Behealthy: Diabetes by Banner Publications Inc.

TWO OUT OF EVERY FIVE AMERICANS WILL DEVELOP

TYPE 2 DIABETES

DIABETES Publisher Melvin Miller Health Editor Karen Miller Senior Editor Yawu Miller Production Caleb Olson Erin Pelikhov Walter Waller Proofreaders Rachel Reardon For advertising opportunities Please contact Karen Miller at (617) 261-4600 x7800 or kmiller@bannerpub.com. Be Healthy is published by Banner Publications, Inc. Volume 2 • Number 1 Fall 2014 Photo from front page: Shutterstock/blvdone

Be Healthy is printed by Cummings Printing 4 Peters Brook Drive P.O. Box 16495 Hooksett, NH 03106 603-625-6901

Diabetes Diabetes: Often preventable............................................. 4 Signs and symptoms.................................................. 4 Complications of diabetes........................................... 6 Risk factors............................................................... 6 You won’t know until you’re tested.............................. 7 Are you at risk?............................................................... 5 Managing your diabetes................................................... 8 Myths vs reality............................................................... 10 A leading cause of blindness............................................ 12 From the streets to the pulpit........................................... 14 Just 7 percent of body weight.......................................... 16

Healthy steps Sugar-sweetened beverages........................................... 18 Diet is a four-letter word.................................................. 20 Not just pasta.................................................................. 21 Chickpea salad................................................................ 22 Exercise is medicine........................................................ 23

November is National Diabetes Month

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DIABETES

often preventable … but the numbers are increasing

It is surprising that a six-inch gland can have such an impact on the body. The pancreas seems hidden by the stomach and other organs, but it is not to be ignored. It secretes a hormone called insulin that springs into action when a simple sugar called glucose begins to build in the blood. The apple or bowl of cereal or even that sugar-sweetened beverage that we consume is chock full of carbohydrates that our digestive system breaks down into glucose. It is glucose that fuels the body. There’s one hitch, though. It can’t enter the cells of muscles and other organs on its own. It needs insulin to “unlock” the cells to let it in. In type 2 diabetes — the most common form of the disease — the body does not make enough insulin or the cells are unresponsive to it. As a result, glucose builds up in the blood, which is not a good Rhonda M. Bentley-Lewis, M.D., thing. High levels of blood Endocrinologist Massachusetts General Hospital glucose wreak havoc on the body and can cause damage to several organs, including the heart, eyes and kidneys. They can even lead to erectile dysfunction. The incidence of diabetes continues to rise. In 2012, more than 29 Frequent urination million people in this country were diagExcessive thirst nosed with diabetes, according to the CenFatigue ters for Disease Control and Prevention. What’s worse is that 8 million people do not Weight loss even know they have it. It may sound odd that Blurry vision a person is unaware of such a serious illness, but in the initial stages, diabetes is often siIncreased hunger lent and can be detected only through testCut and bruises that are ing. Even when silent, however, diabetes slow to heal can be damaging. Tingling, pain or numbness A recent study by the CDC predicted in the hands or feet that the disease is not going away anytime soon. Forty percent of Amer-

icans will develop type 2 diabetes at some point during their adult lives, according to new U.S. government estimates. Black women and Hispanic men and women will be hit the hardest, according to the study. A disparity already exists. The incidence of diabetes is greater in Native Americans (15.9 percent), blacks (13.2 percent), Hispanics (12.8 percent) and Asian Americans (9 percent) than in whites (7.6 percent). Age is also a factor. Almost 26 percent of Americans 65 and older have diabetes, but young people are not exempt. The incidence of type 2 diabetes is on the rise in young people, largely attributed to the obesity epidemic. Diabetes does not develop overnight. In prediabetes, blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. PrediabeM.B.A. tes is becoming more common in the U.S. At least 86 million adults ages 20 or older had prediabetes in 2012, according to the Department of Health and Human Services. Without a change in lifestyle, however, these cases can develop into full-blown diabetes. Diabetes cannot be taken lightly. It accounts for $245 billion in total health care costs, trailing only heart disease and stroke. It is the seventh leading cause of death in the country, but that is probably an underestimate because diabetes is often a contributor to deaths from other chronic diseases. For instance, in Massachusetts Provisional Deaths 2011, a report from the Massachusetts Department of Public Health, when it is considered the underlying cause of

SIGNS AND SYMPTOMS

4 Be Healthy | Diabetes

Diabetes, continued to page 6

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COMPLICATIONS

OF DIABETES ✦✦ Heart and blood vessel disease, such as heart attack and stroke ✦✦ Kidney failure ✦✦ Eye damage, including diabetic retinopathy, cataracts and glaucoma, which can cause blindness ✦✦ Foot damage that can result in amputation ✦✦ Diabetic neuropathy — numbness, tingling in hands and feet ✦✦ Gum disease ✦✦ Skin conditions, such as bacterial and fungal infections ✦✦ Erectile dysfunction

