroparesis.

Never cover an elevated blood sugar with lispro ifyou have notwaitedfor the last dose of regular or lispro to finish working. After all, if twodoses are working at the same time, your blood sugar can drop toolow. This is one reason you should know how long it takes for a doseof regularor lispro to complete its action.

It is convenient to assume that the rapid- and most-rapid-acting insulins continuetheiractionforonly5hoursafterinjection, eventhoughTable 17-1shows8-10 and 6-7 hours, respectively. The reason for ournot-quite-correct assumption is that if we assumed even 6 hours forcompletion of action and you were to correctblood sugarsat least 6hours aftereachinjectionof the rapid insulins (e.g., beforemeals andat bedtime), you would not only have inconveniendy spaced mealsand bedtime, but also would have to remain awake at least 18 hoursdaily, leaving you only 6 hours of sleep. We thereforeassumea 5-houraction time for convenience, in the reasonable assumption that bloodsugar drop thereafter will be minimal. Thus we arrive at a primeguideline for correcting elevated blood sugars: Wait at least 5 hoursfrom your last shot of a rapid-acting insulin before correcting elevated blood sugars.

Suppose target blood sugar is 90 mg/dl and you wake up in themorning and find that your fastingblood sugar is 110,an elevation of20mg/dl. If 1 unit of lisprolowers you40,you'd immediatelyinject Viunit as coverage. If you plan on havingbreakfast in 40 minutes, justtakethis xh unit as a separate shot, in additionto your usualbreakfastdose of regular.

Another timeyoumayfind that 5 hoursafter yourlunchtime regular was injected, your blood sugar is 60mg/dl above your target. If 1unit of lispro lowers you40mg/dl, take Vh unitsof lispro right away.

A major variation from the 5-hour rule applies to children and toanyone who sleeps more than 9 hours overnight and has meals spacedless than 5 hours apart. These people should correct elevated bloodsugars onlyupon arising in themorning, unless an alarmisset to ringduring the night for a 5-7 hour postdinner correction. This alarmcould also signal the timeforthenightiy dose of longer-acting insulinsothat less than 9 hours elapses between the nightdoseand the morning dose,as dictated by the dawn phenomenon (seebelow).

At first, after you cover with lispro, you may want to check your

306 Treatment

blood sugar when the insulin has finished working, to make sure thatthe numbers from your original experiment were correct. After a fewtimes, however, you will become confident that your calibration isproper.

USING LISPRO TO COVER

THE DAWN PHENOMENON

Many of us find that blood sugar increases during the short intervalbetween arising in the morningand eating breakfast. This iswhy, during the first week or twoon our regimen, it isnecessary to check bloodsugar not only upon arising but also when you sit down for breakfast.If such an increase occurs regularly, you should cover it before it occurs — on arising— with the appropriate dose of lispro. This willprevent the dawn phenomenon increase. I find it necessary to take Viunit of lispro everymorning upon arising, in addition to any coverageI might need for a slightly elevated fasting blood sugar.

IF RESULTS DON'T MATCH EXPECTATIONS

Under certain circumstances, lispro insulin will not lower your bloodsugar as much as you would expect based upon your calibration. Let'stake a look at some factors that can cause this.

Your lispro is cloudy. If your blood sugar does not drop as much asyou expect, hold the insulin vial to the light to make sure that it's notcloudy. Compare it with a fresh vial to be sure. Lispro insulin shouldbe crystal clear; if it is even the slightest bit cloudy it has been deactivated and should be discarded. Also discard the vial if it has been

frozen, kept in a hot place, or kept out of the refrigerator for morethan three months, since temperature extremes will also affect its potency. According to the manufacturer, glulisine is more likely to deactivate at elevated temperatures than lispro.

Your fasting blood sugar was high on arising in the morningand you can't get it down. The dawn phenomenon causes more insulin resistance in the morning for some people than for others. If youstart the day with an elevated blood sugar, you may require more

IntensiveInsulinRegimens 307

lispro coverage to bring down the elevation at that time than youwould 4 or more hours later in the day. If you find that early-morninglispro coverage is not very effective, reviewyour blood sugar profileswith your physician.You'll probably be told that you should increaseyour coverage by one-third, one-half, or some other proportion during the first fewhours after you wakeup. More than 3 hours after arising, this increase in any coverage should no longer be necessary.

To prevent overnight blood sugar increases, be sure to wait at least5 hours between your supper premealbolus and your bedtime basalinsulin and correct accordingly. You may do better by reducing yourprotein at supper, and certainly you should eat no bedtime snacks. Besure to take your bedtime insulin lessthan 9 hours before your morning basal dose.

Your blood sugar was higher than 200 or 300 mg/dl. Atsuch highbloodsugars webecomemoreresistant to the effects of injected insulin.This increased resistance may become very significant as blood sugarrises above250mg/dl.But the point at whichresistance becomes significant isnot precise, and its magnitudeisdifficult to determine.Werarelyencounter such high blood sugars once insulin doses and diet are appropriate.If you do measurea veryhighblood sugar, coverit with yourusual caUbration for lisproand wait the usual5 hours or so.Then checkyour blood sugar again.If it has not comeall the waydown to your target, take another coverage dose based on the new less elevated bloodsugar. This time the coverage willprobablybe fully effective.

Infections. If your lispro coverageor any other insulin dose is lesseffective than usual, you may havean infection. Weonce discovered thata patient had an intestinal inflammation called diverticulitis only becausehe waswiseenough to telephonemewhen his blood sugarswerea litde lessresponsive to insulin than usual.It's important thatyounotifyyourphysician wheneveryoufind thatyour insulin appears to be losingitsefficacy. SeeChapter 21.

INTRAMUSCULAR SHOTS WILL GET

YOUR BLOOD SUGAR DOWN FASTER

Intramuscular shots of insulin can be quite useful for bringing downelevatedblood sugar more rapidly than our usual subcutaneous shots.

308 Treatment

You should not ordinarily use them for your usual meal doses of regular insulin, and you should never inject glargine, detemir, or NPHinto a muscle— it makes no sense to speed up the action of a long-acting insulin.

Typically, an intramuscular shot of lispro will begin to lower an elevatedblood sugar within about 5 minutes. It will finish acting about1hour sooner than your usualsubcutaneous injection, and it will haveyour blood sugar closeto your target within about 3 hours.

Problems to Consider

With intramuscular shots, you may experience several problems thatyou do not encounter with subcutaneous shots. Because of this, Igive my patients the option of using or not using this method of self-injection, and fully appreciate the feelings of those few who turn itdown. Here are some obstacles you may confront:

Fat arms. If you havefat arms, don't even try intramuscular shots. Ifyou have a lot of fat over the deltoid muscleon your upper arm (Figure 19-2), the needleon your insulin syringewillbe too short to penetrate the underlyingmuscle.

Missing the muscle. Even moderatelyslim peoplesometimes"miss"the muscle because even the longer (Vi-inch) needle sometimes maynot penetrate deeply enough. Sincewe cannot always tell whether ornot the needle hit the muscle, all of us must wait as long beforerechecking our blood sugars as we would for a subcutaneous shot.

Hitting a blood vessel. You are much more likely to hit a blood vessel than with subcutaneous injections.This can be brieflypainful. Youcan also get blood on your shirt if you shoot right through the sleeveas I do. I estimate that I hit a blood vessel once in every thirty intramuscular injections. (See page 261 for instruction on using hydrogenperoxide to remove bloodstains from clothing.)

Pain. If for whatever reason you're unable to throw the needle inrapidly like a dart, all your intramuscular shots may be brieflypainful — if so, do not evenbother to attempt them.

IntensiveInsulin Regimens 309

Intramuscular Injection TechniquePlease refer to Figure 19-2 as you read the following step-by-step instructions. Do not use a syringe with the new short needles. I keep onhand a supply of syringes with Vi-'mch needles just for intramuscularshots.

1. Locate your deltoid muscle, illustrated in Figure 19-2. It begins atthe shoulder and ends about one-third of the waydown your upper arm. It's wide at the shoulder and tapers to a V shape fartherdown. You may be able to feel the V with your fingers if you liftyour arm to the side until it is parallel to the floor. This willtighten the muscle and make it feel harder. We usually use thedeltoid muscle because it is easy to find, is relatively large andthick, and is less likely to be covered with a deep fat pad thanmost other muscles.

2. Now, allow your nondominant arm (left if you're right-handed)to dangle loosely at your side. This will relax the muscle, so thatthe needle can penetrate easily.

3. The site for injection will be near the upper (wider) end of thedeltoid, about \l/z inches below your shoulder (at about the position of the arrow in Figure 19-2). We use the wide end of themuscle because you are less likelyto miss it with the needle, andbecause you would not want to pierce the axillary nerve, which islocated near the tip of the V, at the lower end.

4. As your nondominant, target arm dangles loosely at your side,pick up the syringe with your dominant hand and "throw" the

Terry Eppridge

Fig. 19-2. Thedeltoidmuscle (arrow

indicates preferred sitefor intramus

cularinjection).

310 Treatment

needle straight into the injection site as you would a dart — but,of course, don't let go of the syringe. Do not grab any flesh, asyou do for subcutaneousshots.Do not inject at an angle,but goin perpendicular to the skin.Befast,as a slowintramuscular shotcan hurt. Push in the plunger rapidly to inject your insulin. Nowpull out the needle. Touchthe injection site with your finger, tomake sure you have not bled.

5. If the shot hurts, you probablyhit a smallblood vessel, so be prepared for some blood. In such a case, press the injection sitefirmly with a finger. Hold it there for about a minute. This willprevent or stop any bleeding. If you do not press, you will developa slightiypainfullump wherethe blood accumulatesunderthe skin. The lump will turn yellow or black and blue after anumber of hours. If you inject through your shirt or blouse andget it bloody,applyhydrogenperoxide,as described on page 261.

Once you havegiven a number of intramuscular shots using yourdominant hand to operate the syringe,try switchinghands and arms.This mayseemcumbersome at first, but with practice youwillbe ableto inject into either arm.

"MIXED" THERAPY — INSULIN PLUS ISAs

As indicated previously, if you are still making some insulin and areinsulin-resistant,you maybe able to take rosiglitazone instead of regular insulin before certain meals. This will depend upon your postprandial blood sugar profile.There may be no therapeutic advantageto such a substitution, but it might be more convenient. Remember,however, that you willprobablyhaveto wait at least 60 minutes beforestarting your meal. It is usuallymore convenientto take a shot of regular insulin, since the waiting time after injecting is generallyonly 45minutes.

A more important use for an ISA in combination with insulin occurs if you are overweight or have polycystic ovarian syndrome(PCOS;seeAppendixE) and your bedtime dose of long-acting insulinis more than 8-10 units. This suggests that you may have insulin resistance, which may respond to one of the ISAs or insulin mimetics. Recallthat ISAs increaseyour sensitivity to insulin.Large dosesof insulinhelp build fat, of course,and can also causefurther down-regulation,

Intensive Insulin Regimens 311

or desensitization, of insulin receptors. If you'reobese,the lessinsulinyou have in your system storing awayfat, the better. So there may besome advantageto reducingyour bedtime insulin dose.

If your physician decides to add one ofthese agents to your bedtimeregimen, he or she will want you to build up the dose gradually whilesimultaneously reducing your dose of basal insulin. She/he mightwant to beginwith the extended-release versionof metformin becauseit will keep working all night and is not likely to cause the digestivediscomfort sometimes found with the more-rapid-acting version. Ifyour bedtime insulin requirements are not reduced while taking themaximum recommended doses of severaloral agents before sleeping,then the bedtime oral agents are serving no purpose and should bediscontinued. The FDA warns against using rosiglitazone or pioglita-zone for people taking insulin, as there is a small risk of congestiveheart failure (due to fluid retention) in susceptible individuals whotake insulin plus thesemedications.* This restriction does not apply tometformin or to the insulin-mimetic agents.

IS IT NECESSARY TO RECORD DAILY

BLOOD GLUCOSE PROFILES AFTER

INSULIN DOSES HAVE BEEN FINE-TUNED?

Type 1 diabetics, and those type 2s whose beta cellsare producing little or no insulin, both tend to show significant blood sugar changesfollowing relativelysmall changes in what they eat, their activity level,and so on. If your blood sugarscommonlyshowchangesof more than20 mg/dl in the course of a day, you probably should measure bloodsugar profiles dailyfor the rest of your life. Suchfrequent monitoringis necessary so that you can correct high blood sugars with lispro orlowblood sugarswith glucose tablets (seenext chapter).

I've seen many individuals on our regimen whose blood sugars arequite stable even though they require the 5 daily shots typical of intensive insulin therapy.Thesepeopleusuallyrequire smalldosesof insulin,typically for adults under 8 units dailyfor alldosescombined. If

* Insulinin largedosescauses fluidretention.Rosiglitazone and pioglitazone canalso cause fluid retention. It is likelythat the people reported to have developedheart failure while taking both rosiglitazone or pioglitazone and insulin weretaking largedoses of insulin to coverthe usual high-carbohydrate diabetes diet.

312 Treatment

you fit into this category, your beta cells are probably still producingsome insulin. This enables your system automatically to smooth outthe peaks and valleys that your blood glucoseprofile would otherwiseshow. With such stable blood sugars (varying less than 20 mg/dldaily), there's no reason to bother taking daily blood sugar profiles.You would, instead, prepare a full blood glucoseprofile (five to seventests) for 1 day every 2 weeks. If you spotted a change in your bloodsugar ranges,you'd checkthe next few daysto see if it continued. If itdid, you would contact your physician, who might want to explore thepossiblereasons for such changes. If you become ill,or if,say, you havea school-age child who brings home a cold, you might want to checkyour blood sugar profiles everyday. If your physician has prescribedoral or injected steroids for other disorders such as asthma or bursitis,you should be checking and recording blood sugars, as they will certainly increase.

SOME FINAL CONSIDERATIONS

REGARDING LISPRO, ASPART,

AND GLULISINE INSULINS

Perhaps as a result of reading one of my prior books, you may alreadybe covering elevated blood sugars with regular insulin. If this is thecase, be very careful when using lispro, glulisine, or aspart for thispurpose. I and many of my patients have found them to be more effective than regular — that is, a given dose is likely to lower bloodsugar more than the same dose of regular. For example, I find thatwhile 1 unit R will lowermy blood sugar 40 mg/dl, 1 unit H will lowerit 60 mg/dl. I advise, therefore, that you initially take two-thirds asmuch lispro (H) as your prior regular (R) for this purpose. Basedupon the initial effecton your blood sugar,you can then adjust subsequent dosesof theseanaloginsulins.The same consideration applies ifyou eat out and use H to covera meal.

We have also observed that when lispro is used to cover meals,blood sugars are lesspredictablethan with regular.This result was notmentioned in reports of clinical trials of lispro, probably because thetrial population followed a high-carbohydrate diet and had such wideblood sugar fluctuation that this effect was not apparent. In spite ofthis consideration, I believe that lispro greatiybenefits those who useit properly.I am most grateful for its availability.

IntensiveInsulin Regimens 313

It's certainly worth mentioning that lispro is available in small(3 cc) cartridges. These can becarried inajacket pocket orsmall pursewithout creating an unsightly bulge or the need for refrigeration.When using cartridges, insert a needle andpull back ontheplunger ofthe syringe very slowly. Do not inject air into these cartridges. Ifyoudraw out too much insulin, do not inject it back into the cartridge.Squirt the excess into a plant or wastebasket, et cetera.

Aspart and glulisine function on a par withlispro, although somewhat lessrapidly.

INSULIN PUMPS

Mucheffortand expense arebeing devoted to promoteand marketinsulin pumps. These devices were designed to make multiple daily injections easier. They also doawaywiththeneed forlong-acting insufins.

The instruments consist of two basic elements:

• A pump unit about the size of a small pocket calculator, whichyou can hang from abelt, keep inapocket, orpintoyourclothing.

• Large-bore plastic tubing that stays in your skin, typically justabove your waist. The plastic tubing, which is inserted into theskin through a large, retractable needle, usually should bechanged every2-3 days.

The pump unitcan beloaded with a supply of lispro or other veryrapid acting insulin that lasts a number of days before refilling isnecessary. It delivers a tinybasal flow of insulin all daylong, giving an effect similar to that of 2 daily injections of long-acting insulin. Thisbasal rate canbepreset bytheuser andcan even besetto change automatically at various timesof the day. Premeal bolusor corrective dosesarereadily produced bysetting thedose andthenpushing a button.

Insulin pumps offer the following advantages over multiple dailyinjections:

• There is no need to carry a number of insulin syringes whenaway from home, but catheters and other supplies must accompany you.

• Correctiveinjections are elegantiy simple.• Pumps canbesetto automatically increase thebasal delivery rate

shortly before arising in the morning, thereby circumventing

314 Treatment

problems associated with the dawn phenomenon. They thus render it unnecessary for you to arise earlyon weekends to take yourlong-acting insulin.

On the other hand, insulin pumps can pose some problems:

• Pump failure, tubing coming out ofthe skin, insulin coagulation,tubing blockage, or kinking can occur in spite of sophisticatedalarms and safeguards. As a result, ketoacidosis has occurredovernight in many type 1users.

• There is a moderate incidence of infections at injection sites.Manyofthesehaveformedabscesses requiring surgical drainage.

• Severe hypoglycemia is more common among pump users, possiblybecause of mechanical problems.

• Insulin pumps cannot be used to give intramuscular injectionsformore rapidlowering of elevated blood sugars.

• All of the long-term (seven-plus years) pump users that I haveseen had fibrosis (scar tissue formation) at the injection site.Thishad impaired their insulin absorption so much that even highdoses failed to control their blood sugars. In addition, bloodsugar effects of pump boluses appeared to be inconsistent inthese individuals.

• Until recendy, pump delivery rates could not be set for less than0.1 units perhour.This makes it necessary forbasal dosing to bein multiples of 2.4 units per day, thereby preventing fine adjustments ofbasal insulin. For example, I require 3 units of glarginetwice daily formybasal insulin.With apump I would haveto takeeither too little — 4.8 units (2 x 2.4) — or too much — 7.2 units(3x 2.4).Some pump manufacturers now maketheir product adjustable to 0.01 units perhour,which overcomesthis problem.

• Many people are turned off by the idea of constandy havinglarge-bore tubing sticking in their abdomens.

• Usersexperience at leastsome inconvenience with the four S's—sleep, showers,swimming, and sex.

In our experience, insulin pumps do not providebetter blood sugarcontrol than multiple injections. Contrary to a common misconception, they do not measurewhat your blood sugarisand correctit automatically. Furthermore, most pumps areprogrammedto produce meal

Intensive Insulin Regimens 315

boluses that are computedto cover varying amounts of carbohydrate,totally ignoring both dietary protein and the Laws of SmallNumbers.

Recendy an insulin pump (OmniPod) has become available thatusesboth a slimmerneedle (28gauge) and a short length of veryfinetubing. The pain is virtuallyeliminated, and the long-term problemscausedbya largeforeign body (i.e., the tubing) under the skin are considerablyreduced. The basal infusion rate, however, is still too great(0.5 units per hour) for most people takingphysiologic doses of basalinsulin. This may be improved in the future.

INHALED INSULIN

In 2006 the FDA approved a powdered human insulin inhalablethrough the mouth and absorbed in the lungs. It is manufactured byPfizer and carries the brand name Exubera. Similar products are under development by other manufacturers.

So at long last, insulin can be administered without puncturing theskin with a needle. Many physicians and members of the press arepraising this accomplishment. Is it reallya benefit to diabetics, or is ittoo good to be true?

Exubera is dispensed in 1 mg and 3 mg packetsand aerosolized forinhaling by a plastic "puffer" measuring about 2 inches in diameter,6Vi inches long when closed, and 11 inches long when open for use.The product has been approved for use before meals by both type 1and type 2 diabetics.

If you've tried our painlessmethod for injectinginsulin, you probably will see no advantage to puffingyour insulin. But what about themajority of insulin users,who are taking the usual large doses and injecting using the conventional "no pain, no gain" method? For thosefolks, this product may be viewedas a blessing. Likewise for those whohave heard horror stories about painful injections (from no less eminent an organization than the Juvenile DiabetesResearchFoundation).Manyof these people willrefuseto injectinsulin and would rather havehigh blood sugars or use the potent OHAs that eventually burn outbeta cells. Clearlysuch peoplewillmake up a major market for inhaledinsulin, so the profit potential for this product will be considerable.

Are there any likelydisadvantages to inhaling insulin? Indeed thereare. They are listed below in random order of importance:

316 Treatment

• There is a possibility of long-term adverse effects upon lungfunction.

• The cost per dosewill be much greater than that of injected insulins. It is unknown whether this cost will be coveredby manyinsurers.

• It will be necessary to carryaround a bulky object for premealboluses.

• Each milligramofpowderisequivalent to 1-3 units ofinsulin after absorption. Thus people who require doses smaller than 1unit cannot be servedby this product.

• The actual dose of absorbed insulin can vary from one puff toanother,by 1-2 units for the 1 mg packet and by asmuch as3-9units for the 3 mg packet. This makes precise dosingimpossible.This may be of uncertain importance for those eating largeamounts ofcarbohydrateand taking large premeal boluses, sincemany diabetics are not following the methods we prescribe andtheir blood sugars are on aroller coaster anyway. If you are reading this book, the chances are that you are seeking to avoidor getoff the roller coaster and therefore will want to avoid the hazards

ofwide blood sugar swings.• The FDA advises against using this product if you have a cold,

smoke, or have any lung disorder such as asthma, seasonal allergic cough, et cetera.

Are there any diabetics who might benefit from inhaled insulin? Ispeculate that there may be many obese type 2s making considerableinsulin of their own who can't control their carbohydrate craving,don't want to use oral agents that push beta cells to make more insulin, and refuse to take injectionsbut want to bring their very highpostprandialblood sugars down to levels that arelesshigh. Inhaled insulin may help them accomplish this. These people will likely neverhave normal blood sugars, but they may not care.

20How to Prevent and Correct

Low Blood Sugars

Useof medications suchasinsulin or the obsolete sulfonylurea-typeand newer, similaroralhypoglycemic agents(OHAs) thatprovoke increased insulin production exposes you to the

ever-presentpossibilitythat your blood sugars may drop below yourtargetvalue.* Because your brain requiresglucose in order to functionproperly, a deficit of glucose— or hypoglycemia — can lead to someoccasionallybizarre mental symptoms. In extreme cases, it can resultin death. Although severe hypoglycemia can be dangerous, it is preventable, and treatable. I encourage you to have your family, closefriends, or workmates read this chapter so they willbe able to assistyou in the event you have a hypoglycemic episode and cannot correctit alone. I mention OHAs repeatedly in this chapter because of thehazard of hypoglycemia that they pose. Please remember that I recommend insulin-sensitizing agentsand insulin mimetics,while I oppose the use of OHAs.

HYPOGLYCEMIA: THE BASICS

For our purposes in this chapter,we willuse the term "hypoglycemia"to designate anyblood sugarthat's more than 10mg/dlbelowtarget."Mild"hypoglycemia isanybloodsugarthat's 10-20mg/dlbelowtar-

* It has been claimedthat the insulin-sensitizing agents(ISAs) cannot causeabnormally low blood sugars. This is not so.As we discussed in Chapter 15, I'veseen it happen — in a very mild diabetic who was using it to facilitate weightloss. Nevertheless, this is a rare occurrence.

318 Treatment

get. As it drops lower, it'sprogressively more "severe," and can, if leftuncorrected, becomethe condition known as neuroglycopenia, whichmeans"too littleglucose in the brain."

Glucose diffuses in and out of your brain slowly, whereas bloodsugar in the rest ofyour body can rapidly dropto zero inanhour froman intramuscular overdose of lispro insulin. Many diabetics developphysical symptoms or signals that enable them to recognize a hypoglycemic episode and think clearly enough to measure blood sugarand correct it.

When blood sugar drops slowly, neuroglycopenia can occur atabout the same time that physical symptoms appear.You may not beawareof them, however, because your brain, severely deprivedof glucose, is less capable of comprehending these things. "Hypoglycemiaunawareness" (reduced or absent ability to experience early signs ofhypoglycemia) is also common in individuals who have recendy hadfrequent hypoglycemic episodes, because of a phenomenon calleddown-regulation of adrenergicreceptors(seepage341). It can also becaused by a class of cardiacdrugs (beta blockers) that slow the heartand lower blood pressure. If you do not notice physical symptoms,you maythen not be able to think clearly enoughto realize that yourblood sugar is too low,and your cognitive state will deteriorate.

Progression of Symptoms of NeuroglycopeniaBelow is a partial fist of the signsand symptoms of hypoglycemia asthey progress, ranging from mild (early) to severe (late), which together make up neuroglycopenia:

• Delayed reaction time— e.g., failure to slowdown fast enoughwhen driving a car.

• Irritable, stubborn behaviorand lack of awareness of the physical symptoms of hypoglycemia(seebox, page 322).

• Confusion, clumsiness, difficulty speaking,weakness.*• Somnolence (sleepiness) or unresponsiveness.• Lossof consciousness (veryrare if you do not take insulin).• Convulsions(extremely rare if you do not take insulin).• Death (extremelyrare if you do not take insulin).

*One study has shown these symptoms to occur when blood sugar drops to45-65 mg/dl.Furthermore, symptoms were foundto continuefor45minutesafter blood sugarswerenormalized.

HowtoPrevent andCorrect Low Blood Sugars 319

Some Common Causes of HypoglycemiaIn various chapters, particularly those covering insulin, we've discussed a numberof different potential causes of lowbloodsugar. Below is a list of some common causes.

• Not waiting at least 5 hours after mealtime insulin before correcting an elevated blood sugar. This is especially dangerous atbedtime.

• Too muchdelay before eating a meal aftertakingregular or lisproinsulinor classic OHAs, suchastheoldsulfonylureas and similarnewer agents.

• Delayed stomach-emptying aftera meal (see Chapter22).• Reduced activity of counterregulatory hormones during certain

phasesof the menstrual cycle.• Sudden termination of insulin resistance after abatement of ill

ness or stress that required higher than usual doses of classicOHAs or insulin.

• Injectingfrom a fresh vial of insulin after having used progressively higherdoses of insulin that hasslowly lost its activity overa period of months.

• Switching from an insulin pump to manually injected insulinwithout loweringthe dose.

• Incorrecdyassumingthat lisproisequivalent in potencyto regular insulin or that biosynthetic human insulinshavethe samepotency as animal insulins.*

• Eating less than the plannedamount of carbohydrate or proteinfor a meal or snack.

• Taking too much insulin or OHA.• Engagingin unplanned physical activityor failingto cover phys

icalactivity with appropriatecarbohydrates.• Drinkingtoo muchalcohol, especially prior to or during a meal.• Failure to shakevialsof NPH insulinvigorously beforeusing.• Inadvertentiy injectinglong-actingor premealbolus insulin into

a muscle.

• Injecting near a muscle that willbe strenuously exercised.

*These new ultra-rapid-acting insulins have about 50 percent more bloodsugar-lowering effect than regular insulin, despite statements to the contrarybytheir manufacturers.

320 Treatment

• Using insulin that contains protamine (NPH; seepage 264).• Taking aspirin in largedoses, or anticoagulants, barbiturates, an

tihistamines, or certain other pharmaceuticals that may lowerblood sugar or inhibit glucose production by the liver (see Appendix C).

• A sudden change from cool weather to warm weather.

Common Signs and Symptoms of Hypoglycemia

Hunger. This is the most common early symptom. A truly well-controlled,well-nourished diabetic should not be unduly hungry —unless he's hypoglycemic. This symptom, although frequendy ignored, should not be. On the other hand, hunger is also very often asign of tension or anxiety. One cannot assume that it automaticallysignals hypoglycemia. Perhaps half of so-called insulin reactions maymerelyreflecthunger pangsprovokedby mealtime,emotional factors,or evenhigh blood sugars. Whenblood sugars are high,the cells of thebody are actuallybeingdeprived of glucose, and you mayfeel hungry.Thus, hunger is very common in poorly controlled diabetics. Ifyoufeel hungry, measure your bloodsugar!

Impaired visual acuity. Even mild hypoglycemia can make for difficultyin reading street signsor fine print. More severe hypoglycemiacan cause double vision.

Elevated pulse rate. Always carry a watch with a sweep secondhand. Knowyour maximum restingpulse rate. When possiblesymptomsof hypoglycemia appear andyouhave no handymeansof testingyour blood sugar (a sign of gross negligence), measure your restingpulse. Many people find it more convenient to measurethe temporalpulse (at the temple, on the side of the head between eyebrow andhairline) or carotid pulse (on the side of the neck just below loweredge of jaw and about 1-3 inches forward of the ear) than the radial,or wrist,pulse.If restingpulseexceeds your maximum restingvaluebymore than one-third, assume hypoglycemia. This measurement maybe normallyelevated if you've beenwalking about during the prior 10minutes. Yourhealth care professionalcan help you learn how to measure your pulse. This exercise should never be necessary since, ofcourse, you haveyour blood sugar meter with you at all times.

How to Preventand Correct LowBloodSugars 321

Nystagmus. This symptom maybe demonstrated by slowly movingyour eyes from side to side while keeping your head immobile. If another person is asked to watchyour eyes, shewillnotice— whenyourblood sugar is low— that they may jerk briefly in the reverse direction,or "ratchet," insteadof moving smoothly. You canobserve the effect of this by looking at the sweep second hand of your watch. If itseems occasionally to jump ahead, you are experiencing nystagmus(actually, asyour eyes jumped to the sideforbrief instants,you missedseeing bits of motion of the second hand).

Absence of erections. For a man, a fairly reliable sign of early-morning hypoglycemia is awakening without an erection, assumingthat he ordinarily experiences morning erections. Failure to experience an erection when sexually stimulated likewise suggests hypoglycemia if this is not a usual problem.

Denial. As hypoglycemia becomes moresevere, or if blood sugarhasbeen dropping slowly, many patients will be certain that their bloodsugars are fine. Anobserver suspecting hypoglycemia should insistona blood sugarmeasurementbefore accepting the diabetic's denial.

TREATING MILD TO MODERATE

HYPOGLYCEMIA, WITHOUTBLOOD SUGAR OVERSHOOT

Historically, the advice for correction of lowblood sugar has been toconsume moderately sweet foods or fluids, such as candybars, fruits,cookies, hard candies, peanut butter crackers, orange juice, milk, andsoda pop. Such treatment has never worked properly, for reasons youcanprobablyguess, knowing whatyounowknowabout variousfoodsand how they affect your blood sugar.

These moderately sweet foods contain mixtures of slow- and rapid-acting carbohydrates. If,forexample, youeator drinkenoughthat therapid-acting carbohydrate in these foods raises yourbloodsugarfrom40mg/dlup to your targetof90mg/dloverthecourse of halfan hour,you mayhavesimultaneously consumed so much slow-acting carbohydrate that your blood sugarwill go up by 300 mg/dl several hourslater.

In the old days, beforeI learnedto maintainmyblood sugarin nor-

322 Treatment

mal ranges, my physicians insisted that very high blood sugars afterhypoglycemic episodes were due to an"inevitable" hypothetical effectthey called rebound,or the Somogyiphenomenon.*Once I learnedtoavoidthe usual foods fortreatinglowblood sugar, I neverexperiencedblood sugar rebound. Nevertheless, the scientific literature does describe occasional mild insulin resistance that lasts up to 8 hours fol-

SIGNS AND SYMPTOMS OF HYPOGLYCEMIA

Signs andsymptomsof hypoglycemia include the following:

• Confusion (e.g., inabilityto read the time or to findthings)

• Headache

• Hand tremors

• Tinglingsensation in fingers or tongue• Buzzing in ears• Elevated pulserate• Dilated pupils• Great hunger• Tight feeling in throat or nearrear of tongue• Numbness or strangesensations in lips or tongue• Clumsiness

• Impaired ability to detect sweet tastes• Stubbornness

• Inappropriate laughter or joking• Irritability• Nastiness

• Anxiety or panic• Pounding hands on tablesand wallsor kicking the floor

or other objects• Miscellaneous visualimpairments, such asblurred or

double vision, seeing spots,visualhallucinations (e.g.,letters or numbers seem to be printed in Chinese)

* If your physician stillbelieves whathe learnedin medical schoolabout this fictional phenomenon, ask him to read "The Somogyi Phenomenon — SacredCow or Bull?," Arch Intern Med 1984; 144:781-787.

How toPrevent andCorrect Low Blood Sugars 323

lowing anepisode ofvery low blood sugar. This isnot thedramatic rebound caused byeating the wrong thing tobring upblood sugar.

Hypoglycemia can be hazardous, as the list of its progression onpage 318 demonstrates. We therefore want to correct it as rapidly aspossible. Complex carbohydrate, fructose, lactose (in milk), and evensucrose, which is used in most candies — all must be digested or

• Poor physical coordination (e.g., bumping into wallsand dropping things)

• Tiredness

• Weakness

• Sudden awakening from sleep• Shouting while asleep (or awake)• Rapid shallowbreathing• Nervousness

• Light-headedness• Faintness

• Hot feeling• Cold or clammy skin, especially on the neck• Resdessness

• Insomnia

• Nightmares• Pale complexion• Nausea

• Slurredspeech• Nystagmus (page 321)

Several ofthesesymptoms mayoccurat the sametime. Onesymptom alone may be the only indicator. In some cases, theremaybe no clearly apparent early signs or symptoms at all.

324 Treatment

processed bythe liver before theywill fully affect blood sugar. Thisdelaymakes these types ofcarbohydrate poor choices for treating hypoglycemia. Furthermore, you need to know exacdy how much yourblood sugar will rise after eating or drinking something to raise it.With most of the traditional treatments you must continually checkyour blood sugar manyhours later to gauge the unpredictableeffect.

Raising Blood Sugars PredictablyWhat, then, can we use to raiseblood sugars rapidly with a predictableoutcome? The answer,of course, is glucose.

Glucose, the sugar of blood sugar, does not have to be digested orconverted by the liver into anything else. Unlike other sweets, it's absorbed into the blood directiythrough the mucous membranes of themouth, stomach,and gut.Furthermore,aswediscussed in Chapter 14,"Using Exercise to EnhanceInsulin Sensitivity," we can compute preciselyhow much a fixed amount of glucosewill raise blood sugar. Ifyou havetype 2 diabetesand weigh about 140pounds, 1 gram of pureglucose will raise your blood sugar about 5 mg/dl — provided thatyour blood sugar is belowthe point at which your pancreas starts tomake insulin to bring it down. If you weigh 140 pounds and havetype 1 diabetes, 1 gram of glucose will raise your blood sugar about5 mg/dl no matter what your blood sugar maybe,becauseyou cannotproduce any insulin to offset the glucose. If you weigh twice that, or280 pounds, 1 gram will raise your blood sugar only half as much. A70-pound diabetic child, on the other hand, will experience doublethe blood sugar increase,or 10 mg/dl per gram of glucose consumed.Thus, the effect of ingested glucoseon blood sugar is inversely relatedto your weight. Table 20-1 gives you the approximate effect of 1gramglucose upon lowblood sugarfor variousbody weights.

If you have handled glucose tablets,be sure to wash your hands before recheckingyour blood sugar.If a source of water is not available,lick the fingeryou intend to prick to remove any residualglucose. Youcan dry the finger by wiping it on your clothing or a handkerchief.

Do not keep glucose tablets near your blood sugar meter or teststrips!

Many countries have available as candies or confections productsthat contain virtually all of their nutritive ingredients as glucose.These glucose tablets are usually sold in pharmacies. Some countrieseven have glucose tablets marketed specifically for the treatment of

HowtoPrevent andCorrectLow Blood Sugars 325

TABLE 20-1

EFFECT OF 1 GRAM GLUCOSE

UPON LOW BLOOD SUGAR

Body weight1 gram glucose will raiselow blood sugar

35 pounds 16 kilograms 20 mg/dl 1.11 mmol/1

70 32 10 0.56

105 48 7 0.39

140 64 5 0.28

175 80 4 0.22

210 95 3.3 0.18

245 111 3 0.17

280 128 2.5 0.14

315 143 2.2 0.12

hypoglycemia in diabetics. Table 20-2 lists a few of the products withwhich we are familiar.

Of the glucose tablets listed, I personally prefer Dextrotabs becausethey're veryeasy to chew, raise blood sugar quite rapidly, taste good,are convenientiy packaged, and are inexpensive. They are also smallenough that they usuallyneed not be broken in halves or quarters tomake small blood sugar adjustments (except for children). Each jar of100 Dextrotabs* comes with a small plastic envelope that holds 20tablets flat. This envelope fits easily into your pocket or purse andcanbe refilled as often as needed. For smaller children I prefer Smarties*or Winkies because of their tiny size. Most glucose tablets begin toraise blood sugar in about 3 minutes and finish after about 45 minutes, if youdon'thave gastroparesis (if youdo, see Chapter 22).

With thisbackground in mind,howshould you proceed whenyouencountera low blood sugar?

*Available at Rosedale Pharmacy, (888) 796-3348.

326

TABLE 20-2

GLUCOSE TABLETS USED FOR TREATMENT

OF HYPOGLYCEMIA BY DIABETICS

Treatment

1 tablet will raise

Country ofmanufacture

Name of

product

Grams of

glucoseper tablet

blood sugar of140-pound personwith low blood sugarapproximately

USA Dextrotabs 1.6 8 mg/dl 0.44 mmol/1

USA Sweetarts or

WackyWafers2* 10 0.56

USA, UK, B-D Glucose 5 25 1.40

Canada Tablets

USA, Canada Smarties or

Winkiest

0.4 2 0.11

USA, Canada Dex4 4 20 1.10

UK, Canada Dextro Energy 3 15 0.83

FRG Dextro-Energen 4 20 1.10

Tablet size may vary.'Availableat kosher stores and at Rosedale Pharmacy or at www.smartiesstore.com.Ideallysuited for childrenbecause of their smallsize.

USING GLUCOSE TABLETS

If you experience any of the symptoms of hypoglycemia detailedearlier— especially hunger — measureblood sugar.If blood sugar is10 mg/dl or more belowtarget, chew enough glucose tablets to bringblood sugar back to your target. If you have no symptoms but discovera lowblood sugarupon routine testing, again,take enough glucose tablets to bring blood sugar back to your target. Having nosymptoms is not a valid reason for not taking tablets. A low bloodsugar without symptoms carries more risk than one with symptoms.If you weighabout 140pounds and your blood sugar is 60 mg/dl butyour target is 90 mg/dl, then you might eat 4 Dextrotabs. This wouldraise your blood sugar,accordingto Table20-2,by 32 mg/dl, bringingyou to 92 mg/dl. If you are using Dextro-Energen, you'd take 1V4tablets.With B-D tablets,you'd take 1.Simple.

HowtoPrevent andCorrectLow Blood Sugars 327

If your lowblood sugarresulted from taking too much insulin orOHA, it may continue to drop after taking glucose if the insulin orOHA hasn't finished working. You should therefore recheck yourblood sugar about 45 minutes aftertakingthe tablets, to rule out thispossibility and to see ifyou're back where youbelong. Ifbloodsugarisstill low, take additional tablets. Ifyou have delayed stomach-emptying,you may have to wait as much as 2 or more hours for full effect.*

What if you'reout of your homeor workplace and don't have yourblood sugar meter? (A major crime, as noted earlier.) If you thinkyou'rehypoglycemic, playit safeand takeenough tablets to raiseyourblood sugar about 60 mg/dl (7 Dextrotabs, for example, or 2 B-Dtablets). You mayworry that this will bringyou too high. If you takeinsulin, this poses no problem. Simply checkyour blood sugar whenyougetbackto your meter. If it'sabove your target, takeenoughlispro(or aspart or glulisine) to bring you backto target,but be sure to wait5 hours after your last dose of rapid-acting insulin. If you don't takeinsulin, your blood sugar should eventuallycome back on its own, because your pancreas is still making some insulin. It may take severalhours, or even a day, depending upon how rapidly you can produceinsulin. In any event,you mayhavesaved yourselfan embarrassing oreven disastrous situation.

WHAT IF BLOOD SUGAR IS LOW

JUST BEFORE A MEAL?

Take your glucose tablets anyway. If you don't, you may become veryhungry, overeat, and be too high many hours later. The medicationyou take for a meal is intended to keep your blood sugar level. So if itwastoo lowbefore a meal, it willbe too lowafter if you don't takeyourglucose but eat properly.

* This time frame can be gready reduced by drinking a glucose solution (seepage 377).

328 Treatment

WHAT IF YOUR SYMPTOMS PERSIST

AFTER YOU HAVE CORRECTED THE

HYPOGLYCEMIA?

Many ofthesymptoms ofhypoglycemia are actually effects of thehormoneepinephrine (which youmay know asadrenaline). Ifyoudo nothave the problems listed in the section "Hypoglycemia Unawareness"on page 340, your adrenal glands will respond to hypoglycemia byproducingepinephrine. Epinephrine, like glucagon, signals the liver toconvertstored glycogen to glucose. It is epinephrine that brings aboutsuch symptoms as rapid heart rate, tremors, pallor, and so on. (Betablocker medications can interfere with the ability of epinephrine tocause these symptoms.) Epinephrine has a half-life in the blood ofabout 1 hour. This means that an hour after your blood sugar comesback to target, about half the epinephrine you made is still in thebloodstream. This can cause a persistenceof symptoms, even if yourblood sugar is normal. Thus, if you took some glucose tablets an houragoand still feel symptomatic, check yourbloodsugaragain. If it's ontarget,try to control the temptationto eatmore.If yourbloodsugarisstill low, more tablets are warranted.

COPING WITH THE SEVERE HUNGER

OFTEN CAUSED BY HYPOGLYCEMIA

Mild to moderate hypoglycemia can cause severehunger and an associated panic. The drive to eat or drink large amounts of sweet foodscan be almost uncontrollable. Newpatients,before starting our regimen, have told me storiesof eatingan entire pie, a jar of peanut butter, a quart of ice cream, or drinking a quart of orange juice inresponse to hypoglycemia. Before I stumbled onto blood sugar self-monitoring and learned how to use glucose tablets, I did much thesame. The eventual outcome, of course, was extremely high bloodsugar several hours later.

Since the effects of glucose tabletsare so predictable, the panic element has vanished for me and for most of my patients.

Unfortunately, rapid correction of blood sugar does not alwayscorrect the hunger.This maybe somehowrelatedto the long half-lifeof epinephrine and the persistence of symptomsevenafter restorationof normal blood sugars. My patients and I have successfully coped

HowtoPrevent andCorrect LowBlood Sugars 329

with this problem in avery simple fashion. You can try thesame trickwe use.

First, consume the appropriate number of glucose tablets.If overwhelming hunger persists, consider what might satisfy it.

Typical options include a full meal (such as another lunch or supper),half a meal, or a quarter of a meal. A full meal means exactly theamounts of carbohydrates and protein that you would ordinarily eatat that meal. Halfa meal means exactly halfthe protein and half thecarbohydrate.

Even ifyour blood sugar has notyet come back to target, since youknow you have consumed the proper amount ofglucose toeventuallybringit back, youcanconfidentiy inject theamount of insulinor swallow the dose of the OHA that you normally use to cover that meal.Forhalfa meal, take halfthe dose; fora quarter of a meal, take one-quarter the dose.

Don'tfrustrate yourself bywaiting theusual 45 minutes or so afterinjecting regular insulin, or the20 minutes after injecting lispro (oraspartor glulisine), or the60-120 minutes after taking an OHA. Just inject and eat. An extra meal now and then won't make you fatter orcause harm. Since you're eating within the controlled boundaries ofyour meal plan and not gorging on sugars or unlimited amounts offood, you'restillabidingbythe Laws of Small Numbers.

Ifyou know how much insulin or OHA you usually take to cover acertain snack, you might have the snack instead of the meal.

HOW FAMILY AND FRIENDS CAN HELP

YOU CATCH A HYPOGLYCEMIC EPISODEWITHOUT MUTUAL ANTAGONISM

Two ofthemost common effects ofhypoglycemia can make thejobofhelping you difficult and unpleasant. These effects are irritable, nastybehavior andfailure to recognize your own symptoms. Atmyfirst interview with many new patients and their families, instances of violence during hypoglycemic episodes are commonly reported. Themost common scenario I hear goes likethis:"WheneverI see that he'slow, I hand him a glass of orange juice and tell him to drink it, but hethrows the juice at me. Sometimes he throws the glass too." Such stories comeas no surprise to me because as a teenager I used to throwthe orange juice at my mother, and when I wasfirst married, I did the

330 Treatment

same tomywife.Whydoes this happen, and how can we prevent suchsituations?

First, it's important to try to understand what's going on in theminds of you and the family member or partner during about withhypoglycemia. The cognitive difficulties that accompany severe hypoglycemia can make the slightest frustration or irritation overwhelming. Your low blood sugar may cause you to act bizarrely, as ifintoxicated — andin asense, youare intoxicated. Because yourthinking is impaired, you may betotally unaware that your blood sugar islow. The similarity to drunkenness is not a coincidence, since thehigher cognitive centers of thebrain, which control rational behavior,are impairedin both cases.

You probably have learned that high blood sugars are tobeavoided,andatsomelevel, youremember this, perhaps even cling to it,despiteyour hypoglycemia. If someone tries to cajole you into eating something sweet, you may decide that it's theother person who's irrational.This is especially true if the other person has done the same thing inthe past, when blood sugars were actually normal or even high. In"self-protection" against the supposed irrational attemptto get youtoeat something sweet, you instinctively may become violent. Mostcommonly, thisoccurs if anattempt is made to put food or drinkinyour mouth. You might view this as an"attack." In less rational moments, you mayeven decide, since youknow that high blood sugarsare harmful,that yourspouse or relative is tryingto kill you.

The helping relative, usually aspouse or parent, maybe terrified tosee such strange behavior. If your loved one hasbeen through manysuch encounters, he or she may, for self-protection, keep candies orother sweets aroundthe housein the hopesthat you willeatthem andthus avoid such situations. The fear canbe exacerbated if your lovedone has seen you unconscious from hypoglycemia, or ismerely awarethat hypoglycemia can cause dire consequences. On otheroccasions,whenyour blood sugar wasn't really low, your loved onemayhave erroneously asked you to eat something sweet. Such erroneous diagnosesare especially common during family squabbles. The spouse orparent mayfeel that"his blood sugar islow, and that's whyhe's yellingat me."Your loved one would rather play it safe and give you something sweet, evenif yourbloodsugar isn'tlow.

There is a solution to this apparent dilemma. First of all, both partiesmust recognize that, as arule, about halfthe time that the relative

Howto Preventand Correct LowBloodSugars 331

suspects hypoglycemia, you do not havea low blood sugar; the otherhalf of the time, blood sugar is indeed low.

No one hasevercontradicted me when I'vemade this point.Encouraging a diabetic to eat sweets when hypoglycemia is sus

pected, despite conventional teaching, does as much harm as it doesgood.A better approach would be for the loved one to say, "I'm worriedthat your blood sugar may be low. Please check it and let me knowthe resultso that I'll feel less anxious." As a patient, you should realizethat living with a diabetic can often be as much or more of a strainthan having diabetes. You, the diabetic, owe some consideration to theneedsof your loved ones. Try to look upon the request to check yourblood sugar not asanintrusionbut as yourobligation to relieve someone else's fear. With this obUgation in mind, you shouldautomaticallycheckyourblood sugar ifasked, justto makethe other person feel better. It doesn't matter whether your blood sugar is low or normal. Ifyour blood sugar is low, you can correct it and find out why. If it'snormal, then you probablywill have diffused the tension of the situation, and now you'll be able to get back to whatever you were doing,unworriedthat blood sugar isofftarget.When you look atblood sugaras something like a clock that you can set — and reset— you takesome ofthe mystery out of it, and can diminish the emotion involved.

If you're without your meter, take enough glucose tablets to raiseyour blood sugar about 60 mg/dl — again to make the other personfeel better. This is the least you can do for someone who may worryabout you every day.

Believe it or not, this simple approach has worked for me and formany of my patients.As I've said previously, I went through this withmy parents and have gone through it with my wife. Spouses reportthat it relieves them of a great burden. Some wives have even criedwhen expressing their gratitude.

HOW FAMILY AND FRIENDS CAN

HELP WHEN YOU ARE CONSCIOUS BUT

UNABLE TO HELP YOURSELF

This more serious hypoglycemic state is often characterized by extreme tiredness and inability to communicate.You may be sitting andbangingyourhand on atable, walking aroundin adaze, or merely fail-

332 Treatment

ing to respondto questions.It's important that those who liveor workwith you learn that this is a fairly severe stage of hypoglycemia. Thelikelihood that it's hypoglycemia is so great that valuable time may bewastedif treatment is delayed while someone fumbles about trying tomeasure your blood sugar. It's quite possible that if you're given glucose tablets you will not chew them, and may even spit them out.

The treatment at this stage is glucose gelby mouth.Glucose prepared asa syrupy gel is sold in the United States under

several brandnames.At least one ofthese productsisnot pureglucose(dextrose) but contains a mixture of long- and short-acting sugars,and therefore willnot exertits full effectasrapidlyaswe'dlike.At present, I ask my patients to purchase a product called Glutose 15 (Paddock Laboratories, Minneapolis, MN 55427; available from RosedalePharmacy).Glutose 15is packaged in a plastic tube (like toothpaste),with a twist-off cap. Each tube contains 15 grams of glucose. FromTable 20-1 (page 325), we see that this amount will raise the bloodsugar of a 140-pound person by 75 mg/dl (15 x 5). An appropriatedose for most adults in this condition would be 1V4 tubes. These

would typicallyraise one'sblood sugar by about 110 mg/dl.Some of the tubes of decorative icing used to write on birthday

cakes contain almost pure glucose (dextrose), so you might savemoney by purchasing those. Look in the baking section of most supermarkets, but make sure of the contents and weight. To convertounces to grams,multiply by 30.Make sure that the major ingredientis glucose, as some brands aremosdy sucrose, which works too slowly.

We recommend that two tubes ofGlutose 15,secured togetherwitha rubber band, be placed at strategic locations about the house andplace ofwork, aswellasin luggage when you travel with acompanion.It should not be refrigerated, asit may hardenwhen cold.To administer, someone should insert the tip of an open tube into the corner ofyour mouth, in between your lower gum and your cheek, and slowlysqueeze out a small amount. You will probably swallow this smallamount. After you swallow, a bit more of the gel should be gentlysqueezed from the tube.Within 5 minutes of ingesting, you should beable to answer questions.

When you have fully recovered, check and correct your blood sugarto your target.Sinceyou may havewiped the sticky geloffyour mouthwith your hands,you shouldwashthem beforestickingyour finger.

Although glucose gels may not be available in many countries, theyare available on the Internet. Most industrialized nations have phar-

Howto Prevent and Correct LowBlood Sugars 333

macies and surgicaldealers that sellflavored glucose drinks to physicians for performing oral glucose tolerance tests. These are usuallybotded in 10-ounce(296ml) screw-top bottiesthat contain 100gramsof glucose. A dose of 2 fluid ounces (60 ml) will provide about 20gramsof glucose, enough to raisethe blood sugarof a 140-poundperson by 100mg/dl. Tiny amounts can be administeredwith the help ofa plasticsqueeze bottle. Whoever feeds you the liquid or gelmust exercisecaution, as the possibilityexiststhat you could inhale some of it,causingyou to choke.The use of liquid is potentially much more hazardous than the gel in this respect, so administer only a tiny amountfor each swallow.

TREATING HYPOGLYCEMIA

IF YOU ARE UNCONSCIOUS

Hypoglycemia is not the only cause of loss of consciousness. Stroke,heart attack,a sudden drop in blood pressure, and evena bump on theheadcanrenderyouunconscious. In fact, veryhighbloodsugar(above400mg/dl) overseveral days, especially in a dehydratedindividual,canalsocause loss of consciousness. We willassume, however, that if youare carefully observing the treatment guidelines of this book,you willnot allow such prolongedbloodsugarelevation to occur.

If you're found unconscious bysomeone who knows how to rapidlycheck your blood sugar, a measurement may be made. Treatmentshould not be delayed, however, while people are scampering abouttrying to find your testing supplies.

The treatment under these conditions is injection of glucagon, ahormone that rapidlyraises bloodsugarbycausing the liver and muscles to convert stored glycogen to glucose. It is imperative, therefore,that thosewho live with you knowhowto give an injection. If you useinsulin,you can give them somepractice byteaching them howto giveyou insulin injections.Glucagon is sold in pharmaciesin many countries as the GlucagonEmergency Kit. This consists of a small plasticbox containing a syringe filled with an inert waterlike solution and alitde vial of white powder (glucagon). The kit also contains an illustrated instruction sheet that your family should read before an emergency develops.The user injects the water into the vial, withdraws theneedle, shakes the vial to dissolve the powder in the water, and drawsthe solution back into the syringe. The tip of the long needle must be

334 Treatment

submerged in the liquid. For adults, the entire contents of the syringeshould be injected, either intramuscularly or subcutaneously; lesseramounts should be used for small children. Any of the sites shown inFigure 16-1 on page251 can be used,as can the deltoid muscle (page309) or even the calf muscle. Your potential benefactors should bewarned that if they choose the buttocks, injection should go into theupper outer quadrant, so as not to injure the sciaticnerve.An injection maybe given through clothingprovidedit isnot too thick (for example, through a shirtsleeve or trouser leg, but not through a coat orjacket).

Under no circumstances should anything be administered bymouth whileyou are unconscious. Since you willnot be able to swallow, oral glucose could asphyxiate you. If your glucagon cannot befound, your companions should dial911 (in the United States)for theemergency medicalservice, or you should be taken to the emergencyroom of a hospital.

When an individual has lost consciousness from hypoglycemia, hemay experience convulsions. Signs of this include salivation, tooth-grinding, and tongue-biting. Although the last can cause permanentdamage in the mouth, no attempt to intervene shouldbe made. Yourheroic savior will not be able to help you if you bite off her fingers. Ifpossible, you should be turned to lieon your sidewith your head positioned so that your mouth is downward.This is to help drain excesssalivafrom your mouth so you won't breathe it in and choke.

