Janine Freeman, RD, LD, CDE
Education Program Specialist,
Department of Food and Nutrition

Document Use:

Many of the current diabetes medications work by increasing the insulin release by the pancreas or decreasing the glucose produced by the liver. Avandia, however, works mainly by increasing insulin sensitivity, one of the major problems in people with type 2 diabetes. It makes muscle cells more sensitive to insulin and thus helps improve the action of insulin. Blood glucose levels and hemoglobin A1c have improved in studies when Avandia is taken alone and in combination with another diabetes drug, Glucophage (metformin).

Avandia is in the same class of drugs as Rezulin (troglitazone), which has been linked to liver failure in some people. Studies so far have not shown Avandia to cause any liver problems. However, to be on the safe side, it is recommended that patients have a liver test before beginning the new drug and every two months during the first year of therapy.

Remember that diabetes drugs are not magic bullets that get your blood glucose under control by themselves. You still need to carefully balance what you eat, stay physically active, and test your blood glucose levels regularly.

You've heard the scare tactics about why you should control your blood glucose levels - blindness, heart disease, foot and leg amputations, and kidney disease. Your health care team is constantly reminding you to eat right, exercise regularly, and keep your blood glucose as close to normal as possible. Still, you end up testing your blood glucose levels infrequently, you eat unhealthy foods too often, you come up with more excuses than a die-hard couch potato for not exercising regularly and your hemoglobin A1c is still running higher than 8%. Why?

If you take the approach that "I don't care if I die 2 years earlier; I want to enjoy myself," you're in for an eye-opener. Unfortunately, you are not going to live a healthy life until the day you die and then just keel over. Diabetes can cause debilitating complications that develop gradually. Losing your vision, having a heart attack or stroke , losing a leg or experiencing painful neuropathy will significantly decrease your quality of life. And it can cause you to lose your independence at an early age.

The good news is that you can help delay or prevent the complications of diabetes by keeping blood glucose levels in good control . This was shown by the results of several long-term studies like the Diabetes Control and Complications Trials (DCCT) conducted with people with type 1 diabetes and the United Kingdom Prospective Diabetes Study (UKPDS) where they studied people with type 2 diabetes. The bad news is that too many people don't take advantage of this good news. Many physicians and other health care professionals believed that the results of these landmark studies would have a major impact on how diabetes was treated and the lifestyle decisions people make. The big question is "why hasn't everyone with diabetes changed their behavior?"

As you know, lifestyle changes are not easy to make. You make decisions every day that affect your blood glucose control - what, when, and how much you eat; whether or not you're going to be active or a couch potato that day; and decisions about taking or possibly adjusting your diabetes medication. Consequently, you make more management decisions regarding your diabetes than your physician and other health care professionals. You are in the driver's seat - you actually decide whether or not your diabetes is in good control. So, don't bury your head in the sand. Start testing your blood glucose regularly and use those numbers to decide how your activity, way of eating, and medication affect your blood glucose levels.

Although your target blood glucose range may vary, in general, if you are not keeping your before-meal readings between 80-120 mg/dl and your bedtime readings below 140 mg/dl, you need to change something. Make sure you get your hemoglobin A1c test at least 2 times per year to determine your overall diabetes control. The goal for most people with diabetes is less than 7%.

Changes you need to make to improve your blood glucose control might include increasing your skill level in meal planning. You may need to visit a registered dietitian to hone your skills at carbohydrate counting or portion control. You can also get some help with an exercise program or suggestions on how to increase your daily activity level without going on a specific exercise program to improve your diabetes control. You also may need changes in your diabetes pills or insulin. You should communicate regularly with your physician and health care professionals to get advice on how you can better control your blood glucose. However, you are the one who is ultimately responsible. It's your life. So, take the reigns and take charge.

If you believe the old adage "you are what you eat", it's time to reevaluate what you and your family are choosing to eat. And believe it or not, you do have control over what you eat. Fast food has become part of our daily lives, but it doesn't have to mean eating more fat and calories. Selections are available at many restaurants that are lower in fat and calories. Some tips in making healthier choices include:

1. Get nutrition information from fast food restaurants or resource books and decide ahead of time what you will select.
2. If you eat more fat and calories at one meal, cut down at other meals in the day.
3. Try to eat about the same amount of carbohydrate at your meals each day (starches, breads, fruits, milk, sugar-containing foods).
4. Order sandwiches without the mayonnaise or special sauces to reduce your fat intake.
5. Select broiled foods such as broiled chicken or fish.
6. Choose potatoes or tossed salads with low-fat or fat-free dressing on the side.
7. Try to choose fast-food restaurants that offer some vegetables and/or fruit.
8. Eat your 5 fruits and vegetables each day by using them as raw, between-meal snacks if you are unable to get them when eating out.
9. Bring a grilled chicken sandwich home and supplement it with a green vegetable, a piece of fruit, and a glass of skim milk..
10. At restaurants where nutritional information is unavailable, ask questions about fat content and food preparation.

Remember to compare the nutritional content of foods in your favorite fast food restaurants so that you can choose the healthiest ones. An example from McDonald's follows.