RISK FACTORS Overweight and obesity Excessive abdominal fat Inactivity Age: diabetes increases with age, especially after age 45 Family history: risk increases if parent or sibling has the disease

Race: people of color are more likely to develop diabetes than whites Gestational diabetes: diabetes during pregnancy Polycystic ovary syndrome High blood pressure and high cholesterol

DIABETES continued from page 4

death, diabetes ranks ninth in the state. However, when adding contributing deaths, such as stroke or heart attack, it ranked third. There are several symptoms of diabetes, including increased thirst, frequency of urination, blurred vision, fatigue and tingling in the hands and feet. And even weight loss. “This is one situation where losing weight is not a good thing,” said Dr. Rhonda Bentley-Lewis, an endocrinologist at Massachusetts General Hospital. An endocrinologist specializes in the treatment of diabetes and other gland disorders. “The increased urination is associated with an increase in loss of glucose in the urine, which is associated with a loss of calories,” she explained. Some patients express frustration when Bentley-Lewis starts them on insulin because, although their glucose is better controlled, they begin to gain weight. The key to controlling diabetes is early detection, but screening recommendations vary by organization. The American Diabetes Association recommends screening for diabetes in people who are overweight and have any of several risk factors, including physical inactivity, first-degree relative with diabetes, minority race or high blood pressure. Screening may be as simple as having a fasting blood glucose or A1C test. These are inexpensive, low risk tests that are potentially high reward if you can identify someone with diabetes early, she explained. Some risk factors have more impact than others. “The obesity epidemic and the diabetes epidemic go hand in hand,” said Bentley-Lewis. Although body weight matters, the distribution of fat is also important. Central obesity — fat that accumulates around the waist — has been considered to be more metabolically active and a greater risk for heart disease and type 2 diabetes than fat elsewhere, such as the hips or thighs. Unfortunately, waist sizes are burgeoning. While the overall obesity rate is stabilizing, abdominal obesity is on the rise. A study published in the Journal of the American Medical Association noted that between 1999 and 2012 the average women’s and men’s waist size increased by 1.5 inches and .8 inches, respectively. The risk for diabetes and heart disease increases with a waist measurement that is greater than 35 inches in women and greater than 40 inches in men.

Age is another strong risk factor. “We want to age, but we want to age well,” Bentley-Lewis explained. “Unfortunately, as we age we may become less physically active, gain weight and lose muscle mass, all of which increase our risk for developing diabetes.” In addition, the pancreas ages with us and its ability to provide the insulin needed will become impaired over time. However, we can support pancreatic function by maintaining healthy activity and eating habits, she explained. The point that Bentley-Lewis continues to hammer home is that type 2 diabetes is largely preventable and controllable once diagnosed. The key is a healthy lifestyle, which includes a healthy eating plan, not smoking, regular physical activity and weight loss, if you’re overweight or obese. “Losing as little as 5 to 7 percent of body weight can improve your body’s ability to use insulin effectively,” she said. Taking medications, including pills and insulin,

as prescribed, is also key for those with the disease. Although bariatric surgery (weightloss surgery) has been touted as a “cure” for diabetes, “I do not recommend it to control diabetes,” she explained. “It does

“

Forty percent of

Americans will develop type 2 diabetes at some point during their adult lives.”

— Centers for Disease Control and Prevention not address the underlying problem. It may be a ‘quick fix’ but there is no substitute for lifestyle changes involving phys-

YOU WON’T KNOW UNTIL YOU’RE TESTED

A1C(%)

The A1C test measures your average blood glucose for the past two to three months, and requires no preparation.

Since diabetes is often silent, it can be found only through testing. There’s more than one test used to diagnose diabetes. Generally, the test is repeated before a diagnosis is confirmed.

NORMAL: Less than 5.7 PREDIABETES: 5.7 to 6.4 DIABETES: 6.5 or greater

FASTING BLOOD GLUCOSE (mg/dl)

The fasting blood glucose test checks your blood glucose levels after at least eight hours of fasting – not eating or drinking fluids except water.

ical activity and healthy eating.” There is some good news to share regarding diabetes. A recent CDC study showed that rates of five diabetes-related complications — amputation, end-stage kidney failure, heart attack, stroke and deaths due to high blood sugar — declined substantially in the last 20 years. Bentley-Lewis is not surprised. Early diagnosis and treatment of diabetes will help to prevent the damage high blood glucose levels inflict on nerves and blood vessels over time. There’s more good news. If a person adopts a healthy lifestyle early in the course of disease and incorporates healthy eating and exercise as a regular routine, it is possible to maintain blood glucose without the benefit of medicines and insulin. Bentley-Lewis said she recognizes the difficulty in living with the disease. “I know how challenging managing diabetes can be and how it can change every aspect of your life,” she said.

ORAL GLUCOSE TOLERANCE (mg/dl)

The oral glucose tolerance test is a two-hour test that checks how well your body processes glucose.