You should begin to show signs of recovery within 5 minutes of aglucagon injection. You shouldfully regain consciousness and be ableto talk sensibly within 20 minutes at most. If steadyimprovement isnot apparent during the first 10 minutes, the only recourse is theemergency squad or hospital. The emergency squad should be askedto inject 40 cc of a 50 percentdextrose (glucose) solution into a vein.Individualsweighing under 100pounds (45kilograms) should receiveproportionately smaller amounts (e.g., a 70-pound child would receive 20 cc of the dextrose solution).

Glucagon can cause retching or vomiting in some people. Yourhead should therefore be turned to the side so that if you do vomit,you won't inhale the vomitus. Keep a 4-ounce (120 ml) bottie ofmetoclopramide syrup on hand, attached with a rubber band tothe Glucagon Emergency Kit. One gulp of metoclopramide, takenafter you are sitting up and speaking, should almost immediately

Howto Preventand Correct LowBloodSugars 335

stop the feeling of nausea. Do not consume more than one gulp, aslarge doses can cause unpleasant side effects (see page 368). In theUnited States, metoclopramide is available onlyupon prescription bya physician.

One doseof glucagon canraise yourbloodsugarbyas much as 250mg/dl, depending upon howmuchglycogen was storedin your liver atthe timeof the injection and subsequendy converted to glucose. Afteryou've fully recovered yoursenses, youshould check yourbloodsugar.If at least 5 hours have elapsed since your last dose of a rapid-actinginsulin, take enough intramuscular (or subcutaneous) lispro (or aspart or glulisine) insulin to bringyourbloodsugar backdownto yourtarget. This is important, because if your blood sugar is kept normalfor about 24hours,your liver will rebuild its supply of glycogen. Thisglycogen reserve is of great value for protection from possible subsequent hypoglycemic events.

Bythe way, if we tried to give glucagon to someone twice in thesame day, thesecond shotmight not raise blood sugar. This ispossiblebecause liver glycogen reserves may have been totally depleted in responseto the firstinjection. Thus,monitoringand correctionof bloodsugarevery5 hours for 1 full dayis mandatoryafter the use of glucagon. Additional blood sugar measurements should be taken every2l/z hoursto make surethat you're not again hypoglycemic, but do notcorrect for high blood sugars every 2l/i hours; wait the full 5 hourssincethe last shot of rapid-actinginsulin (see page305).

Although reading about possible loss of consciousness may befrightening, remember that thisisanextremely rareevent, and usuallyresultswhen a type 1diabeticmakes a majormistake, such asthose included in the liston pages 319-320.1 know of no case where a type2diabetic experienced severe hypoglycemia whenusing anymedicationthat we recommend.

HOW TO DETECT HYPOGLYCEMIA

WHILE YOU ARE SLEEPING

Thesigns of hypoglycemia duringsleep include cold, clammy skin, especially on the neck, erratic breathing, and restlessness. It certainlyhelpsto havea lightsleeper sharingyourbed.Parentsshouldcheckdiabeticchildren at night and should feel their neck.

336 Treatment

KNOW WHY YOU WERE HYPOGLYCEMIC

Review your Glucograf data sheet after all hypoglycemic episodes,even mild ones. It's important that you reconstruct the events leadingup to any episode of low blood sugar, even if it caused no notablesymptoms.This is one of the reasons why we recommend (page 76)that most insulin-taking diabetics keep faithful records of data pertinent to their blood sugarlevels and whywewent into so much detailin Chapter 5 teaching you howto recordthe information.Since severehypoglycemia can lead to amnesia for events of the prior hour or so,habitual recording of relevantdata can be most valuablefor this scenario. It is certainly helpful to record times of insulin shots, glucosetablets, meals, and exercise, as wellas to note if you overate or under-ate, and so on. Recording blood sugar data alone may not help you tofigure out what caused a problem. If you experience a severe hypoglycemic episode or several mild episodes and cannot figure out howto prevent recurrences, read or show your Glucograf data sheet toyour physician. Your doctor may be able to think of reasons that didnot occur to you.

BE PREPARED

Keeping Hypoglycemia SuppliesGlucose tablets,glucose gel (Glutose 15),and glucagon can each potentiallysave your life. Theywon'thelp if they're not around or are allowed to deteriorate. Here are some basic rules:

• Place supplies in convenient locations around your house andworkplace.

• Showothers whereyour supplies are kept.• Keep glucose tablets in your car,pocket, or purse.• When traveling, keep a full set of supplies in your hand luggage

and also in your checked luggage — just in case a piece of luggageis lost or stolen.

• It may be wise to replace glucagon on or before the expirationdate on the vial. In an emergency, however, it isn't necessary foryour savior to worry about the expiration date. In the UnitedStates, glucagon isusuallysoldwithveryshort dating.Manypeople are sold costiy emergency kits markedwith expiration dates

Howto Prevent and Correct LowBlood Sugars 337

YOUR HYPOGLYCEMIA TOOL KIT

To make sureyouarenot caught unprepared bylow bloodsugars, you should always keep the following supplies on hand atboth your home and yourworkplace:

If You Take OHAs or Even ISAs

• 1-3 bottles (100 tablets each) Dextrotabs or other glucose tablets; always carryglucose tablets withyou

If You Take Insulin and Do Not Live Alone, You Also

Need

• One package of three tubes Glutose 15• Glucagon EmergencyKit• 4-ounce bottle metoclopramidesyrup

only a few months later. Don't worry. Glucagon is sold as afreeze-dried powder that will probably remain effective for fiveyearsafter the "expiration"date, unlessof course it has been exposed to moisture or extreme heat (as in a closed car in the summertime). It retains its longevity especially if it is refrigerated.Once diluted, however, it is good for only 24hours.

• Always replace supplies when some have been used. Never allowyour stock to become depleted. Keep plenty of extra glucosetablets and blood sugar test strips on hand.

Emergency Identification TagsIfyou useinsulinor OHAs, youshouldwear an identification tag thatdisplays a recognizable medical emblem, such as a red serpent encirclinga red staff. The tag,whichmaybe worn as a braceletor necklace,shouldbe engraved with a message that relates to the treatmentof hypoglycemia. Myownbracelet is engraved with the following message:DIABETIC. IF CONSCIOUS — GIVE CANDY OR SWEET DRINK. IF UNCON

SCIOUS — to hospital. Since bracelets are more likely to be spottedby emergency personnel, I prefer them to the necklaces.

Most pharmacies and jewelers sellmedical ID tags. Prices begin at

338 Treatment

$5 for stainlesssteeland go into hundreds of dollars for solid gold.TheMedicAlertFoundation, Turlock, CA95381, willkeep a record of yourmedical historyand will sendyoua stainless steelID bracelet or necklace,with their emblem,for $45.Sterling silver or gold-plated IDs costslightly more. Beautiful 14-carat goldIDsareavailable at considerablyhigher cost.Theywillalsoengrave the tag diabetic for the same cost.Alltagsare stamped with your special ID number and with their "callcollect" 24-hour telephonenumber.Byphoning this number, a hospital can secure your name and address, contact information for yournext of kin and physician, a listof allyour medicalconditions, and thedoses of medications that you take. You can obtain an applicationform by writing to the above address or by phoning (800) id-alert.

Diabetics who do not take medications that can cause hypoglycemia would also be wise to wear a MedicAlert bracelet, if only todiscourage the automatic use of intravenous glucose infusions — acommon practiceof emergency personnelon victims of motor vehicle accidents, heart attacks, and so on.

Emergency Alarm ServiceIf you live alone, you may want to consider using an emergency alarmsystem.These can automaticallyphone a friend, relative, or emergencysquad when you push a button on a necklace.The system can also beactivated if you do not "checkin"at predetermined time intervals.Theleast expensive system that I have encountered is supplied by theMedicAlertFoundation. Their "failureto checkin"alert unfortunatelycan only be activated at 24-hour intervals,so you can be unconsciousfor 24 hours before someone is notified.

The Continuous Glucose Monitor

Mostof us have jobsthat bringus into contactwith other peopleduringthedayand familywithwhomwehave contact afterwork. These contactsoffer considerable protection from severe hypoglycemia, as colleaguesand relatives willintervene ifyoustartwalking into walls or talkingsilly. Asleeping partner can frequendy pick up on the labored breathing andcold, clammyskin or damp nightclothes that accompany hypoglycemiaand then awaken you and askyou to checkyour blood sugar.

If you liveor sleepalone,or if your sleepingpartner is an extremely

HowtoPrevent andCorrect Low Blood Sugars 339

deep sleeper, however, youdon't have thisprotection at night.* A newbackup is now available.

Several companies are now marketing continuous blood glucosemonitors.1 A continuous blood glucose monitor works via a tiny sensorimplantedbeneaththe skin,usingatechnique similar to that usedfor insulin pump tubing.The sensor constantly measures glucose concentration in the tissue fluid present at its subcutaneous location. Acombinedpower supplyandradio transmitter attaches to yourskinorclothing. The transmitter sends up to several hundred glucose readings daily to a small portable receiver that you can keep in a pocket.The number displayed is approximately equal to the blood sugarabout 20 minutes prior to the reading. So if you had taken a readingwith yourconventional method 20minutesago, thiswouldbe roughlythe sameasthe reading from the sensor right now.

Also displayed is an up or down arrow to indicate whether bloodsugar is increasing or decreasing. What's most valuable is an audiblealarm that can be set to sound at any selected blood sugar value andalso to signal rapid drops in blood sugar.

There aresome potential problems associated with these devices,sothey're not for everyone,and certainly not for me.

• The sensorremains under the skin for 3 days. During this time,there is always a possibility for inflammation or infection (probably a low risk).

• Fibrosis, or scartissue, can potentiallybuild up at the sensor siteover time (although how long this would take is as yet unclear)and eventually make measurements less accurate.

• Measurements are inherently less accurate than ordinary bloodsugar monitoring, so the devices need to be calibrated againstfinger-stick blood sugars about twice daily. For now, at least, Iwould recommend that any blood sugar correction be madebased on finger-stick measurements.

• Both the equipment and the disposable sensors with associatedsupplies arequite costly and may not be coveredby many insurance policies.

* Manyinsulin users will awaken automatically when blood sugar gets too lowduring sleep,so these people have built-in protection.*Search the Webfor "continuous glucose sensor"to comparedifferentmodels.

340 Treatment

• Advertising for these products may falsely imply (but does notstateoutright) that a sensor-insulin pump combinationwillautomatically monitor and inject insulin to keep blood sugars ontarget around the clock.

• The sensor is typically implanted in the abdomen, and has abulky exterior.

• The sensor will typically work for only 3 days, because the enzymeused is then depleted.

• The setup requires training to use.

While the sensors have at best limited usefulness at the moment, it

isentirely feasible—just froman engineering perspective—thattheywillvastlyimproveovertime.That said,I'm not holdingmybreath —this technology hasbeen around for decades, and manufacturershavemade plenty of money by employing it shoddily. One can still hope,however, that some brilliant entrepreneur will develop a highly accurate and timelysensor that can provideconstant, accurateblood sugarreadings.

But we'renot there yet.Soto sum it up, if I werelivingalone,I'd usethe sensor to protect from nighttime hypoglycemic episodes and forget about using an insulin pump.

"HYPOGLYCEMIA UNAWARENESS"

Some diabetics have absent or diminished ability to experience thewarningsigns of hypoglycemia. Thisoccurs under five circumstancesthat have been documented in the scientific literature:

• Severe autonomic neuropathy (injury,by chronicallyhigh bloodsugars, to the nerves that control involuntary bodily functions).

• Adrenal medullary fibrosis (destruction, by chronically highblood sugars, of the cells in the adrenalglandsthat produce epinephrine). This is especially common in long-standing poorlycontrolled diabetes.

• Bloodsugarsthat are chronically too low.• The use of beta-blocking medication for treatment of hyperten

sion or cardiac chest pain.• The use of large(nonphysiologic) dosesof insulin,as is common

for individuals on high-carbohydrate diets.

How to Preventand Correct LowBloodSugars 341

All ofthese situations result in lowered production of, or sensitivityto, epinephrine, the hormone that produces tremor, pallor, rapidpulse, and other signs that we identify withhypoglycemia. It is ironicthat epinephrine production or sensitivity ismost commonly diminished in those whose blood sugars have been chronically either veryhigh or very low.

Injury to the autonomic nervous system by elevated blood sugarhasbeendiscussed on pages 61-62. Individuals whose heart ratevariation on the R-R interval study is severely diminished may be especially susceptible to this problem.

People who have frequent episodes ofhypoglycemia or chronicallylow blood sugar tendto adapt to this condition. They appear to belesssensitive to theeffects ofepinephrine, which, when repeatedly releasedin large amounts, down-regulates its own receptors. This conditioncannotbepredicted byR-R studies. It is, however, readily detectable ifyou measure your own blood sugar frequentiy. If caused by chronically low blood sugar, this condition can be reversed bytaking measures to ensure that blood sugaris maintained at normal levels.

Hypoglycemia unawareness can deprive one of potentially lifesav-ing warning signals. To compensate for this disability, blood sugarshould bechecked more frequently. For some rare insulin users, it maybe necessary, for example, to measure blood sugar every hour for 5hours after meals, instead of onlyonceor twice after each meal. Fortunately, we have the tools to circumvent this problem; we need onlyto use them diligendy.

I frequently encounter patients who do not take glucose tablets forlow blood sugar measurements because they "feel fine." These arejustthe people who are most likely to lose consciousness or find themselves in an automobile accident.

Whether or not you have hypoglycemia, it is essential that youcheck your blood sugar before driving a car and — after finding aplace where you can safely stop your vehicle — every hour whiledriving.

POSTURAL HYPOTENSION —

THE GREAT DECEIVER

Syncope, or fainting, is fairly common aspeople get older. It is especially common among diabetics. Even more common isnear-syncope.

342 Treatment

This is merelythe feeling that you will pass out unless you he downrightaway. Simultaneously, your surroundings maylook gray or yourvision may fade. Thereare manycauses of syncope and near-syncope.These include cardiac and neurological problems,certainmedications,and dehydration. Thesecauses are not nearly ascommon in diabeticsasare sudden drops ofblood pressure caused by autonomicneuropathy or by inappropriate useof antihypertensive medications — especially diuretics ("water pills") and alpha-1 adrenergic antagonists,such as prazosinand terazosin.

When most ofus stand from aseated,supine, or squatting position,the brain sends a message to the blood vessels in our legs to constrictreflexively andinstantiy. This prevents blood from poolingin the legs,which would deprive the brain of blood and oxygen. If you've hadhigh blood sugars for manyyears, the nerves that signal the vessels inthe legs may conduct the message poorly (a sign of autonomic neuropathy). A drop in bloodpressure upon standing, called postural, ororthostatic, hypotension, occurs when this pooling in the legs occurs.For some,the heartmaybringbloodpressure backup by increasing itsrateand amount ofcontraction.Unfortunately,this does not occur formany diabetics with autonomic neuropathy.

Alternatively, if you eat a big meal,blood may concentrate in yourdigestive system, also depriving the brain. The normal mechanismsthat protect the brain from this shunting of bloodmaybe deficient ifyou have autonomic neuropathy. It is in part to gauge potential forthese reactions that I measure supine and standing blood pressures,and perform R-Rinterval studies on all my diabetic patients. A recentstudy of medical (mosdy nondiabetic) outpatients in the UnitedStates suggests that 20percent of individuals overthe age of 65and30percent of those over age 70 have documentable postural hypotension. Fordiabetics the incidence is probably much greater.

A common scenario for syncope or near-syncope involves the diabeticwho gets up in the middleof the night to urinate and keels overon the wayto the bathroom. A simple wayto avoid this is to sit at theedge of the bed with feet dangling for a few minutesbefore standing.

Another syncopescenario involves the personwho goes to the toilet and passes out while tryingto produce abowelmovement or urinate. Again, the reflexes thatprevent shunting of bloodaway from thebrain areblunted by autonomic neuropathy.

If syncope iscaused bytransient lowcerebral bloodpressure as aresult of autonomic neuropathy, one should lay the victim out flat and

How to Preventand Correct LowBloodSugars 343

elevate his feethigh abovehis head.He should return to consciousnessalmost immediately.

The symptomsof syncope are similar to those of moderate to severe hypoglycemia. In both cases, the brain isbeing deprived of a basic nutrient — oxygen in the case of syncope, glucose in the case ofhypoglycemia. Furthermore, postural hypotension canalso occurasaresult of hypoglycemia. Some symptoms of near-syncope includefaintness, visual changes, and disorientation.

Whatever the cause of fainting or near-syncope, blood sugar mustbe checked to rule out hypoglycemia. If blood sugar is normal, noamountof glucose will cure the problem. People with recurrent posturalhypotension will usually find reliefbywearing surgical stockingsof 30-40 mm compression. If these are inadequate, waist-high surgical pantyhose should be used.

TWO FINAL NOTES

Ifyou've heard horror stories about the frequency and severity of severe hypoglycemia in type 1diabetes, thepeople you've been hearingabout are probably taking industrial doses of insulin to cover largeamounts of dietarycarbohydrate. On our regimen, this hazard isvirtually nil.Someone would have to make a major mistake, suchas taking an insulin dose twice, or not waiting the full 5 hours beforecorrecting an elevated bloodsugar, forlife-threatening episodes to occur. Many type 1 diabetics seek me out because of their frequent hypoglycemic episodes and not necessarily because of their high bloodsugars. Our regimen takes care of both.

Please don'tneglect toask others to read thischapter. When youaremostin needof help fortreating hypoglycemia, youmay be incapableof rendering it yourself. So show this chapter to your close relatives,friends, and coworkers and ask them to read it. It should increase theirown confidence in coping with such situations, andthepotential payoff to you maybe considerable.

21

How to Cope with Dehydration,Dehydrating Illness, and Infection

When you experience vomiting, nausea, fever, diarrhea, oranyformofinfection, you shouldimmediatelycontactyourphysician. I can't really emphasize enoughthe importance

of getting treatment and getting it fast. To drive home this point, I'llshare the following experience.

Some years ago, I got a call from a woman at about four o'clockon a Sunday afternoon. She wasn't my patient, but her diabetologistwas out of town for the weekend with no backup for emergencies. Hehad nevertaughtherwhat I teach my patients — the contents of thischapter.

She found my Diabetes Center in the white pages of the phonebook. She was alone with her toddler son and had been vomiting continuously since 9:00 a.m. She asked me what she could do. I told herthat she must be so dehydrated that her only choice was to get to ahospital emergency room as fast as possible for intravenous fluid replacement.While she dropped off hersonwithhermother, I called thehospital andtold them to expect her. I gotacall 5 hourslater from anattending physician. He hadadmitted her to the hospital because theemergency room couldn't help her. Why not? Her kidneys had failedfrom dehydration. Fortunately, the hospital had a dialysis center, sothey put heron dialysis and gave herintravenous fluids. Had dialysisnot been available, she would likely have died. As it turned out, shespent five days in the hospital.

Clearly, a dehydrating illness is not something to takelightly, not areason to assumeyourdoctorisgoing to think you'reahypochondriacif you call every time you have one of the problems discussed in this

How toCope withDehydration, Dehydrating Illness, andInfection 345

chapter. This is something that could kill you, andyou need prompttreatment.

Why is it, then, that diabetics have a more serious time with dehydrating illness thannondiabetics? Clearly it has something to do withblood sugars.

DEHYDRATION'S VICIOUS CIRCLE

Ifyou are vomiting orhave diarrhea, you've either been poisoned (unlikely) or have an infectious illness. Ifyou have an infection, whetherit's in your mouth, on your finger, or in your gastrointestinal tract,your blood sugar is most likely going to go up. So you're starting offwith elevated blood sugars just by virtue ofthe infection. Ifyou vomitor have diarrhea, you are losing fluid from a region in the body thatnormally contains fluid. That lost fluid is going to be replaced fromthe largest source of fluid in the body, the bloodstream. It's not thatyou're going to bleed into your stomach —your GI tract is full ofblood vessels that are there in part for the exchange of fluids. That'show fluid is absorbed.

Your body naturally tries tomaintain abalance, sowhen fluid disappears from one place, your body tries toreplace itusing water from yourbloodstream. But as your blood loses water, glucose isleft behind, andyouend up witha higherbloodsugar concentration. In addition, bloodvessels area giantweb throughout thebody, but unlike a web, thevessels narrow as they travel outfrom the center, narrowing from insidethebody to outside, from inside an organ to itssurface, and soon.Atany given time, much oftheblood is inthese narrow, peripheral vessels.

If your bloodstream has lost significant amounts of fluid, as youwould ina dehydrating illness, the periphery is notgoing tobeas wellsupplied as it would normally be. It's like having a whole new insulinresistance simply because insulin andglucose aren't adequately reachingthenarrower vessels. Since less glucose will bedelivered to thecellsadjoining these vessels, yourblood sugar concentration will continueto climb. Furthermore, the higher your blood sugars go, the more insulin resistance you will experience. The more insulin-resistant youare, thehigher your blood sugars are going to be. Avicious circle.

To make the circle even more vicious, when you have high bloodsugars, you urinate —andofcourse what happens then isthatyou get

346 Treatment

even more dehydrated and more insulin-resistant and your bloodsugar goes even higher. Now your peripheral cells have a choice—either die from lack of glucose and insulin or metabolize fat. They'llchoose the latter. But ketones are created by fat metabolism, causingyouto urinateeven moreto ridyourself of the ketones, taking you toa whole new levelof dehydration.

This sequence of events can happen in a matter of hours, as it didwith the womanjust described. Sothe name of the gameisprevention.

Howdo youprevent illness from causing dehydration? Let's sayyouwake up in the middle of the night or in the morning and vomit orhave a bout of diarrhea.What do you do? Callyour physicianand lethim or her know—even if it's two o'clock in the morning, callyourdoctor. Even if it turns out to bejust something you ate and it's a transient episode, callyour doctor or his/her answering service.

We allgetsickfromtimeto time, but ifyou're on our dietand treatment plan,and if you'rereasonably healthy, youshouldn't get sickanymore frequently than the average person— and probably less frequently than the average diabetic. For diabetics, however, such illnesscan pose specialproblems.

As you know, sickness or infection can cause your blood sugar toincrease, and injected insulin— even if you don't normally take insulin — can help preserve beta cell function during illness (as well ashelp keep your blood sugar under control and thereby reduce dehydration). One of the most pressing concerns for diabetics duringillness is dehydration, which, as illustrated above, can lead to life-threatening consequences if not handled effectively and rapidly.

DIABETES AND DEHYDRATION:

A DANGEROUS COMBINATION

Commoncauses of dehydration include not onlymultiple episodes ofdiarrhea or vomiting, and fever and resulting perspiration; they alsoincludefailure to drink adequate fluids, especially during hot weatheror prolonged exercise, andvery high blood sugars. You probably knowthat one of the hallmark symptoms of very high blood sugars is thecombination of extreme thirst and frequent urination. From whatyou've already read in this chapter, you should understand the equation. Still, I think it's noteworthy enough to lay it out again for emphasis.

Howto Cope withDehydration, DehydratingIllness, andInfection 347

1. Dehydrationcauses transitory insulin resistance.*2. During periods of dehydration, blood sugarwilltend to rise.3. High blood sugar,as you know, itself leads to insulin resistance

and further blood sugar increase.4. Blood sugar elevation from dehydration in addition to blood

sugar elevationcaused by the viral or bacterial infection that ledto your vomiting, fever, or diarrhea causes further insulin resistance and blood sugar elevation.

5. High bloodsugarcauses further dehydration asyourkidneys attemptto unloadglucose andketones byproducing large amountsof urine.

6. Increased dehydration causes higher blood sugars, which inturn cause further dehydration. All of which brings us back tonumber 1.

The good news is,however, that simple interventions can halt thisspiraUng of bloodsugars and fluid loss. It'sthe purposeof thischapterto give you the knowledge to prevent the sort of grave consequencesexperienced by the lady who called me on that Sunday afternoon —or worse, death.

KETOACIDOSIS AND HYPEROSMOLAR COMA

There are two acute conditions that can develop from the combination of high blood sugarsand dehydration. The first is called diabeticketoacidosis, or DKA. It occurs in people who make virtually no insulinon theirown (eithertype1diabetics or type2diabetics whohavelost nearly all beta cell activity). Very low serum insulin levels, combinedwith the insulin resistance caused byhighbloodsugars and dehydration, result in the virtual absence of insulin-mediated glucosetransport to the tissues of thebody. In theabsence ofadequate insulin,thebodymetabolizes storedfats to produce the energy that tissues require to remain alive. A by-product of fat metabolismis the production of substances called ketones and ketoacids. One of the ketones,

*It is absolutely important when experiencing dehydrating illness not to do anything that wouldhastendehydration — and that indudes the useof certainmedications, such as ACE inhibitors and diuretics. Never discontinue a medicationwithout discussing itwith your doctor, soask your physician assoon asyou experience such anillness aboutceasing use ofthese andsimilar medications. Ifyou're unsure, mostpharmacists cantell youifa particular drugcanfacilitate dehydration.

348 Treatment

acetone, is familiar as the major component of nail polish remover.Ketones maybe detected in the urineby using a dipstick such as Ke-tostix (see Chapter 3,"Your Diabetic Tool Kit"). Ketones may also bedetected on the breath as the aroma of an organic solvent, which iswhy unconscious diabetics areoften mistaken for passed-out drunks.

Ketones and ketoacids are toxic in large amounts. More important,yourkidneys will try to eliminate themwitheven moreurine,therebycausing furtherdehydration. Some of thehallmarks of severe ketoacidosis are large amounts of ketones in the urine, extreme thirst, drymouth, nausea,frequent urination, deep labored breathing, and highblood sugar (usually over350mg/dl).

The other acutecomplication of highblood sugarand dehydration,hyperosmolar coma, isa potentially more severe condition, and occursin people whose beta cells still make some insulin. ("Hyperosmolar"refers to high concentrations of glucose, sodium, and chloride in theblood due to inadequate water to dilute them.) Diabetics who developthis condition usually have some residual beta cell activity, makingenoughinsulin to suppress the metabolism of fats, but not enoughtopreventveryhighbloodsugars. As a result, ketones maynot appearinthe urine or on the breath. Because this condition most commonly occurs in elderly people, who do not become very thirsty when dehydrated, thedegree ofdehydration isusually greater thaninketoacidosis.Early symptoms of a hyperosmolar state include somnolence and confusion. Extremely highbloodsugars (asgreat as 1500 mg/dl) have beenreported in cases of hyperosmolar coma. Fluid deficit maybecome sosevere that the brain becomes dehydrated. Loss of consciousness anddeath can occur in both the hyperosmolar state and in severe DKA.

The treatment for DKA and hyperosmolar coma includes fluid replacement andinsulin. Fluid replacement alone canhave a great effectupon bloodsugar because it bothdilutes theglucose level in thebloodand permits the kidneys to eliminate excess glucose. Fluidalso helpsthe kidneys eliminate ketones in DKA. Our interest here, though, isnot in treating theseconditions — this mustbe donebya physician orin a hospital — but in preventing them.

VOMITING, NAUSEA, AND DIARRHEA

Vomiting, nausea, and diarrhea aremost commonly caused bybacterial or viral infections sometimes associated with flulike illness. An es-

How toCope with Dehydration, Dehydrating Illness, andInfection 349

sential partof treatment isto stop eating. Since you can certainly survive a few days without eating, this should pose no problem. But ifyou're noteating, itmakes sense toask what dose ofinsulin orISA youshould take.

Adjusting Your Diabetes MedicationIf you're on one of the medication regimens described in this book,theanswer issimple: you take theamount andtype ofmedication thatyou'd normally take to cover the basal, or fasting, state and skip anydoses that are intended tocover meals. If, for example, you ordinarilytake detemir or glargine as basal insulin upon arising andat bedtime,and regular or lispro (or aspart or glulisine) insulin before meals,you'd continue the basal insulin and skip the preprandial regular orlispro for those meals you won't beeating. Similarly, ifyou take anISAon arising and/orat bedtime for the fasting state, and again to covermeals, you skip thedoses for those meals thatyou do not planto eat.

Inbothof theabove cases, it's essential that the medications usedforthe fasting state continue at their full doses. This is in direct contradictiontotraditional "sick day" treatment, butit's amajor reason why patients who carefully follow our regimens should not develop DKA orhyperosmolar comawhentheyare ill.

Ofcourse, ifyou're vomiting, you won't beable to keep down oralmedication and thisposes yetanother problem.

Remember, because infection and dehydration may each causeblood sugar to increase, you may need additional coverage for anyblood sugar elevation. Such additional coverage should usually takethe form of lispro insulin.This is one of the reasons that we advocatethe training of all diabetics in the techniques of insulin injection —even those who, when notsick, can becontrolled byjustdietandISAs.Using insulin when you're sick may be especially important for you,becauseit helps to relieve the added burden on beta cells that leads toburnout. This isbutoneofthereasons it's mandatory thatyou contactyourphysician immediately when you feel ill. Heor sheshould beableto tell you how much coverage with lispro will benecessary, and whento take it.The protocol for such coverage isdiscussed on pages 301—304, butbecause ofits importance, it bears repeating again briefly:

1. Measure bloodsugars on arising and every 5 hours thereafter.2. Inject enough lispro at these times to bring your blood sugars

down toyourtarget value. Intramuscular shots arepreferred (see

350 Treatment

pages 307-310) because of their rapid effect, but subcutaneousinjection isalso acceptable. It isprudentto continue bloodsugarmeasurementsand insulincoverage, evenduring the night, for aslong asblood sugarscontinue to rise.

Ifyou're so illthat youcannotcheck yourownbloodsugars and inject your own insulin, someone else must do this for you, or youshouldbe hospitalized. Thepotential consequences areso seriousthatyou haveno other options.

Medications to Be Discontinued

Certain medications that can accelerate dehydration or temporarilyimpairkidney function should be discontinued duringa dehydratingillness. These include diuretics, ACE inhibitors, and certain arthritismedications such as NSAIDs (ibuprofen, Motrin, Advil) and COX-2inhibitors.NSAIDs may, however, be usedasa last resort to treat feverif other medications are ineffective. Discuss this with your physicianbeforediscontinuing medication he has prescribed. If you can't reachhim, then discontinue.

Controlling the VomitingThe mainstay of treatment is fluid replacement, but if you've beenvomiting, you'll probably be unable to holdanything down,includingfluids. If symptoms disappear aftervomiting once and you can keepthings down, then there's likely no needfor treatmentto prevent further vomiting {butstill notify your physician). Ordinary vomiting canusually besuppressed withTigan (trimethobenzamide hydrochloride)suppositories, administered rectally every 3-5 hours if vomiting persists. Tigan should not be taken bymouth,asit will probably bevomited up before it can work. Suppositories should be stored in yourrefrigerator, as they tend to melt in hot weather. The suppositoryshould be inserted well into the rectum, blunt endfirst, so it won'tcome out.

Tigan works for most people, but in about a third of cases, itdoesn't, which is all the more reason to contact your physician whenyouexperience a potentially dehydrating illness (nausea, vomiting, diarrhea, fever). If vomitingor nauseacontinuesfor more than 4 hours,or if it cannot be haltedby Tigan within 1 hour, he or she may wantyou to try a second or even a third dose or may prescribe a visit to ahospitalemergency room to receive intravenous fluid (saline) and to

How toCope withDehydration, Dehydrating Illness, andInfection 351

have the cause established. Some surgical emergencies such as intestinal obstruction can lead tovomiting, as can poisoning, gastroparesis(Chapter 22), DKA, and so on. Vomiting is a serious problem forpeople withdiabetes, andshould not betreated casually.

Large doses of Tigan cancause bizarre neurological side effects, especially in children and in slim elderly people. When vomiting hasceased, itshould probably notbeadministered more often than every3 hours, or in doses greater than that prescribed by your physician. Iusually recommend 100 mg suppositories for children and slimpeople olderthan 65years, and 200 mgsuppositories for allothers. IfTigan doesn't work fully within 1hour, take more andcall your physician again.

Fluid ReplacementOnce vomiting has been controlled, you should immediately begin todrink fluids. Two questions naturally arise at this point: What fluid?And how much? There are three factors that must be considered inpreparing the fluid to be used.

First, itmustbepalatable. Second, it should contain no carbohydrate(therefore noGatoradeor other sportsdrinks),but artificial sweetenersareokay. Thisguideline alsocontradicts conventional treatment,whichusually calls forsweetened beverages to offset the excessive amountsofinsulin that many diabetics use. Finally, the fluids should replace theelectrolytes — sodium, potassium, and chloride— that are lost fromthebodywhen we lose fluids. Beverages commonly used bymypatientsinclude diet soda, diluted iced tea, seltzer, water, and carbohydrate-free bouillon or clear soup. To these fluids, weadd electrolytes.

To each quart of liquid, add:Exactly but no more than 1 level teaspoon table salt (Vi teaspoon if it tastestoo salty) (provides sodium and chloride)Exactly but no more than V4 teaspoon salt substitute (see list,page 67) (provides potassium and chloride)

If thevomiting ceased after oneepisode without theneed forTigan,it isn'tnecessary to add the salts to the fluid youconsume.

In anticipation of these rare "sick days," you should always haveon hand several 2-quartbottles of dietsoda or seltzer, or two empty2-quart plastic iced tea pitchers. The pitchers can be used to storewhatever rehydration concoction youmayprefer instead of diet soda.

352 Treatment

When the needarises, onepitcher of fluid can bekeptby yourbedside,whilethe second iskept coolin the refrigerator.

Thevolume of fluid youwill require each day, whennot eating, depends upon your size, since large people utilize more fluid than smallpeople. Ifyour blood sugars are elevated orifyour urine ondipstick ispositive for more than moderate amounts of ketones, you will needmuch more fluid than otherwise. The ongoing fluid requirement formost adults without these problems comes to about2-3 quarts dailywhile fasting.* In addition, within the first 24 hours you should replace the estimated fluid loss caused by vomiting, fever, or diarrhea.This maycome to another few quarts, soclearly youwill have to do alot of drinking. Your physician should be consulted for instructionsregarding yourfluid intake while ill. If for anyreason youcannot consume orkeep down theamount of liquid that she orherecommends,you may have tobehospitalized to receive intravenous fluids.

If youdo have to behospitalized for IV fluid replacement, you mayrun into the difficultyof inexperienced or ignoranthospitalpersonnelwanting to give you one or another standard solution that containssomesortof sugar — glucose, lactose, lactated Ringer's solution, fructose, and so on. Do not allowthem to do so, and do not assume theyknow more than you do aboutyour situation. Insist upon a saline solution,1 and if they balk, insist upon speaking with the hospital administrator and threaten malpractice and wrongful death lawsuits, ifnecessary, to persuade them of whatyou need. Although not usuallyeffective outside the United States, such threats are usually effectiveherebecause malpractice insurance companies will likely insist uponthe discharge of the person who precipitates alawsuit.

Diarrhea

Here again we are faced with three basic problems: blood sugar control, control of the diarrhea to prevent further water and electrolyteloss, and fluid and electrolyte replacement.

The guidelines for blood sugar control are the same as if you have

*Figure on 0.02 quarts per pound of body weight (0.044 liters per kilogram).Thus,about 3quarts (or 3 liters) fora person weighing 150 pounds(68kilos),beware of D-5 or D-10 salinesolutions. These contain dextrose (glucose) andwill certainly raise yourblood sugar and thereby cause furtherdehydration. Foruncontrollable diarrhea, halfnormal saline should be used; otherwise, normalsaline.

How toCope withDehydration, DehydratingIllness, andInfection 353

been vomiting (see above). Fluid and electrolyte replacement shouldbe the same as for vomiting, except that 1 level teaspoon of sodiumbicarbonate (baking soda) should be added to each quart of theelectrolyte-replacement mixture. The primary treatment for diarrhea,as for vomiting, is to stop eating. Medications to relieve diarrhea, ifany, should be specified by your physician. Some forms of diarrheacaused by bacteria, such as "traveler's diarrhea," maywarrant the useof Pepto-Bismol (bismuth subsalicylate) and antibiotics such as ciprofloxacin.

In my experience, there is oneantidiarrheal agent that has alwaysworked, Lomotil (diphenoxylate Hcl with atropine sulfate). This is aprescription drug thatyou should have your doctor prescribe inliquidform in adropper bottle (in advance of any illness). The generic versions are muchless expensive and just as effective. You should alwayshave several bottles on hand. You will find dosing instructions on thepackage insert. If diarrhea continues, double thedose every hour untilit ceases and continue the final dose every 3hours until your physicianadvises you to discontinue.(Oncethe diarrhea ceases, it would bemoreconvenient andcheaper for an adult to switch from theliquid tothe tablet form of the drug. One 2.5 mg tablet is equivalent to 1 teaspoon or full dropper of theliquid.) Overdosing will not onlydryoutyour gut, which we are seeking, but can dry out your larynx, mouth,nose, andeyes. Lomotil can also make youdrowsy, but itseffect on diarrhea is miraculous, in my opinion.

FEVER

No doubt you've heard the advice,"Drinkplentyof fluids," for a fever.This isbecause fever causes considerable fluid loss through theskin asperspiration. Your loss of fluid can be difficult to estimate, so yourphysician maywantto assume thatyou'd require 1-2 more quarts offluid daily than you'd normally need. Ordinarily, amildfever helps todestroy the infectious agent (virus or bacteria) that caused the fever.The tendencyto sleep out fever may also be beneficial. For a diabetic,however, thesomnolence that you experience with fever maydiscourage you from checking yourbloodsugar, covering with insulin, drinkingadequate fluid, and calling your physician every few hours. If youdon't have someone awaken youevery 20minutes, youshould useaspirin, acetaminophen (Tylenol), or ibuprofen (Advil or Motrin), in

354 Treatment

accordance withyourdoctor's instructions, to helpfight the fever. Beware, however, that aspirin can cause false positive readings on testsfor urinary ketones, sodon'teven test for ketones ifyou are using aspirin. Never use aspirin or ibuprofen (or any ofthe nonsteroidal antiinflammatory drugs, NSAIDs) for fever in children because of the riskof Reye's syndrome. Excessive doses of aspirin or NSAIDs (naproxen,ibuprofen, and many others) can cause severe hypoglycemia. If at allpossible, try not to use NSAIDs, as the combination of these drugswith dehydration can cause kidney failure. Acetaminophen can behighly toxic if used indoses greater than those indicated on the packagelabel.

If you have fever, the guidelines for blood sugar control and replacement of fluid are almost the same as indicated previously forvomiting. There is one difference, however. Since there is very littleelectrolyte loss in perspiration, it's not necessary to add salts to thefluid you consume if you're not vomiting or experiencing diarrhea.Certainly there isnoreason notto eat ifyou feel hungry—but ifyouwantto eat,cover yourmeals withyourusual dose of insulin or ISA. Ifyou're hungry for only asmall meal, eat halforaquarter ofyour usualprotein andcarbohydrate, and cover it with only halfor a quarter ofyour usual dose of insulinor ISA.

ADDITIONAL SUGGESTIONS FOR

DEHYDRATING ILLNESS

Like hypoglycemia, dehydrating illness canbelife-threatening to a diabetic. Encourage the people you live with to read this chaptercarefully. The supplies mentioned should be kept in locations known toall. Phone yourphysician at the first sign of fever, diarrhea, or vomiting. The chances are that he/she would much rather be contactedearly, when dehydration andloss of blood sugar control canbe prevented. Emergency situations make treatment more difficult, so youcanmake yourlife andyour physician's a bit easier byphoning beforemajor problems occur.

Your physician will probably ask you whether yoururine shows ketones, so use the Ketostix whenever you urinate beforeyou call.Also,let your doctor know if you have taken any aspirin in the prior 24hours, as this can cause a false positive Ketostix reading.If you are noteating, your urine will certainly show"moderate" ketones. Your physi-

How toCope with Dehydration, Dehydrating Illness, and Infection 355

cian should therefore only be concerned if it shows "high" ketonescombined with high blood sugars (160 mg/dl orabove). Always reportyourrecent bloodsugars when you phone yourphysician.

NONDEHYDRATING INFECTIONS

Most infections cancause elevation of blood sugars, from an infectedtoe to infected tonsils to infected heart valves. Most infections causesymptoms that are recognizable, such as burning upon urination ifyou have a urinary tract infection, coughing if you have bronchitis,and soon. So you'll get pretty prompt warning from your body thatyou should immediately contact your physician. Ifyou have type 2diabetes or early type 1, you certainly don't want your blood sugars toget sohigh thatyour remaining beta cells are destroyed. My friend Jayputoffvisiting a urologist until his blood sugars got sohigh thathistype 2diabetes became type 1diabetes andherequired 5daily insulininjections. Occult, or hidden, infections will not become readily apparent unless you notice that your blood sugars have become unreasonably high andyou have the good judgment tocontact your doctor.

By far the most common type ofoccult infection is that family ofinfections that affect dental structures. This includes infections thataffect root canals, gums, and jawbones. A history of elevated bloodsugars over a period of yearspredisposesdiabetics to such infections;these infections, inturn, predispose diabetics tohigh blood sugars andsevere insulin resistance.

Ifone ofmy patients calls ouroffice and complains of recent onsethigh blood sugars but no apparent accompanying infection (nocoughing, for instance), we ask ifshe orhe is reusing insulin syringesand contaminating insulin, making injections relatively ineffective(seepage 257). If the answeris no, then we recommend a visit to thedentist immediately to searchfor an oral infection.

Among thethings thatyour dentist should do are to examine yourgumsverycarefully and to tap every tooth to seeif one or more is tender. Heor she should also touch each tooth with a chip of ice. Painupon exposure to cold is the most common overt symptom of infection in the tooth or jawbone, in my experience. We have hadpatientswith dentists who refused todothis and we've had to instruct thepatients to find better dentists. This is one ofthose many cases ofbeinga good, educated health care consumer in order to get proper treat-

356 Treatment

ment for your diabetes. In each case, when a new dentist performedthesetests, a problem was found. If yourdentistdoes find a problem,he or shewill probably refer youto anendodontist or periodontist totreat the infection.

Even after such dental infections have been successfully treated,however, bloodsugar elevations frequently continue for manymonths.If this occurs, anappropriate antibiotic shouldbe prescribed and continued until blood sugars remain at their preinfection level. Manypeople require continuation of antibiotics for as long as a year aftertreatment to prevent further blood sugar increases. When using oralantibiotics, always take a probiotic every day,* at least 2 hours beforeor after the antibiotic, to replace gastrointestinal bacteria killedby theantibiotic.

To help prevent dental infections, it is wise to arrange with yourdentist for tartar to be removed from your teeth ultrasonically everythree months. You should also brush your teeth at leasttwice dailyandaftermeals floss frombetween yourteeth any foodthat remains there.If your teeth are too tightly spaced for flossing, try Stimudent, whichisa specially designed toothpick withatriangular cross-section. Pushit between yourteeth with the base of the triangle against yourgum.An even easier productto useis Doctor's BrushPicks, available atmostpharmacies.

*My current favorite probiotic issaccharomyces boulardii (brand name Floras-tor). It is availableat most pharmacies.

22Delayed Stomach«Emptying:Gastroparesis

A number of times throughout this book, you've come acrossthe terms "delayed stomach-emptying" and "gastroparesis."As I explained in Chapter 2, elevated blood sugars for pro

longed periods can impair the ability ofnerves to function properly.It's very common that the nerves that stimulate the muscular activity,enzyme secretion, and acid production essential to digestion functionpoorly in long-standing diabetes. These changes affect the stomach,the gut, or both. Dr. Richard McCullum, a noted authority on digestion, has said that ifa diabetic has any other form ofneuropathy (dryfeet, reduced feeling in the toes, diminished reflexes, et cetera), he orshe will also experience delayed or erratic digestion.

Slowed digestion can befraught with unpleasant symptoms (rarely),or it may only be detectable when we review blood sugar profiles(commonly) or perform certain diagnostic tests. The picture isdifferent for each of us. For more than twenty-five years, I suffered frommany unpleasant symptoms myself. I eventually saw them taper offand vanish after thirteen years of essentially normal blood sugars.Some ofthephysical complaints possible (usually after meals) includeburning along the midline of the chest ("heartburn"), belching, feeling full after a small meal (early satiety), bloating, nausea, vomiting,constipation, constipation alternating with diarrhea, cramps a fewinches above the bellybutton, and an acidtaste in the mouth.

GASTROPARESIS: CAUSES AND EFFECTS

Most of these symptoms, as well as effects upon blood sugar, relate todelayed stomach-emptying. This condition iscalled gastroparesis dia-

358 Treatment

beticorum, which translates from the Latin as "weak stomach of diabetics." It is believedthat the major cause of this condition is neuropathy(nerve impairment) of thevagus nerve. This nerve mediates manyof the autonomicor regulatory functions of the body, including heartrate and digestion. In men, neuropathy of the vagus nerve can alsolead to difficulty in achieving penile erections. To understand the effects of gastroparesis, refer to Figure 22-1.

On theleft is a representation ofa normal stomach after a meal. Thecontents are emptying into the intestines, through the pylorus. Thepyloric valve is wide open (relaxed). The lower esophageal sphincter(LES) is tightly closed, to prevent regurgitation of stomach contents.Notshown isthegrinding andchurning activity of the muscular wallsof the normal stomach.

On the right is pictured a stomach with gastroparesis. The normalrhythmic motions ofthe stomach walls are absent. The pyloric valve istightly closed, preventing the unloading of stomach contents. A tinyopening aboutthesize ofa pencil pointmay permit a small amountoffluid to dribble out.When the pyloric valve is in tightspasm, some ofus can sometimes feel a sharpcrampabove the belly button. Since the

Esophagus-

LES

Stomach

Pyloric Valve

Normal Stomach Paretic Stomach

Fig. 22-1. Normal andparetic stomachs.Terry Eppridge

Delayed Stomach-Emptying: Gastroparesis 359

lower esophageal sphincter (LES in Figure 22-1) is relaxed or open,acidic stomach contents can back up intotheesophagus (thetubethatconnects the throat to the stomach). This can cause aburning sensationalong themidline of thechest, especially while the person islyingdown. Ihave seen patients whose teeth were actually eroded over timeby regurgitated stomach acid.

Because the stomach does not empty readily, one may feel full evenafter a small meal. In extreme cases, severalmeals accumulate and causesevere bloating. More commonly, however, youmayhave gastroparesisandnot be aware of it. In mild cases, emptying maybe slowed somewhat, but not enough to make you feel any different Nevertheless, thiscan cause problems withblood sugar control. Consuming certain substances, such as tricyclic antidepressants, caffeine, fat, and alcohol, canfurther slow stomach-emptying and other digestive processes.

Some years ago, I received a letter from my friend Bob Anderson.His diabetic wife, Trish, whowas not my patient andhas since passedaway, hadbeenexperiencing frequent loss of consciousness fromseverehypoglycemia, caused by delayed digestion. His description of an endoscopic exam, when he was allowed to lookthrough a flexible tubeinto Trish's stomach and gut, paints a graphic picture.

Allthisbrings me to today's endoscopy exam. Iwatched throughthe scope and for the first time, I nowunderstand whatyouhavebeen saying about diabetic gastroparesis. Not until I viewed theinside of the duodenum did I understand the catastrophic effectof 33 years of diabetes upon the internal organs. There was almost no muscle action apparent to move food out of the stomach. It appeared as a very relaxed smooth-sidedtube insteadofhaving muscular ridges ringing the passage. I suppose apicture isworth a thousand words. Diabetic neuropathy is more than amanifestation of atilting gait, blindness, andother easily observable presentations; it wrecks the whole system. This you wellknow. I am learning.

HOW DOES GASTROPARESIS AFFECT

BLOOD SUGAR CONTROL?

Consider the individual who has verylittle phase I insulin release andmust take fast-acting insulin orone of theolder-type (sulfonylurea) or

360 Treatment

newer pancreas-provoking OHAs before each meal. If he were to takehismedication and thenskip themeal, hisbloodsugarwouldplummet.When thestomach empties tooslowly, it canhave almost thesame effectas skipping a meal. If we knew when the stomach would empty, wecoulddelay the insulin shotor addsome NPHinsulin to the regular toslowdownitsaction. Thebigproblem withgastroparesis, however, is itsunpredictability. We never know when, or how fast, the stomach willempty. If the pyloric valve is not in spasm, the stomach contents mayempty partially within minutes andtotally within 3hours. On anotheroccasion, when the valve is tightly closed, the stomach may remainloaded fordays. Thus, blood sugar may plummet 1-2hours after eating,andthenrise very high, say 12 hours later, after emptying eventually occurs. It is this unpredictability that can make bloodsugarcontrol impossible ifsignificant gastroparesis isignored inpeople who take insulin(or the type ofOHAs I don'trecommend) before meals.

For most type 2 diabetics, fortunately, even symptomatic gastroparesis may notgrossly impede blood sugar control, because they maystill produce some phase I and phase II insulin. They therefore maynot require significant amounts of injected insulin to cover theirlow-carbohydrate meals. Much of their insulin is producedin response toblood sugarelevation. Thus, if the stomach does not empty, only thelow basal (fasting) levels of insulin are released, and hypoglycemiadoes not occur.Of course, the sulfonylurea and similarOHAs (whichI don't recommend) can cause hypoglycemia under such circumstances. If the stomach empties continually but veryslowly, the betacells of mosttype 2swill produce insulin concurrently. Sometimes thestomach may empty suddenly, as the pyloric valve relaxes. This willproduce a rapid blood sugar rise, caused bythesudden absorption ofcarbohydrate following the entrance of stomach contents into thesmall intestine.Most beta cells of type 2 patients then cannot counterrapidly enough. Eventually, however, insulin release catches up andblood sugar drops to normal, if a reasonable regimen is followed. Ifyour supper doesn't fully leave your stomach before you sleep, youmayawaken witha highmorning bloodsugar due to emptying overnight, even though your bedtime blood sugar was low or normal.

In any event, if you do not require insulin or use a sulfonylurea-type OHA before meals, there isnohazard ofhypoglycemia duetodelayed stomach-emptying. This assumes thatany long-acting insulin orsulfonylurea isadministered in doses that cover onlythe fasting state,as discussed in prior chapters. The traditional use of large doses of

Delayed Stomach-Emptying: Gastroparesis 361

these medications, meant to cover both the fasting and fed states,brings with it the hazard ofpostprandial hypoglycemia when gastroparesis is present.

DIAGNOSING GASTROPARESIS

Efforts atdiagnosis are usually unnecessary ifthere isnoreason tosuspect the presence of gastroparesis. So first we must have an index ofsuspicion. If, at the initial history-taking interview with your physician, you mention symptoms like those described earlier in this chapter, he should have a high index of suspicion. If your R-R intervalstudy (Chapter 2)at the initial physical exam isgrossly abnormal, hecan bequite certain ofgastroparesis. Remember thatthis study checkstheability of the vagus nerve to regulate heartrate. If the nerve fibersgoingto the heart are impaired, the branches that activate the stomachare probably also impaired. Inmy experience, the correlation ofgrosslyabnormal R-R studies with demonstrable gastroparesis isvery real.*

Diagnostic TestsGiven the physical symptoms or the abnormal R-R study, your physician may want to consider further tests to evaluate your condition.The most sophisticated of these studies isthegamma-ray technetiumscan. This test is performed at many medical centers, and is quitecostly. It works this way: You eat some scrambled eggs to which aminute amountof radioactive technetium has been added. Agamma-ray camera trained on your abdomen measures (from outside yourbody) thelow levels ofradiation thetechnetium emits astheeggs passfrom your stomach intoyour small intestine. If thegamma radiationdrops off rapidly, the studyis considered normal.

Aless precise study can beperformed atmuch lower cost byany radiologist. This iscalled thebarium hamburger test. In thistest, youeata V4-pound hamburger andthendrinkaliquid thatcontains theheavyelement barium. Every halfhourorso, anX-ray photo istaken ofyourstomach. Since the barium shows up in these photos, the radiologist

*If, during anR-R study, your heart rate varies only 28 percent between inhalingand exhaling, then you will likely have mild gastroparesis. If the variation isabout20percent, gastroparesis will probably bewhatI call moderate, and if lessthan 15percent, I would call it severe.

362 Treatment

can estimate what percentof the barium remains in your stomach atthe end of each time period. Total emptying within3 hours or less isusually considered normal.

Despite their theoretical usefulness, neither of these studies is anywhere near 100 percent sensitive, because of the unpredictable natureoftheparetic stomach. One day itmay empty normally, another day itmaybeabitslow, and onyet another day its emptying may beseverelydelayed. Because of this unpredictability factor, thestudy may have toberepeated anumber oftimes before adiagnosis can bemade. Thepossibility exists thatyou could have several normal studies but still haveabnormal stomach-emptying. I therefore advise my patients againstusing either ofthese two tests. The R-R study ismy gold standard.

Telltale Blood Sugar PatternsHaving medical tests is bad enough, but having to repeat them withconflicting results naturally proved quite annoying to my patientsmanyyears agowhenI actually repeated them.Worse than annoyance,the studies are not cheap, and most insurance companies will notpay for repeats of the same study unless they're separated by manymonths.Ifyou're regularly measuring yourbloodsugarlevels and trying to keep them in the normal range, it's really not difficult to spotgastroparesis that'ssevere enough to affect bloodsugars. Forpracticalpurposes, thisisjustthedegree ofgastroparesis thatshould concern us.

Below are some of the typical blood sugar patterns that I look for.To call these patterns, though, is slightly misleading. The hallmark ofgastroparesis is randomness, unpredictability from one day to the next.These "patterns" come and goin such a fashion that bloodsugarprofiles are rarely similar on 2 or 3 successive days. Thefirst twopatternstogether arehighly indicative of gastroparesis, while the thirdbyitselfis usually adequate for diagnosis.