The burrito gives you about 1/3 the fat and ½ the sodium of a sausage biscuit. An English muffin would be even a better choice giving you only a fraction of the sodium and fat. You can add orange juice or low-fat milk, depending on your carbohydrate needs.

With a little planning, you can improve your food intake, even in our fast-paced lifestyles. Your county extension agent can answer a lot of the questions you may have about healthy eating. Talk with a registered dietitian if you would like a meal plan designed for your specific needs or if you'd like more detailed information about carbohydrate counting.

Recent studies on protein in diabetes have shown some surprising results. When people with diabetes were given pure carbohydrate snacks (such as fruit) compared to a snack with carbohydrate and protein (7 ounces lean meat), the blood glucose results were very similar. The protein snack did not prevent the blood glucose from dropping several hours later any more than the pure carbohydrate snack. Fat had similar results except that the blood glucose reached a peak (highest level) slightly later with the high fat snack than the carbohydrate snack..

For many years most people with diabetes, especially those on insulin, were taught to eat 1-3 snacks each day in addition to their three meals. The snacks, the professionals claimed, should all include some protein, allegedly to help prevent blood glucose levels from dropping quickly. They emphasized the need for protein particularly at the bedtime snack to help "last through the night". So, dutifully, most people would snack on peanut-butter crackers or cheese and crackers to help keep blood glucose levels more on an even keel.

These guidelines were based on the assumption that protein converts only partially to blood glucose and at a slower rate than carbohydrates. Therefore, for people taking insulin, blood glucose levels would not be as likely to drop to dangerously low levels overnight or before the next meal.

One of the problems resulting from eating cheese or peanut-butter several times a day is consuming too much fat. Since a majority of people with diabetes, especially type 2, are overweight, do they really need to consume protein snacks which are generally high in fat or even snacks at all?

With the newer short and rapid-acting insulins in use now, it makes it easier to adjust insulin to prevent low blood glucose levels. If you take insulin and are trying to lose some weight, you have some other alternatives now to the carbohydrate and protein snacks you've been eating. If your blood glucose levels tend to drop consistently at a particular time of day, you should talk with your physician or other health care professional about changing your insulin dosage that is in effect at that time. That may correct the problem without needing a snack between meals. Another option is to eat a lower-fat snack consisting of just carbohydrate such as a piece of fruit or some pretzels or baked potato chips.

The current nutrition recommendations suggest that meal plans be individualized to each person based on their needs. There are no hard and fast rules. Monitor your blood glucose levels regularly to ensure that what you're doing is working. A healthy way of eating for everyone includes eating less fat. If you don't need protein at your snacks, you'll be on your way to eating less fat which can help to prevent heart disease associated with diabetes.

Well, don't give in to these lazy, hazy days. You can stay active and still be safe, if you take some simple precautions.

1. If you exercise outside, exercise in the early morning or in the evening after the sun goes down.
2. Walk in an air-conditioned place such as a mall to avoid the heat and prevent exercising in the dark.
3. Wear light, loose-fitting clothing. Some of the popular fitness wear is tight-fitting and too heavy for the summer heat.
4. Drink lots of fluids (water is best) at least 2 hours before you exercise. Continue drinking every 20 minutes during exercise and after exercise. It's also important to drink fluids up to 36 hours afterward to completely rehydrate yourself even when you're not thirsty. The first signs of dehydration are thirst, headache, dry mouth, weakness, rapid heart beat, and muscle cramps. As we age, some of these symptoms decrease.
5. Gradually build up your tolerance to exercising in the heat and humidity. Start slowly and exercise for a shorter period of time in the beginning.
6. Watch out for the signs of heat stroke - dizziness, confusion, no longer sweating, high body temperature.

People over the age of 65 and those who are overweight are at a much higher risk of heat-related illness. Drinking alcoholic beverages, working outside in hot, humid weather, and not drinking enough fluids all increase your risk of heat stroke.

Most of all, listen to your body. If you don't feel well, stop exercising or slow down. Take the necessary precautions as usual to prevent low blood glucose reactions during or after exercise. If you take insulin or oral glucose medication, carry glucose tablets or other fast-acting snack and your ID bracelet with you when you exercise. Remember that regular physical activity is important even in the summer, so don't take a summer vacation from good health and fitness.

1. Mix together the sesame oil, soy sauce, ginger, and sherry. Sprinkle over the salmon and let it marinate for 15 minutes.
2. Prepare to steam. Fill the bottom of a large wok or sauce pot with 3 inches of water. Place a steamer rack in the wok or pot. Place the fish fillets on a heat-proof plate. Cover the wok or pot and steam the fish for 10 minutes, until it its tender.
3. Sprinkle the fish with lime peel and scallions. Serve with lime wedges.

6 Servings
Serving Size: 3 ounces
Exchanges: 3 lean meats, ½ fat

Nutrition Information:
Calories: 205
Carbohydrate: 1 gram
Protein: 24 grams
Fat: 11 grams
Cholesterol: 77 mg
Sodium: 109 mg
Fiber: 0 grams
mg = milligrams

Reprinted with permission from Diabetic Meals in 30 Minutes or Less. The American Diabetes Association, 1996.