NORMAL: Less than 100 PREDIABETES: 100-125 DIABETES: 126 or greater

NORMAL: Less than 140 PREDIABETES: 140-199 DIABETES: 200 or greater

Source: American Diabetes Association behealthy.baystatebanner.com 7

MANAGING YOUR DIABETES: Not just glucose levels

Many people with diabetes are advised to check their glucose levels regularly to make sure it is within a healthy range. Excessive sugar in the blood increases the risk of several diseases, such as stroke, and can

cause complications in infectious diseases, such as influenza. It’s not only glucose that requires checking or attention. People with diabetes are advised to have regular checkups and tests.

Condition/Complication

Recommended Action Yearly comprehensive dilated eye exam

Blood pressure check at every doctor’s visit

High cholesterol • Heart disease • Stroke

Yearly lipid test for HDL (good) and LDL (bad) cholesterol, total cholesterol and triglycerides

Nerve damage (neuropathy) • Loss of limb • Numbness, tingling

Daily check of feet for cuts, sores, redness and swelling. Yearly foot exam by a provider

Kidney failure

Yearly blood and urine test

Gum disease, tooth decay

Examination by a dentist every six months

A1C

At least twice a year (measures control of blood glucose in past two to three months)

Flu

Yearly flu shot

Pneumonia

At least one shot; may need another after the age of 65

Hepatitis B

One shot for people with diabetes aged 19-59

These are guidelines only. The schedule will vary by the individual. Some will require more frequent or additional testing. 8 Be Healthy | Diabetes

Centers for Disease Control and Prevention photo

High blood pressure • Stroke

Thinkstock/Stockbite photo

Eye damage • Diabetic retinopathy • Cataracts • Glaucoma

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Type 2 diabetes

MYTHS VS. REALITY Type 2 diabetes is one of the most common chronic illnesses in this country. More than 29 million people, or 9 percent of the U.S. population, are afflicted, according to the American Diabetes Association. Every year another 2 million people join their ranks. Yet, in spite of its prevalence, myths and misunderstandings about the disease abound.

Fact: Actually a healthy diet for a person with diabetes is rel-

Myth: Diabetes is not that serious a disease.

Fact: Contrary to common belief, there are no more “off limits” foods for people with diabetes. Desserts and sweets can be eaten if part of a healthy eating plan. The key to sweets is small portion sizes.

Fact: According to the preliminary data for deaths in 2011, the Centers for Disease Control and Prevention listed type 2 diabetes as the seventh leading cause of death in this country. And the numbers are on the rise. The age-adjusted death rates increased 3.4 percent from 2010 to 2011. In addition, diabetes is often a contributor to deaths from heart disease and stroke, which are the first and fourth, biggest killers in the U.S., respectively.

Myth: People with diabetes have to follow a special diet.

10 Be Healthy | Diabetes

atively the same for a person without the condition. There is no “diabetic diet.” A healthy eating plan consists of fruits, vegetables, whole grains, lean proteins, low-fat dairy products and healthy fats.

Myth: People with diabetes can’t eat sweets or chocolate.

Myth: If you are overweight or obese, you will eventually develop type 2 diabetes. Fact: Not necessarily. Although excessive weight is a leading risk factor for diabetes, age, ethnicity and family history play a role as well. Most overweight people never develop type 2 diabetes. Likewise, many people with diabetes are of normal weight.

Myth: You have to lose a lot of weight for your diabetes to improve. to the American Diabetes Association losing just 10 to 15 pounds can improve blood sugar, blood pressure and cholesterol levels.

the incidence of diabetes. A 20-ounce bottle of soda alone contains almost 17 teaspoons of added sugar and 280 calories. The American Heart Association recommends an upper limit of 6 teaspoons or 100 calories of added sugar each day for women and 9 teaspoons or 150 calories a day for men. But research shows that 22 teaspoons is more the norm.

Myth: If you have to go on insulin, you have not done a good job in controlling your blood glucose.

Myth: Since fruit is healthy, it’s all right for people with diabetes to eat as much as they want.

Fact: Progression from oral medication to insulin is not a reflec-

Fact: Although fruit contains fiber, vitamins and minerals, it also contains carbohydrates. Fruit must be included in a person’s daily meal plan.

Fact: The good news is that a little bit goes a long way. According

tion of how well or how poorly one is monitoring blood glucose levels. Most of the time diabetes is a progressive disease. The first line of attack is oral medications. Over time, however, if the body produces less insulin, oral medications may not be enough to do the job. Taking insulin brings glucose levels more in line.

Myth: Diabetes is caused by eating too much sugar. Fact: Lifestyle factors and genetics are the two major culprits.

However, overweight and obesity are major risk factors for diabetes, and undoubtedly, eating too much sugar can pack on the pounds. Research has found a link between sugar-sweetened beverages and

Myth: I’ve never been tested, but I know I don’t have diabetes. I feel fine. Fact: Type 2 diabetes is usually silent in the early stages and can be detected only through testing. As diabetes progresses symptoms may appear, such as excessive thirst, blurry vision and bruises that are slow to heal. The American Diabetes Association recommends that all adults aged 45 years or older be screened every three years. Those who are overweight or have one or more other risk factors should be tested regardless of age.