• Lowblood sugaroccurring1-3 hours after meals.• Elevated bloodsugar occurring 5 or morehours aftermeals with

no other apparent explanation.• Significantly higher fasting bloodsugars in the morning than at

bedtime, especially if supperwas finished at least 5 hours beforeretiring. If bedtime long-acting insulin or ISA is gradually increased in an effort to lower the fasting blood sugars, we mayfind that the bedtime dose is much higher than the morningdose.On some days fasting blood sugar maystillbe high, but on

DelayedStomach-Emptying. Gastroparesis 363

other days it may be normal or even too low. We're thus givingextra bedtime medicationsto accommodate overnight stomach-emptying— but sometimes the stomachdoesn'temptyovernightand fasting blood sugars drop too low.

Having seen such patterns of blood sugar, we can then perform asimple experiment to confirm that they really are caused by delayedemptying.

Skipsupper and its premealinsulinor ISA one night. When you goto bed, be sure to take your basal (bedtime) insulin or ISA, measureyour blood sugar,and then measureyour fasting blood sugar the nextmorning on arising. If,without supper,your blood sugar has droppedor remained unchanged overnight, gastroparesis is the most likelycause of the roller-coaster morning blood sugars.

Repeat this experiment severaldayslater,and again a third time, after another fewdays.If each experiment results in the same effect,delayed stomach-emptying is virtually certain on one or more of thenights when you had eaten.Whenyouhad previouslybeen eatingsuppers, at least some of the following mornings had shown an overnightrise in blood sugars. Sincesuch risesoccurred on nights when you hadeaten supper, but noton the nights when you did noteat, the rise musthave been caused by food that did not leave your stomach until afteryou went to bed. Be very cautious when performing this experiment,as you may experience severe hypoglycemia upon arising or duringthe night. To play it safe,check your blood sugar midway through thenight and correct it if it's belowyour target.

"False Gastroparesis"I've seen a number of patients whose blood sugar profile or physicalsymptoms could have been diagnostic of gastroparesis, yet their R-Rinterval studies were normal or only slighdy impaired. These peoplehad delayed stomach-emptying but well-functioning vagus nerves.The conflictingdata obligedme to order upper gastrointestinalendoscopicstudies for these people.Endoscopyusesa thin, flexible, lightedfiber-opticcableto look directlyinto the stomach and duodenum.

The endoscopic tests demonstrated that they all had abnormalitiesunrelated to their diabetes. Such findings have included gastric orduodenal ulcers, erosive gastritis, irritable gastrointestinal tract, hiatalhernia, and other gastrointestinal disorders such as tonic or spasticstomach. Each of these conditions required treatment distinct from

364 Treatment

treatment for diabetes. Only with hiatal hernias were we unable to atleast partially alleviate the digestive problem. In such cases, however,surgicalcorrection of the hiatal hernia is possible, but it may or maynot normalize emptying. Blood tests for parietal cell antibodies andserum vitamin B-12might be performed to rule out autoimmune gas-tropathy as a causeof gastritis.

The following suggestions for treating gastroparesis may or maynot facilitate stomach-emptying for the aboveconditions but shouldcertainly be tried. The loud and clear message from this is that theR-R interval study should be performed on every diabetic patientwhoseblood sugar profiles resemble those outlined above.

APPROACHES TO CONTROL

OF GASTROPARESIS

It is worth noting that gastroparesis can be cured by extendedperiodsof normal blood sugars. I've seen several relatively mild cases wherespecial treatment was terminated after about 1 year, and blood sugarprofiles remained flat thereafter. At the same time, R-R studies improved or normalized. Sincemy late teens, I experienced severe dailybelching, and burning in my chest. These symptoms gradually easedoff,and eventually disappeared, but onlyafter thirteen years of nearlynormal blood sugars. My last R-Rstudy was normal. The "sacrifices"in lifestyle required for treatment of gastroparesis may reallypay offmonths or years later.The vagusnerve doesn't control only stomach-emptying — there are a number of other complicationsresulting fromimpairedvagus function that can be reversed by maintainingnormalbloodsugars. Theregained ability to sustaina penileerectionisan important one for many of my male patients.

Once gastroparesis has been confirmed as the major cause of highovernight blood sugars and wide random variations in blood sugarprofiles, we can begin to attempt to control or minimize its effects. Ifyour blood sugar profiles reflect significantgastroparesis, there is noway to get them under control by only juggling doses of insulin.There's just too much danger of either very high or very low bloodsugars for such approaches to work. The only chance for effectivetreatment is to concentrate on improving stomach-emptying.

How do we do this?

We have four basic approaches. First is the use of medications. Sec-

Delayed Stomach-Emptying: Gastroparesis 365

ond is special exercises or massage during and after meals. Third ismeal plan modification utilizing ordinary foods, and fourth is mealplan modification utilizing semiliquid or liquid meals.

It's unusual for a singleapproach to normalize blood sugar profilesfully, so most often we try a combination of these four approaches,adapted to the preferences and needs of the individual. As these attempts start to smooth out blood sugars,we must modify our doses ofinsulin or ISAs accordingly. The guidelinesthat we use to judge the efficacyof a given approach or combination of approaches are these:

• Reduction or elimination of physical complaints such as earlysatiety,nausea, regurgitation, bloating, heartburn, belching, andconstipation

• Elimination of random postprandial hypoglycemia• Elimination of random, unexpectedhigh fastingblood sugars—

probablythe mostcommonsignofgastroparesis that weencounter• Flattening out of blood sugar profiles

Remember that the last three of these improvements may not bepossible even without gastroparesis if you're following conventionaldietary and medication regimens for "control" of your blood sugar.For example, I know of no waythat will truly flatten out blood sugarprofiles if you're on a high-carbohydrate diet and the associated largedoses of insulin.

Medications That Facilitate Stomach-EmptyingThere is no medication that will cure gastroparesis. The only "cure" ismonths or years of normal blood sugars. There are, however, somepharmaceutical preparations that may speed the emptying of yourstomach after a meal if your gastroparesis is only mild or moderate inseverity (page 361, footnote). These will help smooth out your bloodsugar profiles after that meal. Most diabetics with mild to moderategastroparesiswill require medication before every meal.

When gastroparesis is very mild, it may be possibleto get awaywithmedication only before supper. For some reason — perhaps becausemost people tend not to be as physically activeafter supper, and mayhavetheir largestmeal of the day in the evening— digestion of supperappears to be more impaired than that of other meals. It is also likelythat stomach-emptying is slowerin the evening, evenfor nondiabetics.

Medications for gastroparesismay take the form of liquids or pills.The question immediately arisesthat if pillsmust dissolve in the stom-

366 Treatment

ach to become effective, just how effective are they going to be?My experience is that they're of questionable valueunlesschewed. The timerequired for a pill to dissolve in a paretic stomach is likely to belengthy, and consequently the medication may take several hours tobecome effective. I generally prescribe only liquid medications orchewed tablets for stimulating gastric (stomach) emptying.

Cisapride suspension (Propulsid, Janssen Pharmaceutica) stimulates the vagus nerve to facilitate stomach-emptying. I usually prescribe 1 tablespoon (25 mg), 15-30 minutes before meals for adults.Many people will require 2 tablespoons for maximum effect. Largerdoses appear to be of little added value. The manufacturer recommends doses only up to 20 mg (2 teaspoons) for the treatment ofesophageal refluxdisease. This condition is much more responsive totreatment than is diabetic gastroparesis, which as a rule requires thelarger doses. The package insert also recommends a bedtime dose,which serves no purpose for gastroparesis. In many cases, cisapridealone will not bring about completestomach-emptying.We may addother medicationsif blood sugarprofiles don't level off.

Cisapride can inhibit or compete for liver enzymes that clear certain medications from the bloodstream. Your physician should therefore reviewallyour medications,especially antidepressants, antibiotics,and antifungal agents, before prescribing cisapride. Stimulating thevagus nerve will also slowthe heart. Sincediabeticswith gastroparesisusually have an excessively rapid heart rate (more than 80 beats perminute) this is not often a problem. Some individuals, however, havea cardiac conduction defect that abnormally slowsthe heart. For suchpeople,cisapridecanstop the heart, resultingin death.Since, for manyyears, physicians have ignored this bold warning on the package insert, a number of deaths actually have occurred. The product hastherefore been removed from the marketplace in many countries. It isstill available in the United States at no charge as an "investigationaldrug" if prescribed by a gastroenterologist who has been cleared forits use by the investigational review board of his hospital. It is alsoavailable from pharmacies in New Zealand under the trade namePrepulsid (not a misspelling, a different brand name for the sameproduct). It may be purchased via the Internet after searching for Websitescontainingthe words"pharmacy"and "NewZealand." Sucha purchase will not be covered by your insurance (unless you happen to

Delayed Stomach-Emptying. Gastroparesis 367

live in New Zealand), and with shipping charges, it can be expensive.Furthermore, of late, manypharmacies in New Zealand refuse to shipto the United States. Since this agent works by stimulating the vagusnerve, it will not produce results if the nerve is almost dead — as withheart rate variability less than 13percenton an R-R study.

Super Papaya Enzyme Plus has been praisedby many of my patients for its rapid relief of some of the physical symptoms of gastroparesis— bloating and belching, for example. Someclaim that it alsohelps to level off the blood sugarswings caused by gastroparesis. Theproduct consists of pleasant-tasting chewable tablets that contain avarietyof enzymes (papain,amylase, proteases, bromelain,Upase, andcellulase) that digest protein, fat, carbohydrate, and fiber while theyarestillin yourstomach. You would normally chew 3-5 tablets duringand at the end of each meal. The tablets are available in most health

food stores and are marketed by American Health, (631) 567-9500,Ronkonkoma, NY 11779. Theyare alsoavailable from Rosedale Pharmacy, (888) 796-3348. Someof mykosherpatients usea similarproduct called Freeda All Natural Parvenzyme, which is distributed byFreedaVitamins,36 EastForty-firstStreet,NewYork, NY 10017, (800)777-3737, and on the Web at freedavitamins.com. The small amount

of sorbitoland similar sweeteners contained in these productsshouldnot have a significant effect on your blood sugar if consumption islimited to the above dose.

Domperidone (Motilium,Janssen Pharmaceutica) is not yet availablein the UnitedStates. It can be purchasedin Canada,the U.K., andperhaps some other countries. Pharmacies in Canada are no longerpermittedto shipmedications to the United States unless theyareprescribed bya Canadian physician. It therefore may benecessary to purchase it elsewhere viathe Internet.* Since it isnot available asa liquid,weaskpatientsto chew2tablets (10mgeach) 1hour beforemeals andto swallow with 8 ounces of water or diet soda. I limit dosing to 2tablets because largerdoses can cause sexual dysfunction in men andabsence of menses in women. These problems resolve when the drug

*A numberof Canadian pharmacies for an additional charge of $5 can secureprescriptions for distant foreign patientsfromCanadianphysicians. One of theseis Murray Shore Pharmacy, (800) 201-8590.

368 Treatment

is discontinued. Since it works by a mechanism different from those ofthe preceding products, its effects can be additive (that is, useful withother preparations). Janssen maymarketa liquid form of this productin the United States at some time in the future. In the meantime, somegastroenterologists maybe ableto prescribe it, likePropulsid,asan investigationaldrug.

Metoclopramide syrup maypossibly be the most powerfulstimulant of gastricemptying.It worksin a fashionsimilarto domperidone,by inhibiting the effects of dopamine in the stomach. Because it canreadily enter the brain, it can cause serious side effects, such as somnolence,depression, agitation,and neurologicproblems that resembleParkinsonism.These side effects can appear immediatelyin some individuals or only after many months of continuous use in others. Because gastroparesis often requires doses high enough to cause sideeffects, I use this medicationinfrequently and limit dosingto no morethan 2 teaspoons 30 minutes before meals.

If you use metoclopramide, you should keep on hand the antidoteto its side effects — diphenhydramine elixir (Benadrylsyrup). Twotablespoons usually work.Ifside effects become serious enough towarrantuseof theantidote, themetoclopramide should be immediately andpermanentlydiscontinued.

Abrupt discontinuation of metoclopramide has been reported tocause psychotic behavior in two patients after continuous use formore than three months. This information might suggest to yourphysician that it be graduallytapered off if it is to be discontinued after even two months of continuous use.

Erythromycin ethylsuccinate is an antibiotic that has been used totreat infections for many years.It has a chemicalcomposition that resembles the hormone motolin, which stimulates muscular activity inthe stomach. Apparently, when stimulation of the stomach by the vagus nerve is depressed,as with autonomic neuropathy, motolin secretion is diminished. Three papers deliveredto the 1989annual meetingof the American Gastroenterological Association demonstrated thatthis drug can stimulate gastricemptying in patients with gastroparesis. In people without gastroparesis, erythromycin can cause nausea,unless taken after drinking fluids. I ask my patients to drink twoglasses of water or other fluid before each dose. I prescribe erythro-

Delayed Stomach-Emptying: Gastroparesis 369

mycinethylsuccinate oral suspension just beforemeals. Westart with1 teaspoon of the 400 mg/tsp concentration, and increase to severalteaspoons if necessary. As each teaspoon of this suspension contains3.5 grams of sucrose (table sugar), it will be necessary to increaseslightly the dosesof insulin covering mealsto reduceblood sugar elevation while this medication is used. If the liquid is kept in a refrigerator,the tastebeginsto deteriorateafter35days. At room temperature,taste deteriorates after 14 days. I have seen no side effects from thismedication. I insist that patients who use it chronically take 1 probiotic capsule (such as Florastor [saccharomyces boulardii], CulturelleLactobacillus GG, or Nature's Way Primadophilus Reuteri) at least 2hours before or after each dose. This is to restore to the intestine nat

ural bacteria that can be destroyed by this antibiotic. It is also wise toconsume one 150mg fluconazole tablet per month to inhibit growthof fungus in the GI tract or vagina. I have not found erythromycinto be especially effective for treating gastroparesis, despite publishedstudies.

Betaine hydrochloride with pepsin is a potent combination thatcan predigestfood in the stomach by increasing acidityand adding apowerful digestive enzyme. It can be procured at most health foodstores or at Rosedale Pharmacy. Because of its acidity it should not beusedby those with gastritis, esophagitis, or stomach/duodenal ulcers.Food that has been predigestedwillmore likely pass through the narrowedpyloricvalve of gastroparesis. We initially use 1tabletor capsulemidmeal. If no burning is perceived, we increase the dose to 2 andthen eventually3 tablets or capsulesspaced evenlythroughout subsequent meals.It should never be chewed or taken onan empty stomach.Sincebetaine HC1 with pepsin, unlike cisapride, does not attempt tostimulate the vagusnerve, it is frequentlyof value for evenseverecasesof gastroparesis.

Nitric Oxide AgonistsAlthough the aforementioned agents can be veryeffective when gastroparesis is mild, their effectiveness in minimizing blood sugar uncertainty after meals diminishes when this condition is more severe.Myfrustration in trying to circumvent this problem has led to my investigation of a class of substances called nitric oxide agonists. Suchagents are currently being used to relieve effects of angina in patients

370 Treatment

with cardiac disease. Since they work by relaxing the smooth muscle inthe walls of coronary arteries, I assumedthat they could also relax thesmooth muscle of the pyloricvalve.

My initial trial waswith a medication called isosorbide dinitrate. Ihad it prepared asasuspension in almondoil (with flavoring) so that itcouldcoatthe pylorus andwork directiy upon it. I had it compoundedin aconcentrate of5 mg/tsp (1 mg/ml). I waspleased to seethat my assumption proved correct — it was veryeffective fornearlyallofmy patients who used it. Thus far, it appears to be more successful than anyof the agents described above. Nevertheless, it is only partially effectivefor more severe cases of gastroparesis.

This formulation can be prepared by any compounding chemist(see footnote, page 202). The only adverse effect I've observed hasbeen headache in about 10 percent of the users. Although the headache usually resolves after several days of use, I try to prevent it bystartingwith very smalldoses that canthen be gradually increased.

I therefore recommend that initially lh teaspoon be taken 30-60minutes before dinner. After one week, we increase the dose to 1 tea

spoon. If this fails to leveloff blood sugars at bedtime and the following morning, we continue 1 teaspoon for a week and then increase itto 2 teaspoons. If this is not fully effective, we then increase to 3 teaspoons. If this dose doesn't do the trick, I discontinue the treatment, asfurther increases areunlikely to be effective. If 1-3 teaspoonswork, wethen use the same dose 30-60 minutes before each meal. It's been un

usual for this formula to be totallyineffective. The liquid must be vigorously shaken before use.

If you have a cardiac condition, isosorbide dinitrate should not beused for gastroparesis unless approvedby your cardiologist.

Unfortunately, isosorbide dinitrate usually stops working after aperiod of weeks to months. I therefore attempt to increase effectiveness and lower blood sugar levels by applying a chemically similarproduct to the skin direcdy overthe pylorus. What I prescribe is a nitroglycerine skin patch. These are available by prescription at anypharmacy in strengthsof0.1,0.2,0.4, and 0.8 mg. The patch is placedover the pylorus, which is located on the midline of the abdomenabove the navel, about 1V4 inches (37 mm) below the middle of thelowest rib where it forms an invertedV.The patchis applied on arisingin the morning and removed at bedtime. We start with the 0.1 mgpatch and increase the sizeeachweek if there areno adverse effects. Aswith isosorbide dinitrate, nitroglycerine should not be used for gas-

Delayed Stomach-Emptying. Gastroparesis 371

troparesis without your cardiologist's approval if you have a cardiaccondition.

Anotheralternative is the clonidine adhesive skinpatch.Thisproduct is soldas Catapres in allpharmacies to lower bloodpressure andrequires a prescription.It isa powerful smooth musclerelaxant.It can,however, cause somnolence (sleepiness) in some people. We thereforestart at the smallest size (1 mg) for the first weekand increase it to 2mg for the second week, then 3 mg for the third weekand thereafter.Althougheachpatch willwork for a week on most people,we removeit at bedtime and replace it the next morning. Since the patch's adhesiveness willbe reduced after it's removed, you can use paper tape tokeep it attached after the first day. If it causes tiredness, we lower thepatch dosage or discontinue it.

Like the aforementioned nitric oxide agonists, it can stop workingeventually. If it has been effective and stops working,we discontinue itand restart it after a couple of months. Some patients find that a patchwill stop working after 3-4 days. For these people,we change to a newpatch midweek.

The reason we removethe clonidine (or nitroglycerine) patch fromthe skin at bedtime is to slowdown the developmentof tolerance to itsactionwhicheventually occurs. I alsorecommendalternatingdaytimeskin patches— one weekon clonidineand one week on nitroglycerine — alternating over and over.

Exercises That Facilitate Stomach-EmptyingThe pareticstomach maybe described asa flaccid bag,deprivedof therhythmic muscular squeezingpresent in a stomach that has a properlyfunctioning vagus nerve. Any activity that rhythmically compressesthe stomach can crudely replicate normal action. You may perhapshave observed how a brisk walk can relieve that bloated feeling. Ithereforestronglyrecommendbriskwalking for an hour immediatelyafter meals — especiallyafter supper.

A patient of mine learned a trick from her yoga instructor thateliminated the erratic blood sugar swings caused by her moderategastroparesis. The trick is to pull in your belly as far as you can,then push it out all the way. Repeat this with a regular rhythm asmanytimes as you can, immediately aftereachmeal. Over a period ofweeks or months, your abdominal muscles will become stronger andstronger, permitting progressively more repetitions before you tire.Eventually shoot for several hundred repetitions — the more the bet-

372 Treatment

ter. This should require lessthan 4 minutes of your time per hundredreps, a small price to pay for an improvement in your blood sugarprofiles.

Another patient discovered an exercise that I callthe "back flex." Sitor stand while bending backward as far as you can. Then bend forward, about the same amount. Repeat this as many times as you cantolerate.

Although these exercises may sound excessively simple, even silly,they havehelped somepeoplewith gastroparesis.

Mechanical Aids

Hand-held massager. One product of possible value is a variable-speed hand-held massager that can be placed over the stomach (leftside of the abdomen just below yourribs). A 15-30 minute massagemightspeedstomach-emptying. Thisproduct iscalled ProgrammablePercussion Massager withHeat#HF755 and isavailable fromSharperImage Corp., (415) 445-6000 or online at www.sharperimage.com.Usethe largestof the five setsof removable heads.

Chewing Gum Can Make a Big DifferenceTheactof chewing produces saliva, which not onlycontains digestiveenzymes but also stimulates muscular activity in the stomach andtends to relax the pylorus. Orbit is a delicious "sugarless" gum with along-lasting flavor. It contains only 1 gram of sugarper piece and sowill have littleeffect uponyourbloodsugar.* Chewing gumfor at least1hour aftermeals isaveryeffective treatmentof gastroparesis outsideof major dietarychanges. Don't chew one piece afteranother,becausethe grams of sugar can add up.

Meal Plan Modifications, Utilizing Ordinary FoodsMoreoften than not,changes in yourmeal planwill prove moreeffective thanmedication. The problem isthatsuch changes are unacceptable to many patients. We usually proceed from most to leastconvenient in six stages:

*Another worthwhile chewing gumisXlearDent Each piece contains %gramofxylitol, which can kill the bacteria that cause tooth decay. To order it, phone(877) 599-5327, or visit the Web at www.xlear.com.

Delayed Stomach-Emptying: Gastroparesis 373

1. Drinking at leasttwo 8-ounce glasses of sugar-free, caffeine-freefluid while eating,and chewingslowlyand thoroughly

2. Reduction of dietary fiber or first running fiber foods through ablender until nearlyliquid.

3. Virtual elimination of unground red meat, veal,pork, and fowl4. Reduction of protein at supper5. Introduction of four or more small dailymeals, insteadof three

larger meals6. Semiliquid or liquid meals

In the pareticstomach, soluble fiber (gums) and insoluble fiber canform a plugat the very narrowpyloricvalve. This is no problem for thenormal stomach, where the pyloric valve is wide open. Many patientswith mild gastroparesis have reportedbetter relief of fullness and improvedblood sugar profiles after modifying their diets to reduce fibercontent or to renderthe fiber more digestible. This means, forexample,that mashedwell-cookedvegetables must be substituted forsalads, andhigh-fiber laxatives such as those containing psyllium (e.g., Metamu-cil) should be avoided. Acceptable vegetables might include avocado,summer squash,zucchini, or mashed pumpkin (sweetened, if you like,with steviaand flavored with cinnamon). It also means that you wouldhave to give up one of our alternatives to toast at breakfast — brancrackers. You might want to try cheese puffs (page 178) instead.

Most people in the United States like to eat their largest meal in theevening. Furthermore, they usually consume their largest portion ofmeat or other protein food at this time. These habits make control offasting blood sugars very difficult for people with gastroparesis. Apparently animal protein, especially red meat, like fiber, tends to plugup the pylorus if it's in spasm. An easy solution is to move most ofyour animal protein from supperto breakfast and lunch. Many of mypatients have observed remarkable improvements when they do this.We usually suggest a limit of 2 ounces of animal protein, restricted tofish, ground meat, cheese, or eggs, at supper.This is not very much. Yetpeople are usually so pleased with the results that they will continuewith such a regimen indefinitely (of course, as protein is shifted fromone meal to another, doses of premeal insulin or ISA must also beshifted). With a reduction of delayed overnight stomach-emptying,the bedtime dose of longer-acting insulin or ISA may have to be reduced so that fasting blood sugar will not drop too low.

374 Treatment

Some people find that by movingprotein to earlier meals, they increasethe unpredictability of blood sugar after these meals.For such asituation, we suggest, for those who do not use insulin, four or moresmaller meals each day, instead of three larger meals. We try to keepthese meals spaced about 4 hours apart, so that digestion and doses ofISAfor one meal are lesslikelyto overlapthose for the next meal. Thiscan be impractical for those who take preprandial insulin. Remember,you must wait 5 hours after your last shot of preprandial insulin before correcting elevated blood sugars.

Both alcoholand caffeine consumption can slowgastricemptying,as can mint and chocolate. Theseshould therefore be avoided, especially at supper, if gastroparesis is moderate or severe.

Semiliquid or Liquid MealsA last resort for gastroparesis is the use of semiliquidor liquid meals. Isay"lastresort"becausesucha restrictiontakesmuch of the pleasureoutof eating,but it maybe the onlywayto assure near-normal blood sugars.With thisdegree ofbloodsugarimprovement, the gastroparesis mayslowly reverse, as mine did. The restriction can then eventually be removed. In thissection I'll try to give yousomeideas that you can usetocreatemeal plans usingsemiliquid foodsthat still follow our guidelines.

Baby food. Low-carbohydrate vegetables and nearly zero carbohydrate meat, chicken,and eggyolkprotein meals are readily availableasbabyfood.Rememberto read the labels. Also remember that for a typical protein food, 6 grams of protein on the labelcorresponds to about1 ounce of the food itself by weight. To avoid protein malnutrition,youshouldconsume at least 1gramof proteinforevery kilogram (2.2pounds) of ideal body weight. Thus, a slim person weighing 150pounds (68 kilograms) should consume at least 68 grams of proteindaily. This worksout to about 11 ouncesof protein foods. Peoplewhoare still growing or who exercise vigorouslymust consume considerablymore than 1gram per kilogram of idealbodyweight.

When vegetables that only slowly raise blood sugar are ground ormashed, they can raise blood sugar more rapidly. So how can we justify using baby foods? The answer is that we recommend such foodsonly for people whosestomach alreadyempties veryslowly. Thus evenwith babyfood your blood sugarmaystillhavedifficulty keepingpacewith injected regular insulin. Later in this chapter I will show yousome tricks for circumventingthis problem.

Delayed Stomach-Emptying Gastroparesis 375

Below is a brief fist of sometypical babyfoods that can be workedinto the meal-planning guidelines set forth in Chapters10and 11. Donot exceed those guidelines for carbohydrate, sincemost of the Lawsof Small Numbers stillapply, even ifyouhave gastroparesis.

Vegetables Carbohydrate

Beech Nut Green Beans (4.5-ounce jar) 8 gramsBeech Nut GardenVegetables (4.5-ounce jar) 11Heinz Squash (4.5-ounce jar) 8

Meats—Strained Protein

Beef(3-ounce jar) 2.25ouncesChicken (3-ounce jar) 2.25Ham (3-ounce jar) 2.25

Egg Yolks (3-ouncejar) 1.50 (plus 1gramcarbohydrate)

Unflavored whole-milk yogurt. Some brands of whole-milk yogurt, such as Erivan, Brown Cow Farm, or Stonyfield Farm, have noadded sugars or fruits. As noted previously, Erivan is sold at healthfood stores and the other two at supermarkets throughout the UnitedStates. Again, always specify"wholemilk,unflavored." Remember that"low-fat" dairy foods usually contain more carbohydrate than thewhole-milkproduct.

Erivanyogurt contains 11 grams of carbohydrate and 2 ounces protein per 8-ounce container. Stonyfield Farm and Brown Cow Farmboth contain 12 grams carbohydrate and 1.5ounces protein.

Blandfoods likeplain yogurt can be made quite tasty by adding oneof the baking flavor extracts, the powder from truly sugar-freegelatindesserts (i.e., without maltodextrin), Da Vinci sugar-free syrups, orsteviawith cinnamon. The amounts used should suit your taste.

Whole-milk ricotta cheese. Whilenot as Uquid as yogurt or babyfood, ricotta cheese goes down better than solid foods. It can also beput into a blender with some water or cream to render it more liquid.Each 8-ounce serving of ricotta contains about 8 grams of carbohydrate and 2 ounces protein. To my taste, ricotta is a very bland food,but when flavored with cinnamon and stevia, it can be a real treat — ameal that tastes like a dessert.

376 Treatment

Liquid meals. When semiliquid mealsare not fully successful, thelast resort is high-protein, low-carbohydrate Uquid meals. These aresold in health food stores for use by bodybuilders. Only use thosemade from eggwhite proteins or whey, if you wish to be assured of aUthe essential amino acids. Similar products made from soy proteinmay or may not contain these in adequate amounts. Many may contain sterols similar to estrogen.

Possible Last Resorts for Treating GastroparesisOne of my patients claimsthat a cosdynewtreatment has helped considerably both her gastroparesis and her neuropathic pain. It involvesthe appUcation of smallelectriccurrents to acupuncture points on herlimbs and is caUed STS therapy. The electronic device is designatedmodel STS and is manufactured by Dynatronics of Salt Lake City,(800) 432-2924. The instrument costs about $4,000 and the treatmentmust be performed for 45 minutes every day. Its effects begin afterabout 2 months, and it mayactually faciUtate the heaUng of damagednerves. This device should not be used near an insuUn pump or bypeople with implanted electrical devices.

Another costly option iselectrical gastric stimulation.This involvessurgical implantation through the skin of two electrodes that contactthe muscular waU of the stomach.The connectingwiresenter a control box that can be kept in a pocket or on a belt. The control unit canbe set to stimulate the stomach muscles after each meal.

TREATING LOW BLOOD SUGARS WHEN

YOUR STOMACH IS SLOW TO EMPTY

A patient from Indiana with a hiatal hernia once told me, "These Dex-trotabs don't raise my blood sugar one bit. What really works is onestick of that sugar-free chewing gum" (because chewing the gum encourages the stomachto empty a meal that maybe sitting there).

Her commentiUustrates a majorhazardassociated with anycondition that retards stomach-emptying (gastroparesis, ulcers, and so on):treating hypoglycemia rapidlyis nearlyimpossible. Note the qualifier,"nearly." There are sometricksto circumvent the problem.

If your hypoglycemia occurred because your lastmealis stillsitting

Delayed Stomach-Emptying: Gastroparesis 377

in your stomach, you might thereafter try some chewing gum to helpit empty.

Since chewed glucose tablets can take several hours to leave yourstomach, you should suck them or, preferably, try a Uquidglucose solution. Such a product is available as glucose tolerance test beverageunder a number of brand names in the United States. These include

Glucola, Limeondex, Dexicola, and Sun-Dex. The drinks are bottledby manufacturers of clinical laboratory reagents and are stocked inevery hospital lab and private cUnical laboratory. A very convenientversion, calledGlutol, comes in plasticbottles. It is made by PaddockLaboratories, (800) 328-5113, and is alsosold by Rosedale Pharmacy.It contains2.8gramsof glucose per teaspoonand 8.3grams per tablespoon. See Table 20-1 to calculate how much these amounts wiU raiseyour blood sugar.If you don't havea medicinespoon handy and are ina hurry, assumethat one swaUow from the bottle is equivalentto 1 tablespoon.

If you'retraveling and forget to bring alonga bottle of your glucosetolerance test beverage, get some lactose-free milk. This product hasbeen treated with an enzyme that converts the lactose to glucose. Inthe United States, the most widely marketedbrand is Lactaid. Every 4ounces contains 6 grams of glucose. Remember, however, that LactaidwiU spoil after a fewdays if not refrigerated.

Even if you've used the glucose tolerance test drink or Lactaid, youcan speed up the action by chewing gum, by doing the back-flex andstomach exercises described earlier in this chapter, by using a handheld massager, and/or, prior to eating,by using some of the medications mentioned earlier.

MODIFICATIONS OF PREPRANDIAL

INSULIN OR ISA REGIMENS

TO ACCOMMODATE GASTROPARESIS

It takes a while foryourphysician to select and fine-tune a programtoimprove stomach-emptying. In the meantime, it's possible to reducethe frequency and severity of postprandial hypoglycemia. To do this,you must slowthe action of preprandial insulin or ISAto match moreclosely the delayyou experience in digesting your meals. Let's suppose,forexample, that you'U be using preprandial rosiglitazone. Ifyou have

378 Treatment

gastroparesis, your doctor may ask you to take it 10,30, or 45 minutesbefore eating,insteadof the usual60-120 minutes. If you'llbe gettingpreprandial shots of regular insulin,your physician may want you toinject immediately before eating, instead of the usual 45 minutes. Ifregular stiU works too rapidly for your slow digestion, you may beaskedto take it afteryour meal.Alternatively, you might substitute 1ormore units of NPH insuUn for 1 or more units of regular in your syringe, to slow the action. If, for example, you are asked to inject apreprandial mixture containing 4 units of regular and 1unit of NPH,you would draw the 4 units of regular into the syringe in the usualmanner (see pages 255-256). Now insert the needle into the vial ofNPH and shakethe vialand syringetogethervigorously a fewtimes, asillustrated in Figure 16-6. Immediately but carefully draw 1 unit ofNPH into the syringe. Now remove the needle from the vial and drawin about 5 units of air. The exactamount of air is not important. Theair bubble will act a bit like the metal ball in a can of spray paint tohelp mix the insulins. Invert the syringe a fewtimes to permit the airbubble to move back and forth, thereby mixing the two insuUns. (Thisis the only situation in which it is acceptable to mix two different insuUns in the same syringe.)

Now you can inject the contents of the syringe, including the air.The air wiUdissolve in your tissue fluids and cannot do any harm.

If this process confusesyou, don't worry.Your physicianor diabeteseducator should demonstrate it for you and check your technique.

If you use this procedure to slow down your preprandial doseof regular insulin, it'U keep working for an unknown period of timeweU beyond the usual 5 hours. If you routinely correctelevatedbloodsugars with additional shots of Uspro as described on page 301, younow have a real problem. When do you correct an elevated bloodsugar?

The answer is actuaUy simple. Under these conditions, if you addthe NPH to regular beforeevery meal,you are Umited to correcting ahigh blood sugar only once daily—when you arise in the morning.This wiU be about 12hours afteryour suppertime shot of the regular-NPH mixture. Twelve hours is more than enough time for the mixtureto have finished acting.

If you only use the NPH mixture beforedinner, then you may safelycontinue to correct elevatedblood sugars before breakfast and lunch(after waiting the usual 5 hours or more).

Delayed Stomach-Emptying Gastroparesis 379

Do not use lispro to cover meals if you have delayed stomach-emptying. The reasoning here should be self-evident. Feel free, however, to use it to bring down an elevated blood sugar using themethods previously mentioned.

IT MAY BE POSSIBLE TO HEAL THE VAGUS

NERVE EVEN IF BLOOD SUGARS ARE NOT

KEPT VIRTUALLY NORMAL

Remember the insuUn-mimetic antioxidants alpha lipoic acid (ALA)and eveningprimrose oil (EPO)? WeU, studies in the United StatesandGermanyhaveshown them to heal the nervesinvolved in painful diabetic neuropathy of the feet. These studies achieved their results in amatter of months, without anyattempt to control blood sugars. Morerecent brief studies haveactuaUy brought about partial healing of thevagus nerve. The studies that I read, however, utilized very high dosesof one of these agents (25,000 mg of alpha lipoic acid), administeredintravenously.A few naturopathic physicians in the United States andmany in Europe administer such treatment. I'm not set up to do this,but I do ask my patients to take large oral doses of alpha Upoic acidand EPO, asUsted in Chapter 15. Asindicatedin that chapter,I suggestbiotin supplementation whenever alpha lipoic acid is used. The problem here is that at the doses listed on page 241 (1,800 mg ALA daily),the users must take 9-12 daily piUs over and above whatever othermedications or supplements they may be taking. Nevertheless, I continue to prescribe these supplements for those who can afford them inthe hope that vagal healingcan be accelerated, but I don't reaUy expecta miracle.

Asmentioned earUer in this book, many diabeticshave another endocrine disorder, hypothyroidism. Since diminished production ofthyroid hormones can cause neuropathy even in nondiabetics, itwouldbe appropriate for diabetics with neuropathyof the vagusnerve(gastroparesis) to be tested for thyroid insufficiency. If this turns outto be present,the treatment is usuaUy 1piU daily. Aneasy cure for gastroparesis,if it was not causedby high blood sugars.

380 Treatment

THOUGH "CURABLE," GASTROPARESIS

IS SERIOUS BUSINESS

Don't hesitate to use combinations ofthe medications and other treat

ments forgastroparesis thatwe have covered in this chapter. The moremethods you find that wiU work for you,the betterthe likelyoutcome.There is one exceptionto this rule— do notuse both domperidone andmetoclopramide. Use only one or the other, as they both work by thesame mechanism and their potential for adverse effects wiU increasewith the combined dosage.

The effects upon blood sugar of even asymptomatic (symptom-free) delayed stomach-emptying from any cause can be dramatic.Don't think that because you have no symptoms you're free from itseffects upon blood sugar. If you're uncertain, ask your physician toperform an R-R interval study. If you're foUowing the guidelines ofthis book and your blood sugars arestillunpredictable,suggestthat heor she read this chapter.

23

Routine Follow-up Visitsto Your Physician

Taking responsibiUty for the care of yourown diabetes may freeyou from habits thathave beenwith you for manyyears. It alsorequires the estabUshment of new habits, such as exercise and

bloodsugar self-monitoring, thatare easier to abandon than to foUow.Once yourbloodsugars have become controUed, it mayonlytakea

few months for youconveniendy to forget about the pain you usedtohave in your toes, or the parent or friend who lost a legor vision dueto compUcations of diabetes, andsoon.Astime goes on, you wiU findthatwithdiabetes, as withlife in general, youwiU graduaUy tendto dowhat is easiest or most enjoyable at the moment.This backsliding isquite common. When I haven't seen a patient for six months, I'llusuaUy take a meal history and find that some of the basic dietaryguidelines have been forgotten. Concurrendy blood sugar profiles,glycosylated hemoglobin levels, Upid profiles, andeven fibrinogen levels may have deteriorated. Such deterioration can be short-circuitedwhen I see patients every two months. We aU need alittle nudge to getback on track, and it seems that a time frame of about two months

does the trick for most of us. I was not the first diabetologist to observe this, and your physician maylikewise want you to visit him atsimUar intervals.

Dosage requirements for insulin or ISAs may change over time,whether due to weight changes, to deterioration or improvement ofbetaceU output, or just to seasonal temperature changes. So there's anongoing need for readjustment of these medications. Again, two-month intervals are appropriate.

What are someof the things that yourphysician maywant to consider at these foUow-up visits?

382 Treatment

First ofaU, yourdoctorshouldtry to answer anynew questionsthatyoumayhave. These maycover ahostof subjects, from somethingyouread in the newspaper to new physical complaints or dissatisfactionwith your diet. Write down your questions in advance, so that youwon't forget them.

Your physician wiU, ofcourse, want to review yourblood sugar datasheets covering a period of at least two weeks. It makes no sense foryour doctor to review prior data, as that is old history. If he or shewants to adjustyourmedications or mealplan, the changes shouldbebased upon current information. Remember, however, that the datamust be complete and honest. This means, for example, that if youspenta few hoursshopping oroverate, it shouldbenotedon yourdatasheet. It doesn't make sense,and can be dangerous, for your doctor tochange your medications based upon high blood sugars caused by afew unrecorded dietary indiscretions.

Yourphysician wiU also wantto draw someblood.At each visityourHgbAlc (glycated hemoglobin) should be checked. You need not befasting for this test. Up-to-date physicians are now performing thistest in the office using a smaU drop of finger-stick blood. Resultscanbe had in about 6 minutes. At least once annuaUy, a complete lipidprofile including LDL subparticles should be performed, and fibrinogenlevels should be checked; C-reactive protein also should be measured. Kidney function studies including crystatin-c should also beperformed. You'U recaU that these require a 24-hoururine coUection,which must be completedon the day of the visit (see Chapter 2). Remember that the "normal values" for lipid profiles are based uponfasting determinations. Soif yourphysician hasplanned suchtests, tryto book anearly-morning appointment, anddon't eatbreakfast. If youskip breakfast, be sure also to skip your preprandial insulin or ISA ifyou usuaUy usethese medications to cover breakfast. Donot omit glucose tablets or Humalog (Uspro) needed to correct low or elevatedblood sugars. Also remember to take your basal dose of ISA or long-acting insuUn, as their purpose is merely to hold blood sugar levelwhUe fasting. Your physician may also want to perform other bloodtests from time to time, such as a blood count and a chemical profile.If you are takinga statin drug for elevated levels of smaU dense LDL,Uver function tests should be performed.

A partial physical examination, including weight, should be performed every two months. UsuaUy the most important element of

RoutineFollow-up Visitsto Your Physician 383

these visits should be examination of your feet. Such an examinationis not merely to look for injuries, bUsters, or what have you. EquaUyimportant is the discovery of dry skin, athlete's foot, pressure pointsfrom iU-fitting shoes, ingrown or fungus-infected toenaUs, and calluses. Your shoes should also be examined for areas where they havebeen stretchedby prominences on your toes, suggesting that they aresmaUer than your feet. Any of these can cause or may indicate problems that could lead to ulcersof the feet and should be corrected.Dryskin is best treated with daUy appUcations of animal or vegetable oUssuch as vitamin E oU, olive oU,emulsified lanoUn, mink oU,emu oU, or

anyproprietary oU other than mineraloU. The cure foriU-fitting shoesis new shoes (possiblycustom-made) with awide toe box with a deeprise. CaUuses frequendy requirethe purchase of custom orthotics thatredistributethe pressure on the bottoms ofyour feet. Grindingoffcalluses is not the solution, as caUuses are a symptom, not a cause, ofexcess pressure. Their removal is the most common causeof amputations in patients that I seeat my hospital'swound careclinic.

Resting blood pressures, repeated every few minutes until the lowestreading isobtained,are mandatoryateveryvisit ifyourblood pressureis even sUghdy elevated. If yourblood pressure is usuaUy normal,it should be checked everytwelvemonths anyway.

Over the courseof ayear or two, other aspects of physical examination should be performed. The tests need not be done aU at one visit,but may be staggered. These include osciUometric studies ofthe bloodcirculation in your legs, an electrocardiogram, tests for sensation inyour feet, andacompleteeyeexam. The eyeexamshouldincludepupU-laryreflexes, visual acuity, intraocular pressure, the Amslergridtest,atest for double vision,and examination ofyour lenses, anteriorchambers, and retinas through dUated pupUs. This last exam must be performed with certainspecialized equipment that should include directand indirectophthalmoscopes and a slitlamp.If your physician is notso equipped, or ifhe has previouslyfound potentialvision-threateningchanges in your eyes, you shouldbe referred to an ophthalmologistorretinologist.

If your initial physical exam disclosed diabetic complications suchasearlysigns of neuropathy, carpal tunnel syndrome, or Dupuytren'scontractures,examination for these compUcations should be periodi-caUy repeated. The R-R interval study should be repeated every eighteen months, even if it was initiaUy normal.

384 Treatment

The best treatment for the computations of diabetes is prevention.The second best treatment is detection in the very early stages,whuereversal is stillpossible. For theseand the reasons mentioned above, Istronglyrecommendvisits to your physician every two months, or atleast everythree months.

24What You Can Expect from VirtuallyNormal Blood Sugars

I amconvinced frommypersonal experience, from the experiencesof my patients, and from reading the scientific Uterature, thatpeople with normal blood sugars do not develop the long-term

compUcations of diabetes. I am further convinced that diabetics witheven slightly elevated blood glucose profiles may eventuaUy experience someof the long-termconsequences ofdiabetes, but theywiU develop moreslowly andlikely beless severe thanforpeople withhigherblood sugars. In thischapter, I wiU trytodescribe some of thechangesthat I and other physicians have observed when the blood sugars ofour patients dramaticaUy improve.

MENTAL CHANGES

Most common, perhaps, is the feeling of being more alert and nolonger chronicaUy tired. Many people who "feel perfectly fine" beforetheir blood sugars are normalized comment later that they had noidea that they could feelso much better.

Another common occurrence relates to short-term memory. Veryfrequentiy patients or spouses wiU refer to a patient's"terriblememory." When I first began mymedical practice, I would askpatients tophone meat nightwith theirblood sugar dataforfine-tuning ofmedications. My wife, a physician specializing in psychoanalytic medicine,sometimes overheard my end of the conversation and would comment, "Thatperson hasadementia." Weeks later, shewould again hearmy end of a conversation with the same individual, and would comment on the great improvement of short-term memory. This became

386 Treatment

so common that I introduced an objectivetest for short-term memoryinto the neurologic exam that I perform on aU new patients.* Morethan halfmynewpatients indeed display thismUd form of dementia,which appears to Uft after several months of improved blood sugar.The improvement is usuaUy quite apparent to spouses.

DIABETIC NEUROPATHIES

Diabetic neuropathies seemto improve in two phases — a rapid partial improvement that may occur within weeks, foUowed bysustainedveryslow improvement thatgoes on foryears ifbloodsugars continueto remain normal. This is most apparent with numbness or pain in thetoes. Some people wiU even comment, "I knowright away if mybloodsugaris high,because mytoes feel numb again." On the other hand,several patientswith total numbness of their feet have complained ofsevere pain after several months of near-normal blood sugars. Thiscontinues for a number of months and eventuaUy resolves as sensation returns. It is as if nerves generate pain signals whUe they heal or"sprout." The experience may be very frightening and distressing ifyou haven'tbeen warnedthat it might occur.

Erectile dysfunction affects about 60percentof diabetic males, andis the result of years of elevated blood sugars. It may be defined as aninabUity to maintaina rigid enough penUe erection for adequate timeto perform intercourse. It usuaUy results from neuropathy, blockedblood vessels, or both. We can perform simple tests to determinewhichof thesecauses predominates. Whenthe problemis principaUyneurologic, I frequently hearthecomment, sometimes afteronlya fewweeks of near-normal blood sugar profiles, "Hey, I'm able to have intercourse again!" Unfortunately, this turnaround only appears to occur if the man was able to attain at least partial erections before. If atthe original interview, I'm told, "Doc, it'sbeen dead foryears," I knowrecovery isunlikely to occur. Iftesting shows that the problem was dueprimarily to blocked blood vessels, I never see improvement. Note,however, that it's normal to be unable to have erections when bloodsugars are too low, say below 80mg/dl.

* I recite sixdigits (Sam Spade's license number) and ask the patient to repeatthem in reverse order.

What You Can Expectfrom Virtually Normal Blood Sugars 387

Another remarkable change relates to autonomic neuropathy andassociated gastroparesis. I have documented major improvement ofR-R interval studies in many patients, and total normalization in afew. Along with this, we see reduction in signs and symptoms of gastroparesis. UsuaUy such improvement takes place over a period ofyears. Although it occurs most dramaticaUy in younger people, I'vealso seen it occurin seventy-year-olds.

VISUAL IMPROVEMENTS

Diplopia, or double vision, iscaused byneuropathy of the nerves thatactivate themuscles thatmove theeyes. It isavery common finding inthe physical examination thatI perform, but rarely severe enough tobenoticed by patients onaday-to-day basis. Here again, when testingis redone after a few years, we find improvement or even total cureswith blood sugar improvement.

Vacuoles are tiny bubbles in thelens of theeye and are thought tobe precursors ofcataracts. I haveseen a number of these vanish after ayear or two of improved blood sugars. I have even seen thedisappearance of smaU "spokes" on thelens thatsignify very early cataracts.

I've seen mUd cases of glaucoma cured bynormalization of bloodsugars, as weU as retinal hemorrhages, macular edema, and microaneurysms.

OTHER IMPROVEMENTS

Improvements in risk factors forheartdisease, such asmildhypertension, elevated cholesterol/HDL ratios, triglycerides, and fibrinogenlevels, are commonplace. They usuaUy can be observed after abouttwo months of sustained normal or near-normal blood sugars andcontinue to improve for aboutoneyear.

Sinularly, improvements in early changes noted on renal risk profiles are often obtained, usuaUy after one or two years, but sometimesafter a few months.

It has long been known that elevated blood sugars adversely affectgrowth in chUdren and teenagers. As blood sugars approach normal, chUdren with delayed growth rapidly return to theirprediabeticgrowth curves. I,unfortunately, missed this opportunity because I was

388 Treatment

thirty-nine years old when I finaUy figured out how to normalize myblood sugars. I did have, however, the joyofwatching my nondiabeticson and some of my young diabetic patients become giants in comparison to me.

Most dramatic and commonplace is the feeUng of satisfaction andcontrol that nearlyeveryone experiences when they produce normalor nearly normalblood sugar profiles. This is especiaUy true for individualswho had already been takinginsulin,but appears also to occurin those who do not take insulin.

In the late 1970s, the methods of this book were used at the Rocke-feUer University to normalizeblood sugars in a group of type 1 diabetics.They were initiaUy testedby a psychiatrist using the HamUtondepression scale. The starting score for the group was in the "severelydepressed" range. This dropped to normal after the patients becamethe masters of their blood sugars.

Lastbut not least is the feeling that we are not doomed to share thefate ofothers we haveknown, who died prematurelyafteryears ofdis-abUng or painful diabetic complications. We come to reaUze that withthe abiUty to controlour blood sugars comesthe abiUty to preventtheconsequences ofhigh blood sugars.

I have long maintained that diabetics are entided to the same bloodsugars as nondiabetics. But it is up to us to see that we achieve thisgoal.

=== PART THREE

Your Diabetic Cookbook

RECIPES

PageSauces 394

Breakfast Foods 398

Soups 401

Salads 405

Poultry 407

Beef, Lamb, and Veal 411

Pork 416

Seafood 417

Vegetable Entreesand Side Dishes 424

Quiches and Souffles 437

Desserts 439

25

Recipes for LowCarbohydrate Meals

The recipes that foUow are in and of themselveswonderful examples of howyou can eat weU withveryUttle fast-acting carbohydrate.They are, however, not intended asthe end-aU and

be-aU for diabetic nutrition. As you learned in Chapters 9-11, developing a meal plan is at its foundation science, but there is also artinvolved. The science offersyou the metaboUc and nutritional underpinnings ofwhatshould andshould not be in yourmeal plan. The artportion isthe negotiation thathas to take place between youandyourphysician, and between your nutritional needs and your Ufestyle, es-peciaUy your tastes and the time you have to spend in cooking. Youcan do weU with these recipes, but you can also do weU by adjustingthese recipes to your own tastes. The recipes were developed by twoquite talented but different chefs. Karen A. Weinstock, who wrotemost of the newerrecipes in thisbook,isherselfa type 1diabetic. Sheisalso anutritional health care provider. For more than twentyyears,she has taught cooking to individuals, with the goal of maximizinghealth through diet. When she was diagnosed with type 1 diabetesmany years ago, her sense ofhealthy eating went into a tailspin, asherown diet, like that of most Americans — even those who "know

food" — included an excess of refined and fast-acting carbohydrate.After many years of unsuccessfiiUy regulating her own blood sugarlevels, she met me.She says, "This program saved my life by providingme with the necessary guidelines and practical how-tos to livea normal life as a diabetic."

Her goal in creating recipes for this book was to provide the diabetic communitywith deUcious gourmet meals based on our programand her own nutritional expertise. She says, "It is my hope that you

392 Your Diabetic Cookbook

can enjoy both preparing and eating these meals whUe maintaininghealthyblood sugar levels." The recipes she created are identified bythe initials kw at the end. The recipesidentifiedby the initials ta werecreatedbyTimothyJ. Aubert, CWC, for the firstedition of this book.

USING THE RECIPES

AU the recipes are, in one sense, a guide to how you can incorporateinto your diet foods youmaynot have considered eating, and howyoucan use low-carbohydrate foods and protein to arrive at tasty approximations of foods from the high-carbohydrate world.

You can use the recipes exacdy as written and trust that they wiUplaya significant rolein assisting youwithbloodsugarnormalization;or you can playwith them and customize them, to suit your own tastesand dietary guidelines. It is best, however, unless you are a seasonedcookyourself, to try the recipes first astheyarewritten,and then makeadjustments if they seem warranted. Changes in herbs and spices orincluding sUghtiy morewhole-plant vegetables that arelisted in the"SoWhat's Left to Eat?"section in Chapter 10are not likelyto alter bloodsugars significandy, but you should foUow carbohydrate and proteincontent guidelines and check your blood sugars to make sure. If arecipe calls for less carbohydrate than required byyour mealplan,addsome vegetables, salad, bran crackers, et cetera, to the meal to make upthe difference. Referto Chapter 10for some typical suggestions.

If you've flipped straight to these recipes without gaining a goodunderstanding of how to foUow a meal plan, stop and at least readChapters 9-11. Look especiaUy at theboxentided"No-No's in a Nut-shett," on pages 152-153. Then look at the list of vegetables on page151;it's likelythat any vegetable not Usted in that section is not suitably low in fast-acting carbohydrate. Remember that Vi cup of dicedor sUced cookedlow-carbohydrate vegetable (or V4 cup mashed) is approximately equivalent to 6 grams carbohydrate, as is 1cup of mixedsalad. Assume that % cup of whole cookedvegetables is also equivalent to about 6 grams of carbohydrate.

Throughout these recipes the abbreviation cho is used for carbohydrate (cho stands for carbon, hydrogen, and oxygen, the elementsthat make up carbohydrates) and pro for protein. Each recipe showsthe number of servings provided and the approximate grams of carbohydratesand ouncesof protein in eachserving. (Ifyou are adapting

Recipes for Low-Carbohydrate Meals 393

these recipes or creating yourownand consulting food value books,remember our rule of thumb, that to convert grams of protein toounces of a raw protein food, you divide by6.Divide by9 for cookedprotein foods.)

PREPARING POWDERED ARTIFICIAL

SWEETENERS

As you know, thepaper packets containing granulated, so-caUed sugar-free sweeteners usuaUy contain about 96 percent glucose, maltodex-trin, or other sugar, making them inappropriate for diabetics. You canprepare your own granulated sweetener for use in some of the foUowing recipes by crushing or grinding aspartame or saccharin tablets(not packets) in one of the foUowing ways:

• in a mortar and pesde• betweentwo spoons• in a pepper miU• in a smaU electric coffee grinder

You can also dissolve the crushed tablets in a smaU amount of hotwater (unless the recipe caUs for powdered sweetener).

Aspartame (but not saccharin) wiU lose its taste if added to food before cooking, soit must beused only after cooking. You may prefer touse stevia, since it is sold as powder or liquid and is not degraded byheat. Make surethat youonlypurchase powdered stevia that does notcontain maltodextrin.

SUBSTITUTIONS

A number of these recipes include bran crackers. Some have beenwritten for Wasa Fiber Rye crackers (5 grams carbohydrate each),some for Bran-a-Crisp crackers (4 grams carbohydrate each), andothers for G/G Scandinavian Bran Crispbread (3 grams carbohydrateeach). Although these crackers are simUar in texture, they vary incarbohydrate value. Make theproper food count adjustment ifyou shouldswap Wasa, say,for G/G.

Just because you're diabetic doesn't mean you can'teatweU. In fact,you are likely toeatbetter than theaverage person who husties abagel

394 Your Diabetic Cookbook

or donut for breakfast, scrounges fast foodfor lunch, then doeswhatever for dinner.

So bon app&it, salut,and enjoy.

MORE RECIPES

My book The Diabetes Diet, also pubUshed by Littie, Brown, has ahundred newlow-carbohydrate recipes for breakfast, lunch, and dinner designed specificaUy forbloodsugarnormalization.

SAUCES

ITALIAN-STYLE RED SAUCE

6 servings, about Vi cup each Perserving: 5.6 gm cho, <0.5 0Z PRO

CHO(gm) PRO (gm)

3 cups diced red beU peppers 27.6 3.6

1Tbsp oliveoU — —

Va cup chopped freshbasU 0.4 0.2

2 cloves garlic, minced 2.0 0.4

1 cup CoUege Inn chicken broth — 1.0

Vi cup heavycream 2.2 1.6

Vi tsp salt — —

Vs tsp black pepper — —

l/i tsp dried oregano 1.0 0.2

l/i tsp steviapowder (1 packet) — —

2 Tbsp gratedParmesan cheese 0.4 4.2

Inasaucepan, bring aquart ofwater toaboU. Add diced peppers, cover,and simmer for 20 minutes. Drain Uquid from peppers by pouringthrough acolander. Add peppers tofood processorworkbowl andpureefor 2-3 minutes. The finished texture of the puree wiU contain somepulp. Heat oUve oU inasaucepan over a low flame. Add basU andgarUc.Saute" on a low flame until the aroma is released, 3-4 minutes. Stir in thepepper puree, chicken broth, andheavy cream. WhUe stirring, add remaining seasonings except forgrated cheese. Simmer the sauce uncovered for 40minutes. Addgratedcheese to sauce justbeforeserving.

This recipe yields about 3 cupsof sauce.Thissauce canbeused in manyrecipes that caU fora redsauce, such

as meatioaf or stuffedcabbage. It wiU keep in the refrigeratorfor 4-5days. It may bestored in thefreezer for2-3 months, kw

Recipesfor Low-CarbohydrateMeals 395

RED PEPPER COCKTAIL SAUCE

16servings, about 1 Tbsp each Perserving: 1.2 gm cho, <0.1 OZPRO

CHOfem) PRO(gm)

2 cups diced red beU pepper 18.4 2.4

lA tsp salt — —

Vi tsp steviapowder (1 packet) — —

2 tsp white horseradish — —

1 Tbsp Worcestershire sauce 1.0 —

1 Tbsp cider vinegar — —

Hot sauce to taste — —

In a saucepan,bring a quart of water to a boU. Add diced red pepperand cover the pot. Reduceheat to a simmer and cook for 15 minutes.Drain water from peppers and put them into a blender.Blendpeppersto a pureed consistency. Pour puree into a glass bowl and refrigeratefor 30 minutes.Remove the chiUed pepper puree from the refrigerator.Add the salt and stevia to the puree and combine. A whisk is helpfulhere. Add horseradish, Worcestershire sauce, vinegar, and hot sauce.Serve this sauce with chiUed shrimp or other seafood. This recipeyields 1 cup of cocktaU sauce.

The saucewiU keep in the refrigerator for 2-3 days in a glass jar. Itmay be stored in the freezer for 2-3 months, kw

RUSSIAN DRESSING24 servings, 1 Tbsp each Per serving: <1gm cho, <0.1 oz pro

CHO (gm) PRO (gm)

1Vi cups diced red beU pepper 13.8 1.8% cup mayonnaise — —1 Tbsp canola oU — —1 tsp Worcestershire sauce 0.3 —Vi tsp stevia powder (1 packet) — —Va tsp black pepper — —2 Tbsp diced sour diU pickle 0.5 —

In a saucepan,bring 1 quart ofwater to a boU. Add peppers and cover.Reduce heat to simmerfor 10minutes. Drainpeppers in a colanderanddiscardcookingUquid. Addpeppers to the workbowl of a food processor.Chop for 2-3 minutes.The consistencyshould be smooth, but someof the fiber wiU remain. Add the mayonnaise, oU, and Worcestershiresauce. Blend together for a moment. Add the stevia and black pepperand blend again. Scrape mixture from the workbowl into a glassbowl.Fold in diced pickle. This dressing wiU keep in the refrigerator for10-14 days. (Don't try to freeze.) Store in an airtight container, kw

396 Your Diabetic Cookbook

DIJON MUSTARD BUTTER

12servings, 2 Tbsp each Per serving: (17gm cho, <0.1 OZPRO

CHO(gm) PRO(gm)

2 Tbsp minced shaUots 3.4 0.6

\lAcups {2l/isticks) butter, softened — 2.5

3 Tbsp Dijon mustard 3.0 —

1 tsp lemon juice 0.43 0.03

1 Tbsp Worcestershire sauce 1.0 —

Tabasco sauce to taste 0.5 —

SauteshaUots in 1teaspoonof the butter.In a food processor, combineshaUots with aU other ingredients until smooth. Place on parchmentpaper or on plasticwrap. RoU butter in the paper or wrap until youhave a 1-inch-diameter cylinder. Refrigerate until butter is needed.Slice into V4-inch pieces to use (3 sUces = 1 tablespoon), ta

LEMON BUTTER

4 servings, 2 Tbsp each Per serving: 0.7gm cho, <0.1 ozproCHO (gm) PRO(gm)

Vi cup (1 stick) unsalted butter, softened — 1.02 Tbsp lemon juice 2.6 0.2Salt and white pepper to taste — —

In a food processor,combine aU ingredients until smooth. RoU butterinto a 1-inch-diameter cylinder as directed for Dijon Mustard Butter,above, and refrigerate untU needed. SUce into V4-inch pieces to use(3 sUces = 1 tablespoon), ta

LEMON PEPPER BUTTER4 servings, 2 Tbsp each Per serving: 0.7gm cho, <0.1 ozpro

CHO (gm) PRO (gm)

Vi cup (1 stick) butter, softened — 1.02 Tbsp lemon juice 2.6 0.2Vs tsp salt — —Ys tsp white pepper — —Lemon pepper seasoning, to taste — —

In a food processor,combine aU ingredients until smooth. RoU butterinto a 1-inch-diameter cylinderas directed for Dijon Mustard Butter,above, and refrigerate until needed. SUce into V4-inch pieces to use(3 sUces = 1 tablespoon), ta

Recipesfor Low-Carbohydrate Meals 397

GINGER SCALLION BUTTER

12 servings, 2 Tbspeach Perserving: 0.5 gm cho, <0.1 OZPRO

CHO(gm) PRO(gm)

Wa cups {2Vi sticks) butter, softened — 2.5

4 minced scaUions 1.85 0.45

Va tsp minced garUc 0.5 0.08

Vi tsp minced freshginger 0.15 0.01

1 Tbsp minced parsley 0.6 0.3

1 Tbsp soy sauce 2.0 2.0

1 Tbsp lemon juice 1.3 0.1

In a food processor, combine aU ingredients until smooth. RoU butterinto a 1-inch-diametercylinder as directedfor Dijon Mustard Butter,above, and refrigerate until needed. Slice into V4-inch pieces to use (3sUces = 1 tablespoon), ta

TARRAGON BUTTER

12servings, 2 Tbsp each Per serving: 1.7gm cho, <0.5 oz pro

Ya cup white wine1 bay leaf7 black peppercorns, crushed3 Tbsp tarragon vinegar2 Tbsp minced shaUots1 cup heavy creamVa cup (IVz sticks) butter, softenedV4 tsp chopped fresh tarragonPinch salt and white pepper — —

Combine wine, bayleaf, crushedpeppercorns, vinegar, and shaUots ina nonreactive pan. Bring to a boU and reduce to about 2 tablespoons.Strain, removing bayleafand crushed peppercorns. Reduce creambyhalfin a separate pan and add to thewine reduction. GraduaUy whiskin the butter over low heat. When aU the butter is dissolved, add thechopped fresh tarragon and seasonto taste,ta

SPICY MUSTARD SAUCE16servings, 2 Tbsp each Per serving: 2.3gm cho, <0.5oz pro

CHO (gm) PRO (gm)V2 cup minced shaUots 19.2 2.8Va cup cider vinegar — —1 tsp black peppercorns, cracked 1.4 0.2

IO(gm) PRO(gm)

7.2 0.6

0.3 0.1

0.7 0.1

4.8 0.7

6.6 4.9

— 1.5

0.8 0.4

398 Your Diabetic Cookbook

1 bay leaf 0.3 0.1

1 cup dry white wine 9.6 —

1 cup heavycream 6.6 4.9

Wicups (3 sticks) unsaltedbutter, softened — 3.0

Dijon-style mustard to taste — —

Creolemustard (or any other spicymustard)to taste — —

Combine the first 5 ingredients in a smaU nonreactive saucepan andreduce to Vi cup.Add heavy cream and reduce mixture by half.Strainand return to the stove. Cut softenedbutter into smaU piecesand slowlyadd to the sauce whUe whisking. After aU the butter is incorporated,add the mustard to taste, ta

BREAKFAST FOODS

Breakfast is the meal where you mayfindyou miss carbohydrate the most. No more home fries or hash browns, toast,pancakes, French toast, waffles, cereals, and the like. Therecipe suggestions that follow can put some zip back intobreakfast while keeping carbohydrates waydown.

MUSHROOM OMELET WITH BACON1 serving Perserving: 3.1 gm cho, 2.8 oz pro

CHO (gm) PRO (gm)

2 sUces bacon — 4.0

1 fresh mushroom, sUced 1.5 0.35Butter to taste — —

2 eggs 1.2 12.01 Tbsp heavy cream 0.4 0.3Salt and black pepper to taste — —

Pan-fry bacon and removeto paper towelto drain. Saute" sUced mushroom in butter for 2-3 minutes. In a smaU bowl, mix eggswith cream,then add to mushrooms. Cook eggs without stirring for 2 minutes, oruntil desired firmness. Season with salt and pepper to taste. RoU orfold omelet and turn out on a plate.Servewith the bacon, ta

Recipesfor Low-Carbohydrate Meals 399

SCRAMBLED EGGS WITH ONIONS, PEPPERS,

AND STRIPPLES1 serving Perserving5.3gm cho, 2.4 ozpro

CHO (gm) PRO (gm)

2 sUces Stripples (soybacon) 2.0 2.02 eggs 1.2 12.01 Tbsp cream 0.4 0.3Butter to taste — —

1 Tbsp minced onion 0.9 0.31Tbsp minced green beU pepper 0.8 —Saltand black pepper to taste — —

Microwave Stripples and set aside. Combine eggs and cream thoroughly in a smattbowl.Heat butter in saute" pan, add eggs, and cookfor 1 minute. Add minced onion and green pepper. Seasonwith saltand pepper to taste and cook to desired consistency, ta

HAM AND CHEESE OMELET

1 serving Perserving. 3•6gm CHO, 6 oz PRO

CHO(gm) PRO(gm)

2 eggs 1.2 12.0

1Tbsp cream 0.4 0.3

Butter to taste — —

1 sUce (2 oz) ham, diced or juUenned — 18.0

2 oz cheese, grated or sUced thin 2.0 12.0

Saltand black pepper to taste — —

Mix together eggsand cream in a smaU bowl.Heat butter in saute" panand cook egg mixture 1-2 minutes without stirring. Place ham andcheese on top and season to taste with salt and pepper. Either roU orfoldthe eggs and cookto desired consistency, ta

SAUSAGE AND EGG OR HAM AND EGG

OPEN SANDWICHThis recipewasdeveloped byAmyZ. Kornfeld and Hank Kornfeld.

J serving Perserving: 8 gm cho, 5 ozproCHO (gm) PRO (gm)

2 sausage patties, 1 oz each, or2 slices ham, turkey,or salami — 12.0

1 Tbsp butter or 1 tsp vegetable oU — —2 eggs 1.2 12.0

400 Your Diabetic Cookbook

2 G/G crispbreads 6.0 2.02 slices cheese (about Va ounce total) 0.8 4.0

Brownsausage,ham, turkey,or salamiand drain off fat. Keep warm in250°F oven. Heat butter or oU in a nonstick skiUet until water dropssprinkled on surface skitter across. Breakeggs into pan. Fry eggs for2-3 minutes over medium heat. If desired, flip them over and fry foranother minute or so.Put crispbreads on an ovenproofplate and placeeggs on top. Cover with sausage, ham, turkey, or salami, and top offwith cheese. Warm brieflyin oven to melt cheese, ta

FRENCH BRAN TOASTThis is another recipe from AmyZ. Kornfeldand Hank Kornfeld.

1 serving Perserving: 9 gm cho, 1.4oz proCHO (gm) PRO (gm)

2 Bran-a-Crisp crackers 8.0 2.02 tsp water — —1 eggor eggsubstitute 0.6 6.0Va tsp cinnamon — —V% tsp nutmeg — —Vs tsp vaniUa extract — —Artificial maple or fruit-flavored baking

extract, to taste — —

1 Tbsp cream 0.4 0.31 tsp vegetable oU — —Melted butter to taste — —

1 or more ground or crushed Equal tablets,or a pinch of stevia powder — —

Soakcrackersin 2 teaspoonswater for 5 minutes, or just long enoughto soften. MeanwhUe, in a broad shaUow bowl beat eggor eggsubstitute with cinnamon, nutmeg, vaniUa, and other flavor extract. Add1Tbsp creamand beat gendy. Place softenedwafers in egg mixture for1-2 minutes. Heat nonstick skiUet until water droplets sprinkled onsurface skitter across. Add oU to skiUet and spread it around with afolded paper towel. Place egg-soaked wafers in pan and cook overmedium heat for about 3 minutes per side.When done remove frompan and pour on melted butter, or sprinkle to taste with the groundEqual tablets or steviapowder.

Recipesfor Low-Carbohydrate Meals 401

PANCAKESAmyZ. Kornfeldand Hank Kornfeld alsosuggested

this substitute for traditional pancakes.1 serving Perserving: 7 gm cho, 1.4ozpro

CHO (gm) PRO (gm)

2 G/G crispbreads 6.0 2.01 egg,beaten 0.6 6.0Vs tsp nutmeg — —Va tsp cinnamon — —Vz tsp vaniUa extract — —Artificial vaniUa, orange,or almond baking

extract, to taste — —

1 Tbsp cream 0.4 0.31 tsp vegetable oU — —Melted butter to taste — —

1 or more Equal tablets, ground, or pinchstevia powder — —

Grindcrispbreads in blender, food processor, or electric coffee grinderto a flourUke consistency. Combine egg, nutmeg, cinnamon, vaniUa,baking extract, and cream in bowl. Add ground crispbreads and mix.HeatnonstickskiUet. Whenhot, add oil to skiUet and spreadit aroundwith a paper towel. Add one-quarter of batter to skiUet. Cook for2 minutes. Turn carefuUy and cook other side for another 2 minutes,to producefirstpancake. Repeat 3 timesto produce3 more pancakes.Cover with melted butter. Sprinkle pancakes with ground Equal orstevia powder.

SOUPS

ACORN SQUASH BISQUE4 servings, about 1 cupeach Per serving: 8 gm cho, <0.5 oz pro

CHO (gm) PRO (gm)

1smaU (1 lb) acorn squash (seeNote) 21.4 1.61 Tbsp butter — —2 stalkscelery, thinly sUced diagonaUy

(set aside leaves for garnish) 3.0 0.61smattleek, cleanedand thinly sUced

diagonaUy 4.0 0.4Vi tsp salt — —Vi cup heavycream 3.3 2.5

402 Your Diabetic Cookbook

V/a cups water — —Va tsp cinnamon 0.4 —

Quarter the acorn squashand scrapeout the seeds. Usesome cautionwhen cutting the squash — the skin can be tough and the flesh isdense,so work your knife in graduaUy as you cut.

In a largesaucepan,bring 5 cups of water to a boU. Add squash andsimmer until tender,about 15minutes.Drain liquid from squash andaUow to cool. Scoop pulp from the outer peel into the workbowl ofyour food processor. Discard peel. Puree cooked squash in the foodprocessor untU liquefied. This should yield about 1 cup of squashpuree (anymore wiU increase the carbohydrate count).

In the same saucepan, add butter and saute* celeryand leeks withsalt for 5-7 minutes, or until wUted. Addsquashpuree,heavy cream,and water and stir weU. Heat on a low flame for 10 minutes. Stir in cin

namon, garnish with the fresh celery leaves, and serve warm. Thebisque wiU keep in the refrigeratorfor 2-3 days.It maybe stored in thefreezer fori month.

This is a recipe that, because of its texture, can be fairly easfly digested by those who sufferfrom gastroparesis.

NoteAcorn squash has a wonderful flavor, verycloseto sweetpotatoes, with lots ofcarotenoids but with considerablylessfast-actingcarbohydrate.Youcan substitute canned pumpkin for the squash, but be sure to read food labels andensure that what you buy doesn't haveadded sugar (it doesn't as long as theonly ingredient is pumpkin), kw

CUCUMBER SOUP4 servings, about3A cupeach Perserving: 3.9gm cho, <0.5 oz pro

CHO (gm) PRO (gm)1 whole cucumber, peeled and sUcedVi cup chopped fennel1 Tbsp whole-milk yogurtVi cup cold water — —Vi tsp fresh diU — —Lemon pepper seasoning to taste — —

In a blender combine sliced cucumber, fennel, yogurt, water, anddiU. Puree untU smooth, season with lemon pepper seasoning, andserve, ta

8.3 2.1

6.3 1.1

0.75 0.75

Recipes for Low-Carbohydrate Meals 403

ZUCCHINI SOUP3 servings, about1¥i cups each Per serving: 3.2gm cho, <0.5oz pro

CHO (gm) PRO (gm)4 medium zucchini, cleaned and sliced 4.0 3.51lh Tbsp chopped onion 1.35 0.151 Tbsp butter — 0.13 Tbsp hot water — —1 cube Knorr's chicken bouiUon, crushed 2.0 0.8Salt, blackpepper,and garUc powderto taste — —xh cup heavycream 2.2 1.63

In a 2-quart pan, saute zucchini and onion in butter until tender.Transfer vegetables to a blenderand puree.Addhot waterwith crushedbouiUon cube; blend for 1-2 minutes. Season with salt, pepper, andgarUc powder to taste. Serve hot or cold. Add cream to individual portions, about 2 tablespoonsper serving, ta

CHICKEN EGG-DROP SOUP WITH SCALLIONS

4 servings Per serving: 3.5gm cho, 2.3 oz proCHO(gm) PRO (gm)

2 large eggs 1.2 12.4

4 cups CoUege Inn chicken broth — 4.0

Vi cup finely chopped scaUions 3.7 0.9

6 oz cooked chicken breast fiUet, shredded(see Note 1) — 54.0

1 Tbsp soy sauce 2.0 2.0

1 Tbsp arrowroot powder (see Note 2) 7.0 —

2 Tbsp cold water — —

In a mixing bowl, crackopen eggs and whisk togetherwith Vi cup ofthe chicken broth. Place this mixture in the refrigerator. Place the remaining 3Vi cups chicken broth in a saucepan. Bring liquid to a lowboU. Add scaUions, shredded chicken, and soysauce. Reduce heat andsimmer 3-5 minutes. Remove egg mixture from the refrigerator.Slowly add egg mixtureto the soup, while stirringthe soup constantly.As you stir in the egg, it wiU feather out and thicken. Dissolve arrowroot powder in coldwaterin a smaU bowl. Stirthisinto the soup.Cookfor3-5 minutes witha lid. Serve warm. This recipe wiU keep in the refrigerator for 4-5 days. It may also be stored in the freezer for 2-3months.

404 Your Diabetic Cookbook

Notes

1. Leftovercooked chickenworksbest for this recipe. It is easiest to shredchickenwhen it is cold,usinga fork or tongs.

2. Arrowroot powder (alsocalled arrowroot flour) is a thickening agentused like cornstarch. It must be dissolved in a small amount of cold water be

fore being added to warm ingredients, kw

SEAFOOD CHOWDER TRIO

6 servings Perserving: 2.9 gm CHO, 2.8 OZ PRO

CHO (gm) PRO (gm)

Vi lb shrimp in their sheUs 0 31.6

3 cups water — —

2 Tbsp butter — —

Vi cup thinly slicedbutton mushrooms 4.0 1.7

1 stalk celery, diced 1.5 0.3

Vi tsp dried tarragon 0.4 —

1bay leaf — —

1 tsp salt — —

Vi tsp black pepper — —

Vi lb scrod, cod, or other firm white fish — 40.4

Vi cup heavycream 3.3 2.4

Vi cup dry white wine 4.8 —

Vi lb bay scaUops 3.6 25.3

To clean shrimp, rinse in a colander under cold running water. Remove sheUs and set them aside.They wiU be used for the soup stock.Remove the vein along the back and discard it. Cut shrimp into smaUbite-sizedpieces and set aside. Place sheUs in a saucepanwith 3 cups ofwater. Bringto a boU and simmerfor 10minutes. Strainout sheUs andreturn stock to saucepan. In a skiUet, heat butter on a low flame. Addmushrooms, celery, tarragon, bayleaf, salt, and blackpepper. Saute" for3-5 minutes. MeanwhUe, add scrod, heavycream, and white wine tothe seafood stock.Add the cooked vegetables from the skiUet. Turn onheat under saucepan and bring chowderto a low boU. The scrod wiUfaU apart asit cooks, sothereisno needto cut it. Reduce heatand simmer covered for 15 minutes. Add scaUops and shrimp to chowder.Cook for 3-5 minutes. Remove bay leaf, adjust seasoning, and servewarm.

The chowder wiU keep in the refrigeratorfor 3-4 days. It may alsobe stored in the freezer for 1 month, kw

Recipesfor Low-Carbohydrate Meals 405

SALADS

CURRIED CHICKEN SALAD WITH JICAMA

4 servings Perserving: 3 gm CHO, 4 OZPRO

CHO (gm) PRO(gm)

1 lb chicken breasts, boned and skinned — 96.0

1 stalk celery, diced 1.5 0.3

Vi cup coarselygrated jicama (see Note) 5.3 0.4

Vi cup diced green beU pepper 4.6 0.6

3 Tbsp cider vinegar — —

3 Tbsp mayonnaise — —

Vi tsp salt — —

Vi tsp black pepper — —

Va tsp stevia powder (Vi packet) — —

Vi tsp curry powder 0.6 0.1

To cookchicken breasts, steamthem until tender and no longer pinkinside, 12-15 minutes.AUow to coolbefore sUcing. Cut chicken breastsinto bite-sized chunks.

In a medium-sizedglass mixingbowl, combine chicken and celery,jicama,and green pepper.Addvinegarand mayonnaise and mix thoroughly. Add salt, pepper, stevia, and curry power to chicken salad.Blendin aU seasoning by evenly coatingthe ingredients. Serve chiUedor at room temperature.

Note

If you're not famttiar with jicama, it has brown skin like a potato and isshaped something likea turnip. Its flesh hasa pleasing crunch,almostlikeacrisp apple. When purchasing jicama, which is available these days in mostsupermarkets, makesure the skinis firmwithoutbruises. The smaU variety,about the sizeof an orange, is the best for its taste and texture, kw

ROASTED EGGPLANT SUMMER SALAD4 servings Perserving: 9.4gm cho, 0.5 oz pro

CHO (gm) PRO (gm)1 eggplant,about Wa lb, peeledand cut

into lV^-inch cubes 27.8 4.67% tsp salt — —5 Tbsp olive oU — —Va tsp dried oregano 0.2 —2 clovesgarUc, minced 2.0 0.2Va tsp black pepper — —1 oz {Va cup) crumbled feta cheese 1.0 5.0

406 YourDiabetic Cookbook

2 Tbsp lemon juice 2.6 0.21 small head of Boston lettuce, washed,

dried,and Ughtiy shredded 3.8 2.1

Preheat oven to 425°F. Rub eggplant chunks with salt and aUow tostand for 10minutes.With a papertowel,patdry any surface moisture(this helpsto removethe bitter taste). In alarge mixing bowl, combinethe eggplant, 4 Tbsp olive oU (set aside 1Tbsp olive oU for final seasoning), oregano, garUc, andblack pepper. Mix thoroughly and placein a 9 x 13 bakingdish. Bake uncovered for 45minutes.Remove fromoven and aUow to cool. Sprinkle with feta cheese, lemon juice, and 1Tbsp oUve oU beforeserving on abed of Bostonlettuce.

Serve chiUedor at room temperature, kw

MARINATED CUCUMBER SALAD WITH FRESH DILL

4 servings Per serving. 2.6gm cho, <0.5oz proCHO (gm) PRO(gm)

4 picklingcucumbers, sliced intoy3-inch rounds 5.6 1.6

2 stalkscelery, sUced in thin crescents 3.0 0.6

2 Tbsp diced red onion 1.8 0.6

1Tbsp fresh diU, chopped,or 1tsp dried diU 0.1 1.0

Vi tsp salt —

—

Vi tsp stevia powder(1 packet) — —

3 Tbsp cider vinegar — —

In a large glass mixing bowl, combine cucumbers, celery, onion, anddiU. To preserve the crunchiness of the vegetables, Ughtiy mix the salt,stevia, and vinegar into them (aheavyhand whfle mixing wiU tend tosoften the vegetables). Cover the salad and refrigerate for aminimumof 30 minutes beforeserving. The longer it marinates the more "pickled" the flavor. Store the salad in the liquid to maintain its freshness. ItwiU keep in the refrigerator for 3-4 days in an airtight container, kw

GREEN CABBAGE COLE SLAW WITH LEMON ZEST

4 servings Per serving: 5.8gm cho, <0.5 ozproCHO (gm) PRO (gm)

4 cups shredded green cabbage 15.2 4.0Vi cup dicedgreen beU pepper 4.6 0.6Vi cup coarsely chopped flat-leaf parsley 1.9 0.9Vi tsp salt — —Vi tsp grated lemon zest (see Note) — —

Recipes for Low-Carbohydrate Meals 407

Va tsp black pepper — —Vi tsp celery seeds 0.4 0.24 Tbsp cider vinegar — —2 heapingTbsp mayonnaise 1.0 —

In a large glass mixing bowl, combine cabbage, green pepper, andparsley. Add the salt. Work it intothefiber of thevegetables. Thesalt,as it dissolves and mixes with the greens, wiU drawmoisturefrom thevegetables. Add to theslaw thelemon zest, black pepper, celery seeds,andvinegar, then the mayonnaise. Mix thoroughly.

AUow thecole slaw tostand about 30 minutes in therefrigerator before serving. It wiU keep in the refrigerator for 4-5 days in anairtightcontainer.

Note

Lemon zest is the fragrant outer yeUow part of the lemon peel. Don'tgratebelow to the bitter,pulpywhite, kw

POULTRY

GROUND TURKEY BURGERS WITH MARJORAM4 servings Per serving: 3.3gm CHO, 5 OZ PRO

CHOfem) PRO(gm)1oz (Va cup) grated cheddar cheese 1.0 7.0Vi cup chopped scaUions 3.7 0.9

Vi cup dicedgreen beU pepper 4.6 0.6

2 Tbsp mincedelephantgarlic (see Note) 2.0 —

iegg 0.6 6.2

1 Tbsp olive ofl — —

1 tsp dried marjoram 0.4 0.1xh tsp salt — —

Va tsp blackpepper 0.9 —

1 lb ground turkey — 105

Ina smaU glass mixing bowl, combine cheese, scaUions, green pepper,and garlic. Inaseparate, large mixing bowl, Ughtiy whisk together egg,oU, andseasonings. Stir thevegetable mixture into theeggs, thenaddtheground turkey. Mix evenly andform into 4 thick patties. Handlethe uncooked burgers delicately. At first theywiU seem fragfle, buttheywiU bind nicelyonce they start to cook.

Heat up a large cast iron skiUet. Add oU and coat the bottom of theskiUet, then place the patties in the skiUet. Do not cover the skiUet.

408 Your Diabetic Cookbook

Start your cooking over medium-high heat, and after a few minutesreduce to medium low. Cook for 12-15 minutes on the first side, thenflip gently and cookanother 12-15minutes (you don't need to raiseheat when you turn the patties). When burgers are done they wiU befirm to the touch. Checkfor doneness by cutting into the center of aburger with a paring knife. Theyshould look evenly cooked, and theinside color should be white, not pink. These burgers can be servedon a bed of lettuce with sliced cucumber and your favorite low-/no-carbohydrate condiment.

Note

Elephant garlic is usuaUy available in natural food stores. Ifyoucan't findit,an equivalent amount of conventional garUc or shaUots maybe substitutedwithout significandy altering foodcount, kw

TURKEY MELT2 servings Per serving: 4.5gm cho, 1.8oz pro

CHO (gm) PRO (gm)

2 G/G crispbreads 6.0 2.02 slices cookedturkey, 1 oz each — 18.02 slices Stripples(soybacon),cooked 2.0 2.02 slices cheese, xh oz each 1.0 6.0

Place G/Gcrispbreads in a smaU brofler pan and layturkeyand cookedStripples on top. Cover with cheese. Place in a 325°F oven or toasteroven untUcheese is thoroughlymelted.Serve hot. ta

IALAPENO CHICKEN WITH BROCCOLI

AND IACK CHEESE4 servings Perserving: 5.2 gm cho, 5 oz pro

CHO(gm) PRO(gm)

1 Tbsp cream of tartar 1.8 —

2 Tbsp cold water — —

2 Tbsp oUve oU — —

2 Tbsp diced jalapeno pepper 2.0 —

lh cup diced red beU pepper 4.6 0.6

2 Tbsp minced shaUots 3.4 0.6

3 chicken breast cudets, 6 oz each,cut into thin strips — 108.0

Va tsp ground cumin 0.2 0.1

Vi tsp salt — —

Recipes for Low-Carbohydrate Meals 409

1 cup broccoU florets 7.8 6.41oz (Va cup) grated Monterey Jack cheese 1.0 6.0

In a small bowl, dissolve cream of tartar into cold water and set aside.Heatofl in a skiUet overalow flame and saute* jalapeno pepper, redbeUpepper, and shaUots. Stir ingredients and cook for 2-3 minutes. Addchicken strips, cumin, and salt. Cover and cook for 5-7 minutes. Adddissolved cream oftartar to the chicken mixture, stirring asit thickens.Add broccoU florets and cook 3-4 minutes. Remove the skiUet fromthe flame. Sprinklewith grated cheese and serve warm, kw

GRILLED CHICKEN WITH TARRAGON BUTTER

J serving Perserving: 3.8 gm CHO, 6.2 OZ PRO

CHO(gm) PRO(gm)

1Tbsp oU — —

1Tbsp lemon juice 1.3 0.1

1 tsp chopped fresh tarragon 1.6 0.8

Saltand black pepper to taste — —

Vi chicken breast (6 oz) — 36.0

1Tbsp Tarragon Butter (page 397) 0.9 0.06

Combine oU, lemon juice, chopped tarragon, salt, and pepper. Pourmixture over chicken breast and let marinate for at least 15 minutes.Grill chicken to desired doneness. Top withpats of Tarragon Butter, ta

CHICKEN SHISH KEBAB WITH VEGETABLES

1 serving Perserving: 6 gm cho, 4.1 oz proCHO (gm) PRO (gm)

4 oz chicken, cut into 1-inch cubes — 24.01oz yeUow onion, cut into 1-inch squares 2.4 0.31oz redbeU pepper, cut into 1-inch squares 1.8 0.251oz green beU pepper, cut into 1-inchsquares 1.8 0.25Salt and pepper to taste — —

Thread chicken, onion, and pepper pieces alternately on skewer. Season with saltand pepper and griU untU chicken is fuUy cooked, ta

410 Your Diabetic Cookbook

CHICKEN DIJON1 serving Perserving: 0.35 gm cho, 4 oz pro

CHO (gm) PRO (gm)

4 oz chicken breast — 24.0

Salt and black pepper to taste — —1Tbsp Dijon MustardButter (page396) 0.35 0.02

Season chicken breastwith salt and pepper. GriU, bake,or brofl to desired doneness. Placechickenon plate,put pats ofDijon Mustard Butter on top, let melt, and servehot. ta

LEMON CHICKEN1serving Perserving: 0.35gm cho, 4 oz pro

CHO (gm) PRO (gm)

4 oz chicken breast — 24.0

Salt and black pepper to taste — —1Tbsp Lemon Butter (page396) 0.35 0.025

Season chicken breast with salt and pepper. GriU, bake, or brofl to desired doneness.Place chicken on a plate,put pats of Lemon Butter ontop, and let melt. Serve hot. ta

BROILED CHICKEN SALAD

1 serving Perserving: 1.9 gm CHO, 4 oz PRO

CHO(gm) PROfem)

4 oz chicken breast — 24.0

2 Tbsp salad oU — —

1 Tbsp vinegar — —

1Tbsp chopped onion 0.9 0.3

1 clove garlic, minced 1.0 0.2

BasU, parsley, chives, and salt andblack pepper to taste — —

GriU or brofl chicken. Cool and cut into V4-inch strips. Combine oU,vinegar, onion, garUc, basU, parsley, chives, and salt and pepper totaste. Serve cold over chicken strips.

Additional vegetables (up to % cup) or saladgreens (up to 1 cup)may be chopped and added to taste. Be sure they are not on the No-No's list on pages 152-153, and makesure you add their cho contentto your computation, ta

Recipes for Low-Carbohydrate Meals 411

GRILLED MARINATED DUCK BREAST4 servings Per serving: 1.3 gmcho, 4.2oz pro

CHO (gm) PRO (gm)4 duck breasts, 4 oz each — 96.02 Tbsp soysauce 4.0 4.03 Tbsp water — —% tsp chopped fresh ginger 0.23 0.031 clove garUc, chopped 1.0 0.2Salt and black pepper to taste — —

Trim duck breasts ofvisible fat, if necessary, andplace in a large bowl.Combine aU the remaining ingredients in a smaU bowl and pour overduck. Turn duck breast over to evenly coat. Let duck marinate refrigerated for several hours or overnight, turning occasionaUy. Removeduckfrom marinade and griU or saute\ skin side down, until goldenbrown. Turn breasts over and cook 1-2 minutes more. Remove duckfrom griU or saut£pan. Duckshouldbe medium rare to medium. SUceon the diagonal to serve hot withvegetables or salad, ta

BEEF, LAMB, AND VEAL

Note that serving size for most recipes in this section is4 ounces protein. This does not imply any preference for thisparticular amount. In fact, many people will wantmore protein. Ifthis is the caseforyou, simply eata larger serving orincrease recipe ingredients proportionately.

GRILLED CHEESEBURGER WITH CANADIAN BACON

1 serving Perserving: 2 gm cho, 4 oz proCHO (gm) PRO (gm)

2V4 oz hamburger patty — 15.0Saltand blackpepper to taste — —1 sUce cooked Canadian bacon (1 oz) 0.5 6.01 sUce cheese (Vi oz) 0.5 3.01 sUce pickle 1.0 —

Season hamburger to taste and griU or fry until almost cooked to desireddoneness. Place Canadian bacon and cheese on top and let thecheese melt.Serve with slice of pickle, ta

412 Your Diabetic Cookbook

GRILLED STEAK WITH MUSHROOM SAUCE

4 servings Perserving: 2.3gm cho, 4 oz proCHO(gm) PRO(gm)

4 small steaks, 4 oz each — 96.0

Salt and black pepper to taste — —

OU — —

4 oz mushrooms, caps sliced, stems chopped 1.6 0.7

3 Tbsp butter — 0.4

1 oz minced shaUots 4.8 0.7

1 sprig thyme 0.45 0.05

Vi bay leaf,crumbled 0.1 0.05

Va cup dry red wine 2.4 —

Va cup water — —

Preheat griU. Season steaks withsaltand pepper, coatlightly with oU,and set aside.

On medium to high heat, in a smaU saucepan, saut£ sUced mushroom capsin butter untilsoft. Remove mushrooms and keepwarm.Inthe same saucepan, saute* shaUots until shaUots become translucent.Add the chopped mushroom stems and cook until moisture is released. Add thyme, bay leaf, red wine,water, and salt and pepper totaste. Simmer to reduce sauceby one quarter.

WhUe sauce is simmering, grill steaks to desired doneness. Strainsauce, add the precooked mushroom caps, heat, and serve oversteaks, ta

MARINATED FLANK STEAK5 servings Perserving: 0.4gm cho, 8 oz pro

CHO (gm) PRO (gm)

2Vi lb flank steak — 240.02 cloves garUc, minced 2.0 0.4Vi cup oUve oU — —Va cup red wine vinegar — —% cup white wine vinegar — —Salt and black pepper to taste — —

Place flank steak in a shaUow glass baking dish. Combine remainingingredients in a smaU bowl and mix weU. Pour over steak and coverdish with plasticwrap.Marinatemeat 12-24hours, refrigerated, turning occasionaUy.

Remove steak from refrigerator about 1 hour beforeyou are readyto cook it.When grillishot, remove steakfrom marinade and griU ap-

Recipesfor Low-Carbohydrate Meals 413

proximately 8 minutes per side for medium rare. To serve, carve inthin sUces, cutting diagonaUy across the grain, ta

FILET MIGNON WITH GREEN AND BLACK

PEPPERCORN SAUCE2 servings Perserving: 2.2 gm cho, 4 oz pro

CHO (gm) PRO(gm)8 oz filet mignon — 48.01Tbsp oil — —Saltand blackpepper to taste — —Va cup dry red wine 2.4 —6 wholegreen peppercorns 1.0 —6 wholeblack peppercorns 1.0 —1tablespoon butter — 0.1

Preheat oven to 350°F. Lightly coat filet with oU and seasonwith saltand pepper. Set aside.

Heat an ovenpan on top of the stove. Whenveryhot, placefilet init and sear on aU sides. Place pan with filet in oven and bake (8 minutes for rare, 10-12 minutes for medium, or 15-18 minutes for welldone). Remove panfrom oven, place filet onaplate, andkeep itwarm.

Deglaze pan with wine on stovetop, scraping aU drippings frombottom of pan. Add peppercorns. Simmer until liquid is reducedby one-quarter of original amount, then swirl in butter. Divide filetmignon into twoequalportions,pour sauce over, and serve, ta

BROILED STEAK SALAD

1serving Per serving: 1.9gmcho, 4 oz proCHO (gm) PRO (gm)

4 oz lean steak — 24.02 Tbsp oU — —1 Tbsp vinegar — —1Tbsp chopped onion 0.9 0.31 clove garlic, minced 1.0 0.2BasU, parsley, and saltand pepperto taste — —

GriU orbrofl steak todesired doneness. Cool and cutinto Vi-inch strips.Combine remaining ingredients thoroughly in a bowl, then add steakand mix. Correct the seasoning.

Additional vegetables (up to %cup) or salad greens (up to 1cup)may be chopped and added to taste. Be sure theyare not on the No-

414 Your Diabetic Cookbook

No's list on pages 152-153, and make sure you add their cho contentto your computations, ta

BEEF BURGUNDY STEW

4 servings Perserving: 7.9gm cho, 5.3 ozproCHO(gm) PRO(gm)

1 Tbsp butter — —

1 lb beef stew cubes — 122.4

1bay leaf — 0.1

2 stalkscelery, chopped 3.0 0.6

Vi cup sUced button mushrooms 4.0 1.7

1 cup turnip cut in largechunks 7.6 1.2

1 smaU celeryroot, peeledandquartered (4 oz) (seeNote) 10.4 1.7

Vi tsp salt — —

Vi tsp black pepper — —

Vi tsp dried tarragon 0.5 —

Vi cup burgundy wine (dry red) 4.8 —

1 tsp arrowroot powder 2.3 —

2 Tbsp cold water — —

Heat butter in a largeheavypot and brown cubes of beef for 3-5 minutes. Remove beef from pot and set aside.Add to the pot bay leaf,celery, mushrooms, turnip,andcelery root.Saute" vegetables and add salt,blackpepper, and tarragon. Cookon a lowflame for 3-5 minutes.Return browned beef to pot, placing it on top of vegetables. Add wine,cover with a tight-fitting lid, and cookfor 40 minutes overlow heat.Thicken cooking Uquid at the end of cooking time by dissolving arrowroot powderin coldwater, then addingit to the stew. Stir contin-uaUy as it thickens. Continue cooking the stew, covered, for 3-5minutes. Serve warm. The stew wiU keep in the refrigerator for 4-5days. It mayalsobe storedin the freezer for 2-3 months.

NoteCelery root,or celeriac, canbe found in mostgroceries, usuaUy alongside jicama and other tuberousvegetables. It is a bulbousroot about the sizeof anorange, with a brownish, gnarled, sUghdy hairysurface. Despite its appearance,it's quite tasty, with a mildcelery flavor, kw

RecipesforLow-Carbohydrate Meals 415

MANDARIN BEEF SAUTE4 servings Per serving: 1.2gm cho, 4.1 oz pro

CHO (gm) PRO(gm)1 Tbsp roasted sesame oU(see Note 1) — —xh tsp minced fresh ginger 0.15 0.02Vi tsp crushedred pepper flakes (optional) — —Vi cup slicedbutton mushrooms 2.6 1.131 lb thinly sUced lean beef (seeNote 2) — 96.01Tbsp soysauce 2.0 2.02 Tbspcidervinegar — —

Ina large heavy skiUet, heat oU ona low temperature. Add ginger, redpepper flakes,and mushrooms, then saute* for 2-3 minutes. Add sUcedbeef tothe skiUet and increase temperature toamedium-high setting.Stir continuously for 3-4 minutes. Stir in soy sauce andvinegar. Immediately remove skiUet from burner and serve warm. This recipe wiUkeep in the refrigerator for3-4 days. It wiU store in thefreezer for2-3months.

Notes

1. Oriental-style roasted (dark) sesame oil is made from natural sesameseeds that are roasted before the oil is extracted. The taste is richer than thatofthelighter variety. Either one can beused for this recipe.

2. SUce beef by holding the knife ona diagonal angle across the grain. Athin cut provides the best flavor for this quick cooking style. The meat is easierto slice if it'sslightly frozen, andyouget nicer slices, kw

LAMB SHISH KEBAB

4 servings Per serving: 5 gmcho, 4.2oz proCHO (gm) PRO(gm)

1 lb lamb, cut into 1-inch cubes — 96.0Saltand pepper to taste — —4 ozyeUow onion, cut into 1-inch squares 9.6 1.24 ozgreen beU pepper, cut into 1-inchsquares 7.2 1.08 whole mushrooms 3.2 1.4OU, to coat —

Preheat broUer or grUl. Season lamb cubes with salt and pepper. Onskewers alternate pieces oflamb, onion, green pepper, andwhole mushrooms. Lightly brushwithoU andbroU or grill to desired doneness. ta

416 Your Diabetic Cookbook

VEAL SCALLOPINI1serving Per serving: 7gm cho, 6.8 oz pro

CHO (gm) PRO (gm)

6 oz veal cutiets for scaUopini — 36.0Salt and black pepper to taste — —2 TbspfuU-fat soyflour, to Ughtiy coatveal 3.8 3.62 Tbsp butter — 0.31 tsp minced shaUots 0.85 0.153 Tbsp white wine 1.8 —3 Tbsp water — —1 Tbsp chopped parsley 0.6 0.03

Season veal with saltand pepperand Ughtiy coat with soyflour. Heatsauti panandadd1tablespoon butter. Sautiveal until golden brownon both sides. Remove from pan and keep warm. AddshaUots to pandrippings and sauti briefly. Remove pan from heat and add whitewine. Scrape bottom of pan to get aU the drippings, add water, andsimmerto reduce sauce slightly. Add the parsley and 1tablespoon butter to finish the sauce.Season to taste. Place finished veal on a platter,pour sauceoverveal, and serve, ta

PORK

PORK CHOPS WITH HORSERADISH SAUCE

2 servings Perserving: 3 gm cho, 3.7 ozproCHO (gm) PRO (gm)

4 Tbsp grated freshhorseradish 1.6 1.8Va cup cider vinegar — —Va cup water — —Vi cup sour cream 4.0 3.21eggyolk 0.3 2.8Vi-\ Equal tablet, crushed, or stevia

to taste (optional) — —Salt and black pepper to taste — —2 smaU pork chops, eachabout 4 ozwithbone — 36.0

Soak horseradish in vinegar and water to cover for 15 minutes ormore. In the top of a double boUer, combine sour cream, eggyolk,crushed Equal tabletor stevia, and saltand pepper to taste. Stir over,not in, hot water until thick and smooth. Drain horseradish in astrainer, pressing to remove excess Uquid, andaddto thesauce. Adjustseasoning, cover sauce, and keep warm.

Recipesfor Low-Carbohydrate Meals 417

Seasonpork chops with salt and pepper.GriU, bake,or brofl to desired doneness and serve with warm horseradish sauce, ta

STIR'FRIED PORK

WITH SWEET AND SOUR CABBAGE

1 serving Perserving: 5.8gm cho, 4.3 oz proCHO(gm) PRO(gm)

Vi cup shredded red cabbage 2.1 0.5

V4 cup shreddedwhite cabbage 1.9 0.5

Vi cup bean sprouts 0.6 0.7

Pinch cumin seeds — —

1Tbsp cidervinegar — —

Vi-\ Equal tablet, crushed, or stevia to taste — —

Salt and black pepper to taste — —

1 Tbsp oU — —

4 oz pork tenderloin, cut into stripsVa inch thick — 24.0

2 Tbsp dry white wine 1.2 —

In a large saute* pan or medium pot,combine redcabbage, white cabbage,and 2 tablespoonswater. Cook overmedium heat until the cabbage wUts. Add beansprouts, cuminseeds, vinegar, and crushed Equaltablet or stevia to taste. Season with salt and pepper. Cook over lowheat for 3-5 minutes, or until vegetables are tender. Cover and keepwarm. In a medium sauti pan or wok, heat 1 tablespoon oU. Seasonporkstrips withsaltand pepper. Add to hot oU, and stir constantly toprevent scorching. Whenthe pork isalmost cooked through (thiswiUtake just 2-3 minutes), add white wine and cook another minute or soto let the alcohol bod away. Serve with the cabbage, ta

SEAFOOD

TUNA MELT

1serving Per serving: 8gm cho, 8.2 oz proCHO (gm) PRO (gm)

1 can (6 oz) tuna fish — 54.02 Tbsp mayonnaise — —Blackpepper to taste — —2 G/G crispbreads 6.0 2.02 oz cheese slices 2.0 12.0

418 Your Diabetic Cookbook

Drain tuna and mix with mayonnaise and pepper. Mound tuna mixon G/G crispbreads and top with cheese sUces. Place in oven or toasteroven at 350°F until cheese is fuUy melted, ta

SALMON SALAD

3 servings Perserving: 11.8 gm cho, 4.4 oz proCHO (gm) PRO (gm)

1 can(13oz) salmon — 117.0

1 rib celery, chopped 1.5 0.3

Va cup chopped onion 1.8 0.25

1 tsp chopped parsley — —

Va spearpickle, chopped 1.0 —

Lemon pepper seasoning, to taste — —

2-3 Tbsp mayonnaise — —

1Tbsp preparedmustard — —

Vi tsp minced chives — —

Saltand black pepperto taste — —

Place salmon in a large bowl with next 8 ingredients (celery throughchives) and mix weU. Season to taste with salt and pepper and chill.Serve cold, ta

STUFFED AVOCADO WITH CRABMEAT

2 servings Perserving. 7.2gm CHO, 3.7OZPRO

CHO(gm) PRO(gm)

6 oz crabmeat (see Note 1) — 54.0

1 heaping Tbsp mayonnaise — —

1 tsp olive oU — —

1Tbsp cidervinegar — —

Vi tsp poppy seeds — —

Vi tsp paprika 0.6 —

Va tsp salt — —

1 stalk celery, diced 1.5 0.3

1heapingTbsp minced scaUion 0.4 0.1

1 ripe Haas avocado (see;Note 2) 12.0 4.8

Place crabmeat in a glass mixing bowl and gently break up any lumpswith a fork. Add mayonnaise,olive oU, and cidervinegar.Mix togetherwith a light hand (do not break up the fiber of the crabmeat,merelyseparate the flakes). Add poppy seeds, paprika, salt, celery, and scal-Uon. Slice avocado in half and remove the pit. Using the tines of ametal fork, Ughtiy score the inside surface of the avocado halves. Do

Recipes forLow-Carbohydrate Meals 419

not penetrate the pulp aU the wayto the skin. FUl each half with halfthe crabmeat mixture. Serve chiUed or at room temperature. You canstore thecrabmeat fiUing in the refrigerator for2-3 days. Donot splitand stuffthe avocado until youare ready to serve it.

Notes

1. A variation of this recipe is to use othersalad fillings in place of thecrabmeat. Tuna or chicken salad would substitute nicely. Be sureto make theproper food count adjustments.

2. Haas avocados area smaU variety with a thick, pebbled skin. They areripe when slightiysoft to the touch, kw

FIVE-SPICE SHRIMP WITH BEAN SPROUTS

2 servings Per serving: 5.6gmcho, 4.5oz proCHO (gm) PRO(gm)

1 Tbsp roasted sesame oU(seeNote 1,page 415) — —

1 tsp minced fresh ginger 0.3 0.032 cups mung bean sprouts (seeNote) 8.0 6.0lhlb medium shrimp (cleaned) — 46.01 Tbsp soy sauce 2.0 2.0xh tsp Chinese five-spice seasoning — —2 Tbsp chopped scallion 0.8 0.2

Ina large heavy skiUet, heat oU ona low temperature. Add ginger andsaut£ for a minute or two, until it is fragrant. Don't let it burn. Addsprouts andshrimp to skiUet. Raise heat tohigh andstircontinuously.Add soy sauce and seasoning. Cook for 4-5more minutes. Shrimp aredonewhen theyturn pinkandareno longer translucentGarnish withscaUions at theendof thecooking time. Serve warm. This recipe wiUkeep in the refrigerator for2-3 days in a tightly sealed container.

Note

Mung bean sprouts aresold packaged in therefrigerated section of the produce aisle. Check for a freshness date onthe package. The sprouts should appear firm and dry with no Uquid accumulated in the bag. Rinse sproutsbriefly in a colander under cold water before using, kw

420 YourDiabetic Cookbook

SCALLOPS PROVENCAL

4 servings Perserving: 5.0gm CHO, 3.2 OZPRO

CHO(gm) PRO(gm)

1Tbsp butter — —

1Tbsp minced shaUot 1.7 0.3

Vz cup leeks finely sUced diagonaUy 4.0 0.4

Vi cup celery finely sUced diagonaUy 3.0 0.4

Va tsp salt — —

Vs tsp dried thyme 0.2 —

V% tsp dried tarragon 0.1 —

Vs tsp dried rosemary 0.1 —

1 lb seascaUops (seeNote 1) 10.8 76.0

4-6 leaves fresh basU, chiffonade cut(see Note 2) 0.1 0.1

In a medium skiUet, heat butter on a low temperature. Add shaUot,leeks, celery, salt, and dry herbs. Saute for 2-3 minutes. Addthe scallops to the skiUet and cook over medium heatfor4-5 minutes. Scallops wiU bedone when they arefirm in texture andyousee smaU spUtson the top surface. Add shredded basU, cover the skiUet, and immediately remove from heat. Setaside for 1-2 minutes. Serve warm.

Notes1. If yousubstitute bayscaUops (thesmaU variety) for sea scaUops, they

tendto cookvery quickly, soreduce thecooking timebyaminuteor two. Thefood counts wiU be the same.