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Photo courtesy National Eye Institute

A leading cause of blindness

he symptoms were there — increased thirst and frequent urination. But Joseph Carter (not his real name) didn’t give it much thought. He attributed it to the hot Trinidadian sun. His blurred vision and those pesky floaters that sometimes blocked his vision got his attention, though. The report from the ophthalmologist was a rude awakening. “You are diabetic,” his doctor said. “And you’ve had it (diabetes) for a long time.” That was news to Carter. There was no history of diabetes in his family. Nor did he recognize the symptoms. “It never clicked in my brain that I was drinking more water than usual,” he explained. Besides, he reasoned that he was young and healthy. Nothing could possibly be wrong with him. Carter, 57, had diabetic retinopathy, which causes damage to the blood vessels in the retina. He is not alone. Up to 50 percent of people who have had diabetes for 15 years or more have diabetic retinopathy, according to Dr. Jean-Bernard Charles, an ophthalmologist at Whittier Street Health Center. The retina acts like the film in a camera and converts images to electric signals and sends them to 12 Be Healthy | Diabetes

the brain. In other words, one cannot see without a healthy retina. Diabetic retinopathy is one of the leading causes of blindness in this country, according to the National Eye Institute. It is estimated that more than 4 million people with diabetes are afflicted. By the time of his diagnosis Carter’s condition was at the advanced stage. The fragile blood vessels that formed in the retina had ruptured. That explained the bits of blood — what he called floaters — obscuring his vision. The blurring was a result of swelling in the macula, a small area in the center of the retina. The macula is responsible for pinpoint vision. Diabetes retinopathy is often progressive. It starts with swelling in the retina’s tiny blood vessels. Eventually the vessels are blocked, depriving the retina of oxygen. New blood vessels form but are so delicate they can burst with just a sneeze. The rupture results in inflammation and scar tissue and if left untreated can cause retinal detachment. The condition is largely preventable, especially when blood glucose levels are controlled. “We recommend a yearly screening eye exam,” explained Charles. Screening can often detect the condition

even if there are no symptoms. In some cases, when found and treated early, vision can be restored, said Charles. Otherwise, treatment merely prevents progression of the condition. Sight lost may not be regained When Carter reported to his district clinic in Trinidad he discovered that diabetes was not his only problem. He had high blood pressure, high cholesterol and his kidneys were functioning at 50 percent capacity — all consequences of diabetes. Symptoms for all these diseases were silent. His vision was the only giveaway that a very serious disease was lurking. Carter eventually underwent a vitrectomy, a surgery to remove the blood and scar tissue in the retina. As is usually the case, both eyes were affected. Although the vision in his left eye was worse, Carter elected to have the surgery in his right eye. “The left eye was too bad to salvage,” he reasoned. “I wanted to save the vision in my right eye.” Things were going pretty well, according to Carter. Although his vision was poor, he could see well enough to get around. All that changed one day when he went to retrieve something from the

tes, as noted by the American Diabetes refrigerator. He accidentally hit a glass Association. In 2010, that accounted for bottle that fell and shattered. roughly 73,000 amputations. Although he cleaned up the pieces his The good news is that his leg healed poor eyesight caused him to miss a fragwell. In July of last year he received a prosment or two. Carter, who was barefoot thesis and is able to walk independently at the time, stepped on a piece of glass, with a cane. “It gives which started a casme a sense of stability cade of misfortunate and confidence,” he events. explained, and allows He cut his right him to take a cab to foot. The wound his appointments eventually healed at Whittier Street with antibiotics and Health Center withstitches. But two out assistance. years later an ulcer If he could turn appeared. “It would back the hands of not heal properly,” time, Carter said he Carter explained, would make a few even after two years changes. “I would of constant treathave checked for ment. Finally, In January 2013, he diabetes. People Jean-Bernard Charles, M.D., M.P.H. should start at age had his right leg Ophthalmologist 20 since it can attack amputated below Whittier Street Health Center at any age.” the knee. Every six months About 60 percent he gets his eyes checked at Whittier. The of non-traumatic lower-limb amputadoctor has a good report. “It’s clean and tions among people aged 20 years or oldclear,” the doctor says, which means that er occur in people with diagnosed diabe-

Photos courtesy National Eye Institute

there is no blood buildup in the retina. Carter says he wants to keep it that way. He knows his vision cannot improve, but he wants to save what he has left. He knows the key to success. “I keep my sugar under control,” he said.

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FROM THE STREETS TO THE PULPIT Overcoming kidney failure

William Smith believes in miracles. He should. He has experienced two in his 61 years. Smith’s life was going nowhere fast. He was an alcoholic and drug abuser without any redemption in sight. He was a street person. His first miracle came at the age of 35 when he became a single parent to a one-year-old son. “I had given up on life,” Smith explained, “but I couldn’t give up on him.” That’s when he took his last drink. “My son was my motiBishop William T. Smith vation,” he said. Pastor Good Tidings Deliverance Ministries Smith joined Alcoholics Photo by Ernesto Arroyo Anonymous and Narcotics Anonymous. His “clean date” is August 15, 1988 and he has not looked tion prescribed worked well, according to back. Instead, he has looked forward but is Smith, but that doesn’t mean he followed giving back. He became a licensed alcohol his doctor’s advice. and drug counselor (LADCII) and coun“I was a bad patient,” Smith confessed. sels people struggling with addictions. He didn’t keep appointments and he took But his tribulations were not quite done. his meds haphazardly. “The doctor kept Five years later he was diagnosed with diatelling me if you’re not careful, you’re going betes and high blood pressure. These two to wind up needing a kidney transplant.” diseases often go hand-in-hand, but Smith Diabetes is the leading cause of kidney failwas not aware he had either. Alcoholics are ure, according to the National Institutes of not inclined to go to the doctor, accordHealth. ing to Smith. “You tend to go when you The warnings fell on deaf ears. Smith think you’re dying, then go right back to decided to tackle his health problem andoing what you were doing,” he explained. other way. He had become a minister and Health screening was not on the agenda, thought that prayer would do the trick. and during the five years since his sobriety He soon learned that although he believed he did not catch up on recommended tests. strongly in the power of prayer, his faith The diagnosis of his diabetes was by accould not overcome his steadily increasing cident. Actually, Smith went to the doctor blood glucose levels. for a complaint that appeared unrelated to Or his steadily increasing creatinine levdiabetes – frequent urination. “I had no idea el. Creatinine is a waste product that results what the symptoms were,” he confessed. from muscle metabolism. Healthy kidHe barely reached home before the docneys are able to prevent creatinine buildup. tor called telling him to come right back. Smith did not correlate his weakness and His blood glucose was over 300. A random excessive fatigue to kidney failure. “I didn’t blood glucose test should not exceed 140. know what was going on,” he explained. “He put me on medication right away,” A normal creatinine measurement is Smith explained. around one. By the time Smith’s kidneys But when the medication caused unfailed it had reached seven. pleasant side effects, Smith stopped taking “I was on dialysis for nine months,” he it without his doctor’s consent. A year latsaid. er when his glucose again was high, Smith Then came Smith’s second miracle. He returned to the doctor. The new medicaneeded a kidney transplant. His blood type 14 Be Healthy | Diabetes

is B+, which means that he can receive a kidney only from a person with blood type B or O. He did not have to look far. His wife happened to have blood type O-. She is a universal donor. Smith remembers the day well — May 5, 2010. He said he recuperated quickly. “Everything went back to normal,” he said. “Everything is under control.” If he could do it over Smith said he would make a few changes. “I would follow the doctor’s orders,” he said. “I would take better care of myself. Staying positive is not enough.” He credits his team at Whittier Street Health Center for keeping him on track. His journey is not over, however. He needs to watch carefully what he eats. He cannot consume too much potassium since it overtaxes the kidneys. Popeye’s fried chicken is out; fruits, veggies and whole grains are in. He has to watch the salt to keep his blood pressure under control. Smith is quite aware that healthy eating and exercise go hand-in-hand to keep his diabetes and blood pressure in check. That’s not always easy. He’s got the meds and healthy eating better under control. But exercise remains a sticking point. Smith admits it’s a challenge. The spirit is willing but the body resists. Perhaps he needs another miracle.

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JUST 7 PERCENT OF BODY WEIGHT Diabetes Prevention “ Almetta Cooper, a grandmother of two, said she’s not asking for much. “I don’t want to wear a bikini,” she said. But she wouldn’t mind being “tall and sexy” she commented with a laugh. To get there she knows she has to shed a few pounds to fit her five-foot-ten frame. Being tall and sexy is not really Cooper’s major motivation in joining the Diabetes Prevention Program at the Roxbury YMCA. She discovered that she has prediabetes. That means that her blood glucose level has not reached the diabetes range, but is on its way. Prediabetes and her weight are not her only risk factors for diabetes. The disease runs in her family, she has high blood pressure, she eats a bit too much and exercise is not a regular routine. If she perseveres in the program and follows advice, it may be possible to keep diabetes in her rear-view mirror. The Y’s Diabetes Prevention Program is not new. The organization began the lifestyle-changing interventions in 2010 and now offers the program at over 600 locations in almost 40 states. The goal is to expand the program to other communities of need. The Y found that need in Roxbury, a section of Boston that has a high percentage of black and Latino residents. The most recent Health of Boston report by the Boston Public Health Commission noted that in 2010, 11 percent of the res-

16 Be Healthy | Diabetes

I didn’t know how much fat and how many calories were in a cheeseburger.”