2. A chiffonade cut is done by uniformly stacking the leaves of basU ontop of one another, rolling themintoa tight pendl shape, then sUcing intothin diagonal strips, kw

GRILLED SALMON WITH LEMON PEPPER BUTTER

1 serving Perserving; 1.3gm cho, 8.4 oz proCHO (gm) PRO (gm)

8 oz salmon steak — 50.0OU, to coat — —Salt and black pepper to taste — —Vi Tbsp lemon juice 0.65 0.052 Tbsp LemonPepperButter (page 396) 0.65 0.05

Preheat griU or broUer. Coat salmon with oU and season with saltandpepper. Place salmon onheated griU orbroUer panandgriU about4 minutes per side. When the salmon is ready to be turned over, be

Recipesfor Low-Carbohydrate Meals 421

careful not tobreak themeat apart. After thesalmon isturned, pour Vitablespoon of lemon juice over it and finish cooking. Remove fishfrom griU and place on a heated plate. Cover withLemon Pepper Butter and serve, ta

BLACK OLIVE CRUSTED SALMON

2 servings Per serving: 6.5gmcho, 4.5 oz pro

CHO(gm) PRO(gm)2 Wasa Fiber Rye crackers 10.0 2.0

6 smaU blackolives, pitted 1.8 —

3 Tbsp chopped scallions 1.2 0.3

2 Tbsp butter, softened — 2.0Vi tsp salt — —

Va tsp black pepper — —

Canola oU forbaking trayand oUingthe top of the fish — —

2 small salmon steaks, 4 oz each — 50.0

Check to make sure that the workbowl of your food processor iscompletely dry, then add the crackers and process for 1-2 minutes,making coarse-textured crumbs. Remove crumbs toamedium mixingbowl. Add oUves, scaUions, andbutterto your food processors workbowl (don't worry if there are stiU a few crumbs) andprocess for 1-2minutes. Add salt and pepper and blend again. Transfer this mixtureto thebowl with thecracker crumbs. Blend these ingredients togetherevenly. Refrigerate thismixture untilready to use. Place salmon steakson an oUed tray for broiling. Lighdy oU the top of the salmon. BroUsalmon for 4-5 minutes. Remove trayfrombroUer. Turn salmonwitha spatula. Remove black oUve mbcture from the refrigerator. Gendypress the top surface of each salmon steak with3 Tbsp of black oUvecoating. Place salmon back under broUer. Donot place it too close tothe heat, because the crust wUl burn before the salmon cooks. Cook anadditional 4-5 minutes. When the salmon isdone it wiU easUy flakeapart with a fork. Serve warm. The salmon wiU keep in the refrigerator, covered,for 2-3 days,kw

STEAMED SCROD WITH WATERCRESS AND GINGER

4 servings Per serving: 5.1 gmcho, 4.7ozproCHO (gm) PRO(gm)

Wi cups thinly sUced (Va inch) daikonradishor white turnip 7.5 1.5

1cup sUced yeUow squash 7.8 1.6

422 Your Diabetic Cookbook

16 oz fresh scrod fillet (Vi inch thick),cut into 4 pieces — 103.(

% cup water — —

1Tbsproasted sesame oU (see Note 1,page 415) — —

Va tsp grated fresh ginger 0.08 —

1 Tbsp soy sauce 2.0 2.0

1tsp creamof tartar dissolved in Va cupcold water 0.6 —

2 Tbsp sesameseeds 1.8 4.2

Vi bunch watercress, washed thoroughlyand drained 0.6 1.2

In the bottom of a large skiUet, layer first the daikonand then the yellowsquash. Place thescrod on topofthevegetables. In a smaU mixingbowl,combinethe %cup water, sesame oU, ginger, and soysauceandwhisk together. Pourthe mixture evenly over the fish and vegetables.Cover the skiUet and bring the Uquid to a boU, then reduce the heat.Simmer for 5-7 minutes. Stir the dissolved cream of tartar into thecooking Uquid. Keep the flame low as the Uquid thickens. Add thesesame seeds and watercress, cover skiUet, and immediately removefrom the heat. AUow the watercress to cook in the accumulated heat ofthe coveredskiUet as it sits for 3-4 minutes before serving.Usea slotted spoon or metalspatula to serve each portion of fish and vegetables. Serve warm, kw

PAN-FRIED SWORDFISH WITH

GINGER SCALLION BUTTER1serving Per serving; 7.6gm cho, 4.8 oz pro

CHO (gm) PRO (gm)

Va cup soysauce 4.0 4.02 Tbsp dry whitewine 1.2 0.1Va tsp minced garUc 0.25 0.051 tsp minced freshginger 0.3 0.22 scaUions, minced 0.93 0.03Vi Tbsp lemon juice 0.65 0.054 oz swordfish steak — 24.0Salt and pepper to taste — —2 Tbsp butter — 0.31TbspGinger ScaUion Butter (page 397) 0.25 0.3

Combine first 6 ingredients (soy sauce through lemon juice) in a shallow glass bowl and place swordfish steak in it, turning to coat both

Recipes forLow-Carbohydrate Meals 423

sides. AUow the fish to marinate for 30 minutes. Remove swordfishand blot dry. Season withsaltand pepper. Heat butter in a saute panover medium-high heat. When butter starts to foam, add fish andcookto desired doneness. Remove fish from panandplace on a heatedplate. Serve withpatsof Ginger ScaUion Butter on top. ta

TROUT AMANDINE1serving Per serving: 3.4gmcho, 5.2oz pro

CHO (gm) PRO(gm)5 oz trout fiUet — 30.0Saltand blackpepper to taste — —2 Tbsp butter — 0.32 Tbsp sliveredalmonds 1.72 1.681 Tbsp lemon juice 1.3 0.12 tsp chopped parsley 0.4 0.2

Season trout on both sides with salt and pepper. Saute* the trout in 1tablespoon butter until almost cooked. Remove to a warm plate andkeep warm(fish wiU continue cooking). Pourexcess butter fromsaute*pan. Add remaining tablespoon butterandletbrown sUghtly. Add thealmonds and brown them. Just before serving, stir in lemon juice andparsley,and pour sauce over trout, ta

BLUEFISH WITH SPICY MUSTARD SAUCE

1 serving Per serving: 2.3gm cho, 4 oz proCHO (gm) PRO (gm)

2 TbspSpicy MustardSauce (page 397) 2.3 0.114 oz bluefish steak — 24.0OU to coat bluefish — —

Saltand black pepper to taste — —

Preheat griU or broUer. Make Spicy Mustard Sauce and keep warm.Lightly coatbluefish withoU andseason withsalt andpepper. Cook todesired doneness and serve nappedwithmustardsauce, ta

424 Your Diabetic Cookbook

VEGETABLE ENTREES AND SIDE DISHES

MOUSSAKA A LA BERNSTEIN6 servings Perserving: 8.4gm CHO, 3.7OZPRO

CHO(gm) PRO(gm)

3 Tbsp oUve oU, approximately — —

1 medium eggplant, about 1 lb,peeled and sliced into Vi-inch rounds 20.0 3.2

Salt and black pepper to taste — —

1Tbsp minced garUc 3.0 0.6

Vi cup diced red beU pepper 4.6 0.6

1 lb ground beef — 75.2

1 tsp dried oregano 0.5 0.1

1 tsp ground cumin 0.9 0.4

2 Tbsp butter — —

Vi cup thinly sUced turnip 4.1 0.6

1 cup whole-milk ricottacheese 8.0 24.0

1 cup heavycream 6.6 4.8

Vi tsp paprika 1.2 0.3

2 eggs,Ughtiy beaten 1.2 12.6

Vi cup grated Parmesancheese — 11.0

Preheatovento 375°F. In a large skiUet, heat 2Tbspof the oUve oU overa mediumflame. Addeggplant slices, working in batches ifnecessary toavoid overcrowding thepan.Sprinkle theeggplant withsaltand pepperand brown for 5 minutes on a side. Remove from skiUet. If working inbatches, youmaywantto add a Uttle moreoU to the skiUet before eachnew batch. When aU the eggplant sUces have been browned and removed, add 1Tbsp oUve oU to the skUlet, alongwith the garUc and redpepper. Saute* for 2-3 minutes. Add groundbeef, oregano, cumin,salt,andpepper. Brown evenly. Inanother large skiUet heat2Tbsp butterona lowtemperature. Layer turnips in skiUet, sprinkle with salt and pepper. Brown for5 minutes on each side. Use a spatula to flip turnips. In amedium mixing bowl combine ricotta cheese, heavy cream, salt, andpaprika. Add eggs andblend together. Ina Ughtiy buttered 9x13 bakingdish, layer eggplant, ground beef, and turnips. Pour ricotta cheesemixtureoverlayered ingredients. Sprinkle casserole with gratedParmesan cheese. Place casserole in the oven and bake for 45 minutes.

Serve moussakawarm. It wiU keep in the refrigerator for 3-4 days.It mayalso be storedin the freezer for 2-3 months.It is convenient topackage the casserole in individual servings if youare going to freezeit. KW

Recipesfor Low-Carbohydrate Meals 425

CREAMED SPINACH WITH NUTMEG4 servings Per serving: 8.6gm cho, <0.5 oz pro

CHO (gm) PRO (gm)2 lbs fresh baby leaf spinach (see Note) 27.2 0.91 Tbsp butter — —Vi tsp salt — —Va tsp black pepper — —Vi tsp nutmeg 0.6 —1 cup heavy cream 6.6 4.8

Bring 4 quarts of water to a boil in a large pot.Addspinachand cookat a boil for 3-4 minutes. Drain spinach in a colander and rinse withcold water. Squeeze out the excess moisture from spinach. Placespinach on a cuttingboardand chop intobite-sized pieces. Melt butter in a nonreactive skillet. Add cooked spinach and season with salt,pepper, and nutmeg. Stir in the heavy cream. Reduce the flame andcook for 30 minutes. Do not cover the skillet; the spinach will releasetoo muchmoisture and dilute the flavor. To avoid scorching the food,keep the flame at a low setting and stir frequently. You can also use aheat deflector (an inexpensive round metal disk, often with a woodenhandle, that you can place between pot andburner while cooking) toprevent scorching. Serve spinach warm. It will keep in the refrigeratorfor 3-4 days.

This dish is a good one for those who suffer from gastroparesis ifthe spinach is chopped finely.

Note

You can often buy spinach prewashed. Getting it this way will save somepreparation time, as spinach can be very gritty and bunch spinach must bethoroughly washed. You can also use mature spinach leaves, but they shouldbe stemmedand roughlyshredded, kw

BAKED CHEDDAR CHEESE FRITTATA

4 servings Per serving: 7.2 gm cho, 2 oz proCHO (gm) PRO (gm)

4 eggs 2.4 24.0

1 cup heavy cream 6.6 4.8

1Tbsp butter — 0.1

1 cup sliced button mushrooms 8.0 3.4

1 cup sliced red bell pepper 9.2 1.2

% tsp salt — —

Va tsp dried oregano 0.3 —

426 Your Diabetic Cookbook

Va tsp cayennepepper (optional) 0.4 0.1Vi cup grated cheddar cheese 2.0 14.0

Preheatoven to 375°F. Blend togethereggs and heavy cream in a mixingbowl and set aside. In a 9-inch ovenproof skUlet (see Note), meltbutter overmedium heat and saute* sUced mushrooms and beU pepper.Add salt, oregano, and cayenne pepper (optional; omit if you don'tcare for spicy foods or suffer from gastroparesis) and cook for 3-5minutes, until the mushrooms are tender and the peppers are wUtedbut not mushy. Add theegg andcream mixture to thesaut6ed vegetables.Cook on a low flamefor 2-3 minutes. Sprinkleon grated cheddarcheese justbefore placing the skiUet in the oven. Bake in the oven for20 minutes uncovered.

Serve warm.This recipe worksweU asa Ught mealfor lunch or supper. It canbeserved warm or at roomtemperature. It wiU storefor2-3days refrigerated in an airtightcontainer.

NoteIfyourskiUet hasaplastic handle, before baking, transfer theegg, cream, andvegetable mbcture to a greased 9-inch roundbaking pan or pie plate, thensprinkleon the cheddar. kw

ROASTED FENNEL WITH ROSEMARY

8 servings Perserving: i6.6gm cho, <0.5 oz proCHO(gm) PROfem)

2 bulbs trimmed fennel (see Note),sUced in quarters lengthwise 34.2 5.8

1cup leeks, washed thoroughly and sUcedin ^-inch diagonals 8.0 0.8

Vi cup diced red beU pepper 4.6 0.6

3 Tbsp chopped blackoUves 4.0 —

4 Tbsp oUve oU — —

Vi tsp salt — —

Vi tsp blackpepper 0.9 —

1 tsp dried rosemary 0.8 0.1

Preheat oven to 425°F. In a large mixing bowl, gendytosstogetherfennel,leeks, redpepper, andblack oUves. Add oUve oU, salt,blackpepper,and rosemaryto the vegetables and mix ingredients together, takingcarethat aU vegetables areUghdy coated with the oU and seasoning. Ina baking tray, arrange the fennel first, placing cut sides down.Evenlydistribute the remainingingredients over the fennel. Bake the vegetables uncovered on the middle oven rack for 45 minutes.

RecipesforLow-Carbohydrate Meals 427

The roasted vegetables should be servedwarm. They wiU keep inthe refrigerator for 4-5 daysin an airtight container.

Note

Fennel resembles a smooth celeryin color and shape but has a fragrance likeanise or Ucorice. Its base is bulbous and it has featherlike strands in its center

(its leaf looks a bit like dill). Select fennel that has smooth skin and does notappearwrinkledor dried out. Lookfor one with a largebulb, sUghdy smallerthan a baseball. For this recipe trim away all parts of the vegetable but thebulb, kw

TURNIP "MASHED POTATOES" WITH FRESH CHIVES

4 servings Perserving: 9.3 gm cho, <0.5 oz PRO

CHOfem) PRO(gm)

4 medium turnips, trimmed at the rootand stem ends and quartered 33.6 0.8

Vi tsp salt — —

2 Tbsp butter — —

Vi cup heavy cream 3.3 2.4

Va tsp black pepper — —

3 Tbsp finely chopped chivesor scaUions 0.3 0.3

In a medium saucepan,bring 3 quarts water to a boU. Add turnips andsalt. Cover the pot and cook 30-40 minutes, or until tender whenpricked with a fork. Drain turnips in a colander.WhUe the turnips arestiU warm, put them into a large mixing bowl. Add butter and heavycream. Usinga potato masher,mix ingredients together. (If you wouldlike a whipped texture you can use a food processor. Put the mixtureinto the food processor workbowl and blend for 2-3 minutes.) Addblack pepper and chives.

Serveturnips warm as a vegetable side dish. This recipe's soft texture and mUd flavor would nicely complement Steamed Scrod withWatercress and Ginger, page421. kw

BAKED MUSHROOMS FLORENTINE

4 servings Perserving; 9.4gm CHO, 1.1 OZPRO

CHO(gm) PROfem)

2Wasa Fiber Rye crackers 10.0 2.0

12large white mushrooms(large enough to stuff) 16.0 6.8

4 cups fresh spinach leaves 8.0 6.4

3 strips crisp-cooked bacon, crumbled(optional) — 6.0

428 Your Diabetic Cookbook

2 Tbsp grated Parmesan cheese 0.4 4.2

1Tbsp butter — —

1 tsp minced garUc 1.0 0.2

Vi cup heavycream 2.2 1.6

Preheat oven to 375°F. In the food processor workbowl,blend crackersinto coarse crumbs. Remove the cracker crumbs from the workbowl

and set aside. With a paring knife remove the stems from the mushrooms. Keep the mushroom caps intactand set them aside. In the foodprocessor, finely chop mushroom stems and spinachleaves. You mayneed to add the spinach in two portions because of its volume. Remove processed ingredients to a large mixing bowl and blend in thebacon and cheese. In a heavy skUlet, heat butter on a low flame. AddgarUc and spinachmixture. Stir in the heavycream.Saute* for4-5 minutes.Transfer ingredients to a mixing bowl. Spoon the fiUing into themushroom caps. Lighdy grease a baking tray. Place fUled mushroomson the trayand bakeuncovered for 45minutes. Serve the mushroomswarm. They wUl keep in the refrigerator for 3-4 days. In the freezerthey wiUkeep for about a month, kw

MEDITERRANEAN EGGPLANT STEW

6 servings Perserving: 8.5gm <CHO, 3.2 oz PRO

CHO(gm) PRO(gm)

1Tbsp oUve oU — —

1Tbsp minced shaUot 1.7 0.3

lh cup sUced button mushrooms 4.0 1.7

Vi cup diced red beUpepper 4.6 0.6

2 medium eggplants, about 1 pound each,peeled and cut into large chunks 40.0 6.4

1 tsp salt — —

1 tsp dried oregano 0.5 0.1

Vi tsp red pepper flakes 0.6 —

1 lb ground turkey — 105

Heat oU over low temperature in a Dutch oven. Add shaUots, mushrooms, beU pepper,and eggplant. Add seasonings and stir ingredientstogether. Raiseheat to medium. Vegetables wiU start to "sweat," or release Uquid, as they cook. Continue stirring for 7-10 minutes, aUow-ing some of this Uquid to cook away. Add the ground turkey to the potand stir gendy to blend. Cover pot, lower the temperature, and aUowto cook for 45 minutes. It is not necessaryto stir the pot as long as theheat is low. Serve the stew warm. It wiU store for 3-4 days in the refrigerator. It may also be storedin the freezer for 2-3 months, kw

Recipesfor Low-Carbohydrate Meals 429

STUFFED SAVOY CABBAGE WITH RED SAUCE

4 servings Perserving: 11.3gnuZHO, 5.7OZPRO

CHO(gm) PROfem)

8 outer leaves Savoy cabbage (seeNote) 6.0 —

2 Wasa Fiber Rye crackers 10.0 2.0

Wa lb lean ground beef — 120.0

2 eggs 1.2 12.6

1 stalk celery, diced small 1.5 0.3

1 cup green beUpepper, diced smaU 9.2 1.2

Vi tsp salt — —

1 tsp dried oregano 0.5 0.1

Wi cups ItaUan-Style RedSauce (page394) 16.8 0.9

Remove 8 outer leaves from a head of Savoy cabbage. Rinse them under cold water.Bring 2 quarts of water to a boU in a stockpot. Add thecabbage leaves and cook at a boUfor 4-5 minutes. Remove the leavesfrom the water and place in a colander to drain.

In the food processor workbowl, blend crackersinto coarse crumbs.Combine the ground beef and eggs in a large mixing bowl.Add thecrackercrumbs,celery, beU pepper,salt,and oregano. ThoroughlymixaU ingredientstogether, then divide the mixture into 8 portions.

Stuff the cabbage leaves one at a time. Place a leaf of cooked cabbageon a flatsurface. Using a paringknife, remove about Vi inch fromthe bottom of the centerrib, to makethe leafeasierto roU. Place a portion of the meat and crumb mixture in the center of the leaf near the

bottom. Fold the sides of the leaf over the fiUing. Starting at the bottom, roU up the leaf to enclose the fiUing. The finished roU should beabout 2x3 inches. Continue in this fashion until aU the leaves arestuffed.

Preheat oven to 375°F. Pour % cup of the red sauce on the bottomof an 8 x 8 bakingpan. Place cabbage roUs on the saucewith seamsidedown.Pour the remaining red sauceoverthe cabbage. Bake uncoveredfor 1hour.Serve warm.Thestuffed cabbage wittkeep in the refrigerator for 3-4 days. The roUs may also be stored in the freezer for 2-3months.

Note

Savoy cabbage resembles the commonvariety of greencabbage in color andshape.Its leaves are thinner and havea lacysurfacetexture.You can substitute green cabbageif you are unable to find Savoy. Food counts wiU remainunchanged, kw

430 Your Diabetic Cookbook

SPAGHETTI SQUASH FRITTERS / LATKES

4 servings Perserving: 10.1 gm CHO, 1.2 OZPRO

CHO(gm) PRO(gm)

2 cups cooked spaghetti squash (seeNote) 20.0 2.0

3 WasaFiber Rye crackers 15.0 3.0

3 eggs 1.8 18.9

2 Tbsp grated Parmesan cheese 0.4 4.2

1 tsp paprika 1.2 0.3

V2 cup coarsely chopped flat-leaf parsley 1.9 0.9

V2 tsp salt — —

Va tsp black pepper — —

1 cup canola oU — —

Prepare squash as describedin Note below. Measure2 cups choppedpulp into a large mixing bowl and set aside. (Discard remaining pulpor savefor another purpose.)

Blend crackers in the food processor workbowl for 2-3 minutes,until they are in coarsecrumbs. Remove crumbs from workbowl andset aside. Combine eggs, cheese, paprika, parsley, salt, and pepper inthe workbowland blend together for 2-3 minutes.

Add egg-cheese mixture from workbowl to the cooked squash inthe largemixingbowl. Stir to combine. Addcrackercrumbs to squashmixture and mix in evenly. Measure 2 Tbsp of mixture for each fritter.Shape them into pattiesabout Vi inch thick.

Add the canola oU to a heavy skiUet. Heat on medium-low flame.Test the cooking temperature by adding a drop of batter. You've gotthe right temperature when the batter cooks on the surfaceof the oU.CarefuUy lower the fritters into the oU a few fritters at a time. Donot overcrowd the skUlet. Cook for 4-5 minutes on each side. Place

cooked fritters on paper towels to absorb excess oU. This recipe yields12 fritters.

Note

Spaghetti squashis an oblong, paleyeUow squash. Its hard outer sheU is notedible. Theinside pulpseparates intolongspaghetti-like strandsaftercooking.

Tocook the squash,sUce it in half lengthwise. Remove the seeds.OU a baking tray and placethe squash cut side down on the tray.Bakeat 375°F for 50minutes.Afterthe squashcools, scoopout the pulp.Coarselychop the cookedsquash before adding to fritter recipe,kw

Recipes forLow-Carbohydrate Meals 431

BAKED ZUCCHINI WITH FRESH BASIL

AND FETA CHEESE

4 servings Perserving: 8.3 gm CHO, 0.7OZPRO

CHO(gm) PRO(gm)

2 Tbsp oUve oU —

—

1 cup diced red beU pepper 9.2 1.2

Vi cup sUced button mushrooms 4.0 1.7

1Tbsp minced garUc 3.0 0.6

Vi tsp dried oregano 0.2 —

6 leaves fresh basU, chiffonade cut(see Note 2, page 420) 0.1 0.1

Pinch of salt — —

Va tsp black pepper — —

2 medium zucchini 14.0 2.4

3 oz (about Vi cup) crumbled feta cheese 3.0 12.0

Preheatovento 375°F. In a heavy skUlet, heat 1Tbspof the oUve oU overlowheat.AddbeU peppers, mushrooms, garUc, oregano, basU, salt,andpepper. Sauti for 3-5 minutes and set aside. Cut zucchini diagonaUyinto Vi-inch-thick sUces. Coat a bakingpan with remaining 1Tbsp oiland add zucchini, placing the cut sides down. Spoonthe saut^ed vegetable mixture over the zucchini. Sprinkle the crumbled feta cheeseovervegetables. Coverthe bakingpan with foU and placein the oven.Bake for 45 minutes. The zucchini should be tender at the end of thebaking time. Serve baked zucchini warm. It wiU keep in the refrigeratorfor 4-5 days.It may also be stored in the freezerfor 2-3 months, kw

PAN-FRIED TOFU WITH SWEET AND SOUR

DIPPING SAUCE4 servings Perserving: 3.2gm cho, 2.3 oz pro

CHO (gm) PRO (gm)

1 lb firm tofu (see Note) 10.0 55.01 Tbsp canola oU — —2 Tbsp prepared mustard — —3 Tbsp mayonnaise — —Vi packetsteviapowder (scant Va tsp) — —Vi tsp poppy seeds 0.3 —1 Tbsp minced scaUions — —1Tbsp minced sauerkraut (Uquid drained) 0.5 —1Tbsp roasted sesame oU

(seeNote 1,page 415) — —1 Tbsp soysauce 2.0 2.0

432 Your Diabetic Cookbook

SUce tofu into 4 thick slabs. Place the torn on an absorbent kitchen

towel. Fold the towel over the tofu and firmly press out the excessmoisture for a few moments. Removing excess Uquid helps tofu tobrown. In a heavyskiUet, heat oU over a low flame. Add the tofu andbrown on each side for 5-7 minutes.The tofii wUl become a goldencolor. Do not cover the skUlet. Combine remaining ingredients in asmaU mixing bowl and set aside. You wiU serve this sauce with thecooked tofu. Remove tofu from the skUlet and serve warm. The tofu

and the saucewiU keep in the refrigeratorfor 4-5 days.

Note

Tofu is made from soybeans that havebeen cookedand pressed into cakes.It's sold in the refrigerator case in many food stores. Check the expirationdate for freshness beforebuying. Uncooked tofu should be stored in water ina sealedcontainer and wiU keepin the refrigerator for 2-3 days. CookedtofuwiU keepin the refrigerator for 4-5 days, kw

CELERY CHIPS8 servings Perserving: 2.6 gm cho, <0.1 oz pro

CHO (gm) PRO (gm)

1 medium celeryroot (8 oz)(see Note, page 414) 20.8 3.4

2 Tbsp canola oU — —Vi tsp salt — —

Preheat oven to 425°F. Removethe thick peel from the celery root witha paring knife. Slice the root lengthwise into quarters. Slice into thinquarter-rounds. In a mixing bowl, combine celery root with oU andtoss to evenly coat the slices. Addthe saltand mixagain. Place the celery root sUces in a single layer on a baking tray. Bake for 30 minutesuncoveredon the middle rackof the oven.Chips can be servedimmediately.

AUow chips to cool before storage. Place them in an airtight container in the refrigerator. TheywiU keepfor 2-3 days. Reheat them ina 425°oven for 5-7 minutes before servingfor a crunchy texture. Thisrecipeyields2 cups of celerychips,kw

Recipes for Low-Carbohydrate Meals 433

CREAMY STRINGBEAN CASSEROLE WITH SAGE

MUSHROOM SAUCE

6 servings Perserving: 12.3gm CHO, <0.6 OZ PRO

CHO(gm) PRO(gm)

1Tbsp oUve oU — —

2 cups slicedbutton mushrooms 16.0 6.8

1 Tbsp minced shaUot 1.7 0.3

Va tsp ground sage 0.3 —

Vi tsp salt — —

Vi tsp blackpepper — —

1 heaping Tbsp arrowroot powder 7.5 —

8 oz CoUege Inn chickenbroth — 1.0

Vi cup heavycream 3.3 2.4

4 cups chopped frozenstring beans 39.2 9.6

1 cup Celery Chips (see previous recipe) 5.2 0.3

Preheat oven to 375°F. Heat oU over low temperature in a mediumskUlet. Add mushrooms, shaUot, sage, salt,and blackpepper. Saute" for5-7 minutes. Dissolve arrowroot powder in chicken broth. Add thisUquid and heavycream to mushroom mixture in the skUlet. The Uquid wUl thicken as it heats. Stir the ingredients together for 3-5 minutes. Place the string beans in a layeron the bottom of a baking pan.Evenly pour the mushroom sauceoverstring beans. Layercelerychipson top. Bake uncovered for 45 minutes. Serve warm. This recipe wUlkeep in the refrigerator for 2-3 days. It may also be stored in thefreezer for about 1 month, kw

PUREED CAULIFLOWER WITH CELERY ROOT

6 servings Perserving: 8.8gm cho, <0.5 oz proCHO (gm) PRO (gm)

xh tsp salt — —1 bayleaf — —1 medium celeryroot (8 oz), peeledand cut

into large chunks (seeNote,page414) 20.8 3.41 smaU head cauUflower,

cut into 1-inch pieces 31.2 13.21 Tbsp oUve oU — —Vi tsp dried diU weed 0.6 —1Tbsp minced parsley 0.3 —

Addsalt and bay leaf to 2 quarts water in a large saucepan. Bring Uquid to a rolling boU. Drop in the celery root and cauliflower, reduce

434 Your Diabetic Cookbook

temperature,and simmer for about 30 minutes. Vegetables are readywhen they are fork tender.Strain vegetables from cookingUquid andplace in the workbowl ofyourfood processor. Blend until theyacquirea creamytexture (3-4 minutes).AddoU, dUl, and parsley. Blendingredients again for 1 minute. Serve pureed vegetables warm. This recipewiU keep in the refrigerator for 3-4 days. It may alsobe stored in thefreezer for 2-3 months.

This recipe is helpful for gastroparesis. The soft texture and mUdflavor of the pureed vegetables faciUtate easier digestion when a low-bulk diet is recommended, kw

PAN-FRIED OKRA WITH TAMAR1 SCALLION GLAZE

4 servings Per serving: 9.9gm cho, <0.5 oz proCHO (gm) PRO (gm)

1 Tbsp oliveoU — —1 lb okra, trimmed and cut into Vi-inch

rounds (see Note 1)1cup dicedyeUow squash1 tsp arrowroot powder(seeNote2,page404)Vi cup cold water1 Tbsp minced scaUionsVi tsp fresh ginger juice (seeNote 2)1 Tbsp tamari or soysauce

Heat oU overlowtemperature in a heavy skiUet. Add okra and yeUowsquash.Raise the cooking temperatureto medium-high.Stir continuouslyfor 4-5 minutes. Dissolve arrowrootin Vi cup coldwater. Lowertemperature under skiUet, pour in arrowroot Uquid, and stir as Uquidthickens. Add tamari, scaUions, and gingerjuice.Coverthe skiUet andcontinue cooking for 4-5 minutes. Serve warm.This recipe wiU keepin the refrigeratorfor 2-3 days.

Notes1. Okra is a green, pod-shaped vegetable. Select okra that is firm to the

touch and without discoloration or bruising.Asit cooks,it releases a gelatinous Uquid that is helpfulas a thickening agent.

2. It is not necessary to peelthe gingerbeforegrating.Firstwash it withcoldwaterto remove anysurface dirt.Use thefine sideof aboxgraterto pulpthe ginger. Place the pulpin a garUc press (or in yourhand) and squeeze outthe Uquid. Avoid adding thepulpto thisrecipe, because it istoo fibrous, kw

24.4 6.4

10.0 —

2.3 —

0.4 0.1

0.15 0.02

2.0 2.0

Recipesfor Low-CarbohydrateMeals 435

AVOCADO SPREAD2 servings Perserving: 6.6gm cho, <0.5 oz pro

CHO (gm) PRO (gm)

1 ripe Haas avocado (see Note 2, page 419) 12.0 4.81 Tbsp mayonnaise — —1Tbsp heavy cream 0.3 0.42 Tbsp cider vinegar — —Va tsp salt — —1 Tbsp minced roasted red pepper 1.0 —1 tsp minced fresh cUantro — —

SUce the avocadoin half and removethe pit. Scoopout aU of the pulpwith a metal spoon and discard the skin. Place the pulp in the workbowlof your food processor. Addmayonnaise, heavy cream,vinegar,and salt.Blendtogether for 2-3 minutes.Remove the avocado mixtureto a glass mixing bowl. Byhand, mix in the roasted red pepper andcUantro. Servethe avocado spread either chUled or at room temperature. It is best served with low-carbohydrate crackers or as a dip withstrips of rawvegetables such as red and greenbeU peppers,cucumber,yeUow squash, zucchini, and celery. It wiU keep in the refrigerator for3-4 days in a tightlysealed glass container, kw

CHINESE-STYLE SCALLION PANCAKE

1 serving Perserving: 10.6gm CHO, 1.8 OZ PRO

CHO(gm) PRO (gm)

1 Wasa Fiber Ryecracker, crumbled intofine crumbs 5.0 1.0

2 Tbsp fuU-fat soyflour 3.8 3.6

Va tsp salt — —

Va tsp Chinese five-spice powder — —

legg 0.6 6.0

2 Tbsp heavycream 0.8 0.6

2 Tbsp water — —

1 Tbsp minced scallion 0.4 —

2 Tbsp canola oU — —

In a smaU mixingbowl, blend together cracker crumbs,soyflour, salt,and five-spice powder. In a separate, medium-sized mixing bowl,combine the egg, heavy cream, water, and scallion.A whisk is usefulhere in blending the ingredients. Addthe dry ingredientsto the Uquidingredients and blend together thoroughly. Heat oU in a heavy skilletovermedium temperature. Using a rubber spatula, scrape the batter

436 Your Diabetic Cookbook

from the bowl into the hot skillet. Use the spatula to spread out thebatter before it sets in the skillet. Cook pancake for 3-4 minutes oneach side. Serve the pancake warm as an accompaniment to MandarinBeefSaute (page 415) or another warm lunch or dinner entree. Breakoff pieces and dip into the sauce of the entree or eat by itself.

To make multiple pancakes,quadruple the recipe and use about %cup batter per pancake. Leftover pancakes will keep for 3-4 days in atightlysealed container in the refrigerator, and ifyou prepare them beforehand, you can heat them to warm in the microwave. They willkeep in the freezer for 1-2 months. Do not freeze uncooked batter, kw

SAUTEED KALE WITH CRIMINI MUSHROOMS

2 servings Per serving: 8.4gm CHO, <0.5 OZ PRO

CHO (gm) PRO (gm)

5-6 large leaves kale (see Note 1) 11.2 4.0

1 Tbsp olive oil — —

1 tsp minced garlic 1.0 0.2

Vi cup thinly sliced crimini mushrooms(see Note 2) 4.0 1.7

1 tsp soy sauce 0.6 0.6

In a large pot, bring 4 quarts of water to a rolling boil. Add kale andcook at a boil for 2-3 minutes. Remove kale from water and place incolander. Quickly rinse with cold water. Squeeze out excess moisturefrom leaves and place on cutting board. Cut off the stems and slicethem into small pieces. Slice the leaves into bite-sized pieces (thereshould be about 2 cups). In a largeskillet, heat oil on a low temperature. Add garlic and mushrooms and saute for a minute or two. Thenadd kale leaves and stems to the skillet. Raise the temperature tomedium high and quickly saute for 2-3 minutes, stirring frequently.Season with soysauce and serve warm. Remove vegetables from hotskillet to avoid overcooking. Thekale will keep for 2 days in the refrigerator.

Notes

1. Select kalethat hasan even dark greencolor. Anyyellow color indicatesa loss of nutritional value. Leafy greens are perishable and should be usedquickly once purchased. Wash kale in a large bowl of cold water and rinseseveral times until the water runs clear. Leafy greens like beet tops, collards,turnip tops, and broccoli rabe are similar to kale in their selection and handling.

2. Crimini mushrooms are tan to dark brown in color. Select mushroomsthat are dry to the touch, without any soft spots or discoloration, kw

Recipes forLow-Carbohydrate Meals 437

QUICHES AND SOUFFLES

QUICHE LORRAINE4 servings Perserving: 12.2gm cho, 3.6 oz pro

10G/G crispbreads, crushed5 Tbsp butter, softened5 sUces bacon

Wi cups (6 oz) shredded Swiss cheeseVi cup chopped scaUions1 cup heavycream4 eggs, separatedVa tsp nutmeg — —Va tsp salt — —Black pepper to taste — —

Preheat oven to 350°F. To make crust, combine crushed crispbreadswith softened butter. Press mixture into an 8-inch pie pan, makingsure that it is of even thickness aU over.

Cook bacon untU crisp.Letcool,then crumble. In a bowl,combineaU other ingredients except the egg whites. Whip whites to soft peaksand then fold into mixture. Stir in the crumbled bacon. Pour into the

cracker crust and bake for 30-40 minutes, or untU top is light togolden brown, ta

CHEESE QUICHE

HO(gm) PRO (gm)

30.0 10.0

— 0.7

0.16 9.8

6.0 36.0

3.7 0.9

6.6 4.9

2.4 24.0

3 servings Perserving: 14.2gm CHO, 4.3 OZ PRO

CHO(gm) PRO(gm)

10 G/G crispbreads, crushed 30.0 10.0

5 Tbsp butter, softened — 0.7

Va cup grated Parmesan cheese 1.5 10.0

Vi tsp dry mustard — —

Va tsp salt — —

Va tsp black pepper — —

Va cup (3 oz) shredded Swiss cheese 3.0 18.0

Va cup (3 oz) shredded cheddar cheese 3.0 18.0

3 eggs, separated 1.8 18.0

Vi cup heavycream 3.3 2.45

Preheat oven to 350°F. To make crust, combine crushed crispbreadswith softened butter. Press mixture into an 8-inch pie pan, makingsure that it is of eventhickness aU over. In a bowl, combine remaining

438 Your Diabetic Cookbook

ingredients except egg whites. Whip whites to soft peaks, then foldinto the cheese mixture and pour into the pie crust. Bake for 30-40minutes, or until top is light to golden brown, ta

SPINACH SOUFFLE

6 servings Perserving: 6.9gm CHO, 2.9 OZPRO

CHO (gm) PRO(gm)2 Tbsp butter — 0.3

Va cup fuU-fat soy flour 7.5 7.3

10 oz frozen chopped spinach, thawed,squeezed to remove excess moisture 10.0 8.0

Va cup grated Parmesan cheese 1.5 10.0

1clovegarlic, minced 1.0 0.2

Vi tsp salt — —

Va tsp black pepper — —

1 tsp preparedmustard — —

1 cup milk 11.4 8.0

Vh cups (6 oz) cheddarcheese, shredded 6.0 36.0

6 eggs,separated 3.6 36.0

Vi tsp creamof tartar 0.6 —

Preheat oven to 350°R Use a bit of the butter and soy flour to Ughdygrease and flour an 8-inch souffle" dish. In alarge bowl, combine aU ingredients, including the spinach, except egg whites. Whip whites tosoft peaks and then fold into the other ingredients. Pour the mixtureinto the greased and floured dish.Bake for 30-40 minutes, or until topis Ught to golden brown, ta

ZUCCHINI SOUFFLE

6 servings Per serving: 7.1 gm cho, 1.7 oz proCHO(gm) PRO(gm)

2 Tbsp butter — 0.5

Va cup fuU-fat soy flour 7.5 7.3

Va cup grated Parmesan cheese 1.5 10.0

1 lb zucchini, sUced 15.2 6.4

1 medium onion, chopped 6.9 0.9

1 garUc clove,minced 1.0 0.2

Va cup dry white wine 2.4 0.8

2 Tbsp minced parsley 0.4 0.2

1Tbsp lemon juice 1.3 0.1

2 Tbsp diced pimiento 2.0 —

Vi tsp cream of tartar 0.6 —

Recipesfor Low-Carbohydrate Meals 439

Nutmeg,pinch, or to taste — —Saltand black pepper to taste — —6 eggs, separated 3.6 36.0

Preheat oven to 350°F. Use a bit of the butter and soyflour to Ughdygrease and flour an 8-inch souffle" dish. Heat remaining butter in asaute" pan and saut£ zucchini sUces, onion, and garUc until zucchinibecomes translucent. Put saut£ed mbcture into food processor andpulse to mince. Pour into a large bowl and add the restof the soyflourand aU remaining ingredients except the eggs. In a separate bowl, beategg yolks until frothy. Blend into the mbcture. In a separate bowl, beateggwhites into soft peaks.CarefuUy foldinto the zucchinimixture andpour mixture into prepared souffledish. Bakefor 30-40 minutes, untU top is light to golden brown, ta

DESSERTS

CHOCOLATE VANILLA CHEESECAKE8 servings Perserving: 4.9gm cho, 1.8oz pro

CHO (gm) PRO (gm)1 tsp butter — 0.042 Tbsp fuU-fat soy flour 3.8 3.66 eggs,separated 3.6 36.06 Equal tablets, crushed, or

powdered stevia to taste — —1 lb cream cheese 11.2 36.81 cup sour cream 8.0 6.46 drops vaniUa extract 0.6 —Va cup cocoa powder 12.0 4.0

Preheat oven to 350°F. Butter an 8-or 9-inch springform pan and dustwithsoyflour. In a large bowl, beategg yolks withEqual or stevia untU foamy. Add cream cheese,sour cream, and vanUla extract, and beatuntil fluffy. In a separate bowl, beat egg whites until stiff. Fold intocream cheese mixture. Pourhalfthemixture into the springform pan.Mixcocoapowder into remaininghalf,then spoon it overvaniUa mixture alreadyin pan. Bake until golden (about 25-30 minutes), ta

440 Your Diabetic Cookbook

INDIVIDUAL CHOCOLATE SOUFFLES

4 servings Per serving: 2.9gm cho, 1.8oz proCHO(gm) PRO(gm)

4 eggs, separated 2.4 24.0

4 Equal tablets,crushed,or steviato taste — —

8 oz cream cheese,cut into smaU pieces 5.6 18.4

1 Tbsp sour cream 0.5 0.4

1Tbsp cocoapowder 3.0 1.0

Beat egg yolks with crushed Equal tablets or stevia until foamy. Addcream cheese,sour cream, and cocoa powder.Beat until very smooth.In a separate bowl, beattheegg whites untiltheyformstiffpeaks, thenfold into the cream cheese mixture. Pour into individual souffle" cupsand bake at 350°F for 15-20 minutes,or until golden brown, ta

RHUBARB PIE

6 servings Per serving: 10.5 gm cho, 0.7ozproCHOfem) PRO(gm)

10G/G crispbreads,crushed 30.0 10.0

5 Tbsp butter, softened — 0.7

2 packets JeU-0 unsweetenedlemon pudding mix 13.0 —

1 cup sour cream 8.0 6.4

1 egg, separated 0.6 6.0

Equaltablets,crushed,or stevia to taste — —

2 cups rhubarb cut into 1-inchpieces 11.2 2.4

Preheat oven to 350°F. To make crust, combine crushed crispbreadswith softened butter. Press mixture evenly into an 8-inch pie pan.Combinelemonpuddingmix, sourcream, egg yolk, and Equaltabletsor stevia. Beat until smooth. In separate bowl, beategg whiteuntil stiffpeaks form. Fold theegg white intopudding mixture. Putcut rhubarbinto pie sheU and cover with lemonpudding mixture. Bake at 350°Ffor 25-30 minutes, or until goldenbrown, ta

BEIGNETThis recipe wascreated bymypatient Elise Bahar

when shewasa nineteen-year-old finearts student.1 serving Per serving: 2.9gm cho, 1.4oz pro

CHO (gm) PRO (gm)

1 cup vegetable oU — —1 egg 0.6 6.0

RecipesforLow-Carbohydrate Meals 441

1Tbsp fuU-fat soy flour 1.9 1.81Tbsp heavy cream 0.4 0.3Stevia to taste — —

Cinnamon to taste — —

Heat vegetable oU for about5minutesin a2-quart saucepan whUe youmix the batter. Beat egg, soy flour, cream, and stevia in a bowl untilfuUy mixed. Drop a smaU amount of batter into hot oU. If the droprises to the top, pour rest of batter into hot oU. Wait until edges ofbeignet are golden, then flip to other side. When edges are golden, remove beignet from oU and place on paper towel to drain. Sprinklewith powdered cinnamon.

APPENDIX A

What About the Widely Advocated DietaryRestrictions on Fat, Protein, and Salt, andthe Current High-Fiber Fad?

Most of thisbook is instructional, of the how-tovariety. Theintent of this appendix isto provide youwith aUttle of thescience that surrounds the program described in the restof

the book.With respect to anumber of the issues raised in this section,I would also refer you again to Gary Taubes's award-winning Sciencearticle "The Soft Science of Dietary Fat," which is avaUable on theWeb site for this book, www.diabetes-book.com/articles/ssdf.shtml, orfrom the March 3,2001, edition of the journal Science. Anothermasterpiece by Taubes, "What If It's AU Been a Big Fat Lie?" appeared asthecover article in theNew York Times Magazine of July 2,2002. It canalso be found on this book's Web site.

I hope that I cancut through someof the myths that clouddietandthe treatment of diabetic complications sothatyouwiU have thewhythatsupports the how-to. We've already discussed someof the myths.We'U lookatthe origins of those myths to try to give you as many ofthe facts as are avaUable at thiswriting. If youronly interest is in thehow-to, feel free to skip this appendix.

Once you've started to foUow a restricted-carbohydrate diet, youmay find yourselfpressured by weU-meaning but uninformed friendsor famUy, or even newspaper articles, to cease penaUzing yourself andeat more"fun" foods — sweets, bread, pasta, and fruits. This chapterwiU provide you with specific scientific information that underpinsmy approach and wiU perhaps give you some ammunition for responding to this pressure. Even if you skip it now, you may want tocome backto it later, or show it to your loved ones to lay their concernsto rest.As I don't expect most readers to be scientists, I've triedto keep aU these explanations relatively simple. Some of the explana-

444 AppendixA

tions may at this moment represent more theory than fact,but they'rebased on the latest information avaUable to us.

HOW DID THE COMMONLY PRESCRIBED

HIGH-CARBOHYDRATE DIET COME ABOUT?

If, like me, you've had diabetes for a whUe, you've probably been toldto cut waydown on your dietary intake of fat, protein, and salt, and toeat lots of complexcarbohydrate.You mayevenstill read this adviceinpublications circulatedto diabeticpatients.

Why is such advice being promulgated, when the major cause ofsuch diabetic compUcations as heart disease, kidney disease, highblood pressure,and blindness is high blood sugar?

When I firstdeveloped diabetes, in 1946, Uttle wasknownabout whythis disease, even when treated, caused early death and such distressingcompUcations. Priorto theavaUabiUty of insulin, about twenty-five yearsearUer, peoplewith type 1 diabetes usuaUy died within a few months ofdiagnosis. TheirUves couldbe prolonged somewhat witha diet that wasverylowin carbohydrate and usuaUy highin fat. Mostsufferers fromthemilder type 2 diabetessurvivedon this type ofdiet,without supplemental medication. When I became diabetic, oral hypoglycemic agentswere not avaUable, and many peoplewerestiU foUowing very low carbohydrate, high-fatdiets. It wasat about this time that diets very high insaturated fats,with resultant high serum cholesterollevels, were experi-mentaUy shown to correlate with blood vessel and heart disease in animals. It wasprompdyassumed bymanyphysicians that the then-knowncompUcations of diabetes, most of which related to abnormaUties oflarge or smattbloodvessels, were caused bythehigh-fat diets. I and manyother diabetics weretherefore treatedwith a high-carbohydrate, low-fatdiet. This new diet wasadopted in the mid-1940s by the American Diabetes Association (ADA), the New York Heart Association, and eventu-aUy by theAmerican HeartAssociation (AHA) and other groupsaroundthe world.On the new diet,most of us had much higher serum cholesteroland triglyceride levels, andstill developed thegrave long-termcompUcations of diabetes. Seemingly unaware of the importanceof bloodsugar control, the ADA raisedthe recommendedcarbohydratecontentfrom 40 to 50 percentof calories, and then more recentiy to 60 percent.The ADA's most recentguidelines havebackedoffbyvaguely stating thatsome diabetics maydo betterwith less carbohydrate.

What About Dietary RestrictionsonFat, Protein, and Salt? 445

RECENT DEVELOPMENTS REGARDING RISK

FACTORS FOR HEART DISEASE

In the past twenty years, researchstudies havegenerated considerablenew information about heart disease and vascular (blood vessel) disease in general, and their relationship to diabetes in particular. Someof this recent information is summarized here.

A number of substances have been found in the blood which relate

to riskof heart attacks and vascular disease. These includeHDL(high-density Upoprotein), LDL (low-density Upoprotein), triglyceride,fibrinogen, homocysteine, C-reactive protein, ferritin (iron),and Upoprotein^). High serum levels of dense, compact LDL particles, triglyceride, fibrinogen, homocysteine, C-reactive protein, ferritin, andlipoprotein(a) tend to be associated with increasedcardiovascularrisk,whUe high levels of HDL tend to protect from cardiovasculardisease.Cholesterol is a component of both LDL and HDLparticles. The fraction of totalcholesterol found in LDL particles isan indexof risk,whUethe fraction of cholesterol found in HDL particles is an indexof protection.Nowadays, whenwewant to estimate the effects of Upids (fattysubstances) upon the riskof coronaryarterydisease, welook at the ratio of total cholesterol to HDL and also at fasting triglyceride levels.Someone with high serum HDLcan thus have a high total cholesteroland yetbe at lowstatistical riskfor a heart attack. Conversely, a personwith lowtotal cholesterol and verylowHDLmaybe at high risk.

Alargemulticenter study (the LipidResearch ClinicsTrial) investigatedthe effects of a low-fat, high-carbohydrate dietversus a high-fat,low-carbohydrate diet on nondiabeticmiddle-aged men with elevatedcholesterol levels. The study foUowed 1,900 people for seven years.Throughout this period, total cholesterol had dropped only 5 percentfrom baseline in the low-fat group, but serum triglyceride went upabout 10 percent! (Serum triglyceride rises very rapidly aftera high-carbohydrate meal in nondiabetics, and moves up and down withbloodsugarlevels in most diabetics.) As withprior studies, no significant correlation was found between serum cholesterol levels and

mortality rates. Furthermore, a study reported in the Journal of theAmerican Medical Association in 1997 showed that a 20 percent increase in either saturated or monounsaturated dietary fat loweredtherisk of stroke to one-eighth of what it was in individuals on lower-fatdiets. Unsaturated fats showed no such benefit.

On average, diabetics with chronicaUy high blood sugarshave ele-

446 AppendixA

vated levels of LDL (the "bad" cholesterol) and depressed levels ofHDL (the "good"cholesterol), even though the ADA low-fat diet hasnow been in use for many years. Of great importanceis the recentdiscoverythat the forms of LDLthat harm arteries are smaU, dense LDL,oxidized LDL,and glycated LDL. AU of these increase as blood sugarincreases. In addition, independendy of blood sugars, high serum insulin levelsdictatedby high-carbohydrate diets bring about increasedproduction of the potentiaUy hazardous smaU, dense LDL particlesand enlargement of the ceUs lining the arteries. We now can measurethe size distribution of these LDLsubparticles as a routine laboratorytest. Most labs report the benevolent large, buoyant LDL subparticlesas"type A."

Under normal conditions, receptors in the liver remove LDL fromthe bloodstreamand signal the Uver to reduce its manufactureof LDLwhen serum levels rise even sUghdy. Glucose may bind to the surfaceof the LDL particle and also to liver LDLreceptors, so that LDL cannot be recognized by its receptors. In people with high blood sugars,many LDLparticles become glycosylated, andare therefore not clearedby the Uver. This glycosylation is reversible ifblood sugar drops. Afterabout 24hours,however, a rearrangement ofelectronbonds occursinglycosylated proteins, so that the glucose can't be released even ifblood sugar drops. This irreversible glycosylation is caUed glycation,and the affected proteinmolecules are said to be "glycated." They arealso referred to as AGEs, or advanced glycosylation end products.These AGEs accumulate in the blood, where they can become incorporatedinto thewaUs of arteries, forming fatty deposits caUed atheroticplaques. Since Uver LDL production cannot be turned off by theglycosylated/glycated LDL (and also the presence of glycosylated/glycated LDL receptors), the liver continues to manufacture moreLDL,even though serum levels maybe elevated.

The proteins in the waUs of arteries can also become glycosylated/glycated, rendering them sticky. Otherproteins in the bloodthen stickto the arterial waUs, causing further buUdup of plaque.

Serum proteins glycosylate in the presence of glucose. White bloodceUs caUed macrophages ingest glycosylated/glycated proteinsand glycosylated/glycated LDL. The loaded macrophages sweU up, becomingvery large. These transformed macrophages, loaded with fatty material, are catted foam ceUs. The foam ceUs penetrate the now sticky arterialwaUs, causing disruptionof the orderly architecture of the artery,and narrowthe channel throughwhichblood can flow.

What About Dietary Restrictions onFat, Protein, and Salt? 447

The middle layer ofthewaUs oflarge arteries contains smooth muscle ceUs that caninvade the fatty coating (plaque) that theseceUs create. They then prevent the plaque from breaking loose. When thenerves that control this smooth muscle die, as in diabetic autonomicneuropathy (caused by high blood sugars), the muscle layer dies andcalcifies. It thencannot prevent plaque rupture. When a piece of ruptured plaque enters the blood it can block narrow vessels upstreamand cause a heart attack or stroke.

In recentyears, the tendency ofblood to clothascome into focus asa majorcause of heart attacks. People whose blood clots too readUyare atvery high risk.You may recaU that one of the medicalnames fora heartattackis coronary thrombosis. A thrombus is a clot,and coronary thrombosis refers to the formation of alarge clot in oneof thearteries that feed the heart. People who have elevated levels of certainclotting precursors or depressed levels of clotting inhibitors in theirblood are at high riskof dying from heart attacks. This risk probablyfar exceeds that caused by high LDLor low HDL. Some of the bloodfactors that enhance clotting include fibrinogen and factor VII. Another factor, Upoprotein(a), inhibits the destruction of smaU thrombibefore they become large enoughto cause a heart attack. AU of thesefactors have been found to increase in people with chronicaUy highblood sugars. Platelets, or thrombocytes, are particles in the blood thatplaymajorroles in the blocking of arteries andthe formation of clots.These have been shown to clump together and stick to arterial wallsmuch more aggressively in people with high blood sugars. What is excitingis that aU of these factors, including stickyplatelets, tend to normalizeaslong-term blood sugars improve.

Diabetics die from heart faUure atarate far exceeding thatof peoplewith normal glucose tolerance. Heart faUure involves a weakening ofthe cardiac muscleso that it cannot pump enoughblood. Most long-term, poorly controlled diabetics have a condition called cardiomyopathy. In diabetic cardiomyopathy, the muscle tissue of the heart isslowlyreplaced by scar tissueovera periodof years. This weakens themuscle so that it eventuaUy "faUs." There is no evidence linking cardiomyopathy with dietary fat intake or serumlipids.

A fifteen-year study of 7,038 French policemen in Paris reportedthat "the earUest marker of a higher risk of coronary heart diseasemortality is an elevation of serum insulin level." A study of middle-aged nondiabetic women at the University of Pittsburgh showed anincreasing risk ofheart disease asserum insulin levelsincreased. Other

448 AppendixA

studies in nondiabetics have shown strong correlations between elevated serum insuUn levels and other predictors of cardiac risk such ashypertension, elevated triglyceride, and lowHDL. The importance ofelevated serum insulin levels (hyperinsulinemia) as a cause of heartdisease and hypertension hastakenon such importancethat a specialsymposium on this subject was held at the end of the 1990 annualmeetingof the ADA.A report in asubsequent issue of the journal Diabetes Care quite appropriately pointsout that"thereare few avaUablemethods of treatingdiabetes that do not resultin systemichyperinsulinemia [unless the patient is foUowing a low-carbohydrate diet]."Furthermore, research pubUshed in the journal Diabetes in 1990 demonstrated that elevated serum insulin levels cause excessive leakage ofprotein from smaU bloodvessels. This isacommon factor in the etiology ofblindness(viamacular edema)and kidney disease in diabetics.

Although the AHA and the ADA have been recommending low-fat, high-carbohydrate diets for diabetics for many decades, no onehad compared the effects on the same patients of low- versus high-carbohydrate diets until the late 1980s. Independent studies performedin Texas and CaUfornia demonstratedlowerlevels ofblood sugarandimproved blood Upids when patients wereput on lower-carbohydrate,high-fat diets. It was also shown that, on average, for every 1 percentincrease in HgbAlc (the test for average blood sugar over the priorfour months), total serum cholesterol rose 2.2 percent and triglycerides increased 8 percent. A long-term study of 7,321 "nondiabetics"in 2006 showed that for every 1percent increase in HgbAlc above 4.5percent, the incidence of coronary artery disease increased 2.5-fold.The same study also showed that for every 1 percent increase inHgbAlc above 4.9 percent, mortality increased by28 percent.

The National Health Examination FoUow-Up Survey, which followed 4,710 people, reported in 1990 that "in the instance of totalblood cholesterol, we found no evidencein anyage-sexgroup ofa riskassociated with elevatedvalues." That's right: they found no risk associated direcdywith elevated total cholesterol. On the same page, thisstudy lists diabetes asby far the single most important risk factor affecting mortality. In males aged 55-64, for example, diabetes wasassociatedwith 60 percent greater mortality than smoking and double themortaUtyassociated with high blood pressure.

The evidence isnow simply overwhelmingthat elevatedblood sugaris the major causeof the high serum lipid levels among diabetics and,more significantiy, the major factor in the high rates of various heart

What AboutDietary Restrictions on Fat, Protein, and Salt? 449

andvascular diseases associated withdiabetes. Many diabetics were puton low-fat diets for so many years, andyet theseproblems didn't stop.It is only logical to look to elevated blood sugar and hyperinsulinemiafor the causes of what kills and disables so many of us.

My personal experience with diabetic patientsis very simple.Whenwe reduce dietary carbohydrate, blood sugars improve dramaticaUy.Afterseveral months of improved bloodsugars, we repeat our studiesof Upid profiles and thrombotic risk factors. In the great majorityofcases, I see normalization or improvement of abnormaUties.* ThisparaUels what happenedto me more thanthirty-fiveyears ago, when Iabandonedthe high-carbohydrate, low-fatdiet that I had been foUowing since 1946.

Sometimes,months to years aftera patienthasexperienced normalor near-normal blood sugars and improvements in the cardiac riskprofile,we wiU seedeteriorationin the resultsofsuch tests as those forLDL, HDL,homocysteine,and fibrinogen. AU too often, the patientorhis physician wiU blame our diet. Inevitably, however, we find uponfurther testingthat his thyroidactivity hasdeclined. Hypothyroidismis an autoimmune disorder, like type 1 diabetes, and is frequendy inheritedby diabetics andtheirclose relatives. It canappear years beforeor after the development of diabetes and is not caused by high bloodsugars. In fact, hypothyroidism can cause a greater likelihood of abnormaUties of the cardiac risk profile than canblood sugar elevation.The treatment of a low thyroid condition is oral replacement of thedeficient hormone(s)— usuaUy one piU daUy. The best screening testis free T3, tested by tracer dialysis. If this islow, thena fuU thyroid riskprofile should be performed. Correction of the thyroid deficiency inevitably corrects the abnormaUties of cardiac risk factors that itcaused.

*Ifyourphysician finds aU of thishardto beUeve, he or shemightbenefit fromreadingthe seventy articles and abstracts on this subjectcontained in the Proceedings of the Fifteenth International Diabetes Foundation Satellite Symposiumon "Diabetes and Macrovascular CompUcations "Diabetes 45,Supplement3, July 1996. Also worth reading is "Effects of Varying Carbohydrate Contentof Diet in Patients with Non-Insulin Dependent Diabetes MelUtus," by Garg etal., Inl Amer Med Assoc 1994; 271:1421-1428. Many studies comparing low-carbohydrate andlow-fat diets arepresented each year at meetings of the Metabolism and NutritionSociety. The low-carbohydrate dietsinvariably haveshownreduced cardiac risk.

450 AppendixA

WHY IS PROTEIN RESTRICTION

SO COMMON?

About 30 percent of diabetics develop kidney disease (nephropathy). Diabetes is the greatest single cause of kidney faUure in theUnited States. Earlykidneychanges can be found within two to threeyears of the onset of high blood sugars. As we discussed briefly inChapter 9, the common restrictions on protein intake by diabetic patients derive from fear regarding this problem, and ignorance of theactual causesof diabetic kidney disease.

Bylooking at how the kidneyfunctions,one can better understandthe relative roles of glucoseand protein in the kidney faUure of diabetes.The kidney filters wastes, glucose, drugs, and other potentiaUytoxic materials from the blood and deposits them into the urine. It isthe urine-making organ. A normal kidney contains about 1 miUionmicroscopic blood filters, caUed glomeruli. FigureA-1 iUustrates howblood enters a glomerulus through a tiny artery caUed the incomingarteriole. The arteriole feeds a bundle or tuft of tiny vessels caUed cap-Ularies. The capUlaries contain tinyholesor pores that carry a negativeelectrical charge. The downstream ends of the capUlaries merge into

Incoming Arteriole

Blood In

(Low Pressure)

CapillaryTuft

Capsule

GlomerulusHigh Pressure

Fig.A-1. The microscopicfiltrationunitof the kidneys.

Outgoing Arteriole

Blood Out

•Mesangium

•Pore

NegativeElectricalCharge

Terry Eppndge

WhatAboutDietaryRestrictions onFat, Protein, andSalt? 451

an outgoing arteriole, which is narrower than the incoming arteriole.This narrowing results in high fluid pressure when blood flowsthrough the capUlary tuft. The high pressure forces some of the waterin the blood through the poresof the capUlaries. This water dribblesinto the capsule surrounding the capUlary tuft. The capsule, acting likea funnel, empties the waterinto a pipelike structurecaUed the tubule.The pores of the capUlaries areof such a size that smaU molecules inthe blood, such as glucose and urea, can pass through with the waterto form urine. In a normal kidney, large molecules, such as proteins,cannot readUy get through the pores. Sincemost blood proteins carrynegative electrical charges, even the smaUer proteinsin the blood cannot easUy get through the pores, because they are repeUed by the negativecharge on each pore.

The glomerular filtration rate (GFR) is a measureof how much filtering the kidneys perform in a given period of time. Many diabeticswith frequent high blood sugars and normalkidneyswiU initiaUy havean excessively high GFR. This is in part because blood glucose drawswaterinto the bloodstream from the surroundingtissues, thus increasingbloodvolume,blood pressure, andblood flow through the kidneys.A GFR that is one-and-a-half to two times normal is not uncommon in

diabetics with high blood sugars priorto the onsetofpermanent injuryto theirkidneys.These peoplemay typicaUy have asmuch glucose in a24-hour urine coUection asthe weightof 5 to 50 packets of sugar. Accordingto an ItaUan study,an increase in blood sugarfrom 80 mg/dl to272mg/dl resulted in anaverage GFR increase of40 percent evenin diabetics with kidneys that were not fuUy functional. Before we knewabout glycosylation of proteins and the other toxic effects of glucoseupon blood vessels, it was speculated that the cause of diabetic kidneydisease (nephropathy) wasthis excessive filtration (hyperfiltration).

The metabolism of dietary protein produces waste products such asurea and ammonium, which contain nitrogen.* It therefore had beenspeculated that in order to clear these wastes from the blood, peopleeatinglarge amounts of protein would have elevated GFRs. As a result,diabetics have been urged to reduce their protein intake to low levels.Studiesby an IsraeU group, however, of nondiabetic people on high-protein (meat-eating) and very low protein (vegetarian) diets,disclosed

* A 1995 article in the journal Nutritional Biochemistry, 6:411-437, demonstrated that a higher protein diet enables the kidneys to increase their capacityfor net acid secretion as ammonium.

452 Appendix A

no differencein GFRs. Furthermore, overmany years on these diets,kidney function was unchanged between the two groups. A report fromDenmarkdescribed astudyinwhichtype 1diabetics without discerniblekidney disease were put on protein-restricted diets, and experienced averysmaU reduction in GFR andno change in other measures ofkidneyfunction. As long ago as 1984, a study appeared in the journal DiabeticNephropathy demonstrating thatelevated GFR isneither anecessarynora sufficient condition forthe development ofdiabetic kidney disease.

This evidence would suggest that the currendy prevaUing admonition to aU diabetics to reduce protein intake is unjustified.

Studieson diabetic rats haveshown the foUowing: Ratswith bloodsugars maintainedat 250mg/dl rapidly develop diabetic nephropathy(kidney disease). If their dietaryprotein is increased, kidney destruction accelerates. At the samelaboratory, diabetic ratswith blood sugarsmaintained at 100 mg/dl Uve fuU Uves and neverdevelopnephropathy,no matter how much protein they consume. Diabetic rats with highblood sugars and significant nephropathy have showntotal reversal oftheir kidney disease after blood sugars were normalized for severalmonths.

Other studies have enabledresearchers to piecetogether a scenariofor the causes of diabetic nephropathy, where glycosylation of proteins, abnormalclotting factors, abnormalplatelets, antibodiesto glycosylated proteins, and so on, join together to injure glomerularcapUlaries. Early injury may only cause reduction of electrical chargeon the pores. As a result, negatively charged proteins such asalbuminleak through the pores and appear in the urine. Glycosylated proteinsleak through pores much earUer than normal proteins. High bloodpressure, and especiaUy high serum insuUn levels, can increase GFRand force even more proteinto leakthrough the pores. If some of theseproteinsare glycosylated or glycated, they wiU stick to the mesangium,the tissue between the capUlaries. Examination of diabetic glomeruUindeed discloses large deposits of glycated proteins and antibodies toglycated proteins in capUlary waUs and mesangium. As thesedepositsincrease, the mesangium compresses the capUlaries, causingpressurein the capUlaries to increase (enlarging the pores) and larger proteinsto leak from the pores. This leads to more thickening of the mesangium, more compression of the capUlaries, and acceleration of destruction. EventuaUy the mesangiumand capUlaries become a mass ofscar tissue. Independentiyof this,both high blood sugars and glycatedproteins cause mesangial ceUs to produce type IV coUagen, a fibrous

WhatAbout DietaryRestrictions onFat, Protein, andSalt? 453

material that further increases their bulk. Increase in mesangial volume hasbeen found to be commonplace in poorlycontroUed diabetesevenbefore albumin or other proteins appear in the urine.

Many studies performed on humans show that when blood sugarsimprove, GFR improves and less protein leaks into the urine. Whenblood sugars remain high, however, there is further deterioration.There isa point of no return, where aglomerulus has beenso injuredthat no amount of blood sugar improvement can revive it. Althoughthis seemsto be true for humans,blood sugar normaUzation hasactu-aUy brought about the appearance of new glomeruU in rats.

Nowadays many diabetics who have lost aU kidney function aretreated by artificial kidneys (dialysis machines) that remove nitrogenous wastes from the blood. In orderto reduce the weekly number ofdialysis treatments, which are cosdy and unpleasant, patients are severely restrictedin their consumption of both water and dietary protein. Instead ofusinglarge amounts of carbohydrate to replace the lostcalories, many dialysis centers now recommend oUve oU to their diabetics.OliveoU is high in monounsaturated fats, which arebeUeved bysome to lower the risk of heart disease.

Becausethe survival rate of diabetics on dialysis is so much lowerthan that of nondiabetics, some dialysis centers are now using low-carbohydrate, high-proteindiets for their diabetic patients.

In summary: Diabetic nephropathy does not appear if bloodsugar iskept normal. Dietary protein does not causediabeticnephropathy, butcan possibly (stiU uncertain) slightly accelerate the process once therehasbeen major, irreversible kidney damage. Dietary proteinhasno substantial effect upon the GFR of healthykidneys, certainlynot in comparison to the GFR increase caused by elevated blood sugar levels.*

*Your physician might find informative the following articles on this subject:"Molecular and Physiological Aspects of Nephropathy in Type 1 Diabetes MeUi-tus," by Raskin and Tamborlane, Jnl Diabetes and Its Complications, 1996,10:31-37; "The Effects of DietaryProtein Restrictionand BloodPressureControlon the Progression of Chronic Renal Disease," byS.Klahr et al.,New England JnlMed, 1994,330:877-884; also,in the same issueof NewEngland Jnl Med, the editorial "The Role of Dietary Protein Restriction in Progressive Azotemia" (pp.929-930). Another study, in the journal Diabetes Care, 25:425-430, in the year2000, showed that obese people on a high-protein diet lost more fat and lessmuscle mass than those on a low-fat diet. They also showed more than doublethe reduction in LDL (the "bad" cholesterol).

454 AppendixA

The May 1996 Journal of the American Medical Association pubUshed a summary of fifty-six studies demonstrating that in nondiabetics increased protein consumption actuaUy lowered bloodpressure.

RESTRICTIONS ON SALT INTAKE: ARE

THEY REASONABLE FOR ALL DIABETICS?

Manydiabetics have hypertension, or highblood pressure. Abouthalfof aU peoplewith hypertension wUl experience blood pressure elevations when they eat substantial amounts of salt for at least twomonths. This rarelyoccurs in those who are not alreadyhypertensive.Hypertension accelerates glomerulopathy (destruction of the glomerulus) in peoplewith chronicaUy elevated blood sugars,but in type 1diabetes, hypertension usuaUy appears after, not before, the appearance of kidney damageas indicatedbysignificantamounts of albuminin the urine. Is it therefore appropriate to ask aU diabetics to lowertheir salt intake?* Let us look at a few of the mechanisms involved in

the hypertension that some diabetics experience.People with advanced glomerulopathy wUl inevitably develop hy

pertension, in part because GFRis severelydiminished. These peoplecannot make enough urine, and therefore they retain water. Excessivewater in the blood causes elevated blood pressure. There are manyother ways hypertension can be caused by high blood sugars. Themere presenceof high blood sugarwiU causewater to leavetissues andenter the bloodstream, even experimentaUy in nondiabetics.

It is not unusual to observe reduction in blood pressure concomitant with control of blood sugar. Studies have shown that many, andpossibly most, hypertensive nondiabetics are insulin-resistant, andthereforehavehigh serum insulin levels. In addition to causingeleva-

* A study of older individuals who were rotated between low-, moderate-, andhigh-saltdietsdemonstrated that thoseon low-salt dietsexperienced significantlymore sleep disturbances, and had more rapid heart ratesand higher serum epinephrine (adrenaline) levels. An international study called Intersalt, covering10,079 people in 32 countries, reportedin 1988 that "salt has only smaU importance in hypertension."More recendy, another study showed that salt restrictionincreases insulin resistance and thus can indirectlyincrease blood pressure.

Large amounts of dietary salt can facilitate loss of calcium from bones ofpost-menopausal women, who are already at high risk for osteoporosis (boneweakening).

WhatAboutDietaryRestrictions onFat, Protein, andSalt? 455

tion of serum triglycerides and reduction in serum HDL in nondiabetics, high serum insulin levels have long been known to foster saltand water retention by the kidneys. Furthermore, excessive insulinstimulates the sympathetic nervous system, which in turn speeds upthe heart and constricts blood vessels, causing further increase inblood pressure. Thus type 2 diabetics who eat lots of carbohydrate,and therefore wiU tend to make excessive insulin, can readUy develophypertension. Type 1 diabetics treated with the usual industrial dosesof insulin to cover high-carbohydrate diets are likewise more susceptible to hypertension.One dramatic studyshowedthat in hypertensiveindividuals, blood pressure is directiy proportional to serum insulinlevel.A report from Nottingham, England, showed that a brief infusion of insulin and glucose would increase blood pressure in normalmen without changing their blood sugars. A 1998 study in Glasgow,Scodand, demonstrated that salt restriction increased insulin resis

tance in type 2 diabetics.Why don't aU diabetics on high-carbohydrate diets or aU poorly

controUed diabeticshave hypertension?One reason is that the body has several very efficient systems for

unloadingsodium (a component of salt) and water. One of the moreimportant of these systems is controUed by a hormone manufacturedin the heart caUedatrial naturietic factor (ANF). When the heart is expanded by evenaslight fluid overload, it produces ANF. The ANFthensignals the kidneys to unload sodium and water. Hypertensive individuals,and the chUdren of two hypertensiveparents, tend to producemuch lower amounts of ANF than do normal people. Nonhyperten-sive diabetics apparentiy are able to produce enough ANF to controlthe blood pressure effectsofhighblood sugars andhigh serum insulinlevels, providedthey do not havemoderatelyadvanced kidney disease.Indeed, a study, in which some of my patients participated, showedthat diabetics with highblood sugars produce significantly moreANFthan those with lower blood sugars.

Howdoes aU this apply to you? First, youandyourphysician shouldknow if you have glomerulopathy. This is readUy determined if the renal risk profile tests suggested in Chapter 2 are performed. If thesetests are abnormal, your physician may advise you to reduce your saltintake because salt is much more likely to cause hypertension inpeople with diminished GFR.

Whetheryourrenal riskprofile isnormal or abnormal, yourrestingblood pressure should also be measured. A proper measurement re-

456 AppendixA

quires that you be seated in a quiet room, without conversation, for15-30 minutes. Blood pressure should be measuredevery 5 minutes,until it dropsto a lowvalue andthenstartsto increase. Thelowest reading is the significant one.Ifyougetnervous in the doctor'soffice, thenyou should measure your own blood pressure at home in a simUarfashion. Repeated measurements with lowvalues just exceeding 125/75suggest that yourbloodpressure is"borderline." You then maybenefitfrom dietarysalt reduction. The onlyway to find out is to check yourblood pressure whUe on your current salt intake, and again after followinga low-salt (sodium) diet for at least two months.*Your physician can give you guideUnes for such a diet, and you can consultnutritional tablessuchas those in the books listedin Chapter 3.1wouldsuggest that restingblood pressures be measured several times a day,and at the samehours eachday, throughout the study. Eachday'sbloodpressures can then be averaged, and the averages compared. If yourblood pressure dropssignificandy on the low-salt diet,your physicianmayurgeyou to keep the saltintake down. Alternatively, he maywantyou to take small amounts of supplementalpotassium,which tends tooffset the effects of dietary salt on blood pressure. People with advanced kidneydisease should not consume supplemental potassium.Recentstudies suggest that as many as 40 percent of hypertensive patients (the so-caUed low-renin hypertensives) may show lower bloodpressureswhen they take calciumsupplements.

WHAT ABOUT DIETARY FIBER?

"Fiber"isa generalterm that hascometo referto the undigestible portionof many vegetables andfruits. Some vegetable fibers, suchasguarand pectin,are soluble in water. Anothertype of fiber, whichsome ofus caU roughage, is not water soluble. Both types appear to affect themovement of food through the gut (soluble fiber slows processing inthe upper digestive tract,whUe insoluble fiber speeds digestion fartherdown). Certain insoluble fiber products, such as psyUium, have long

*To complicate things somewhat, a 1998 report in the Journal of Clinical Endocrinology andMetabolism demonstrated that saltrestriction in nonhypertensivetype 2 diabetics reduced insulin sensitivity by 15 percent. A prior article in theAmerican Journal ofHypertension found a similar effect in hypertensive individuals.Another study of rats,publishedin the journal Diabetes in 2001,found that thisinsulinresistance cannotbe reversed by the insulin-sensitizing agentpioglitazone.

WhatAbout DietaryRestrictions on Fat, Protein, andSalt? 457

been used as laxatives. Consumption of large amounts of dietary fiberis usually unpleasant, because both types can cause abdominal discomfort, diarrhea, and flatulence. Sources of insoluble fiber includemost salad vegetables. Soluble fiber is found in many beans, such asgarbanzos, and in certain fruits, such as apples.

I first learned of attempts at using fiber as an adjunct to the treatmentof diabetesabout thirty yearsago. At that time, Dr.DavidJenkins, in England, reported that guar gum, when added to bread, could reduce themaximumpostprandial bloodsugarrise from an entire meal by 36 percent in diabetic subjects. Thiswas interesting forseveral reasons. FirstofaU, the discovery occurred at a time when few new approaches to controlling blood sugar were appearing in the medical literature. Second, Imissed the high-carbohydrate foods I had given up, and hoped I mightpossibly reinstatesome. I managedto trackdown a supplier of powderedguar gum, and placeda considerable amount into a folded slice of bread.I knew how much a sliceofbread would affectmy blood sugar, and so asan experiment, I used the same amount of guar gum that Dr. Jenkins hadused, and then ate the concoction on an empty stomach. The chore wasdifficult, becauseonce moistenedbymysaliva, the guar gum stuck to mypalate and was difficultto swallow. I did not find any change in the subsequent blood sugar increase. Despite the unpleasantness of chokingdown powdered guar gum (which is often used in commercial productssuch as icecream as a thickener),I repeatedthisexperiment on two moreoccasions, with the same result. Subsequendy, some investigators haveannounced results similar to those of Dr. Jenkins,yet other researchershavefound no effect on postprandial blood sugar. In any event,a reduction of postprandial blood sugar increase by only 36 percent reaUy isn'tadequate for our purpose, sincewe're shooting for the same blood sugars as nondiabetics. This means virtually no rise after eating.

Dr. Jenkins also discovered, however, that the chronic use of guargum resulted in a reductionof serum cholesterol levels. This isprobablyrelated to the considerable recirculation of cholesterol through the gut.The liver secretes cholesterol into bile, which is released into the upperintestine. This cholesterol is later absorbed lower in the intestines, andeventuaUy reappears in the blood. Guar binds the cholesterol in the intestines, so that rather than being absorbed, it appears in the stool.

In the light of these very interesting results,other researchers studied the effect of foods (usuaUy beans) containing other soluble forms offiber. When beans were substituted for faster-acting forms of carbohydrate, postprandial blood sugars in diabetics increased more slowly,

458 AppendixA

and the peakswereevensUghdy reduced. Serum cholesterol levels werealso reduced by about 15percent. But subsequent studies, reportedin1990, have uncovered flaws in the original reports, casting seriousdoubt upon anydirect effect of these foods upon serumUpids. In anyevent,postprandial blood sugars ofdiabetics werenevernormalizedbysuch diets.

Many popular articles and books have appearedadvocating"high-fiber" diets for everyone— not just diabetics. Somehow,"fiber"cameto mean aU fiber, not just soluble fiber, even though the only viablestudies had utilized such products asguargum and beans.

In my experience, reductionof dietarycarbohydrate is far more effective in preventing blood sugar increases after meals. The lowerblood sugars, in turn, bring about improved Upid profiles. It is true,however, that low-carbohydrate vegetables are usuaUy composedmosdy of insoluble fiber and therefore contain far lessdigestible carbohydratethan starchy vegetables. Thus ifwe compare fiber to starch,there is great valuein "high fiber."

Another food to jointhe high-fiber trendis oatbran. This hasgotten a lot of playin the popular press. A patientof mine startedsubstituting oat bran muffins for protein in her diet. Beforeshe started,herHgbAlc (see Chapter 2) was withinthe normal range andher ratio oftotal cholesterol to HDLwasvery low (meaningher cardiac risk ratiowas low). After three months on oat bran, her HgbAlc became elevated and her cholesterol-to-HDL rationearlydoubled. I tried one ofhertiny oatbran muffins after first injecting 3 unitsof fast-acting insulin (as much as I use for an entire meal). After3 hours, my bloodsugar went up by about 100 mg/dl, to 190 mg/dl. This iUustrates theadverse effect that most oat bran preparations can have upon bloodsugar. This is because most such preparations contain flour. On theother hand, I find that certain bran products, such asthe bran crackersUsted in Chapter 10, raise bloodsugarveryUttle. Unlike most packaged bran products, they contain mosdy bran and Utde flour. Theytherefore have very Utde digestible carbohydrate. You can performsimUar experiments yourself. Just useyourblood glucose meter.

Beware of commercial "high-fiber" products that promise cholesterol reduction. If they contain carbohydrate, they must at least becounted in your meal plan and wUl probably renderUttle or no improvement in your Upid profile.

Fiber, likecarbohydrate, is not essential for a healthy life. Just lookat the Eskimos and other hunting populationsthat survivealmost ex-

WhatAboutDietaryRestrictions onFat, Protein, and Salt? 459

clusively on protein and fat, anddon't develop cardiac or circulatorydiseases/

WHAT ABOUT THE GLYCEMIC INDEX?

For a number of years, the term "glycemic index"has popped in andout of the popular press. It also hasbeena pet subject for manydietitians and diabetes educators. I wUl explain why, but I think it's important to make clearthat there is simplyno wayto determine objectivelyhow any given food at any given time is going to behavein any givenindividual, unless blood sugar is tested before and for a number ofhours after its consumption. It sounds likean elegantidea — mashedpotatoes do X; table sugar does Y. Aswith a lot of elegant ideas,however,the reaUty is far more complex.

This term was,as I recatt,first coined by the same Dr. Jenkins mentioned in the abovesection.The concept is more compUcated than thepopular press would haveyou beUeve.

Imagine two graphs, eachdepictinga curveof a blood sugar increaseover a 3-hour time span. The first curve is after eating pure glucose,the standard. The second is after eating any other food of equivalenttotal carbohydratecontent (20 grams glucose versus 20 grams carbohydratecontent of, say, rice).

Dr. Jenkins defined the glycemic index for a given food in termsofhow its curve related to that of the glucose curve.

So to arrive at the index for rice, for example,the area under the 3-hour curve of blood sugar increase caused by the rice would be divided by the area under the curve for pure glucose. The measurementis usuaUy made on a number of nondiabetics and then averaged, andfinaUy expressed as a percent. Thus, if a food generates a 3-hour areaone-fifth that of glucose, its glycemic indexwould be 20 percent.

So what's wrong with that?

*As the firstedition of this book wasgoing to press, a report appeared entitled"Dietary Fiber, Glycemic Load, and Risk of Non-Insulin-Dependent Diabetes inWomen" (JnlAmer MedAssoc 1997; 277:472-477). This study of 65,173 nursesand former nurses found a strong association between diets high in starch, flour,and sweet foodsand the development of type2 diabetes. Furthermore,consumptionofminimaUy refined grain(such asbranwithout flour) lowered thisrisk Thecombination of high glycemic foods and lowintake of unrefined insoluble fiberwasassociated with a 2.5-foldhigher incidence of diabetes. If you remember ourdiscussion of beta ceU burnout (pages 39-42), this should comeas no surprise.

460 AppendixA

As attractiveasit may seem,the concept is clearly flawed in three respects: First, diabetics show much higher blood sugar increases thannondiabetics. Second,digestionof the carbohydrate portion of a mealtypicaUy takes at least 5 hours (in the absence of gastroparesis), andthe index ignores effects upon blood sugar that last longer than 3hours. FinaUy, the index is an average ofvalues fora number of different people,and true numbers have been found to vary considerablyfrom one person to another, from one time to another, and from onestudy to another. As I've pointed out, a food that makes my bloodsugar rise dramaticaUy mayhaveUttle or no effecton that ofone ofmypatients who stiU makes some insulin.

Unfortunately, many dieticians and diabetes educators stiU recommend foods that have been"shown" to have a"low"glycemic index insome study, and assume that an indexof 40or 50 percent is low.Theymaythus select apples, limabeans, andthe likeas appropriate fordiabetics, even though consumption of typical portions of these foodswUl cause considerable blood sugar elevations in diabetics.

A "medium-sized" apple, according to one table of food values,contains 21 grams of carbohydrate. It wUl raise my own blood sugarby 105 mg/dl, and much morerapidly than I canprevent with an injection of rapid-acting insulin. Peanuts usuaUy have the lowestglycemic indexin many studies (about 15 percent), yet 1ounce contains 6 grams of carbohydrate and close to 1 ounce of protein. I'vefound this portion to raise my blood sugar by 80 mg/dl, albeit muchmore slowly than the apple. Since peanuts work so slowly (moreslowly than 3 hours), I can substitute 1 ounce for 6 grams carbohydrate and 1 ounce protein in a meal — but who can eat only onehandful of peanuts?*

The carbohydrate foods that we recommend, salads and selectedvegetables (Chapter 9),have glycemic indices lower than peanuts andwork moreslowly. Furthermore, they are more fiUing. The issue here,though, is to understand that such indices are unreliable and won'thelp you keep yourblood sugars normalized.

*By the way, natural peanut butterhasa glycemic index much higherthan thatofthepeanuts from which itwas created because it isdigested more rapidly.

What About Dietary Restrictions on Fat, Protein, and Salt? 461

WHAT DIET WILL WORK FOR YOU?

Actual results are the yardstick for an appropriate diet. We have thetools for self-monitoring of blood sugarand blood pressure. Wehavetests for measuring kidney function, HgbAlc, thrombotic risk profiles,and Upid profiles (seeChapter2). Underyour doctor'ssupervision, tryour diet recommendations for at least three months. Then try anyother dietplan for threemonths and seewhathappens.The differencesmaynot be in the direction that the popularUterature would predict.

FinaUy, in its most common usage, "diet" usuaUy indicates somesort of franchise. "The Diet" (you can fiU in the blank) usuaUyhas a particular name or marketingterm associated with it and oftencomes with products ready for your consumption. When I use theterm, I'm referring to diet in the verysimplesenseof what you eat. I'mnot selling a brand or products, but providingguidelines so that youcan understand how foods are likelyto affectyou.You can then createyour own diet, one that wiU not only aUow you to keep your bloodsugarsnormalized but also to satisfy yourself.

APPEN DIX D

Don't Permit Hospitalization or LengthyOutpatient Procedures to Impair YourBlood Sugar Control

If ever it is necessary for you to become a hospital patient almostanywhere in the world,the chances are overwhelmingthat no reasonable thought wiU be given to controlling your blood sugar.

Most of the medical orthodoxy doesn't do it anywhere else, so whyshould they do it in the hospital?

The reasons for such neglect, of course, are many: lack of bloodsugar control skUls on the part of most hospital medical staff; un-awareness of the importance of normal or near-normal blood sugarsin the face ofUlness or surgery; and an almost pathological fear of severe hypoglycemia (and the potential for lawsuits in the United Statesif it occurs).Many if not most hospitaldietitians havebeen indoctrinated by the ADA,with the resultthat diabetic inpatients are forced toeathigh-carbohydrate foods andare deprived ofproteinand fat. Someof my patientsteU stories of havingto sneak in their own insulin andblood sugar meter, throw out hospital food, and fight tooth and naUwith weU-meaning but uninformedhospital personnel.

Many studies of hospitalized patients have demonstrated that elevatedbloodsugar delays surgical healing, increases riskof postsurgicalmorbidity and mortality, delays recovery from infections, and leavespatients open to new infection. It alsohasbeen shown to increase deathrate of patients who havebeen hospitalized for heart attack or stroke,and increases the likelihood of a new stroke or heart attack.

What can you do to help keep your blood sugars under controlwhUein the hospital?

Most of my patientslivegreat distances from my office,so that I amnot the admitting physician or surgeon when they are hospitalized,

Don'tPermitHospitalizationto ImpairBloodSugar Control 463

and I am thus not in a positionto write theirorders, help controltheirdiets, and directly overseetheir medical care.

After sharing the frustration of my patients over the years, I'vecome up with aletter that hasworkedrepeatedly for elective hospitalization,such as for surgeries plannedin advance. As you wiU see,it relies on the prevailing fear of Utigation that appropriately permeatesthe medical caresystem in the United States. This letter should be sentby youor yourdiabetologist to the admittingphysician, with acopytothe hospital administrator. I've composed the letter as if you werewriting it, since the odds arethat you arenot under the careof a diabetologist. It can,of course, be modified to suit your circumstances.

Dear Dr. :

I am scheduledfor admission toyour hospital on . Ihavetype [1 or2] diabetes andam naturally concerned aboutcontrol of my blood sugars while hospitalized.

It is nowgenerally accepted thatelevated blood sugar levels impederecovery, prolong hospitalization, andincrease theincidenceofhospital andsurgical morbidity anddeath. Major health problems brought aboutby inappropriate blood sugar elevations duringhospitalization have justifiably ledto litigation.

Since I have been successful at keeping my blood sugars essentially normalaround theclock, I naturally expectequivalentcarewhileYm in the hands of medical professionals.

I currently takethefollowing medications for controlling mybloodsugars:

[Listhere doses, times, and purposes of medications:"basal insulin(or ISA) to cover the fasting state — must be given even if noteating,""prelunch (breakfast, supper) insulin (or ISA), to beskipped if meal is skipped." Detail also any use of insulin, glucose

tablets, or Uquidoral glucose for correctingoff-target blood sugars,etcYou may also include a sampleGlucograf sheet and requestthat allmedications used by the hospital that may affect bloodsugarbe listed on it if you arenot capable of listing them yourself.]

My hospital orders should call fora "normal diet"and not a"diabetic diet," so that I can select my own meals.

464 Appendix B

Routine intravenous fluids should not contain caloric substances such asglucose, fructose, lactose, lactated Ringer s solution,orsaline with added glucose (except for treatment ofblood sugarsthatarebelow my target). Allof these substances will raise myblood sugar to unacceptable levels. Normal saline solution isperfectly adequatefor routine hydration. My target blood sugar is

mg/dl.IfI am conscious andwithoutcognitive impairment, I should

have full responsibility for treatment ofmy diabetes — withoutoutside interference.

My blood sugar meter andblood sugar control medications, including insulin syringes, should notbeconfiscated by hospital personnel. This isa barbaric practice that is rapidly being abandonedin modern hospitals.*

IfI am unable tocare formyown blood sugars, I expect that thehospital staffwillexercise every effort to maintain myblood sugarswithin therange of [00-00].

Sincerely,

cc: [Hospitaladministrator][Close relative orfriend]

This lettermay also be ofvalueif you are to havecertain outpatientprocedures, such asendoscopy, cataract surgery, herniarepair, and soon. These are frequendy performed in physicians' offices or in hospitals without the requirement for staying overnight.

*Many hospital pharmacies do not stock theproducts thatwecommonlyutilizein thisbook,suchas25-30-unit insulin syringes with V4-unit markings, detemir(Levemir) or glargine (Lantus) insulins, and lispro (Humalog) or aspart (No-volog) insulins.

APPENDIX C

Drugs That May AffectBlood Glucose LevelsStephen Freed, RPh, Diabetes Educator

Publisher, www.DiabetesinControl.com and www.diabetes91 l.net

David Joffe, RPh, FACA

Editor in Chief, www.DiabetesinControl.com

When we look at drugsthat may affectglucose levels, we needto invoke some special rules. There aremedicines that cancause hypoglycemia (low blood sugar) or hyperglycemia

(highblood sugar) in diabetic and in nondiabetic patients. These pharmaceuticals wUl have an even greater effect on the patient with diabetes and should either be avoided or used with vigUance and with aconsideration ofchanging the amount ofthe diabetes medicationused.

Some medications are found to havea possibleeffect on the patientwith diabetes but canbe used more freely. Again, however, vigUance iswarranted.

There is also a category of medications that interact with diabetesmedications. These medications don't actuaUy cause hypoglycemia orhyperglycemia, but rather they can interfere with the action of themedicines you aretaking for your diabetes.

Whenever you startanew medication,it's important to understandif it wUl affect your blood sugars or interfere with your blood sugarmedication.In eithercase, it is important to monitor your glucose levels carefuUy.

Except for the proprietary names given in some headings,* onlygeneric names areused in the foUowing lists. Your pharmacistwiU beableto teU you the brand names or generic names of medications youuse. Due to the aggressive reporting requirements of the FDA, new

* Proprietary names appearing in these tables: Actos,Amaryl, Avandia, Byetta,Diabeta, Diabinase, Exubera, Glucophage, Glucotrol, GlucotrolXL, Glucovance,Glynase, Glyset, MetagUp, Micronase, Prandin, Precose, PresTab, Starlix, Symlin.

466 Appendix C

contraindication information is constandy becoming avaUable. Checkwith your pharmacist on a regular basis.And remember: If you haveanyquestionsabout howyour medicines can affect your blood sugars,be sure to ask your physician or pharmacist

DRUGS THAT INTERFERE WITH SULFONYLUREAS

• Sulfonylureasmay induce a disulfiram-Uke reaction with ethanol(alcohol)

Glimepiride (Amaryl)

• GUmepiride mayincrease the effects of cyclosporine.• Glimepiridemay inducea disulfiram-Uke reactionwith ethanol (alcohol).

May increase theeffects of glimepiridedelavirdine

ketoconazole

nicardipineNSAIDS

piogUtazone

May decrease theeffects of glimepiridecarbamazepinecharcoal

corticosteroids

estrogen

isoniazid

nicotinic acid

NSAIDS

oral contraceptivesphenobarbitalphenothiazinesphenytoinrifampinrifapentinesecobarbital

sypathomimeticsthiazide and other

diuretics

thyroid productsurinary alkaUnizers

May increase thehypoglycemic effectsof glimepiridebeta blockers

chloramphenicolcimetidine

fibric acid derivatives

fluconazole

pegvisomantsalicylatessulfonamides

tricydicantidepressants

Glyburide (Diabeta, Glynase, PresTab, Micronase)Glyburide + metformin (Glucovance)*

Glyburide mayinducea disulfiram-Uke reaction with ethanol (alcohol).

May increase theeffects of glyburidebeta blockers

NSAIDS

oral anticoagulants

phenytoin, otherhydantoins

salicylatessulfonamides

* Also see interactions with metformin.

May decrease theeffects of glyburidecorticosteroids

thiazide and other

diuretics

DrugsThatMayAffectBloodGlucose Levels 467

Glipizide (Glucotrol, Glucotrol XL)Glipizide + metformin (MetagUp)*

GUpizide may induce a disulfiram-Uke reaction with ethanol (alcohol).

May increase theeffects of glipizideandrogens cimetidineanticoagulantsdelavirdine

digitalis glycosidesfluconazole

gemfibrozilH2 antagonistsketoconazole

MAO inhibitors

methyldopanicardipine

NSAIDS

piogUtazoneprobenecidsaUcylatessulfonamides

tricycUc antidepressants

urinary acidifiers

May decrease theeffects of glipizidebeta blockers

carbamazepine

* Also see interactions with metformin.

charcoal

cholestyraminehydantoinsphenobarbitalphenytoinrifampinrifapentinesecobarbital

thiazide diuretics

urinary alkaUnizers

Chlorpropamide (Diabinase)

• A disulfiram-Uke reaction can occur with concomitant use of ethanol

(alcohol).

May increase theeffects of chlor

propamideFluoroquinolone an

tibiotics may possibly interact, causinga potential hypoglycemic effect

Toxic potential isIncreased withbeta blockers

hydantoins

NSAIDS

oral anticoagulantsphenylbutazonesaUcylatessulfonamides

May decrease theeffects of chlor

propamide^calcium channel

blockers

corticosteroids

coumarin derivatives

These drugs tend to produce hyperglycemia.

estrogens

isoniazid

nicotinic acid

oral contraceptivesphenothiazinesphenytoinsypathomimeticsthiazides and other

diuretics

thyroid products

468 Appendix C

DRUGS THAT INTERFERE WITH MEGL1TINIDES

Repaglinide (Prandin)

• Avoid alcohol— maycausehypoglycemia.• Avoidgymnema and garlic— maycausehypoglycemia.• When givenwith food,AUC of repaglinide is decreased.• St.-Iohn's-wort maydecrease repaglinide levels.

May increase theeffects of repaglinideConcurrent use with

other oral hypoglycemicagents

azole antifungals:fluconazole

itraconazole

ketoconazole

clarithromycindelavirdine

diclofenac

doxycycineerythromycin

gemfibrozilimatinib

isoniazid

macrolide antibiotics

nefazodone

nicardipineNSAIDS

pioglitazonepropofolprotease inhibitorsquinidinesulfonamides

telithromycinverapamil

NategUnide (Starlix)

•Avoid alcohol— maycause hypoglycemia.

May increase theeffects of nategUnideclarithromycindelavirdine

diclofenac

doxycycineerythromycinfluconazole

gemfibrozUimatinib

isoniazid

ketoconazole

MAO inhibitors

nefazodone

nicardipine

nonselective beta

blockers

NSAIDS

pioglitazonepropofolprotease inhibitorsquinidinesalicylatessulfonamides

telithromycinverapamU

May decrease theeffects of repaglinideaminoglutethimidecarbamazepinenafciUin

nevirapinephenobarbitalphenytoinrifampinrifapentinesecobarbital

May decrease theeffects of nategUnideaminoglutethimidecarbamazepinecorticosteroids

nafciUin

nevirapinephenobarbitalphenytoinrifampinrifapentinesecobarbital

sympathomimeticsthiazide diuretics

thyroid products

Drugs ThatMayAffect Blood Glucose Levels

DRUGS THAT INTERFERE WITH

ALPHA-GLUCOSIDASE INHIBITORS

Acarbose (Precose)

Limit alcohol.

Acarbose decreases theabsorption/serum concentration ofdigoxin.

469

May increase theeffects of acarbose

Acarbosemay increasethe risk of hypoglycemia when usedwith hypoglycemicagents

May decrease theeffects of acarbose

calcium channel

blockers

charcoal

corticosteroids

digestive enzymepreparations:amylasepancreatin

estrogen

isoniazid

nicotinic acid

oral contraceptivesphenothiazinesphenytoinsympathomimeticsthiazides and other

diuretics

thyroid products

Miglitol (Glyset)

Digestive enzymes(amylase, pancreatin,charcoal) may reduce the effect ofmiglitol and should not be takenconcomitantly.

May Increase theeffects of miglitolNone found

May decrease theeffects of miglitolDecrease in absorption

and bioavailabiUtyof digoxin, propranolol, ranitidine

DRUGS THAT INTERFERE WITH OR

ARE AFFECTED BY THIAZOLIDINEDIONES

Pioglitazone (Actos)

May increase the ef garUc propofolfects of pioglitazone gemfibrozil protease inhibitorsazole antifungals gymnema quinidinechromium imatinib sulfonamides

clarithromycin isoniazid telithromycindelavirdine nefazodone thioridazine

diclofenac nicardipine (arrhythmia)erythromycin NSAIDS verapamU

470 Appendix C

Pioglitazone (Actos) (continued)

May decrease the ef hydrocodone negletidefects of pioglitazone oxycodone nefazodone

aminoglutethimide St-John's-wort paroxetinecarbamazepine tramadol phenytoinnafciUin risperidonenevirapine Pioglitazone may in ritonavir

phenobarbital crease the effects of rosigUtazonephenytoin amiodarone sertraline

rifampin amphetamines thioridazine

secobarbital select beta blockers

dextromethorphanwarfarin

May decrease levels fluoxetine Pioglitazone may deof prodrug substrates glimepiride crease the effects of

in pioglitazone gUpizide oral contraceptivesbUe acid sequestrants lidocaine

codeine mirtazapine

RosigUtazone (Avandia)

May increase the ef May decrease the ef gUmepiridefects of rosigUtazone fects of rosigUtazone gUpizidechromium bile acid sequestrants negletidedelavirdine carbamazepine phenytoinfluconazole phenobarbital pioglitazonegarlic phenytoin sertraline

gemfibrozil rifampin warfaringymnema rifapentineketoconazole secobarbital RosigUtazone may denefazodone St-John's-wort crease the effects ofnicardipine oral contraceptivesNSAIDS RosigUtazone may inpioglitazone crease the effects of

sulfonamides amiodarone

fluoxetine

Drugs ThatMayAffect BloodGlucose Levels 471

DRUGS THAT INTERFERE WITH OR ARE AFFECTED

BY METFORMIN (GLUCOPHAGE)

May increase the May decrease the Metformin may ineffects of metformin effects of metformin crease the effects of

Cationic drugs: calcium channel None of significanceamiloride blockers known

digoxin corticosteroids

morphine diuretics Metformin may deprocainamide estrogen crease the effects of

quinidine isoniazid oral contraceptivesranitidine nicotinic acid

triamterene oral contraceptivestrimetheprim phenothiazinesvancomycin phenytoin

chromium sympathomimeticscimetidine thyroid productsfurosemide

garUcgymnema

DRUGS THAT INTERFERE WITH

BYETTA (EXENATIDE)

Due to its effect on gastricemptying, Byetta mayreducethe rate and extent of absorption of oraUyadministered drugs.Administer medications 1 hour prior to use of Byettaas recommended bythe manufacturer.

Ethanol (alcohol) and aU antidiabetic medications may cause hypoglycemiawhen used with Byetta.

DRUGS THAT INTERFERE WITH

SYMLIN (PRAMLINTIDE)

Due to its effecton gastric emptying,Symlinmay reduce the rate and extent of absorption of orally administered drugs.Administermedications 1-2 hours prior to use of Symlinas recommended by the manufacturer.

•Ethanol (alcohol) and aU antidiabetic medications may cause hypoglycemia when used with Symlin. This is especiaUy true of insulin.

472 Appendix C

DRUGS THAT INTERFERE WITH

EXUBERA (INHALED INSULIN)

• Ethanol (alcohol) and all antidiabetic medications may cause hypoglycemia when used withExubera.

• Discontinuation of inhaledsteroids maydecrease absorptionof Exubera.• Smoking cancause fluctuating increases in absorption of Exubera.

APPENDIX D

Foot Care for Diabetics

Although not direcdy related to the normalization of bloodsugars,this short but important section on foot carehas beenincluded becauseof the constant danger diabetescan present

to the lower extremities.

The incidence of Umb-threatening ulcerations in diabetics is veryhigh, affecting approximately one in she to seven patients. Nonhealing"diabetic"ulcersarethe major causeof leg, foot, and toe amputationsin this country, after traumatic injuries such asthose occurring in motor vehicle accidents.These ulcerations do not occur spontaneously;they are always preceded by gradual or sudden injury to the skin bysome external factor. Preventing such injuries can prevent their sadconsequences.

VirtuaUy aU diabetics who haveexperienced ongoing higher-than-normal blood sugars for more than five years suffer some loss of sensitivity in their feet to pain, pressure,and temperature. This is becauseprolongedblood sugarelevation can injure and eventuaUy destroy aUsensory nerves in the feet (sensory neuropathy). Furthermore, thenervesthat control the shapeofthe foot are likewiseinjured,with aresultant deformity that includes "claw" or "hammer" toes, high arch,and prominent heads of bones at the bases of the toes on the underside of the foot. The nerves that stimulate perspiration in the feet arealsoaffected.This results in the classic dry, often crackedskin that weseeon diabetic feet. Dry skin is both more easUy damaged and slowerto heal than is normal, moist skin, and cracks permit entry of infectious bacteria.

Long-term elevated blood sugar also may cause impairment of circulationin the major arteries of the legs, asweU asin the minor arter-

474 AppendixD

iesand smaU capUlary bloodvessels that supplythe skin of the feet. Inorder to heal, injured skin can require fifty times the blood flow ofnormal skin. If this increase in flow is unavailable, the injury wUlprobably deteriorate, becoming gangrenous, and facilitate aninfectionthat spreads up the leg. This infection maynot respond to antibiotics.

Blood circulation to the normal foot can readUy increase one hundredfold, if necessary, in order to conduct the heat of warm objectsaway from the skin. Impaired circulation may make this impossible,and the resultant burn may not even cause pain.

A deformed foot with bony prominences (knuckles of toes, tips oftoes, heels,and metatarsal headsat soles) may be continuaUy rubbedor pressed by shoes. This foot is frequendy unableto perceive the extent of such pressure and may not heal readUy if injured. It can beburned at relatively low temperatures. Impaired circulation likewisecan prevent the warming of cold feet so that prolonged exposure tocold can cause frostbite.

The following guidelines are therefore essential for aU diabetics, toprevent foot injury and the potentiaUy grave consequences that mayensue:

• Never walk barefoot, either indoors or out.

• Purchase shoes or sneakers late in the day, when foot size is thegreatest. Shoes must be comfortable at the first wearing andshould not require breaking in. Request shoes with deep, widetoe boxes.Pointed-toe shoesshould not be worn, even if the tipsareblunted. Some dress shoes arenow avaUable with wide, deeptoe boxes. A number of currendy avaUable brands of athleticshoes and walkingshoesare especiaUy accommodating and evenhave removable insoles so that orthotics (see below) wiU fit,without making the shoe too tight. If necessary, I prescribe orthopedic or custom oxfords for certainofmy patients.

• Inspect the insides of your shoes daUy for foreign objects, tornfining, protruding naUs, or bumps. Have them repaired if youfind any of these.

• Don't wear sandals with thongs between the toes.• Tryto alternate at least two differentpairs ofshoesevery fewdays.• IdeaUy, your feet should be examined daUy for possible injury

or signs of excessive rubbing or pressure from shoes — bUsters,cracks or other openings in the skin, pink spots, or caUuses. Besure to checkbetween your toes. Inspect your soles. If necessary,

FootCarefor Diabetics 475

usea mirroror askanother person to check them. Contact yourphysician immediatelyif anyof the above signs are found.

• If the skinofyour feet isdry, lubricate the entire foot. Suitable lubricants include oUve oU, any vegetable oU, vitamin E oU, emuoU, mink oU, andemulsified lanolin. Many oUs andlotions thatcontain these products as major ingredients are avaUable com-merciaUy. Do not use petroleum jeUy (Vaseline), mineral oU, orbabyoU, asthey are not absorbed by the skin.

• Do not smoke cigarettes. Nicotinecancause closureofthe valvesthat permit blood to enter the smaU vessels that nourish the skin.

• Keep feet away from heat. Therefore no heating pads, hot waterbotdes, or electric blankets. Do not place feet near sources ofwarmth such asradiators or fireplaces. Baths and showers shouldfeel cool— not even lukewarm. Temperature should be estimatedwith yourhandorabaththermometer, not with your feet.Watertemperatureshouldbe less than 92°F, aseven this temperaturecan causeburns when circulation is impaired.A bath thermometer is suggested.

• Wear warm socks and shoes of adequate size when outside incold weather. It is wise for aU diabetics to have the circulation in

their feet measured every few years. If circulationis impaired, donot remain in the cold formore than twenty minutes at a time.

• Do not soak your feet in water for more than 3-4 minutes, evenifso instructed by a physician. This causes macerated skin, whichbreaksdown more easUy and doesn't healweU. When bathing orshowering, get in, get washed, and get out. Don't soak. Bewareofrain, swimming pools, and any environment that may wet yourfeet or your shoes. If you swim regularly for exercise, before getting in the water, apply petroleum jeUy (Vaseline) to your feet toprotect them from the water. After leaving the water, remove thepetroleum jeUy with a towel.

• Do not put adhesive tape or other adhesive products like cornplasters in contact with your feet. FragUe skin might be peeledoffwhen the tape is removed.When applyingabandage, tape shouldnot be appUed to the skin,but to the bandage only.

• Do not put any medications in contact with your skin that arenot prescribed by your physician. Many over-the-counter medications, such as iodine, salicylic acid, and corn-removal agents,are dangerous. Iodine products or hydrogen peroxide shouldneverbe appUed to wounds even ifsodirected by a physician.

476 Appendix D

• If the skin of your feet is dry, your cardiologist should try toavoid medicines called beta blockers for hypertension or heartdisease,as these can inhibit perspiration that moistens the feet.

• Do not attempt to file down, remove, or shave callusesor corns.This is dangerous. The toughened skin of a callus is the body'sway of protecting against irritation, such as by a shoe that rubsyour foot. Filing it off removes that protection, and in my experience, this is the most common initial cause of foot ulcers and

resultant amputations. Do not permit podiatrists, pedicurists, oranyone else to do so. If calluses are present, show them to yourphysician.Askher or a podiatrist to arrange for your shoes to bestretched, prescribe special shoes, or prescribe orthotic inserts.Yourphysician may instruct you in the use of a shoe stretcher ora "ball and ring," both of which can be ordered by a shoe repairshop. Byeliminating the pressure on your foot, the callus shouldresolve over time.

• Do not trim your toenails if you cannot see them clearly. Ask afriend or relative, podiatrist, or your physician to do this foryou.If the corners of your nailsare pointed,you can file them with anemery board or have someone else trim them.

• If you have thickened toenails, ask your physician to have clippings tested for fungal infection. If infection is present, he shouldprescribe Tincture of Fungoid. This solution must be appliedtwice daily to the nails to be effective. It must be used for abouttwelve months to effect a cure. It helps to first have thickenednails ground down bya podiatrist,but she/he must be very careful not to damage skin or nail bed.

• Don't wear stockings or socks with elastic bands that are tightenough to cause visible depressions in the skin.Don't usegarters.Don't wear socks with holes or that have been darned, have thickseams, or are so large that they bunch up.

• Phone your physician immediately if you experience any injuryto your foot. I consider even a minor foot injury to be an emergency. Procrastination can be disastrous.

Put a copy of these instructions in your tickler file so that you canreread them everyfew months. Eventually, you should know them byheart.

APPENDIX JE

Polycystic Ovarian Syndrome

A syndrome is not an infection, nor aspecificUlness, but acombination of pathologic signs or symptoms that appear in theaggregate in a single individual. Polycystic ovarian syndrome,

when it isdiagnosed (and frequendy it isnot), usuaUy becomesapparent at the onset of puberty in young women. AnatomicaUy, it consistsof small cysts on the tiny follicles that release egg ceUs at ovulation.The condition is hard to diagnose in partbecausethe cysts areusuaUytoo smaU to be displayed by conventional imaging techniques, although they can sometimes be observedwith transvaginal ultrasound.

The syndrome includes several menstrual characteristics that manifest more or less, depending upon the individual, such as amenorrhea(no periods whatsoever); irregular timing of periods; irregular flowduring menstruation; or abnormaUyheavy menstrual flow. Some butnot aU of affected individuals have hirsutism (excessive body hair) —for example, dark mustache hair that the doctor never notices becausethey bleach it; hair on their arms that they shave; hairy abdomen orbreasts; and so on. They frequendy, but not always, have a chunky,boxerlike, masculinebuUd, but I've also seensome who appear classi-caUy feminine.

Not a tremendous amount is known about the etiology or originsof polycystic ovarian syndrome, or PCOS. It is often a disorderof elevated levels of male sex hormones, which can cause insulin resistance

in women. UsuaUy this is caused somehow by excess serum insulinlevels secondary to insulin resistance. So these people, if they're nondiabetic, may have high serum insulin levels, which bring about thehigh levels of male sex hormones. The precise mechanism for this ismurky. Many but certainly not aU of these people become diabetic,

478 Appendix E

probably by the same mechanism of beta cell burnout that we see intype 2 diabetes. Mostbut not allof thesewomen have difficulty losingweight. Forexample, I have a teenaged patientwho isabout five and ahalf feet tall and came to me weighing 160 pounds. She'scurrently under treatment for PCOS. The best I've been able to do so far is get herweight down to about 150, but she's only eating 7 ounces of proteinand 24 grams of carbohydrate per day. Her weight seems to have leveled off, and although we've instituted other measures (which we willdiscuss), I don't know whether she'll be able to get any more weight offwithout severe caloric deprivation.

A serious consequence of this condition is infertility, which affectsmany but not all people with this syndrome. I have one patient whohad children but had to have a total hysterectomy— and it was onlythen that her PCOS was discovered on microscopic examination ofher ovaries.