— Almetta Cooper

idents of Roxbury had diabetes versus 6 percent in all of Boston’s neighborhoods. The hospitalization rate for diabetes in Roxbury is twice that of Boston. Blacks and Latinos are impacted more than whites. The program is based on a study financed by the National Institutes of Health. The purpose of the study was to determine if lifestyle changes or metformin, a medication to treat diabetes, could effectively delay or prevent diabetes in a diverse population of overweight or obese American adults at high risk of diabetes compared to a placebo. The results were so striking that the study was terminated early. Lifestyle change, which included exercise and healthy eating, reduced the number of new cases of type 2 diabetes by as much as 58 percent during the three-year follow-up period. In those 60 years and older, the reduction was even greater at 71 percent. Metformin was also successful at reducing the risk of developing

diabetes, but at a lower rate of 31 percent. The most striking finding from the study was the small amount of weight loss required to deter or delay the onset of diabetes. The researchers found that losing just 7 percent of body weight did the trick. For a 250 pound person, that’s only 17 and one-half pounds. Required exercise was a mere 30 minutes a day for five days a week. The yearlong Y program meets weekly for the first four months and then once a month for the next eight months. It is led by a trained lifestyle coach who facilitates the group and provides the tools and education to promote healthy lifestyles. The goals mirror the findings of the NIH study — lose 7 percent of one’s body weight and gradually increase physical activity to 150 minutes a week. Candidates are 18 years or older, have a BMI (body mass index) of 25 or more and are at risk of developing type 2 diabetes or have prediabetes. A BMI of 25 and above is an indicator of overweight or obesity. Just a few weeks into the program, Cooper has had a few eye-opening experiences. “I eat a lot of sugar,” she dis-

covered. Her consumption of sodium is greater than she realized as well. More striking, said Cooper, is the amount of food she eats. As part of the program requirements, she wrote down everything she eats and drinks every day. “You’re supposed to tell the truth,” she said. She found that the truth can hurt. “That’s too much,” she said, referring to her list. “I did not know I ate that much. Maybe I can cut that list in half.” Those cheeseburgers are looking less attractive now. “I didn’t know how much fat and how many calories were in a cheeseburger,” she said. Cooper already sees some improvement. She lost four pounds in the second week, but gained back two the next week. But she’s still ahead of the game.

She knows she has a long haul ahead of her, but she’s not worried. “When I start something I finish it,” she said. Moreover, she has a great motivator. “I want to be healthy,” she explained.

Almetta Cooper (l) gets advice from Ericka Florence, coach of the YMCA’s Diabetes Prevention Program at the Roxbury branch. Photo by Ernesto Arroyo

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SUGAR-SWEETENED BEVERAGES Twelve ounces a day increase the risk of diabetes Samara Gaul, a resident of Dorchester, knew something had to change. Like many women, she had put on some extra weight after giving birth to her two children. She did her best to change her eating habits and to get more exercise, but this busy working mom was still not getting the results she wanted. Then one day she learned that much of that extra weight and feeling rundown was likely due not just to what she was eating, but also to what she was drinking. That little bit of knowledge changed everything. “When I learned that a can of fruit punch or soda a day can add five pounds of fat to your body each year, I was flabbergasted,” said Gaul, an administrative assistant at the Boston Public Health Commission. Sugar-sweetened juice drinks and teas were a big part of Gaul’s life, and all that sugar was adding up. Over a threeyear period she had gained 45 pounds.

18 Be Healthy | Diabetes

And the added weight was not the only cost she was paying for drinking sugary beverages. Gaul found out that she was at a higher risk of developing diabetes. All that added sugar was taking a toll. A 2010 study by researchers at the Harvard School of Public Health underscored the harmful effects of sugar,

not just in weight gain, but also in contributing to diabetes. The study found that people who consume sugary drinks regularly — 12 ounces or more per day — have a 26 percent greater risk of developing type 2 diabetes, when compared to people who rarely consume such drinks. While consumption of too much added sugar from any type of food can contribute to obesity and diabetes, sugary drinks are the largest single source of sugar in Americans’ diets. This includes soda, sports drinks, sweetened tea, coffee and energy drinks. The American Heart Association estimates that 100,000 cases of diabetes over the past decade were caused by the consumption of sugar-sweetened beverages.

Drinking sugar-sweetened beverages delivers a one-two punch to your health. With no nutritional value, they’re full of ‘empty calories’ that lead to weight gain, which is itself a risk factor for diabetes. And the consumption of ‘liquid sugar’ without some fiber to slow down its digestion causes a quick rise in blood glucose (blood sugar). Our bodies produce a hormone called insulin that converts blood glucose into energy for our cells. But the repeated spikes in blood glucose caused by one or two sugary drinks a day can disrupt the body’s ability to produce insulin, leading to insulin intolerance and eventually diabetes. Your blood glucose peaks and valleys can also feel like an energy yo-yo, making you feel sluggish when your blood glucose declines. According to recent surveys, 20 percent of adults in Boston report having one or more sugar-sweetened beverage a day, and the rates are higher for black (29 percent) and Latino (29 percent) residents compared to white (13 percent) residents. While overall self-report of diabetes among adults in Boston was almost 9 percent in 2013, these rates were also

higher for black (14 percent) and Latino (13 percent) residents compared to white (5 percent) residents. Faced with such alarming rates and inequities, the Boston Public Health Commission has led a series of public awareness campaigns to educate Bostonians about how they can make changes. The “Rethink Your Drink” campaign