Aswith many syndromes, there is no single test to determine if onehas PCOS, unless it can be seen on transvaginal ultrasound. The diagnosis is made either on a discovery such as the one mentioned in thepreceeding paragraph, or on clinicalgrounds, based upon a combination of signs and symptoms. One of these, as noted, is insulin resistance. But how does one diagnose insulin resistance?

One way is to experimentally determine how much 1 unit of arapidlyacting insulin,such as lispro, will lower a person'sblood sugar,assuming that the person is on a stable blood sugar control regimenand the blood sugars are not going to be dropping or increasing. For a140-pound insulin-using type 1 diabetic, 1 unit of regular insulinwould lower blood sugarabout 40 mg/dl,while 1 unit of lispro wouldlower it by about 60 mg/dl. So if you have a person of this weightand 1 unit of either insulin only lowers her blood sugar by 20 mg/dl,that's a good indicator of insulin resistance. If the person alreadyhas abdominal obesity or generalized increase in body fat, you don'tknow how much of that insulin resistance is caused by the body fatand how much may be caused by the syndrome. So ultimately the diagnosis still depends upon inference from a combination of signs andsymptoms.

Another way of diagnosing the syndrome is to observe the influence of the insulin-sensitizing agent metformin on insulin requirements and upon menses of these patients. If someone who has noperiods finally starts to have periods when she's put on metformin,there's a good likelihood of a positive diagnosis. There are also some

Polycystic Ovarian Syndrome 479

laboratory tests that can be performed to identify hormonal disturbances. The foUowing abnormal bloodtests can be cosdybut in combination arehighly suggestive of this disorder: LH at leastthree timesas high as FSH; elevated free or total testosterone, 17-alpha-hydroxyprogesterone, estronel, free estradiol, 1GF-1, and androstenodione;chminished 1GF-1 binding protein.

This condition does not necessarily lead to poor blood sugar control.One of my PCOS patients is a lovely young ladywho has essen-tiaUy normalblood sugars but cannotlose weight. She's distressed bythat circumstance and also distressed by her faUure to ovulate andhaveperiods, which means that unless we canimprove things she wiUnot be able to have chUdren.

There are treatments for this condition. For many years, a diureticcaUed spironolactone was given for female hirsutism. It was quite effective and is stiU being used for this element of the syndrome. Whenusing this medication, serum potassium levels should be checked regularly, as they might increase unduly. A number of years ago, I wastreating a diabetic patient who had been trying to become pregnantforat least five years. Shewasnot obese, but shedid havesUghdy hairyarms and some dark hair in the mustache area. Although she had quitenormal blood sugars, I noticed that she had to inject considerablymore insulin than I would have anticipated for someone of herweight. I therefore decidedto try her on the insulin-sensitizing agentmetformin (Glucophage), which lowers insulin resistance in the liver.In a few months, she had become pregnant— after years of unsuccessful visitsto infertilityspeciaUsts. Furthermore, her insulin requirements dropped considerably.

Several years after I made this observation, the first papers on theuse of metformin to treat this particular syndrome were published.Because these women — in my practice, mosdy teenagers — are sodistressed by theirweightproblems, andbecause ofmy anticipation oftheir infertiUty, I have tried them on everymedication that lowersinsulin resistance that I can think of. When I learn of a blood test that

wiU focus on a substance that causes insulin resistance, such as tumor

necrosis factor alpha, I wiU test these patients, and indeed,I haveseenvery high levels of this substance in some— but again, not aU — ofthem. When I find TNF-alpha elevated, I may prescribe several substances that have been shown to lower the blood levels or to reduce its

action. Some TNF-alpha inhibitors thatcame upon anInternet searchinclude the nonsteroidal anti-inflammatory agent sulindac; EGCG,

480 Appendix E

the main constituent of green tea; 1,25 dihydroxy vitamin D3 (cal-citriol), which is sold only by prescription and whose dosagemust becarefully regulated to prevent hypercalcemia; quercetin, a widely marketed dietarysupplement (most often made from the skins of onionsand garlic); circumin; and Trental, or pentoxyphylline. This last medication has been used for manyyears, with only limitedsuccess, for intermittent claudication, a condition caused by poor circulation in thelegs. Pentoxyphylline I save as something of a last resort, because itmust be taken at the end of a meal, and if a person mistakenly takes iton an empty stomach, it can cause considerable gastricdistress.

I refer likely PCOS patients to specialized physicians called reproductive endocrinologists for confirmation of my diagnosis and forprescription of sexhormone replacement therapy (birth control pills).I continue to address their blood sugar problems myself.

When treating PCOS, I usuallystart with metformin, starting withthat time of day when insulin doses are greatest. For example, I mayuse the time-release GlucophageXRat bedtime to help lower bedtimedosagesof detemir or glargine insulin. I will also try one of the thiazo-lidinediones, insulin-sensitizing agents that reduce the insulin resistance of fat and muscle cells.

Next I would add a medication called ramipril, which has also beenshown to lower insulin resistance. Ramipril is used commonly to treathypertension and diabetic kidney disease. It is an ACE inhibitor butdiffers from other such medications in that it affects more tissues than

the other ACE inhibitors currently available. It can, however, cause adry cough in some users that resolveswhen it is discontinued.

I also try to use all the supplements recommended at the end ofChapter 15 for the amelioration of insulin resistance.

For several years I havebeen following the development of a medication that has been shown to ameliorate some of the consequencesof PCOS. Its chemical name is d-chiro inositol. It has been shown to

lower blood levels in women of the male sex hormone testosterone —

both in the free and protein-bound forms. According to a study published in the April29,1999, issue of the New England Journal ofMedicine, its use increased the rate of ovulation from 27 percent in thosetaking a placebo to 86 percent in those taking the drug. Aswith otheragents that lower insulin resistance, it lowered serum cholesterol andtriglyceride levels as well as blood pressure. It also lowered serumDHEAsulfate, a precursor of male sexhormones. An appropriate dosewould be 1,200 mg daily.

Polycystic Ovarian Syndrome 481

Since my patients suffering from PCOS are very distressed by theirinabUity to lose weight, even afterwe have gotten them to ovulate, Isearched the Internet for sources of d-chiro inositol. I indeed found

the product already being sold in the United States and manufacturedin New Zealand. It isbeingdistributed through several retaUers by Hu-manetics Corporation of Chanhassen, Minnesota, under the brandname Inzitol. They can be found on the Web at www.humaneticsingredients.com

I suspect that the problem of PCOS is more common than mostphysicians realize, simply because usuaUy it can only be diagnosedin-ferentiaUy.

Glossary

Adrenaline: SeeEpinephrine.Aerobic exercise: Activity that is mUd enough to permit muscles to

function for extended periods without developing an oxygen deficit.Examples include jogging, casual biking, slow swimming, walking,dancing. Seealsoanaerobic exercise.

Alpha cells: The cells of the pancreasthat produce glucagon.Amino acids: The "buUding blocks" of proteins. Protein molecules are

stringsof amino acids bound together in various sequences and patterns.Amino acidscan be partiaUy converted to glucose veryslowly bythe liver and, to a lesserdegree,by the kidneys and intestines.

Anaerobic exercise: Strenuous activity that causes a temporary oxygendeficit in the muscles beingexercised. Suchexercise can be performedonlybrieflybefore yourun out ofbreathor the muscle fatigues. Anaerobic exercise utilizes nineteen times as much glucose as aerobic exercise for a given amount of work. It tends to buUd muscle bulk andthereby reduce insulin resistance. Examples include sprinting, uphiUbiking, push-ups, speed-swimming, and repetitive lifting of heavyweights.Seealso aerobic exercise.

Analog Insulin: A synthetic insulin whose molecular structure differsslighdy from that of human insulin, usuaUy in order to make it actmore rapidly or much more slowly than human insulin. Analog insulins include lispro,glulisine, aspart, glargine, and detemir.

Aspart insulin: A clear, very rapid acting analog insuUn, slower thanlisprobut morerapid than regular insulin. Brandname: Novolog.

Atherosclerosis: Injuryto or plaque deposits on the liningof any largeartery. This can eventually leadto total blockage of the artery and lossof the tissues or organs to which it supplies blood. Also called arteriosclerosis or macrovascular disease.

Autonomic neuropathy: Damage to autonomic nerves by chronicaUy

Glossary 483

elevated blood sugars. Autonomic nerves direct bodUy functions thatarenot consciously controUed —such asheart rate, digestion, sweating, erections of the penis,blood pressure, bladder tone, and dUationand constriction of the pupUs of the eyes.

Basal: In discussions of blood sugar control, refers to the fasting state.Basal insulin refers to long-acting insulins administered in just therightdoses to prevent blood sugar rise whUe fasting. Basal doses oforalblood sugar-lowering agents are the exact doses of long-acting piUsthat wiU prevent blood sugar rise whUe fasting.

Beta blockers: Medications used for thetreatment of high blood pressureor angina (heartpain) that tend to slow the rateand contractilityof the heart.

Beta ceU burnout: Destruction of pancreatic betacells caused by overstimulation of insulin production orbytoxic effects ofhighbloodsugars.

Beta cells: CeUs located in the pancreas that produce and store insulinand another hormone, amylin,and release them into the bloodstream.

Blood glucose: Bloodsugar.Blood glucose profile: A record of bloodsugars (glucose) measured a

number of times daUy for a period of several days or weeks. Often accompanied by related data on meals, medications, exercise, infectionor illness, and any other eventsthat may affect blood sugar levels.

Blood glucose self-monitoring: The act of measuring and recordingyour own blood sugars, usuaUy utilizing a single drop of finger-stickblood and a blood glucose meter.

Bolus insulin: Aninjectionof rapid-acting insulinusedto preventbloodsugar elevation by a meal or to lower an elevatedblood sugar. Seealsocoverage.

Carbohydrate: One of the three basic sources (protein, fat, carbohydrate) of calories or energy in foods. Carbohydrate molecules are usuaUy chains of sugars strung together like beads on a necklace. Of thethree basic caloric foods, carbohydrate raises blood sugar the most.

cc: Cubic centimeter. A measure of volume; 1/1000 of a Uter or quart.Also caUed milliliter (ml).

Complex carbohydrate: Made from longer, more complex chains ofsugars, some are digested more slowly and raise blood sugar lessrapidly than simple sugars.

Counterregulatory hormones: Hormones produced by the body,oftenin times ofstress or illness,that bring about an increase in blood sugar.These include glucagon, epinephrine, Cortisol, and growth hormone.

Coverage: The practice of injecting fast-acting insulin to lower an elevated blood sugar. Coveragemay also refer to the use of a fast-actinginsulin or oral hypoglycemicagent to covera meal, thereby preventinga postprandial blood sugar rise.Seealso bolus insulin.

484 Glossary

C-peptlde: A by-productof insulinproduction by the pancreas, whichwhen measured in the blood indicates how much insulin was recentiymade.People who make no insulinmake no C-peptide.

Creatinine clearance: Akidneyfunctiontest that estimates the glomerular filtration rate. It requires a 24-hour urine collection and a smallsample of blood.

Crystalline insulin: Seeregularinsulin.Dawn phenomenon: An apparent reduction in the effectiveness of in

sulin in loweringor maintainingblood sugardue to rapid clearance ofinsulin from the bloodstream by the Uver. It may begin about an hourbefore arising in the morning and continue for 2-3 hours after awakening.

Delayed stomach-emptying: Seegastroparesis.Detemir insulin: A long-actinganalog insulin that can be dUuted with

saline for more precise measurement in smaU doses. Brand name:Levemir.

DKA: Diabetic ketoacidosis. See ketoacidosis.

Dyslipidemia: Anyabnormality in the lipid profile.Epinephrine: Ahormone producedbythe adrenalglandsin responseto

stresses such as pain, fright, anger, and hypoglycemia. Elevated bloodlevels of epinephrine can cause tremors, sweating, and increases ofheart rate and blood sugar.Also calledadrenaline.

Essential amino acids: Aminoacidsthat the body cannot manufactureand therefore must, for survival, be provided in the diet.

Essential fatty acids: Fattyacidsthat the bodycannot manufacture andtherefore must,for survival, beprovided in the diet. See also fatty acidand triglycerides.

Fasting blood glucose, fasting blood sugar: Blood sugarvaluewhenmeasuredbefore the firstmealof the day, usuaUy at least 12hours after any prior consumption of food.

Fat: Oneof the threebasic sources (protein, fat, carbohydrate) of caloriesor energyin foods. It canbe found in milk, cheese, egg yolk, meat,fish,fowl, nuts, oUs, and some vegetables. Consumption of pure fat doesnot direcdy affectblood sugar.

Fatty acid: A chain of carbon and hydrogen atoms that is one of thebuUding blocksof fat.Seealso triglycerides.

Fibrinogen: A precursor of fibrin, which is the structural element ofbloodclots. Elevated levels of fibrinogen in thebloodcanbe caused byhigh blood sugars and are associatedwith increased risk for heart attacks, strokes, retinopathy, kidneydamage, and other complicationsofdiabetes.

Fructose: AsugaroccurringespeciaUy in fruits, fruit juices, and honey.Gastroparesis: A neuropathy causedby yearsof blood sugar elevation,

Glossary 485

which canseverely impair themuscular andsecretory activities of thestomach. Gastrointestinal discomfort may sometimes be present aftermeals. Blood sugars after meals may beunpredictable because ofa random effect upon the rate of stomach-emptying. Also called delayedstomach-emptying and gastroparesis diabeticorum.

Glargineinsulin: Aclear, long-acting analog insulin. Brand name: Lantus.Glomerular filtration rate (GFR): The kidneys filter blood and pro

duce urine by means of about 1 miUion microscopic glomeruU. TheGFR isameasure ofhow much filtering thekidneys perform inagiventime period. Seealso glomerulus.

Glomerulopathy: The condition ofdamaged glomeruli.Glomerulus: Themicroscopic filtering unitof thekidneys that removes

water and other substances from blood, thereby creating urine.Glucagon: Ahormone produced bythealpha ceUs of the pancreas that

raises blood sugar bycausing theliver andmuscles to break down proteins and stored glycogen to glucose.

Glucograf III data sheet: A preprinted form used by diabetics forrecordingblood sugar measurements, medications, exercise, and meals.iUustrated on page85.

Gluconeogenesis: The conversion of amino acids (the buUding blocksof proteins) to glucose by the liver and to a lesser degree by the intestines and the kidneys.

Glucophage: Seemetformin.Glucose: A naturaUy occurring sugar, which when measured in the

bloodiscaUed bloodsugar. Glucose is the buUding block of most carbohydrates and of glycogen.

Glucose challenge: An event, such as a high-carbohydrate meal, thatcan raiseblood sugar significandy.

Glucose transporters: Specialized protein molecules that insulin causesto migrate from inside a ceU to the surface. They protrude from thesurfaceand bring blood glucose into the ceU.

Glulisine insulin:Arapid-acting analog insulin. Brand name: Apidra.Glycation: The permanent binding of glucose to proteins of blood or

body tissues. Glycation of proteinscan adversely affect their structureand function,leadingto manyof the complications of diabetes.

Glycemic index: A crude index that attempts to compare the bloodsugar-raisingeffect of a food to that of pure glucose.

Glycogen:Astarchy substance formed fromglucose that is storedin theUver and muscles. It canberapidly converted backto glucose bythe action of certain counterregulatory hormones.

Glycosylated hemoglobin: By measuring the glycation or glycosylationof hemoglobin, the principalprotein of red blood ceUs, we can estimateone's average bloodsugar over thepriorfourmonths. See also glycation.

486 Glossary

Glycosylation: The reversible binding of glucose to proteins of blood orbody tissues. If a protein is glycosylated for more than 24 hours, a rearrangement of the attachment renders it permanent. See also glycation.

H: The abbreviation for lispro insulin used in this book. SeeHumalog.HDL: Abbreviation for high-density lipoprotein, a submicroscopic parti

cle found in the blood that transports cholesterol and triglyceridesfrom arterial walls to the liver. Also known as the "good" cholesterol.High blood levels of HDL arebelieved to offer protection from coronary artery disease, peripheral vascular disease, and stroke. See alsoLDL.

Hemoglobin A,c (HgbAIC): The most commonly measured indicator ofglycatedor glycosylated hemoglobin.

High-density lipoprotein: See HDL.Humalog (H): Brand name for a clear, "ultra fast acting" insulin. Also

known generically as lispro.Human insulin: Any insulin whose molecular structure is identical to

that of human insulin. The only human insulins currently on the market in the United States are regular and NPH.

Hyperglycemia: Abnormally high blood sugar.Hyperinsulinemia: Abnormally high blood insulin level.Hyperlipidemia: A vague term that commonly refers to any of a num

ber of abnormalities of fatty substances in the blood. These may include elevated triglycerides, elevated LDL (the "bad" cholesterol), orlow levels of HDL (the "good" cholesterol). More properly called dys-lipidemia.

Hyperosmolar coma: A frequently fatal dehydrated condition with lossof consciousness, caused by extremely high blood sugars in diabeticswho make enough insulin to prevent ketoacidosis. Usually affects elderly type 2 diabetics.

Hypertension: High blood pressure.Hypoglycemia: Abnormally low blood sugar.Hypoglycemia unawareness: Inability to experience or perceive the

physical symptoms of lowblood sugar.Hypotension: Abnormally low blood pressure.IDDM: Abbreviation for insulin-dependent diabetes mellitus; see type 1

diabetes.

Impaired glucose tolerance (IGT): A mild or early form of diabetesthat can slowly cause many of the long-term complications of "fullblown" diabetes. Frequentlyprecedes the onset of diabetes. A treatabledisorder.

Incretin mimetics (IMs): Prescription drugs that either act like the hormone amylin (Symlin) or stimulate the production of amylin by sur-

Glossary 487

vivingbeta ceUs (Byetta). Amylin plays a role in fine-tuning postprandial blood sugars.

Insulin:Ahormone producedbythe betaceUs of the pancreas glandthatfacUitates the entry of glucose into most cells of the body. Insulin isalso the principal fat-buUding hormone. Seealso analog insulin andhuman insulin.

Insulin-mimetic agent (IMA): An oral agent (piU) that lowers bloodsugar by acting like insulin but without causingfat storage.

Insulin receptors: Protein molecules on the surface of most cells of thebody that bind circulatinginsulin. It is the binding of insulin by a ceUthat indirecdy facUitates the entry of glucose into the ceU.

Insulin resistance: Reduced sensitivity of the body to the effect of insulin on blood sugar.

Insulin-sensitizing agent (ISA): Anoralagent(pill) that controlsbloodsugar by lowering insulin resistance.

Intramuscular (IM): Usedto describe an injection (as of lispro insuUn)into musclein order to speed up its action.

Islets: Also caUed isletsof Langerhans. Clusters of ceUs in the pancreasthat include the beta ceUs, which make insulin and amylin,and the alpha cells, which makeglucagon.

Ketoacidosis: An acute, life-threatening condition caused by the combination ofveryhigh bloodsugarsand dehydration. It involves highbloodlevels of ketones, includingacetone, and an acidification of the blood.

Ketones: By-productsof fat metabolismthat include acetone, the principal component of naU polish remover. May be present in the bloodwhen a person is fasting or losing weight, or when blood sugars arevery high in people who don't make insulin. Seealso ketoacidosis.

Lactose: A sugar found in mUk and some cheeses that is converted toglucoseby the liver.

LAN: The abbreviation used in this book for glargine insulin. Brandname: Lantus.

LDL: Abbreviation for low-density Upoprotein, a particlein the blood thatdeposits cholesterol and triglycerides in arterialwalls. Alsoknown as the"bad" cholesterol.ElevatedLDL is a risk factor for coronary artery diseaseand peripheral vasculardisease. More important as a measure ofdisease risk than the LDL value itself is the ratio ofLDL to HDL. For ac

curate measurement, a "direct LDL" test must be ordered. LDL is harmful only when it is oxidizedor glycated or in the form of smaU, denseparticles, aU ofwhich are causedbyelevated blood sugars.Seealso HDL

Lipid profile: A battery of measurements of fatty substances in theblood. It may include LDL, total cholesterol, triglycerides, HDL,Upoprotein(a).

Lipoprotein: Submicroscopic particle that carries fatty substances such

488 Glossary

as cholesteroland triglycerides through the bloodstream. ExamplesofUpoproteins includeHDL, LDL, apolipoproteins, and Upoprotein(a).

Upoprotein(a): A lipoprotein that increases risk of heart attack by interfering with the body's mechanism for dissolving blood clots.Abbreviated Lp(a).

Lispro: SeeHumalog.Low-density lipoprotein: See LDLLower esophageal sphincter (LES): A muscular band near the lower

end of the esophagus, a tube connecting the throat to the stomach.Normal contraction of this band after swaUowing prevents regurgitation of stomach contents.

Macrovascular: Relating to largeblood vessels.Maturity-onset diabetes: Seetype 2 diabetes.Metformin: Sold genericaUy and under the brand name Glucophage,

this ISA is one of the most effective that we have. Rather than increas

ing insulin production and "burning out" pancreatic beta ceUs, it increases the body's sensitivity to its own or injected insulin. In myexperience, not aU generic metformins match the efficacy of the original or extended-releaseGlucophage.

mg/dl: MilUgrams per decUiter. The unit of bloodsugarmeasurementinthe United States. See also mmol/1.

Microaneurysms: BaUooning of microscopic blood vessels, caused bydestruction of ceUs that line the outer waUs of these vessels. Microa

neurysms are often found in the retinas of the eyes of diabetics whohave had elevated blood sugars for prolonged periods.

Microangiopathy: Injury to small blood vessels, commonly found inlong-standing poorlycontroUed diabetes. A major causeof bUndnessand kidney disease in diabetics.

Microvascular: Relating to smallblood vessels.mmol/1: MiUimoles per liter. The international unit of blood sugar mea

surement. Seealsomg/dl (1 mmol/1 = 18mg/dl).Monounsaturated fats: Fats whose molecules contain fatty acids that

are missing one pair of hydrogen atoms. These fats are beUeved bysometo offerprotectionfromvascular disease because their consumption lowersserum LDL and raisesHDL in some high-risk individuals.

Nephropathy: Damageto kidneys. In this book, the term is limited todamagecausedby diabetes.

Neuroglycopenia: A blood sugar so low that inadequate glucose is getting into the brain. As a result, cognition, coordination, and level ofconsciousness maybecomeseverely impaired.A severeform of hypoglycemia.

Neuropathy: Damageto nerves. In this book,the term is limited to damage caused by diabetes.

Glossary 489

Neurotransmitters: The chemical "messengers" of the central and peripheral nervous systems.

NIDDM: Abbreviation fornon-insulin-dependent diabetes meUitus. Notentirely accurately usedinterchangeably withthe termtype2 diabetes,or maturity-onset diabetes. Seetype 2 diabetes.

NPH insulin: A cloudy, intermediate-acting human insulin that lowersor maintains bloodsugar fora period ofabout10hoursafterinjectionwhen usedin physiologic doses.

Oral hypoglycemic agent (OHA): PU1 used to lower blood sugar intype2 diabetes bystimulating the pancreas to produce more insulin.

Pancreas: Alarge abdominal organ thatmanufactures insulin, glucagon,amylin, and other hormones, secreting them into the bloodstream.Thepancreas also produces digestive enzymes and bicarbonate, whicharesecreted into the uppergastrointestinal tract,beyond the stomach.

Phase I insulin response: Asudden release of insulin bythepancreasin response to a glucose challenge, such asa meal. This may representthe release of stored insulin granules. UsuaUy impaired in early diabetes.

Phase II insulin response: The continued slower release of (probablynewly manufactured) insulin from the pancreas that occurs after thephase I insulin response.

Physiologic doses of insulin: Doses of injected insulin calculated toapproximate the amounts made in the bodyby nondiabetics. Theserelatively smaU doses are in contrast to the large, "industrial" dosesusuaUy prescribed byphysicians whodo not foUow themethodsof thisbook.

Platelets: SmaU particles in the blood thatplay a major role in causingblood to clot.

Polyunsaturated fats: Fats made from fatty acids thataremissing morethanonepairof hydrogen atoms. Dietary consumption appears to reduce elevated serum LDL levels for some individuals. These fats areunstable and readUy oxidized.

Postprandial: After a meal.Postural hypotension:Asudden drop inblood pressure uponstanding.Preprandial: Before a meal.Progressive exercise: A planned exercise program wherein the work

required per session becomes greater and greater over a period ofweeks, months, or years.

Protein: One of the three basic sources (protein, fat, carbohydrate) ofcalories or energy in foods. The principal nutritional component offish, poultry, lean meat, and egg white, it isalso present in other foodsin lesser amounts.The majorcomponentof most human tissues otherthan fat and water.

490 Glossary

Pyloricvalve (pylorus):Amuscular band at the exitof the stomachthatrelaxes to permit stomach-emptying in normal individuals. In peoplewith diabetic gastroparesis, the pyloric valve may be randomly inspasmand thereby delay stomach-emptying.

R: Seeregularinsulin.Regular insulin, or regular (R): A commonly used clear, rapid-acting

human insulin. Also caUed crystalline insulin. Not as rapid-acting asUspro, gluUsine, or aspart analog insulins.

Renal: Relating to the kidney.Renal risk profile: A series of tests that can reflect damagesufferedby

the kidneys.Retinopathy: Injuryto the retina, or Ught-sensing surface, in the rear of

theeye. UsuaUy caused bychronicaUy high blood sugars in diabetics.R-R interval study: A quantitative, objective test for autonomic neu

ropathy. The test is simUar to an electrocardiogram, but the patientbreathes deeply whUe the test isunderway.

Sequelae: Consequences. In this book, the term refers to the adverseconsequences or "compUcations" of chronic bloodsugar elevation.

Stevia: A sugarless herbal sweetener, soldas Uquid or powder in healthfood stores.

Subcutaneous: Below the skin but above muscle, as in a subcutaneous

injection.Sucrose: Table sugar. Thesucrose molecule consists of one glucose mol

ecule bound to one fructose molecule.Sugars: Agroupof chemical compounds consisting of sixcarbonatoms

bound to hydrogen andoxygen atoms. Mostsugars tastesweet and canbe converted to glucose (blood sugar) by the body. Some sugars areformed bythejoining together of two othersugars. Sugars arethe simplestcarbohydrates.

Sulfonylureas: A class of oral hypoglycemic agents that are chemicaUyrelated to sulfadrugs. Theylower bloodsugarby stimulating pancreatic beta ceUs to make more insulin, and carry with them a danger of"burning out" those ceUs.

Thiazolidinediones: Aclass of drugs that lowerinsulin resistance, principaUy in fat and muscle ceUs. They also inhibit renal deteriorationfrom high blood sugars independendy of their effect upon bloodsugar. They have also beenfound to delay or prevent the onsetof diabetes in some high-risk individuals. The thiazoUdinediones avaUablein the United Statesare rosigUtazone and piogUtazone.

Thrombotic risk profile: Agroup of blood teststhat can reflect the tendency of bloodto clot inappropriately, thereby increasing the risk forheart attacks, poor circulation, and certaintypesof stroke.These testsinclude fibrinogen, lipoprotein(a), and C-reactiveprotein.

Glossary 491

Total cholesterol: The sum of serum HDL plus serum LDL plus approximately one-fifthof serum triglycerides.

Triglycerides: Substances found in blood and fatty tissues comprisingthe storage form of fat. Each triglyceride molecule consists of threefatty acid molecules bound to a glycerol molecule. Serum triglycerideis frequendy elevated when bloodsugar is high. Elevated levels can bea risk factor for cardiac and vascular disease.

Truncal obesity: A form of obesity, also caUed central or visceral obesity, in which the circumference of the waist is greater than the circumference of the hips in males or greater than 80percent of the hipcircumference in females.

TVpe 1 diabetes: Atype ofdiabetes, usuaUy appearing before theage offorty-five, that involves total or near total loss of the capacity to produceinsulin.Also caUed insulin-dependent diabetes meUitus (IDDM),autoimmune diabetes, or juvenUe-onsetdiabetes.

Type 2 diabetes: The type of diabetes that usuaUy appears after theage of forty-five and is commonly associated with obesity. It usuaUyinvolves partial lossof insulin-producing capabUity, diminished non-insulin-mediated glucose transport, and resistance to the glucosetransport effects of insulin. Also not quite accurately called non-insuUn-dependent diabetes meUitus (NIDDM), insulin-resistant diabetes,or maturity-onset diabetes. Nowfound to appear in many obesechUdren.

Unit: A measure of the biological effectiveness of insulin at reducingblood sugar. The lines on the scale of an insulin syringe frequendymeasure increments of 1 unit. The lines on some newer syringes represent increments of Vi unit.

Vagus nerve: The largest nerve in the body, and the main neural component of the part of the nervous system that regulates the parasympathetic autonomic (involuntary) functions of the body, includingheart rate, blood pressure, breathing, penUe erections, and digestion.

Vascular: Relatingto blood vessels.Visceral obesity: Seetruncal obesity.

Recipe Index

BEEF, LAMB,ANDVEAL

BeefBurgundyStew,414Beef Sautl, Mandarin, 415Cheeseburger, Grilled,with Canadian

Bacon, 411

FiletMignon with Green and BlackPeppercorn Sauce, 413

Flank Steak, Marinated, 412-413Lamb Shish Kebab, 415

Steak, Grilled, with Mushroom Sauce,412

Steak Salad, Broiled, 413-414VealScallopini,416

BREAKFAST

French Bran Toast, 400

Ham and Cheese Omelet, 399

Mushroom Omelet with Bacon, 398Pancakes, 401Sausage and Eggor Ham and EggOpen

Sandwich, 399-400ScrambledEggs with Onions, Peppers,

and Stripples,399

DESSERTS

Beignet,440-441Chocolate Souffles, Individual, 440Chocolate Vanilla Cheesecake, 439Rhubarb Pie, 440

PORK

Pork Chopswith Horseradish Sauce,416-417

Stir-Fried Pork with Sweet and Sour

Cabbage,417

POULTRY

Chicken, Grilled, withTarragonButter,409

Chicken,Jalapeno,with Broccoliand JackCheese, 408-409

Chicken, Lemon, 410

Chicken Dijon, 410Chicken Salad, Broiled, 410ChickenShishKebab withVegetables, 409Duck Breast, Grilled Marinated, 411

GroundTurkey Burgers with Marjoram,407-408

TurkeyMelt,408

QUICHES AND SOUFFLESCheese Quiche, 437—438Quiche Lorraine, 437Spinach Souffle,438Zucchini Souffle\ 438-439

SALADS

Curried Chicken, with Jicama, 405

GreenCabbageColeSlawwith LemonZest, 406-407

Marinated Cucumber, with Fresh Dill,

406

RoastedEggplantSummer,405-406

SAUCES

Dijon Mustard Butter, 396GingerScallionButter,397Italian-StyleRed,394Lemon Butter, 396

Lemon Pepper Butter, 396Red Pepper Cocktail, 395

494

Russian Dressing, 395SpicyMustard,397-398Tarragon Butter, 397

SEAFOOD

Bluefish with SpicyMustardSauce, 423Crabmeat, Avocado Stuffed with, 418-419Salmon, Black Olive Crusted, 421Salmon, Grilled, with Lemon Pepper

Butter, 420-421

Salmon Salad, 418

Scallops Provencal, 420Scrod, Steamed, with Watercress and

Ginger,421-422Shrimp,Five-Spice, withBeanSprouts,

419

Swordfish, Pan-Fried,with GingerScallionButter, 422-423

Trout Amandine, 423

Tuna Melt, 417-418

SOUPS

Acorn Squash Bisque,401-402ChickenEgg-Drop, withScallions,

403-404

Cucumber, 402Seafood Chowder Trio, 404Zucchini, 403

RecipeIndex

VEGETABLE ENTREES

AND SIDE DISHES

Avocado Spread,435Cabbage, StuffedSavoy, with RedSauce,

429

Cauliflower, Pureed,with CeleryRoot,433-434

CeleryChips,432EggplantStew, Mediterranean, 428Fennel,Roasted,with Rosemary,426-427Frittata, Baked Cheddar Cheese, 425-426Kale, Sauteed, with Crimini Mushrooms,

436

Moussaka a la Bernstein, 424Mushrooms Florentine, Baked, 427-428Okra, Pan-Fried, with Tamari Scallion

Glaze, 434Scallion Pancake, Chinese-Style, 435-436SpaghettiSquashFritters/Latkes,430Spinach,Creamed,with Nutmeg, 425StringbeanCasserole, Creamy, with Sage

Mushroom Sauce, 433Tofu, Pan-Fried, with Sweet and Sour

Dipping Sauce,431-432Turnip"MashedPotatoes" with Fresh

Chives, 427Zucchini, Baked, with Fresh Basil and Feta

Cheese, 431

General Index

A. Seeaspartinsulinacarbose(Precose), 247,469ACE(angio-converting enzyme)

inhibitors, 347n, 350,480

acesulfame-K (artificial sweetener), 142,159

acetaminophen, 353-354Actos.Seepioglitazone"acute phasereactants," 57ADA (American Diabetes Association), 19

diet recommendations, xiii, 26,136,448;alcohol, 137; author'soppositionto,xi, 107,123,133,140n, 150;

"exchange" system, 134,168;* guidelines,169,444;and hospital

dietitians,462;margin oferror,103; medication cancelingout, 247

ineffectiveapproach,112,116,265ninjection recommendations, 256,260,

268

statistics from, 39

adrenaline. SeeepinephrineAdvil, 350,353AGEs(advancedglycosylationend

products),446agricultural society,127-128,300Agriculture,U.S.Department of, 132,

165

AIDS(acquired immunodeficiencysyndrome), 60

airlinepilots,diabetic, 247air travel, 282-283,289-290

ALA (R-alphalipoic acid), 238-239,240,241,243,245,379

Albert EinsteinCollegeofMedicine, xxalcohol(asantiseptic),78,259alcohol (ethanol, asbeverage), 93n,

136-137,163,177,189,319,374

drugreaction with, 466,467,468,469,471,472

alcoholism,hypoglycemic symptomssimilar to, xv, 137,330,348

allergic reactionto protamine, 265alpha-glucosidase (enzyme), 247

inhibitors,drug interferencewith,469

alphalipoicacid.SeeALAAmaryl (glimepiride), 466American Diabetes Association. See ADA

American Gastroenterological Association,368

American Health company, 367American Heart Association (AHA), xiii,

444,448

American Journal ofHypertension, 456amino acids, 92,124,132

amiodarone,470amnesia, hypoglycemiaand, 336amputations, 12-13,16,42,63,72,473Amsler grid test,63,383amylin (hormone), 98,204,205,206Amylin Pharmaceuticals, 205amyloid (toxic substance),236Anderson, Bob and Trish, 359

anemia,iron deficiency, 55,58anesthesia andblood sugar, 96ANF (atrial naturietic factor), 455antibiotics, 244,368-369

and probiotics,356,369

496

anti-inflammatory agents, 249n, 350,354,479

antioxidants, 65,238-239

Apidra.SeeglulisineinsulinApo B (apolipoproteinB) test,57Arch Intern Med(periodical), 322«arteries, blocked. Seeheart diseasearthritis medications, 350

aspartame. See sweeteners, artificialaspartinsulin (A), 285,303

action time, 269,271,275,301,313

Novolog, 106,464npotency of, 270,277n;diluting,272,273;

and size ofdose, 272,304

regularvs., 312aspirin, x, 194,320,353-354atherosclerosis, 129,130,212,233,249«

Monckeberg's,xviiatherotic plaques,446-447athletes, 47,132,171,202,226

Aubert, Timothy J., 392Australianaborigines,187autohypnosis, 196-201,209autoimmune diabetes, latent. See LADA

Avandia.Seerosiglitazoneavocado, 151,153,170,373

baby food, 374-375barium hamburger test, 361-362basalinsulin dose.Seeinsulin dosagebath thermometer, 68,72,475BayerCorporation, 69,77B-D glucosetablets,67,71,326,327B-D Ultrafine syringes,68Benadrylsyrup (diphenhydramine),368beta blockers, 318,328,340,476

beta cells. See pancreatic betacellsbetaine hydrochloridewith pepsin,369Better Than Bouillon Chili Base, 174

beveragescoffee or tea, 163,173for fluid replacement,351-352glucosedrinks, 69,71,377no-calorie, 150

powdered, 163soft drinks, 163,351,377; diet soda, 144,

163,351

sweeteners for, 158,163; in fluid

replacement,351Seealsoalcohol; fruit and fruit juice;

milk and milk products

General Index

Bihari, Dr. Bernard, 203

Biostator GCIIS device, 249-250

biotin supplements, 238,243birth control pills.Seecontraceptives,oralblacks,diabetes among, 33,187blindness.See eyesblood, removing from clothing,67,70,261blood clot See thrombus

blood pressure, 383measurement of, 455-456

See also hypertensionblood sugar(glucose)

amino acids converted into, 92,124anesthesia and, 96

checking: beforeand during driving,operatingmachinery,and scubadiving,281n, 341; before,during,and after exercise, 221,281; afterexperimental fasting, 303n;to ruleout or avoidhypoglycemia,326-327,331,335,341,343,363; during illness,349-350; beforeandaftersnacking,299; duringweight loss, 194

in children. See children

continuous monitoring of, 336-340controlof: in gastroparesis, 5,62,206,

279,359-361,380;by hospitalpatient,352,462-464; mealplanningand, 168

dehydration and,347dietary fatand, 47dietarysourcesof, 42-43,242. Seealso

carbohydrate (cho)elevated. See bloodsugar (glucose), highexercise and,214-216,221,281;changes

contraindicating, 215gastroparesis and.See gastroparesisglycogen convertedinto. Seeglycogenhunger and,40,49impairedglucosetolerance(IGT), 49;

improvement in, 119infection and. See infections

insulinresponseto consumption of.See insulin response

and LDL cholesterol, 446

measurementof. See blood sugarlevels,self-monitoringof

medications affecting.Seemedicationsin nondiabetic ("normal"), 43-47,75,

91,110,115

patterns of, 362-363

General Index

protein converted into. Seegluconeogenesis

raisingpredictably, 324-326rebound (Somogyi phenomenon), 322swingsin levelof, xv, 5,28,46-47,99,

110,301;gastroparesisand, 372;stressand,94-96;too highandtoo lowinsameday,92

testing food for. See diet testsof(HgbAlc). See tests

transformed into body fat,43,44"transporters," 35,44,224,238

bloodsugar (glucose), high(hyperglycemia), 117,137,333

carbohydrates and.See carbohydrate(cho)

and cardiac/other risks, 115n, 169,387,447,462

complications from, 35,42n; reversal of,12

conventionalinsulin therapyand, 123dehydration and, 345-346,347,348,355and erectileimpotence, 9-10exercise and, xvi, 218fatigue ashallmark of, 55oand frequenturination, 348as hallmark ofdiabetes, 42and high lipid profile, 130-131in hyperosmolarcoma, 348and insulin resistance, 40,96,307,347

medicationsaffecting.Seemedicationsmorning, 306-307; overnight increases,

307

"natural"sugarsand, 144-145postprandial, 43,48«, 49,107,108,134,

139,169,281,457

rapid correction of, 61,301-304toxicity of, to beta cells,40,49,99when to cover, 304-306

blood sugar(glucose),low.Seehypoglycemia

bloodsugar (glucose) profiles, 53-54,75-77,278

frequency and continuanceof, 76;daily,311; during illness,281,312

normalization of, 75-76,118-119,

271-272

postprandial, 310samplescenarios, 277-280taking to doctor, 81-82, 111,113-114,

276,293

497

when to measureblood sugarlevels,82See also Glucograf III data sheets

bloodsugar levels, normalizationof,xvi-xviii, 3,52,83

andblood glucose profiles,75-76,118-119,271-272

case studies, 3-30

exercise or diet askey factor, 214-216,242; meal plan, 139-140

infectionor illnessimpairing,242,307physical andmentalimprovementsdue

to, 57-58,61-62,191,385-386,388;

testsshowing,65predictability askey to, 102-103reducing riskof or reversing

complications,38-39,58,236targetBG (blood sugargoal),84,86,

110-111,114-117,299-304,327; for

children, 300,324; establishing,115-116,117

tight control, 5,29,116treatment plans,109-118;treatment

goals, 118-119visionimprovedby,387

bloodsugar levels, self-monitoringofand diet, 138-166

how and when to measure, 75-77,82,

280; finger-sticking techniques, 78-81whilelosingweight, 194physicians'resistanceto/acceptance of,

xix

recording,83-90supplies for. Seeblood sugarmeter;

Glucograf III datasheets;test stripstesting the accuracyof, 53,64world symposia on, xixSee alsofinger-sticking

blood sugarmeter, xv, xviii, 67,69,78,80-81,115,320

continuous monitor, 338-340

failure to carry, 88selecting,76-77

bloodsugar test strips.See test stripsblood tests. See tests

bolus insulin rate, 284,285n, 286,287,289,

302

bone mass and density, 35,180,213,226,230,454n

books and publications,68,72,107,126,210

food value manuals, 164-165

498

bowelmovement changes,diet and, 166bran and bran flakes, 146

bran crackers, 157-158,160n, 373,458;Bran-a-Crisp,157,170,174,393;brancracker cereal, 157

bread, 135,145,169converts to sugar,raises bloodsugar, 46,

133,139,140n, 222

substitutes for, 158,178,373

breakfast, 169,173-175

breakfast dose, 292-296menus, 181,182

omitting, 173. Seealso fasting (beforetest)

toast substitutes, 158,178,373

breakfast cereals, 146,174-175

substitute for, 157Brown Cow Farm yogurt, 156,170,171butter and margarine.Seemilkand milk

productsByetta. Seeexenatide

Cadbury Beverages, Inc., 159caffeine, 374. See also coffee; teacalcitriol (vitamin D3), 480calcium and calcium supplements, 124n,

155,166,195,244

calcium loss from bone, 245,454n

need for, with fiber, 179-180calorie consumption, 126,127(graph)

in alcohol, 136cutback in, 168

calorie counter (exercise measurement),232

Campbell's soup, 155Canada, insulin sold in, 266

Canadian pharmacies,367-368cancer, liver, 58candy,323,324

"fat-free," 125"protein bars,"146"sugar-free," 143,144,152

carbohydrate (cho), 123,131-136addiction to/craving for,42,132,188,

204,222,242; hereditary,40,135addiction to, curbed: by autohypnosis,

196-201,209;bydiet, 135,209;byendorphins, 201-202;bymedication,ix, 189-190,202-204,209,247

"complex"and "simple," 133,134,169

General Index

convertedto blood sugar (glucose),133-134;and blood sugar rise,46,97,139-140,458;guidelineformeasuring,220

coveringexercise with, 219-222coveringwith insulin, 46;dangers of,

125,275,291

crucial role of, 40

deceptivelabel claims,149,164definition of, 133estimating, lawof,103-104euphoriaproducedby,42,135,

187-188

fast-acting, 133,134,136,139,144,170,275; avoidance of, 108

as fat source, 128-130

fiberlistedas,on packagelabel, 158filling up on, 97,108high consumption of,40,131juggling,inadvisabilityof, 179protein foodscontaining,97,171-172restricting, 138-140;difficulty of, 112,

196; result of, 107,129slow-acting, 108,169-171,179,275vegetable content, 150-151,170-171Seealsodiet; fiber,dietary

cardiac risk factors. See heart disease

cardiomyopathy, cardiovasculardisease.See heart disease

carpal tunnel syndrome, 64,383carrots, raw and cooked, 148

Catapres (skin patch), 371cataracts. SeeeyesCBC(completeblood count), 54-55CDC (Centers for Disease Control and

Prevention), 126CDrecordings of trainingsessions, 11Incellulose, 134,148cereals. See breakfast cereals

cheese. See milkand milkproductscheesepuffs,175,178,373chewinggum, 141,162,372,376-377children

bloodsugarlevel of,300;and growth,387;unpredictable, 301

blood sugar target for, 300,324blood sugar testingof,69,79; bedtime,

278

carbohydratesfor,guideline formeasuring, 220

cholesterol levels in, xiii

General Index

diabetesin (type 2), 33,185. Seealsodiabetes,type 1

glucosetablets for, 325hypoglycemic,335,354;glucagon

injection for,334insulinsfor, 51,73;dosage, 254,265,

272,283,291; timing ofdose,305meal planning for, 169,171medicationfor, 70;aspirinand NSAIDs

contraindicated, 354; Tigansideeffects, 351

obese, 33,39,126-127,185

parentalfears for, xiii, 51proteinneeds, 194teenagers,39,65,180,185,279,387urine test for, 60

Chinese restaurant effect, 97-98,108,140,178

chlorpropamide. SeeDiabinasecholecystokinin(CCK),208cholesterol

in children, xiii

fiber and, 457-458"good"(HDL)and"bad"(LDL),56-57,

131,446,453n; exercise and, 212

as heart attack risk, 445,448improvement in, 387,453n, 480low-fat diet and, 107,125-126test for (lipid profile).Seeteststhyroid dysfunction and, 58SeealsoHDL (high-density lipoprotein,

"good"); LDL (low-densitylipoprotein, "bad")

circulation,impaired.Seefeetand legscircumin (dietary supplement), 480cisapride suspension(Prepulsid,

Propulsid), 366-368clam broth and juices,154-155Clinistix/Diastix(test strips),68,72,

140-141,154

clonidine skin patch (Catapres), 371coffee, 163,173

lighteners, 147,156Starbucks Mocha drink, 132sweeteners, 158,163

colds, 55,100,312,316

College Inn broth, 155coma, hyperosmolar,348,349Complete Book ofFood Counts, The

(Netzer), 68compounding chemist, 202-203n, 370

499

contraceptives, oral,480drug effects on, 470,471

convulsions (hypoglycemia), 11,318,334corn, corn syrup, 145,148coronary angiography,265Cortisol(hormone), 124n"coverage" asterm, 301,304COX-2 inhibitors, 350

C-peptide,C-peptide test, 54,65,119,293crackers, 145

bran. See bran and bran flakes

C-reactive protein, 56,57,237,382,445cream.Seemilk and milk productscreams, skin. See skin lubricants

creatinine, testing for, 59-60crystalline insulin. Seeregular(crystalline)

insulin

crystatin-c. SeetestsCulturelle Lactobacillus GG (probiotic),

369

CVS Pharmacy,cvs.com, 260cyclamate tabletsand liquid (artificial

sweetener), 73,142,158,163

D. See detemir insulin

dairyproducts.Seemilk and milk productsDaVinci syrups.Seesyrupsdawn phenomenon, 45-46,93-94,240,

271

and bedtime dose, 277-279,280

effectof, on experiment with lispro,302and exercise, 216

and morning dose, 173,291,306-307d-chiro inositol (medication), 480,481deciliter, definition of, 43m

dehydration, 37,349emergency situations, 333,344,354-355fluidand electrolytereplacement,70,

348,351-354; IV, 350,352; salt usedin,67,351

supplies for treating,67,70vicious circle of, 345-346,347

delayed stomach-emptying. Seegastroparesis

dementia.Seememory, short-termdental infections, 100-101,242,355-356

depression, 9,35,209,211,388desserts, 145,152

"fat-free," 125,129-130,164

very low carbohydrate, 144n, 162-163Seeafcojell-O

500

detemir insulin (D; Levemir), 68,73,267-271passim, 302,464n

dosage,278,279,480;diluted,272,273

Dexicola (beverage), 377dextrose, 142,332Dextrotabs, Dextrosol, DextroEnergy,

Dextro-Energen,Dex-4(glucosetablets), 67,70-71,220-221,325-327,337,376

DHEA sulfate, 480

Diabeta (glyburide),466diabetes

ancient Greekdescriptionof,37"autoimmune," 34n; latent (LADA),39.