Sugary drinks are the largest single source of sugar in Americans’ diets. uses the image of a traffic light to offer residents an easy way to think about healthy drink options. A separate campaign, “Sugar Smarts,” aims to educate parents about the negative health effects that sugar-sweetened beverages have on their children. And the “Love That Boston Water” campaign has publicized that

tap water is a cheap, refreshing, healthy alternative to sugary drinks. Such efforts are helping parents like Gaul achieve important health goals for themselves and their children. By changing what she drank, maintaining a healthy diet and continuing her exercise, Samara eventually lost 60 pounds — more than erasing the 45 pounds she had gained over the years. In addition to the many health benefits of maintaining a healthy weight, she also significantly lowered her risk of developing diabetes. What advice would she give others looking to accomplish what she did? “I would show them how much actual sugar that they are ingesting that they probably don’t even know about,” she said. “When you look at it, nobody should be consuming 20 teaspoons of sugar in a day. It’s disgusting.” She’d also tell them how good she feels. “I feel healthy and more energized, and I know this will make a difference for my children as well. We’ve also saved money, because sugary juice drinks are not a necessity as they were before. I know we will all live longer healthier lives because of this change.”

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DIET IS A FOUR-LETTER WORD The diagnosis of diabetes portion sizes and every nibble is not the best news to hear, of cookie. Writing it down can but it’s not a death sentence, help present a clearer picture said Constance Brown-Riggs, of one’s habits. People tend to a certified diabetes educaunderestimate how much they tor. People who control their eat. What one approximates as glucose can live long and proa half cup is really a cup and a ductive lives, she added. Typ“small” helping of ice cream can ically, complications occur burgeon into two portion sizes. when blood glucose levels are The second step is to emnot maintained within norphasize what’s healthy and cut mal limits. back on the junk food and desOne of the biggest hurserts. Contrary to a common dles a person with diabetes myth, people with diabetes Constance Brown-Riggs, M.S.Ed., R.D., C.D.E., C.D.N. must face is healthy eating. can eat desserts, but they have Registered Dietitian But there’s good news on that to be included in the daily Certified Diabetes Educator front. At one time there was a portion of carbohydrates. As specific eating plan that peoa general rule, Brown-Riggs ple with diabetes had to follow. “Not anymore,” said recommends 45 grams of carbs per meal for women Brown-Riggs. The American Diabetes Association and 60 grams of carb per meal for men. has updated its nutrition therapy recommendations It’s hard not to cheat every now and then and eat for the management of adults with the disease. The too much food or too many unhealthy snacks. That eating plan recommended for those with diabetes is will make your blood sugar go up, but “it’s not the end the same as that recommended for everyone: a variety of the world by any means,” Brown-Riggs explained. of fruits and vegetables, whole grains and healthy fats. She has a quick solution. “Take a walk,” she advised. Don’t use the word “diet” around Brown-Riggs. “That will bring your glucose level down quickly.” She considers it a four-letter word. “It’s a lifestyle But she added, you should not incorporate exerchange,” she explained. “It’s a new way of life rather cise into your lifestyle plan just as a quick remedy for than an on-and-off again fad diet.” overeating. She calls exercise free medication. ExerWhat’s even better is that each healthy eating cise on a regular basis may result in the need for less plan is unique. “You must look at the individual,” she medicine for diabetes. explained. “One size does not fit all. Identify what Because high blood pressure often accompanies dithe person is eating and go from there.” abetes, avoid the salt shaker and monitor foods that Chances are you can find acceptable healthier altend to be high in sodium, such as sauces, pickles, olternatives. ives and Chinese food. Don’t be fooled by tricky labels, One of the biggest mistakes made by people such as “seasoned salt.” It’s still salt, she cautioned. with diabetes is to make a 360-degree turn-around A recent study questioned whether breakfast was in what they eat. You cannot sustain that, Brownreally the most important meal of the day and imRiggs cautioned. After about three months, most plied it may not be harmful to skip it. People with people fall off the wagon. Focus on what you already diabetes should eat three meals a day, said Browneat and like rather than try to incorporate popular Riggs, and particularly breakfast. “You have to break trendy foods, such as quinoa, into your diet. the fast,” she explained. After hours of no food the “Make moderate changes that can be sustained,” body will be looking for glucose, or energy, to give she said. For instance, if you drink five cans of sugit a jumpstart. But you don’t have to eat the typical ar-sweetened beverages a day, cut it down to four. breakfast of eggs, toast or cereal. “Leftovers from the That small change takes 10 teaspoons of added sugnight before are fine,” she said. ar a day and 70 teaspoons of added sugar a week out The diagnosis of diabetes can be frightening. of your eating plan. Added sugar provides no nuSome people have a hard time making changes to tritional value and is a culprit behind obesity, heart their eating habits. Brown-Riggs offered a simple disease and diabetes. solution. “If nothing else cut down on portion sizes,” Brown-Riggs gives simple tips to help people start she recommended. Smaller portion sizes will help a plan. First is a self-assessment of what one eats and control weight and prevent a spike in glucose levels. drinks every day. That means everything — including “Any change will improve outcomes,” she said.