Seealso diabetes, type 1"brittle," 4,25"chemical," 6among children.Seechildrencomplicationsof,62,64,130-131;

nondiabetics developing,131;reversal of, 62,118-119,129

deaths from,38,448;asleadingcause,33

definition of, 35and dehydration.Seedehydrationexercise restrictions, 216-219

insulin-resistant, 39-42. See alsodiabetes, type 2; insulin resistance

medications for. See medications

obesityand, 186patients' control of.Seeblood sugar

levels, self-monitoringof"pre-diabetes" (latentautoimmune,

LADA), 39prevalenceof,vii,38,187;increasedin

America, 33,126prevention of,385;medicationfor,237risk factors, 18,115n

and thyroid dysfunction,55treatment of. conventional, xii-xvi, 99,

123; forecasts offuture, 49-51;treatment plansand goals established,109-119, (follow-upvisits)381-384

Diabetes (journal), 448,449n,456nDiabetes:The GlucografMethod for

NormalizingBlood Sugar (Bernstein),xx

diabetes,type 1 (insulin-dependentdiabetes mellitus [IDDM], juvenileonset), xii, 34n, 39,54,56

General Index

anesthesia and, 96and blood glucoseprofiles,311bloodglucose target,117; for children,

300,324

complicationsof,xiv,36-37;gastroparesis, 206;hypertension, 454,455;hypoglycemia, 117,343;ketoacidosis, 347

conventional treatment of, xii-xvi

and dawnphenomenon, 45-46,93-94,216

diet and, 109,188,455;difficultymaintaining,196;frequent smallmeals, 108; snacking, 298

earlyrecognition and treatment of,37-38;basicplan, 109-119;earlysymptoms,39,98;"honeymoonperiod,"98-99

exercise and, 211-212,215,216,222

as former death sentence, 36-37heart rate of, 62

IMAs and ISAs for, 109-110insulin and, 284;injections, 106,249,

272; size ofdose, 117,272,291-292;timing of,271

insulin resistance in, 39-42insulin response to.Seeinsulin response,

phase I and IINIH study of, 38parental fears,xiiipresumed causeof, 37,99and stunted growth, xiii

diabetes,type 2 (non-insulin-dependentdiabetes mellitus [NIDDM],maturity-onset), 34«

anesthesia and, 96

and blood glucoseprofiles,311blood sugar levels, 44,92; stressand,

95-96; target, 117-118,300,324;waking/fasting, 48n

complications of,42;hypertension,42,455;ketoacidosis, 347;prevention of,49

and dawn phenomenon, 94diet and, 109,185-187,455,459n;

difficultymaintaining, 196;frequentsmall meals, 108,173; salt restriction,455,456n

exercise and, 109,212,213,214-215,222,225

IMAs or ISAs for, 109,239,284

General Index

incidence of, 33-34,39;amongchildrenandteenagers, 33,185; amongFijiIslanders, 187

and insulin injections,249,251;notalwaysneeded, 42;size ofdose, 254,272;timing of, 271;which insulin touse, 270,284-285

insulinproducedby individuals with,42,43,360

insulin resistance in, 39-42,190,246;saltrestriction increasing, 455

insulin responsein, 47-49,107,118medication for, 239-241; oral agents to

be avoided, xiobesity and. Seeobesityonset of, 41-42

prevention of, vii, 49as silent killer, 42,46

treatment plans,109-119visualchanges assymptom of,42

Diabetes Care(journal), 115,116,448,453n

Diabetes Center, 69,77

treatment program at, 111-119Diabetes Control and ComplicationTrial

(DCCT), 38-39,285Diabetes Diet, The (Bernstein), 163,164,

173,176

Diabetes Foundation Satellite Symposium,Proceedingsof, 449n

DiabeticNephropathy (journal), 452diabetic supplies and tools, 67-74

forinsulin-using diabeticsonly,68-69,73-74

Seealsobooks and publicationsDiabinase (chlorpropamide), 6,467diarrhea, 55,348

dehydration and, 346-347;and fluidandelectrolyte replacement, 352-353

medication for, 67,70,246,353as medication side effect, 243

Diastix.SeeClinistix/Diastix (test strips)diet

ADA recommendations. See ADA

(American Diabetes Association)artificial sweeteners. See sweeteners,

artificial

basicfoodgroups, 123-136. Seealsocarbohydrate (cho); fat,body;protein,dietary (pro)

and blood sugar, 42-43,242

501

andbowelmovementchanges, 166breakfast. See breakfast

carbohydrate addiction. Seecarbohydrate (cho)

checking nutrition labels. Seelabels,checking

consistency in, 294-295,299"crash," 192

creatingyour own, 13,290,461"diabetic" meals, 290

dietarysupplements, 165-166,238,243,245-246,247,379,456,480. See also

mineral supplements; vitamins andvitamin supplements

"diet foods," 143-144,152diet sodapops, frozen,163diet sodas, 144,152,163,351diverging from(andhypoglycemia), 319eatingbehavior,200;insulin and, 48.See

also overeatingeatingout, 140-141,158,175,196,201,

207,287;scheduling injections,289-291;when traveling,289-290

eatingschedules, 172-173,271; frequentsmall meals, 108,173,373,374;

"grazing," 188; and hypoglycemia,290;timing injections, 289-291;timing medication, 207-208

eliminating sugars, 16,22,24,139,141-150

estimating food requirements, 191-194exerciseadjustments, 87-88"fat-free,""low-fat" food, 125,128,

129-130,132,164

forgastroparesis, 145,150,158,373-376glycemicindex and, 146,459-460guidelines, 138-166"health foods," 149-150,153

"high-fiber," 458.Seealsofiber, dietaryhigh-protein, 97,453-454hospital,462junk food, 135liquid or semiliquid meals,373,374,376lunch. See lunch

meal planning,68,72,139-140,167-183; forgastroparesis, 373-376;and insulin dosage, 292-297;medication adjusted to, 167-168,179;prototypes, 180-183;timing of mealsand snacks, 172-173,329

myths surrounding, xii

502

diet (cont.)"natural" foods, 144-145,149-150

"no-no" list, 141-149,152-153

prepared foods, 153recipesubstitutions, 157,158,178,373,

393-394

snack foods.Seesnackingsoups, 154-155,351"sugar-free" products,141,143-144,

152,159,162-164

supper.Seesuppertestingfood forsugar or flour/grain, 68,

72,140-141,154

"treats," 220,222; fun food, 133,167,222,443

WeightWatchers, 15Seealso beverages; fruitand fruit juice;

meat, fish, fowl,seafood,and eggs;milk andmilk products; mustard,pepper, salt, spices, herbs; vegetables;individualfooditems

diet,high-carbohydrate, low-fat,xiii,xivADA and, 107,444

and beta cells, 99

and carbohydrate addiction.Seecarbohydrate (cho)

Chinese restaurant effect, 97-98,108

compared to low-carbohydrate, high-fatdiet, 128,131,445,448,449n, 453n

dangersof, 107,126,128,131-132,187,340

dietary fatconvertedto body fatin, 128and hypertension, 455insulin covering,343,365media promotes, 130,132andtriglyceride levels, 56,107,129,445andtype 2 diabetes, 185-187

diet, low-carbohydrate, high-fat,xi, 21,118carbohydrate craving endsunder,135,

209

compared to high-carbohydrate, low-fatdiet, 128,131,445,448,449n, 453n

dialysiscentersusing,453fat metabolized in, 128

wronglyblamedfortestresults, 449zero-carb, 132-133,135,153,154,374

diet, low-carbohydrate, high-protein,97,453-454

digestiveproblems,61,206,357,363-364.Seealsogastroparesis

digoxin, 469

General Index

diphenhydramine(Benadrylsyrup), 368diplopia,387.See alsoeyesDisintegrator Plus,260-261diuretics. See medications

DKA. Seeketoacidosis, diabeticDoctor's BrushPicks, 356

domperidone,367-368,380DPP-4 inhibitors, 205,248driving,andcheckingblood sugar, 281nDuPuytren's contractures ofthe fingers, 64Dynatronicscompany,376dysphoria, 187

Eades, Drs.Michaeland MaryDan, 107eatingbehavior, eatingout, eating

schedules. See diet

ECGC (ExportCreditGuaranteeCorporation)greenteaextract,479-480

echocardiogram, 205eggs, 154,174,175

EggBeaters, 174electrical gastricstimulation, 376electrocardiogram, 61-62,383electrolyte replacementSee dehydrationemergency alarm systems, 336emergencysituations. Seedehydration;

hospitalcare; hypoglycemia; illnessEndocrine Practice (journal),244endorphin levels, 187,201-202,213endoscopictests,363enzymes, digestive,124,134,141,244,366,

367

contraindicated, 469

enzyme inhibitors, 246,247,347n, 350,366,460,480

enzyme tablets, 367,360epinephrine(adrenaline), 454n

adrenaline surges, 95-96and hypoglycemiasymptoms, 328,

340-341

Equal. Seesweeteners, artificialerection,penile,63

dysfunction,9-10,12,42,61,321,358;recoveryfrom, 14,62,119,364,386

Erivan yogurt, 155-156erythritol (artificial sweetener), 143erythromycin ethylsuccinate,368-369Eskimos, 458-459

esophageal reflux disease, 366estrogen,low levelsin women, 58

General Index

euphoriaproducedbycarbohydrates, 42,135,187-188

evening primrose oil (EPO), 238-239,240,241,243,245,379

examinations,physical.Seetestsexenatide (Byetta), 205,207-208

drugs interfering with, 471exercise, xiv, xvi, 188-189,211-234,242

aerobic, 223,224,230anaerobic, 212,223-230

appropriate program of, 109,222-223back flex, 372,377

benefits of, 18,180,211-216; effect onbloodsugar,214-216;effectoncholesterol, 212; improves self-image,212,222; lowers insulin resistance,213-214,222-223,224

and bloodsugar,214-216;changescontraindicating,215;checkingbloodsugarbefore,during, and after,221,281

bodybuilding, 212,225-230cardiovascular, 230-233

caution against/restrictions on, 215,216-219,232-234

checking with physician before,216-217,218,219,231

coolingdown after,233coveringwith carbohydrate, 219-222;

guideline for, 220coveringwith glucosetablets,220-221,

222

dawn phenomenon and, 216and diet adjustments, 87-88equipment for,226-227,229,230-232and heart rate, 225,231-232,233

insulin injections and, 215,268,319lower-body, 227;avoidanceof before

tests, 58

muscle-building,191,222-223patient refusing,112progressive,223,233-234sit-ups, 229-230stomach-emptying(gastroparesis),

371-372,377

sustained, 213-214timing of,214-215unpredictable, 301upper body,227walking, 17,214,234,371and weight control, 191,213

503

weight-lifting,217,222-223,225,226-228; form in, 227-228; invertedpyramidsystem,225,228-230

Exubera (inhalable insulin), 315,472eyes

blindness, 34,42,61,448;night,xivcataracts, xiv, 27,387

diet and, 154

diplopia (double vision), 387eyeexamination, 63,64,383,387; before

exerciseprogram, 217glaucoma,11,387lasersurgeryof,22macular edema, xiv, 387,448microaneurysms,387retinal disease, 57; reversal of, 118retinalhemorrhages, 61,217,387; risk

reduced, 237retinopathy,11,38,196,217;

proliferative,61visionimpairedbyhypoglycemia, 320,

322

visionimprovedby improvedbloodsugar, 387

visualchangesas type 2 symptom, 42

factor VII, 447fainting,37,62,67n, 74,94,341-343

during exercise, 217familialdyslipidemia, 172famine, 127-128,185-186,192fasting

afterbedtime dose.Seesleepingblood sugar rise during, 92,93; vs.

normal, 48nexperimental, 280,303n, 363fluid replacementwhile,352insulin stored during, 284medication and, 270,349before test, 54,56,65,114,382

fat, bodycarbohydrateas source of, 128-30dietaryfatand, 41,128fat-muscle ratio, 128-129,213,216,

222

glucosetransformed into, 43,44insulin as builder of, 128-130,

190-191

and insulin resistance, 40-42,129,190,213

Seealso obesity;triglyceridelevels

504

fat, dietary, 123and BigFat Lie,125-131,443and blood sugarlevels, 47convertedto bodyfat, 128differentiatedfrom bodyfat,41"fat-free" and "low-fat" foods. See diet

"fat substitutes," dangersof,130metabolized, 128,132restricted (in specialcase),172and stroke, 445

fatigue, lowbloodsugarand,55nreliefof, 119

fatty acids, 128,130,131,155,208omega-3,154

FDA(Food and DrugAdministration)approval,76,117,130,142,208,209,

315

and labelingor reporting, 146,164,465-466

recommendations, 165,244,245,311,

316

feetand legscareof, 13,72,473-476; suppliesfor,68,

72

corns and calluses, 476

deformities, xiii, xvii, 219,473,474dry skin, 218,383,473,475,476examination of: daily,219;

oscillometric, 63-64,383impairedcirculationin, 16,63-64,72,

218,480; test for, 383injury to, 474,476;whileexercising,

218-219

neuropathy of, 12,27,218-219,473;reversed, 21,118,379,386

numbness of, 196;recovery from,386scaly, 13shoes and socks, 219,383,474,475,476toenails, 383,476

ferritin levels.Seeiron (ferritin) levelsfever, 70,346,347,350

and postponementof test,58-59treatment of, 353-354; children, 354

fiber,dietary, 158,166,170,456-459and calcium supplement, 179-180reduction of, for gastroparesis,373See also cellulose

fibrinogen levels,56,57-58,61,213,387,445,447

fibrosis, 339,340"fightor flight"response,95-96

General Index

FijiIslanders,187finger-sticking, 77,78-81

alcohol(asantiseptic)contraindicated,78,259

calluses from, 78,79

sites to prick, 79-SOspring-activateddevices, 79-80transmissionof diseaseby,81

fish. See meat, fish, fowl, seafood, and

fish oil, 238flavor extracts, 157,156,159-160,163

Florastor(probiotic),356n,369flour,testingfood for,72,140fluconazole tablets, 369fluidreplacement.Seedehydrationfluid retention, 244,245,311,455foam cells, 446-447

folic acid, 58,169

follow-up visitsto physician, 111,381-384

Foodand DrugAdministration.SeeFDAfoodand feedinghabits.SeedietFood Values ofPortions Commonly Used

(Pennington), 68FreedaAllNatural Parvenzyme,367Frio (for insulin storage),68,73,

267-268

Frito-Laypotato chips, 130"frozen" shoulders, xiii, xiv, 64fructose, 134,141,143,144-145,152fruit and fruit juice,135,136,147-148,

153,460

fibrous, 457usein raisingbloodsugardiscouraged,

222

"fun foods." See"treats"

G.SeeglulisineinsulinGADA (pancreaticbeta cellprotein), 39Galloway, John, 106gamma-raytechnetiumscan,361,362garlic(combinedwith drug), 468gastroparesis (delayedstomach-

emptying), 61,196blood sugar control and, 5,62,206,279,

359-361,380

causes and effects, 357-361;vomiting,351

chewinggum as aid in, 141,162,372,376-377

General Index

control of, 364-377; diet modifications,145,150,158,373-376; exercises,371-372,377; fast-acting insulincontraindicated, 290,379; glucosetabletsor liquid, 74,222,325;mechanical aids, 372,376;medications, 303,364,365-371,380;medications contraindicated, 247;modifiedpreprandial insulin or ISAregimens,377-379; skin patches,370-371

diagnosing,361-364"false," 363-364hypoglycemia as risk,86,359,360-361,

363,378

illustration of, 358insulin mixture for, 259reductionin symptoms/reversal, 119,

385

supper menu for, 177unpredictability of,94,301,360,362

Gatorade,351

GCIIS device (Biostator), 249-250gelatindesserts,144n.SeealsoJell-0geneticpredisposition to obesity,128genotype.Seethrifty genotypeGFR.SeeglomeruliG/G ScandinavianBran Crispbread, 157,

170,393

glargine insulin (LAN, Lantus), 68,73,272,302,464n

action time, 269,270-271

dosage,278,279storageof,267;losespotency,266for women with PCOS, 480

glaucoma.Seeeyesglimepiride(Amaryl),466glipizide(medication),467globulins,lowlevelof,55glomeruli, 450,452-453

destruction of (glomerulopathy),454;tests for, 455

glomerularfiltration rate (GFR),451-452,453

GLP-1 mimetics, 205,208

glucagon (hormone), 45,97-98,124,205,206-207

GlucagonEmergencyKit,69,74,333-334,337

in treatinghypoglycemia, 333-335,336-337

505

Glucograf III data sheets, 67,83-90, 111,168,221,269-270,336

where to buy,70Glucola(beverage),377gluconeogenesis, 36,43,44,92-93,97,129,

284

alcohol and, 136-137Glucophage.SeemetforminGlucorellInc.,238nglucose. See bloodsugar (glucose)glucosechallenge, 91glucosegel(Glutose15)or liquid (Glutol),

69,71,73,74,332-333,336,337,

377

glucosetablets,67,70-71,118for children, 325covering exercise with, 220-221,

222

handling and storing, 324,336,337raisingblood sugar with,324-325,

328-329; how many to take, 326-327,331; table, 326

Glucotrol (medication), 467Glucovance (medication), 466glulisineinsulin (G,Apidra), 267,270,273,

275,301

action time, 106,269,271-272,285,

303-304,313

caution regarding,312potency of, 277n

Glutol,Glutose 15.Seeglucosegel (Glutose15)or liquid (Glutol)

glyburide (medication), 466glycated hemoglobin. See HgbAlcglycation,239,446,452

of tendons, 64glycemic index, 146,459-460glycogen, 335

convertedinto glucose(glycogenosis),36,45,97,215,333

glucose converted into, 44glycosylation, 239,446,452Glynase (glyburide), 466Glyset(miglitol),469grainsand grainproducts,153

testingfor,72,140"grazing," 188growth hormone, 124ngrowth stunted, xiii,387-388guar gum, 457gymnema, 468

506

H (Humalog). Seelispro insulinHamilton depressionscale,388Harlan, Bill, 126HDL(high-density lipoprotein,"good"),

56-57,445-446,447

exercise raises, 212

low, 448normal level, 131reduction of, 455

"health food." See diet

health food industry, 149-150heart disease

cardiac risk factors, 5,16,21,42,57,58;blocked arteries, 57,446-447; bloodsugar and, 115n,169,387,462;cholesterol, 16,445,448;druginteraction,244;high-carbdiet, 126;postexercise, 233;recentdevelopmentsregarding,445-449;risk reduced, 38,119,213,237,387;sugarand, 249n,300; testsbeforeexerciseregimen,216-217,218,219;testsfor,55-56;weightloss,194; forwomen, 447

cardiomyopathy,xiv,447cardiovascular exercise, 230-232;

caution, 232-233

insulin levels aspredictorsof,447-448treatment of, 370

heart/pulse rate, 61-62,341elevated,in hypoglycemia, 480exercise and, 225,231-232,233

gastroparesisand, 366metering,231

HemoCuebloodsugarmeter,69nhemoglobin, glycated. See HgbA,cheparin (anticoagulant), 265herbs, 160HgbA|C (glycated hemoglobin), 16,118

conversionto blood sugarvalues,116-117,300

testsof.Seetests,blood sugarhiatal hernia, 196,363-364,376

highblood pressure. See hypertensionhirsutism, female, 477,479Hispanics,incidenceof diabetesamong, 33HMO (health maintenance organization),

52-53

homocysteine levels, 58,61,244n, 445test of, 56

honey, 141,144-145,152

General Index

"honeymoon period" (type 1diabetes),98-99

HoodiaXtra (cactus extract), 203-204hormones

amylinand amylinanalogs,98,204-205,206

anabolic and catabolic, 36n

counterregulatory ("stress"), 95,124n,214-215,284; insulin as, 36

hospitalcare,350-351and blood sugar control/diet, 71,334,

352,462-464

Humalog. SeelisproinsulinHumaneticsCorporation, 481human insulin, 265. Seealso NPH

(isophane)insulin;regular(crystalline)insulin

Humulin N, 269.SeealsoNPH (isophane)insulin

Humulin R.Seeregular(crystalline)insulin

hunger,98,135,187,189,191,204and blood sugar,40,49; as

hypoglycemia symptom,298,320,326,328-329

hydrogenperoxide,67,70,81,261hypercalcemia, 480hyperglycemia. Seeblood sugar (glucose),

highhyperinsulinemia,41,448,449hyperosmolarcoma,348,349hypertension(highblood pressure),383

beta blockers for, 476

andbloodchemistryprofile,55exercise raising,217high-carbdiet and, 455improvementof,119,387insulin levels and, 41,448,455salt and, 160,454-456as type 2 complication,42,455

hypnosis,self-,196-201,209hypoglycemia, 7-8,117,317-343

alcoholcausing,137,319alcoholismsymptoms resembling,xv,

137,330,348

and amnesia, 336behaviorcausedby,xiv-xv, 11,28-29,

322-323,329-332; impairedjudgment, 37,318,330

asblood sugar approaches normal, 84,110

General Index

causes of,319-320; delayed digestion,107,359; exercise, 220;insulinpump,314,319; intramuscular injection intomusclebeing exercised,215,319;NPH insulin, 320

checkingto rule out or avoid,326-327,331,335,341,343,363

in children, 334,335,354elevated pulserate,480gastroparesisand, 86,359,360-361,363,

378

glucose effect on, 327,335;table,325help by familyand friends,74,280-281,

317,329-335,338-339,343

hospitalization and, 334,352,462-464and loss ofconsciousness, 37,67n, 74,

318,359; MedicAlert bracelet and,67n, 71,338; treatment, 333-335

medications and medication

combinations that can cause, 238,320,354,468,471,472; OHAs, 236,

241-242,317-319

medications that can mask, 354postprandial, 107precautions against,290,300,301,304;

overnight 278,279,363; snacks and,297

recordingepisodes, 336signsand symptoms of,318,322-323;

convulsions, 11,318,334; denial, 321;

elevated pulserate, 320;epinephrineand,328,340-341;fainting, 341-343;hunger, 298,320,326,328-329;impaired vision, 320,322; whilesleeping,279,335,338

supplies for,67,70-71,336-340;emergency equipment, 69

travel and, 336

treatment of,321-327,377;emergency,331-337;glucosetablets used for,326(table),327;goalof, 119

unawareness of, 318,340-341

weatherchangesand, 282,320hypotension, postural, 119,341-343hypothalamus, and satiety, 36hypothyroidism.Seethyroid dysfunction

ibuprofen.350,353,354IDDM.Seediabetes,type 1ID tags,337-338JgA, IgG, IgM (immunoglobulins), 55

507

IGF-1 (insulin-likegrowth factor), 61IGT(impairedglucosetolerance),49

improvement in, 119iliotibial band/tensorfascialata syndrome,

xiv, 64

illness

bloodsugarduring,281,312; checking,349-350

emergency, 346,349-350,354insulin injectionsduring, 346,

349-350

size of doseduring,354and test results, 54See also infections; medications

IMAs (insulin-mimeticagents),86,109,235,238-239,245,246

and hypoglycemia, 241-242side effects of, 239,242,243-246typicalprotocols,240-241SeealsoSymlin

impotence.Seeerection,penileIMs (incretins and incretin mimetics)

204-208,209,238-239

Indian Affairs, Bureau of, 185infarcts (blocked arteries). See heart

disease

infections, 41,55,57,60,314bloodsugaraffected by/effect on,

100-101,242,281,307,345,347

effect on insulin dose, 100of feetand legs,474;fungal,476nondehydrating, 355;dental, 100-101,

242,355-356

recurrent, as type 2 symptom, 42infertilityin women, 478,479inflammation, 41,57

anti-inflammatory agents,479;insulin,249n; NSAIDs, 350,354

inositol, d-chiro, 480,481insomnia, 202insulin

abbreviateddesignations for,269-270absorption of, 105-106action times of, 268-269

analog,285n,287basal levels, 36,270,349. See also insulin

dosagecare of, 73,266-268cloudy,264,266,306. SeealsoNPH

(isophane) insulindiluting, 272-274

508

insulin (cont.)fast-acting. See aspart insulin; glulisine

insulin; lispro insulin; regular(crystalline) insulin

-fat connection, 128-130,190-191

human, 265.SeealsoNPH (isophane)insulin; regular (crystalline) insulin

and hypertension,41,448,453inhaled, 315-316,472

injected. Seeinsulininjectionsand insulin supplies,68,73-74long-andintermediate-acting. See

detemir insulin;glargine insulin;NPH (isophane) insulin

mixing,265,268,279,378; forgastroparesis, 259

mixing with ISAs, 239,310-311in nondiabetic ("normal"), 43-45noninjectable, 275,315-316,472phaseI andII.See insulinresponsepolymerizationof, 257-258,259potencyof,270,287,291,319; lossof,

266-267

and pregnancy,x-xiprescriptions for, 73,270produced by diabetic in early stages, 37producedby pancreas. See pancreatic

beta cells

regimensforuse,276-283; intensive,284-316

regular. Seeregular (crystalline) insulinreluctance to use, 51

serum insulin levels, 41,447-448,454-455; in women, 477-478

strengthsof (U.S. vs.othercountries),265-266

"tolerance" to, 41

and type 1diabetes. Seediabetes, type 1what it is and does, 35-36

which to choose, 270,284-285

insulin-dependentdiabetes mellitus(IDDM). Seediabetes,type 1

insulin dosageair travel and, 282-283

basal, 280,281,284,285n, 302,349; ISAadded to, 311

bedtime, 271,276,277-279,280,281,284,374;airtraveland,283;obesityand, 310-311; for women with PCOS,480

for children, 254,265,272,283,291,305

General Index

diluting, 272-274estimating, 134,135; alcoholand, 137;

bedtime, 277-279;preprandial,291-292,378-379; safety factor,300-301; scenariosdemonstrating,292-297;snacking,298-299

and hypoglycemia, 117infections and, 100juggling, 364mealplanningand,292-297measured in units, 253-254,265-266

morning, 173,271,281,284,291,302,305,306-307

preprandial, 284-285,291-292,374; ingastroparesis, 378-379

recording, 86size of, 117,268,279,291-292,304; for

children, 254,265,272,283,291;

covering high-carb diet,343,365;duringillness, 354; graph of, 287;lispro, 290; metformin reduces, 242;obesity and, 93,106,263,272,310-311

splittingdoses,283,289-290timing of, 271; forchildren,305.See also

insulin injectionstravel and, 282-283

weatherchangesand, 281-282Insulin for Life, Inc. (Australia), 80ninsulin injections,xii

adjustedto diet schedule,289-291beforeevery meal (preprandial),76,

285-286; in gastroparesis,377-379benefits of, 249ndiet scheduleadjustedto, 289-291duringillness,346,349-350and insulin absorption, 105-106insulin"pens,"262-263insulin pumps vs. Seeinsulin pumpsintramuscular, 46,262.307-310,314,

349-350; and exercise, 215,268,319mixing insulins in same syringe,378painless,8,77,261-262; how to give,

251-53; jet injectors for,262removingbloodstains from clothing,67,

70,261

self-injectiontechnique, 249-263,349;corrected, 114; intramuscular,

309-310

several insulins at same time, 259,279sizeofdose.Seeinsulin dosage

General Index

syringes for, 68,73;disposing of,260-261; filling, 255-257; hospitalsupply, 464n;how to select,253-255,265-266;insurancecovering,257,262; needlelength,73,254-255,308,309; in othercountries, 266; reusing,257-259,267

timingof, 106-107,108; dangers ofdelay, 288-289,290; eatingschedules,172-173,271,289-291; postprandial,134-135;preprandial, 288-289,310;shifting protein and, 373-374

variabilityof, 105-106insulin-mimetic, insulin-sensitizing

agents. SeeIMAs; ISAsinsulinpumps,46,301,313-315,319,340,

376

insulin resistance, 39-42body iron and, 58,247-248dawn phenomenon and,306-307dehydration and, 347fatcausing, 40-42,129,190,213highblood sugar causing, 40,96,307,

347

hypertension and, 454obesityand.See obesityreversal or lowering of:by diet

supplements,166,245-246; byexercise, 213-214,222-223,224

salt restriction and, 454n, 455

sudden termination of (andhypoglycemia), 319

viciouscircle of (graph), 40in women, 477-480

insulin-resistant diabetes. Seediabetes,type 2

insulin response, phase I and II, 44,129,215,360

diet and, 108,140diminishedor absentphase1,91-92,

107,118,359;and delayin response,48,134,139

fat-muscle ratio and, 129,213,222nondiabetic ("normal"), 43-45,47response to glucoseconsumption

(graph),48Insulow(dietary supplement), 238«,243insurance coverage

ofglucose monitors, 339ofhypnotherapy,200ofinsulin syringes,257,262

509

malpractice, 352of nonprescription drugs,243of phlebotomy, 248ofprescription drugsoutsideU.S.,

366-367

of tests, 52-53,60,64,362of training sessions, 112

Internet, 159-160,204,368,479. See alsoWeb sites

Intersalt (internationalstudy), 454nInzitol (d-chiro inositol), 481irondeficiencyanemia.Seeanemiairon (ferritin) levels, 58,247-248,258,

445

ISAs (insulin-sensitizing agents), 86,109,235-237,241,280,456«

combined with insulin, 239,310-311and hypoglycemia, 241-242,317npreprandial use of, 279,284,286,374side effects of, 242,243-246typicalprotocols,240-241andweightloss,190-191,237for women with PCOS, 480

See also metformin;SymlinIshikawa, Kanji, 102,158isophane(insulin). SeeNPHisosorbide dinitrate, 370-371IV (intravenous) fluid replacement,350,

352

Jannsen Pharmaceuticals, 366,367-368Januvia (sitagliptinphosphate), 204,205,

208,248

Jell-0,144,150,152,161-162,170,178as flavoring, 156

Jenkins, Dr. David, 457,459jet injectors, 262Joslin,Dr.ElliotP.,215Joslin Clinic, 23

Journal oftheAmerican College ofNutrition, 126n

Journal of theAmerican MedicalAssociation, xviii, 445,449n, 454,459n

Journal ofClinical Endocrinology andMetabolism, 456n

Journal ofDiabetes andItsComplications,453n

junk food, 135Juvenile Diabetes Research Foundation,

315

juvenile-onsetdiabetes.Seediabetes,type 1

510

kappa lightchains,polyclonal ormonoclonal, 59

ketoacidosis, diabetic (DKA), 28,314,347-348,349

ketones,buildup of,37,137,346,347-348,352

testingfor,72,354-355Ketostix(for urine testing),67,72,354kidneydisease (nephropathy), 54,100,456

dehydration and, 354diabetic 10,42,57-58,60-61,196,448;

causes of, 450-453; medicationslowing, 237; proteinand,xiv, 125,451-453; reversal of, 58,118,237,452

dialysis treatments for, 58,453reduction in risk for, 38tests for, 57-60

kidneys,function of,36,450-453fluid retention, 455

Knoxunflavoredgelatin,144n, 162kosher products, 67,326,367

kosher mealswhen traveling, 290

labels,checking,142,144,154-156,160,163,170,176,374

deceptiveclaims,143,146,149,164labeling regulations, 143,146,158,164,

465-466; margin of error, 103Lab World (periodical),xvLactaid,377

lactic acidosis, 243-244

lactose.SeesugarLADA(latent autoimmune diabetes), 39.

Seealsodiabetes, type 1lancets,disposable,69Lantus.SeeglargineinsulinLaws ofSmall Numbers, 103,108,139,240,

275,277,292

lawsuits, fear of, 462LDL (low-density lipoprotein,"bad"),

56-57,245,382,445-446,447

diet increasing,107,172exerciseor diet reducing, 212,453nnormal level, 131tests for, 57,446

lente insulin discontinued, 265n

leptin (hormone), 186,246Levemir. See detemir insulin

Life Extension Foundation, 208Lilly, Eli,and Company,68,106,205,209Limeondex(beverage), 377

General Index

lipid profiles,130-131,212,382,458lipid profiletest SeetestsLipidResearch ClinicsTrial,445lipoprotein(a),56,57-58,131,237,445,

447

lipoproteins.SeeHDL (high-densitylipoprotein,"good"); LDL(low-density lipoprotein,"bad")

lisproinsulin(Humalog,H), 68,73,464n

action time, 106,269,272,275

in cartridgeform, 313coverage by,285,301-308;during

illness, 349-350;vs.regular (R),271,286-287,291,312; tableshowing,303;when not to use (gastroparesis),379

diluting,273mixingwith other insulins,259,378potency of,270,291,319prescription needed for,270and size ofdose, 290timingof,106,271,289-290

liver disease, liver cancer, 54,58

liverenzymes,244«,366Lomotil, 67,70,353lowblood sugar.Seehypoglycemia"low-fat" foods. See diet

lunch, 169,175-177lunch dose, 292-296

menus, 181,182,183

lupus erythematosus, 282nlutein, 136,154lycopene,136lymphoma, 60

McCullum, Dr. Richard, 357macrophages (white blood cells),446magnesium,red blood cell,118

testingfor,55,246magnesium supplement,124n, 166,180,

246,247

maltodextrin, 72,142,393Jell-Owithout,150,152

maltose(sugar), 134manganese, 180mannitol (sugar), 162Massachusetts Institute of Technology

(MIT), 187massagers, 376,377

Web site for, 372

General Index

maturity-onset diabetes.Seediabetes,type 2

mayonnaise, 161meal plans. Seedietmeat,fish,fowl, seafood,and eggs, 151,

154,174-175

babyfood,375canned tuna, 176carbohydratecontent, 124,171-172servingsize,171shiftingfromsupper to other meals,

373-374

substitutes for, 154MedicAlert Foundation, 338MedicAlert identification bracelet, 15,67,

71,338

Medical Tribune, 4medications

adjustment of,to mealplanning,167-168,179

adjustment or discontinuance of:in dehydrationor infection,347n,349-350;during weightloss,194

affectingblood glucoselevels,465-472

alcohol (ethanol) reaction with, 466,467,468,469,471,472

anti-inflammatory(NSAIDs), 249n,350,354,479

before snacks, 178,206,207beta blockers, 318,328,340,476for children, 70;aspirin, 354;side

effects, 351for curbingcarbohydratecraving/

overeating, ix, 98,186,189-191,202-205,209,246,247

for diarrhea, 67,70,246,353diuretics, 341,342,347n, 350,479faintingcaused by,342during fasting,270,349for foot care (oils, creams, and lotions),

68,72,383,475

for gastroparesis, 303,364,365-371,380;skinpatches,370-371

hyperglycemia causedby,466-467hypoglycemia causedor maskedby.See

hypoglycemiaincretin mimetics (IMs), 204-208,209,

238-239

interactions of, 244,245,465-471

511

forlosingweight, 189-191,195,202-203,209,237,243

to lowerblood sugar,117,214,301-306;and exercise program, 217,218

multiple agents, 245vs."natural" way, 51forovereating, ix,204-208,247for PCOS, 479-481pregnancy and, x-xipreventingor delayingonset of diabetes,

237

to raiseblood sugar,324-326.Seealsoglucose gel(Glutose15)or liquid(Glutol);glucosetablets

recording,86-87,89forsevere vomiting. See vomitingor

nausea

side effects, 202,206,239,247; in eldersand children, 351;hyperglycemia as,466-467; ofISAs and IMAs, 239,242,243-246;of metoclopramide,andantidote to, 368

Web sites for. See Web sites

forweightloss.SeeweightlossSeealso IMAs (insulin-mimeticagents);

insulin; ISAs (insulin-sensitizingagents); OHAs(oralhypoglycemicagents)

Medicool, Inc., 73meglitinides (drugs), 235,468memory, short-term, 35,63,119,385-386menopause, 237menstruation, 58,193n, 319,477,479Merckand Company,205metabolism, aerobic and anaerobic, 224Metabolismand Nutrition Society,449nMetamucil, 146,373

metformin(Glucophage), 19,117,165,236dosage, 240,241extended release, 241,311medications interacting with, 245,471reducing insulin dose,237side effects, 239,243-244;

hypoglycemia, 242for women: with PCOS, 478,479,480;

pregnant, x

metoclopramidesyrup,69,74,334-335,337,380

side effects ofand antidote to, 368Metropolitan LifeInsurance Company,

192

512

mg/dl (milligramsperdeciliter), xv-xvin,44,49,86,294

excessive, 239

HgbA,c conversion to,116-117,300hypoglycemia and,318n"normal," 43-44,84,115,300

target,84,86,110-111,114-117,299-304,327

microalbuminuria test, 59

microglobulintest, 60Micronase(glyburide),19,466miglitol(Glyset),469Miles Laboratories, Ames Division, xviii

milk and milk products,257cheeseand butter or margarine, 123,

155,172,176

cottagecheese, 147,155,172cream, 147,155,163

lactose-free milk, 377

nondairylighteners replacing, 147,156on no-no list, 153

ricotta, 375

yogurt, 155-156,170,171,375milligram,definitionof,43nmineral supplements, 124n,165,246,247

calcium, 166,180,195,244mineral water, 150,163

mmol/1 (millimoles per liter), xv-xvin,303

mood swings, xv, 5,28eliminated, 30

Morningstar Farms,170Motilium tablets, 367

motolin (hormone), 368Motrin, 350,353

MurrayShorePharmacy (Canada), 367nmuscle mass,increasing, 191,213,214,

215-216

and fat-muscle ratio, 128-129,213,216,

222

musculoskeletal examination, 64

mustard, pepper,salt,spices, herbs,160,454-456

N. SeeNPH (isophane) insulinnaltrexone (medication), 202-203,209naproxen, avoidance of,354nateglinide (Starlix),468National HealthExamination Follow-Up

Survey, 448National Health Service (U.K.), 30

General Index

National Institute ofDiabetes and

Digestiveand Kidney Diseases(NIDDK),38

National Institutes ofHealth (NIH), 33,38,126,132

NativeAmericans,diabetesamong, 33Natural Appetite Control,208"natural" foods, 144-145,149-150

"natural" treatment, 51Nature'sWay PrimadophilusReuteri

(probiotic), 369nausea.Seevomiting or nauseaneedles. See insulininjections, syringes forNeel, JamesV, 185neotame (artificial sweetener), 142,143nephropathy. Seekidney diseasenervedamage. SeeneuropathiesNetzer, Corinne, 68

neuroglycopenia, 318neurologicexamination, 62-63neuropathies(nervedamage),diabetic,

447

autonomic, 218,342

and digestive problems,357,358and fainting, 217,342ofthe feet, 12,27,473; reversed, 21,118,

379,386

and foot injuries, 218-219,474and hypoglycemiaunawareness, 340improvement in, 119,386-388; ALA

and,238-239risk of, reduced, 38and sexual intercourse, 10

vitamin C causing,65neurotransmitters, 42,187-188,189,213

New EnglandJournal ofMedicine, xviii,33,107,115n,453n,480

New York Heart Association, 444New York Times, 15

NewYork Times Magazine, 443New Zealand, 366-367,481niacin, 244n

NIDDM. Seediabetes,type 2nitricoxide agonists, 369-371nitroglycerine skin patch,370-371No-Calsyrups,159nondiabetics, 125

blood sugar("normal") of, 43-47,75,91,110,115

developing diabetes, 115n, 131heart rate, 62

General Index

non-insulin-dependent diabetesmellitus(NIDDM).Seediabetes, type2

no-no list. See diet

Novo Nordisk Inc., 68Novolin N.SeeNPH (isophane)insulinNovolin R.See regular(crystalline) insulinNovolog. Seeaspart insulinNPH (isophane) insulin, 264-265,267,

269,270,272,287n

dosage,277-278,302; bedtime, 271,279;diluted, 273

filling syringe with,255-257Humulin N and Novolin N action

times, 269

hypoglycemia causedby,320mixingwith regular insulin, 378shakingvial,255-257,266,274,319

NSAIDs (nonsteroidal anti-inflammatorydrugs), 249n,350,354,479

NutraSweet (artificial sweetener), 142,143

NutriBase Complete Book ofFood Counts,77ie (Avery), 68,164-165

nutrition.See diet;labels, checkingNutritionalBiochemistry (journal),45Innuts, 146,161,460

nystagmus, 321

oat bran, 458obesity

American epidemic of, 125-128,186;graphshowing, 127; amongPimaIndians, 185-187,224

and "bad" cholesterol, 56and breakfast, 173in children and teenagers,33,39,

126-127,185

and C-reactive protein levels, 57and death rate, 189definition of, 39diabetes as result of, 186diabetes type2 among,34,39-42,

47-48,54,128,185,272; exercise for,225-226; weightlossasgoal, 109n,184,213,243

geneticpredisposition to, 128high-carbohydrate diet and, 107,132,

135,187;vs.high-protein diet 453nhypnotherapyfor,200insulininjectionsbenefiting, 249nand insulin production, 47-49

513

and insulin resistance, 39-41,47-49,478; insulin dose, 93,106,110,263,272,279,310-311;weightlosscurbing, 184,237

overeatingas cause of, 188.Seealsoovereating

sugar as causeof, 132and survival in famine, 128; the thrifty

genotype, 185-188and triglyceridelevels, 41,129visceral, 39,184; defined, 41

Obesity Meds andResearch News, 210OHAs (oralhypoglycemic agents), 145,

327,337

pancreas-provoking,avoidanceof, 19,235,236,360

sulfonylureas,177,214,215,220,317,359-360;dangersof,x,xi, 235n,315,466; and hypoglycemia, 236,241-242,317-319

oils,dietary,123,155,238,453. Seealsoeveningprimrose oil (EPO)

oils, skin lubricant 68,72,383,475Olean (olestra), 130omega-3fattyacids,154OmniPod (insulinpump), 315onions, 149,151

Orbit "sugarless"gum, 162OregonHealthSciences University, 132oscillometry,64-ose or -ol, productnamesendingin,72,

152

osteoporosis, 35,454novereating

and Chinese restaurant effect, 97-98,108,140,178

compulsive, 188-189,204curbing,196-210; bymedication,98,

186,190-191,204-208,246,247;byself-hypnosis, 198,200,209

hypoglycemia and, 107skippingbreakfastand, 173stressprecipitating,95in vicious circle, 40See also obesity; satiety, regulation of

Paddock Laboratories, 69PagerVibratingMulti-Alarm,201npancreas,"artificial,"249-250pancreas-provoking drugs.SeeOHAs(oral

hypoglycemic agents)

514

pancreatic alpha cells, 36,44-45pancreatic amylase (enzyme),247npancreatic betacells

burnout of, 42,349,478; causes of, 19,49,99,236; measurement of, 52;obesityand,39-40; prevented, 37,119,270; reversed,slowed, or halted,99,140,208,236,249-250,270

hormonessecreted by (insulin, amylin,glucagon), 35-36,97-98,205,271,360; vesicles containing, 99.See alsoinsulin response

laboratory replication of,50-51protein(GADA) of,39

pasta, 128,134,135,145-146,169patient"compliance," 112PCOS (polycystic ovarian syndrome), 110,

193n, 310,477-481

medication for, 479-481

peanutbutter,161,460npedometer, useof, 17,234pentoxyphylline (Trental), 480Pepcidantacid,243Pepsi-Cola, 148Perfecta Products, Inc., 261

phenformin sideeffects, 243phenylalanine contraindicated, 235phlebotomy, 247-248phosphate,124nphosphorus,179physical examination. Seetestsphysician, takingrecords to,81-82, 111,

113-114,276

phytochemicals, 136,169Pima Indians, 185-187,224

pinolenicacid,208pioglitazone (Actos), 236,237,240,241,

244-245,311,456n

medications interactingwith, 469-470platelets,447Polar pulsemeter,231polycystic ovarian syndrome. See PCOSpolymersand polymerization, 257-258,

259

popcorn, 148postreceptor defects in glucose utilization,

96

potassium, supplemental, 456potassiumchloride, 70potatoesand potatochips,130,148-149pramlintide. See Symlin

General Index

Prandin(repaglinide), 468prazosin (diuretic), 342Precose. See acarbose

predictabilityofglucose tableteffects,324-326askey to normalization, 102-103andunpredictability: ofexercise, 301;of

gastroparesis, 94,301,360,362; ofindividual reactions, 123; of insulin

release, 105, (with protamine) 264; ofpostprandial blood sugar, 374

pregnancy, medications and,x-xiPrepulsid and Propulsid (cisapride),

366-367,368

Prestab (glyburide), 466Progresso cannedtuna, 176protamine, avoidance of, 264-265,320protein,body,451

C-reactive levels, 56,57,237,382,445pancreatic betacell(GADA),39

protein,dietary(pro), 42-43,123,124-125

amino acids converted to, 92,124carbohydrate content,97,171-172children's need of, 194conversionofgrams to ounces, 171,374convertedto blood sugar(glucose), 104.

Seealsogluconeogenesisduringweightloss,193-194high-protein diet,453-454; andChinese

restaurant effect, 97-98juggling, inadvisability of, 179and kidney disease,xiv, 125,451-453serving size, 169,171shifting fromsupperto earlier meals,

373-374

sources of, 124See also meat, fish, fowl, seafood, and

eggs

"proteinbars," 146ProteinPower(Eades and Eades), 107proteinuria,xiv,xvii, 125,218psyllium(medication), 146,373,456-457pulserate. See heart/pulseratepumpkin, 151

quercetin (dietarysupplement),480

R Seeregular (crystalline) insulinRaab,Ron,80n

R-ALA(R-alpha lipoic acid).See ALA

General Index

ramipril (ACEinhibitor), 480Reaven, Dr. Gerald, 250

record-keeping. SeeGlucograf III datasheets

reflux,esophageal, 366regular (crystalline) insulin (R), 270,273,

275,285

estimating preprandialdose,291-292Humulin R and Novolin R, 68,73,269,

464n

vs.most-rapid-acting,271-272,286-287,291,312

NPH mixed with, 378renalrisk profile.Seetestsrepaglinide(Prandin), 468retinopathy. SeeeyesReye's syndrome,354rice and rice cakes, 145-146ricotta cheese, 375-376

Rockefeller University, 388Rockwell CompoundingAssociates,

202-203n

Rosedale Pharmacy, 66rosiglitazone(Avandia), 236,310,378

beneficial effectsof,237; lowering bloodsugar,239,240,241

fluid retention caused by,244,311interactingwith other medications,

244-245,470R-R interval study. Seetests

saccharin. See sweeteners, artificialsaccharomyces boulardii (Florastor), 356n,

369

St. John's wort, 468

salad, mbced green,135-136,151,170-171,176

cookedvegetables interchanged with orsubstituted for, 177,373

salad dressings, 160-161,170,171,176saline solutions, 272,273,350

insistenceon, in hospital,352salt and salt substitutes, 160

in fluidreplacement, 67,351andhypertension, 160,454-456salt restricted, 454n, 455,456

Sambucol (elderberry extract),100satiety,regulationof, 36,98,187,204,208Science (journal), 126,443scuba diving, checking blood sugar and,

281n

515

seaweed (toasted nori), 158seizures, 94

self-hypnosis,196-201,209self-image, exercise effects on, 212,222seltzer, 150,163,351

serotonin, 42,187

serum albumin, serum globulin,55,454serum betaj microglobulin test, 60serum transferrin saturation, ferritin, total

iron binding capacity(TIBC), 58Sharper ImageCorp.(Web site),372sitagliptinphosphate (Januvia),205skin lubricants, 13,68,72skin patches,370-371sleeping

blood sugarwhile, 177,274,284hypoglycemia while,279,335,338insomnia, 202

Slice (diet soda), 144Slow-Mag (dietary supplement),246Smarties (glucosetablets), 325,326smoking, 186,316,472,475snacking,168,196,202

bedtime,avoiding, 307chewinggum assubstitute for, 162guidelines for, 297-299irondeficiency and,58medication before, 178,206,207snack foods, 135,146,153,298timing of, 172-173,329uncontrollableurge for,58,204

soda pops, frozen, 163soft drinks, 163,351

diet sodas, 144,152,163,351Somogyi phenomenon, 322sorbitol, 143,144

soups, 149,154-155

for fluidreplacement351South African blacks, 187soybeanproducts, 154,155,170,376

carbohydratecontents, 172soybean flour, 156-157soymilk, 147,156,174

spices, 160Spiegel, Dr.David,197Spiegel, Dr.Herbert, 197,200spironolactone (diuretic), 479Splenda.Seesweeteners,artificialStarbucks Grande Caramel Mocha drink,

132

starches, 132,134,140

516

Starlix (nateglinide), 468steroids, 312,472

stevia. See sweeteners, artificialStimudent toothpicks, 356stomach-emptying, delayed. See

gastroparesisStonyfield Farmyogurt, 156,170,171stress, 94-96

infection as, 100.Seealso infectionsstress hormones. See hormones

stroke, risk of, 194,213,217,447,462dietary fat and, 445loweredbyinsulin,249n

STStherapy,376sucralose. Seesweeteners, artificialsucrose, 134,140,143,323,332

sugar

added to artificial sweeteners, 142,143,

393

Americanconsumptionof,132; andcardiac risk, 300

carbohydratesas, 133-134eliminatingfromdiet, 16,22,24,139,

141-150

foundin"sugar-free" foods, 141lactose, 72,141,147,155,159,377"natural," 144-145,149. Seealsofructose"simple," 134,141,147taste of (and euphoria), 42,188testingfood for,68,72,140-141,154Seealsoblood sugar (glucose)

"sugar-free" products,141,143-144,159,161-162,163,164

DaVinci syrup, 144,156-163 passimSugar Twin (artificial sweetener), 142sulfonylureas. See OHAssulindac(anti-inflammatoryagent),479Sun-Dex (beverage),377Sunett (artificial sweetener), 142,159SuperiorQualityFoods, 174SuperPapaya Enzyme Plus, 367supper, 169,177

menus, 182,183shiftingproteinfrom,373-374supper dose, 292-296

surgery, 462eye(laser),22recent, exercise and, 218vomiting after,351

Suther, Charles, xviii, xixsweat, inability to, 218

General Index

Sweetartsglucosetablets, 67,71,326sweeteners, artificial, 72-73,158-159

aspartame, 72,142,149,158,163,393;Equaltablets,68,72,141-142,156,157,158-159,163

forbeverages, 158,163; in fluidreplacement,351

cost of, 68health food industry viewof, 149-150powdered, 141-143,159,163; howto

prepare,393;on no-no list,72,152saccharin tabletsor liquid, 68,72,142,

149,158-159,163,393

Splenda tablets, 142,156,157,159,163

stevia liquid or powder, 142; costof,68;uses of, 144n, 156,157,163,393;

where to buy,159sucralose, 142,159,160,163

sugaradded to, 142,143,393Sweet'nLow,141,142,174

SweetOne,The,142,159

sweets on no-no list, 152-153Symlin (pramlintide), 205,206,207,

208

drugs interferingwith, 471hard stopper on vial,209-210

syncope.SeefaintingSyndrome X (Reaven),250syringes. Seeinsulin injectionssyrups

corn,145

sugar-free:DaVinci,144,156,157,159-163passim; No-Cal,159

Tagamet antacid, 243tagatose (artificial sweetener), 142-143targetBG. See bloodsugarlevels,

normalization of

Taubes,Gary, 126,443T cells, 50T3 andT4 tests, 55,56,449tea, 163,173

"diet," 163green tea extract,479-480iced,in fluid replacement, 351lightener or sweetener for,147,156,158,

163

teenagers. Seechildrenterazosin (diuretic), 342testosterone in women, 480

General Index

tests

Amslergrid.63,383ApoB,57avoidance ofexercise before, 58barium hamburger,361-362blood,53-58,364; forliver enzymes,

244n; for PCOS, 479bloodchemistry profile, 55blood pressure measurement, 455-456blood sugar (HgbAlc), 47,53-54,

64-65,81,112,115-116,118,250,300,382,448; converted to blood

sugar values,54,116-117; cost of, 65;effect of illness on,54.See abo finger-sticking

for cardiac risk factors, 55-56; beforeexercise, 216-217,218,219

CBC (complete blood count), 54-55cost of, 53,65

C-peptide, 54,65,293crystatin-c,60,382eye,63,64,217,383,387fasting before, 54,56,65,114,382gamma-ray technetium scan, 361,362forgastroparesis, 361-362; endoscopic,

363

IGF(insulin-like growthfactor),61illness affecting resultsof,54insurancecoverage of,52-53,60,64,

362

iron (ferritin), 248forkidneydisease, 57-60LDL and HDL cholesterol, 57,446lipid profile, 56-57,65,118,245microalbuminuria, 59microglobulin, 60mineral deficiency, 55,246neurologic,62-63oscillometric, ofcirculation in legs and

feet, 383

physical exam, 61; of feet andlegs,63-64,383; follow-up, 111,381-384;musculoskeletal, 64;takingrecords todoctor, 81-82,111,113-114,276,293

renal risk profile,58-59,118,455;reasons to postpone, 58-59

requesting copies of, 53R-Rintervalstudy,61-62,65,341,342,

383;of gastroparesis, 206,361-364,380

serum homocysteine,244n

517

T3andT4,55,56,449testingfoodfor sugaror flour/grain,68,

72,140-141,154

thrombotic riskprofile,57-58,65,118thyroid profile,55,56urine, 58-61,65,114,382; for children,

60;during illness,67;for ketones,72,354-355

vitamins affecting,54when to perform, 64-65

test strips, 67,68,70,72,78,80-81,140-141

different brands, 76thiazolidinediones, 117,239,243-244,245,

480

drugsinterfering withor affected by,469

effect of, 237

thirst, extreme, 37,346,348thriftygenotype, 185-188,196thrombocytes,447thrombus (blood clot), 265

coronary thrombosis, 447thrombotic activity duringweight loss,

194

thromboticriskprofile. Seeteststhyroid dysfunction,55,58,246

hypothyroidism, 56,379,449thyroid profile,55,56TIBC (total iron bindingcapacity),58Tigan suppositories, 67,70,350

side effects, 351tight-controlregimens, 5,29,116TNF-alpha (tumor necrosis factoralpha)

levels, 479toasted nori (seaweed), 158toenails. See feet

tofu,154. See abosoybean products"tolerance," 4 l,202ntomatoes, tomato paste, tomato sauce,

tomato juice, 149TotallyCool,Website for,73training sessions, 112,113-114

CD of, 11In

Trance andTreatment: Clinical Use ofHypnosis (Spiegel and Spiegel), 197,200

travel, 266,267,336,377byair,283,289-290

"treats,""fun foods,"133,167,220,222,443Trental(pentoxyphylline), 480

518

Trident sugar-free gum, 162triggerfingers, 64triglyceride levels, 128-129,245,387

high,40-41,244,448,455; high-carbdiet and, 56,107,129,445;

medication lowering,245,480;duringweightloss,129,194-195

normal, 131Tufts University report, 226nTylenol,353tyrosine phosphatase (enzyme), 246

ulcers of feet, 218,219ultralente insulin discontinued, 265n

UnitedKingdom(U.K.), 30,73,265nUniversity of Minnesota study, 105University of Pittsburgh study,447urinarytractinfection,59-60urine production,450-451,452,453,454

frequent orexcessive, An, 165; anddehydration,37,345-346,347,348

urine tests. See tests

USA Today, 33USDA(U.S. Department of Agriculture),

132,165

Vaculance(Bayer), 69,77,278vaginal yeast infection,42nvagusnerve,61-62,358,363,366,367,368

healingof, 364,379vanadium compounds, 246,247vascular disease, peripheral, xiii-xivvegetable oil, 155vegetables, 169

acceptable, 135-136; babyfood, 375;carbohydratecontent 150-151,170-171

cooked, 149,150-151,176;interchangedwith salad, 177,373

fibrous, 457

on no-no list, 152-153

prolonged cooking of, 149raw or unmashed, 148,150

sugar contentof, 148-149vitamin supplementation of, 165Seeabo salad, mixed green

vegetarians, 125,154,451vision. Seeeyesvitamins andvitamin supplements,

165-166,169

affecting test results,54

General Index

iron-enhanced, 58

vitamin A or beta carotene, 245-246

vitamin B group, 58,165,244,364vitamin C, 54,65,81,147,165

vitamin D, 124n, 180,195; D3,480

vitamin E, 54,165-166,194,238,239,

245

vitamin deficiency, 244nWeb site, 367

Vitasoysoymilk, 147vomiting or nausea,348

dehydration and,344,345,346,347;fluid replacement, 352

in hypoglycemic incident 334-335medication adjusted or discontinued

during, 349-350medication treating,67,70,74,350-351

WackyWafers (glucose tablets), 326walking.SeeexerciseWasaFiberRyecrackers, 157,170,393Water Sensations (flavor concentrate),

144n, 160,163

weather, effect of, 281-282,320Web sites

ADA, 116

books, 126; this book, 30,64ndata sheets, 70

devices, 73,201n

false information, 142nfood, 157,174; food value manuals, 165;

sugar-free products, 159-160,162glucose monitors, 339nmassagers,372MedicAlert, 71

medications, 71,203,207,238n, 366,

481

needledisposal,260nPima Indians, 185

United Kingdom, 30,73vitamins, 367

weight "ideal," 118,191-192weightgain, 126

inhibited by leptin, 246weightlifting.Seeexerciseweightloss,184-195

checkingblood sugarsduring, 194estimating foodrequirements,191-194exercise and, 191,213importanceof, fortype 2,109n, 184,213medicationadjustment during, 194

General Index

medication for, 189;calciumsupplement, 195; ISAs, 190-191,237;metformin (side effects), 243;naltrexone, 202-203,209

and pregnancy, x-xitargetfor, 191-194thrombotic activity during, 194triglyceride levels during,129,

194-195

as type 1symptom, 37forwomen and girls with PCOS, 193n,

478,479,481

Seeabo obesityWeightWatchersdiet, 15Weinstock, Karen A., 391WestSoysoymilk, 147,156,174Winkies(kosher glucose tablets), 67,71,

325,326

women and girls,bone mass/densityin, 180,230,454ncardiovascular exercise for, 230estrogenlevelsin, 58heart disease risk for,447hirsutism in, 477,479infertility in, 478,479

519

iron (ferritin) levels in, 58,248menopausal, 237; postmenopausal, 180,

454n;premenopausal,58menstruating, 58,193n, 319,477,478obese, 41

with PCOS, 193n,477-481; insulinresistance in, 477-480

serum insulin levels in, 447-448

testosterone in, 480

urine tests for, 59

vaginalyeastinfections in, 42nWorthingtonStripples (soybacon),

170

Wurtman, Drs. Richard and Judith, 187

XlearDent sugarless gum, 162xylitol(sugar), 162

Yale University study,33yoga, 371-372yogurt.See milk and milk productsYu Naturalsoymilk, 147

zinc deficiency, 246Zsweet (artificial sweetener), 143

About the Author

Richard K. Bernstein, MD, isoneof theworld's foremost experts in diabetes treatment and care. He is the first diabetic to monitor his ownblood sugars, apractice that was ridiculed when hebegan but iscommontoday. For more than thirty years hehas been an outspoken proponent ofnormalblood sugars for diabetics.

In 1946, atthe age of twelve, hewas diagnosed withtype 1diabetes.He realized in thelate 1960s that hewas dying from myriad complications of diabetes. Trained as an engineer, he attacked his disease as anengineer would.When the earliest blood sugar meters became available in 1969, theywere available onlyto hospitals and doctors. He obtained one through hiswife, a physician, anddiscovered thathe couldnormalize his blood sugars with the help of the meter and a low-carbohydrate diet. His discoveries about diet and blood sugar normalization were dismissed bythediabetes treatment community.

Dr. Bernstein — then Mr. Bernstein — left his business career atage forty-five to secure amedical degree sothathewouldhave the credentials to publish his findings. Over the years, he has perfected andrefined his program for diabetic blood sugar normalization and hasdeveloped new methods for the treatment of type 2 as well as type 1diabetes. This nationally bestselling book and his book The DiabetesDiet are the fruits of that work.

Dr. Richard K. Bernstein currently serves as a consultant to theArthur S. Abramson Department of Physical Medicine and Rehabilitation of the Albert Einstein College of Medicine. He is the emeritusdirector and former director of the department's Peripheral VascularDisease Clinic at Jacobi Medical Center, and is a fellow of the American College of Endocrinology, theAmerican College of Nutrition, andthe College ofCertified Wound Care Specialists.

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