20 Be Healthy | Diabetes

NOT JUST PASTA Counting carbohydrates Although there is no longer any such thing as a “diabetes diet,” people with diabetes must still keep an eye on their consumption of carbohydrates. It’s those carbs that are broken down into glucose. As a rule of thumb, Constance Brown-Riggs, a dietitian and certified diabetes educator, recommends 45 carbs a meal for women and 60 carbs a meal for men. The problem is that when people think of carbs, bread, pasta and cookies readily come to mind. Oranges and green beans do not. There are three types of carbohydrates. At right is a listing of the types and examples of each.

SUGAR

STARCH

Natural sugar, as found in milk or fruit Added sugar, such as honey or syrup

Vegetables, like peas, corn, potatoes Legumes, like peas, beans, lentils Grains, such as oats, rice, bread

Legumes

FIBER

Fruits and vegetables Whole grains Nuts

Go lean on fats

t’s important to know the difference between fats as well as carbohydrates. Saturated fats and trans fats increase cholesterol, which increases the risk of heart disease, high blood pressure and stroke. People with diabetes have a higher than average risk of having a heart attack or stroke. These conditions strike people

FATS – UNHEALTHY Saturated

Butter, poultry skin, salt pork

Trans Margarine, baked goods, such as cookies, processed foods, such as pepperoni Cholesterol

Egg yolks, liver, ice cream

with diabetes more than twice as often as people without diabetes. Healthy fats — monounsaturated and polyunsaturated fats — on the other hand, improve blood cholesterol levels, which can decrease the risk of heart disease and type 2 diabetes.

The American Heart Association suggests the following daily limitations of fats: • Total fat — 25 to 35 percent of total calories • Saturated fat — Less than 7 percent of total calories

FATS – HEALTHY Monounsaturated

Avocado, nuts, peanut butter, olive oil

Polyunsaturated

Sunflower oil, salmon, trout

• Trans fat — No more than 1 percent of total calories • Cholesterol — Less than 200 milligrams

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CHICKPEA SALAD This is a simple and inexpensive recipe from the American Heart Association’s Simple Cooking with Heart Program. It can serve as a vegetable side dish or be the main dish for a meatless meal or light meal. Each serving is low in calories, sodium and unhealthy fats, but is high in fiber. Fiber helps lower the risk of heart disease and diabetes and is essential for good health. Since foods containing fiber keep you feeling full longer, they may help in weight reduction. It is recommended that adults eat 25 to 30 grams of fiber each day. Nutritional Analysis Per serving:

Makes 4 Servings. Price Per Serving: $1.45

Ingredients 15.5 oz. canned, no-salt-added or lowersodium chickpeas (garbanzo beans), drained, rinsed 1 cup chopped, fresh tomatoes (any type) 1 cucumber, chopped

½ cup chopped, fresh cilantro 1 tbsp. extra virgin olive or canola oil ½ tbsp. balsamic vinegar or lemon juice ½ tsp. ground cumin ¼ tsp. sweet paprika

2 stalks celery, chopped ¼ small red or yellow onion, sliced

Directions 1. Add all the ingredients into a large bowl. 2. Stir to combine and serve.

Calories: 168

Polyunsaturated Fat: 0.5 g

Carbohydrates: 25 g

Total Fat: 4.5 g

Monounsaturated Fat: 2.5 g

Fiber: 6 g

Saturated Fat: 0.5 g

Cholesterol: 0 mg

Sugars: 4 g

Trans Fat: 0.0 g

Sodium: 48 mg

Protein: 7 g Source: 2014 American Heart Association

22 Be Healthy | Diabetes

EXERCISE IS MEDICINE Although exercise is considered pivotal to controlling blood glucose, it is the most underutilized therapy in the treatment and prevention of diabetes, according to Michael See, an exercise physiologist and certified diabetes educator. He’s right about that. A study published recently in Diabetes Therapy noted that adherence to long-term exercise programs can be as low as 10 percent among those with diabetes. That’s not good. The impact of exercise is huge. “It increases the body’s sensitivity to glucose,” he explained. It’s not only blood glucose levels that benefit from exercise. High blood pressure, heart disease and obesity — all correlated to diabetes — are more apt to be controlled with exercise. But the benefits are transient. One has to exercise regularly to maintain its impact. Exercise has evolved from a uniform strict and rigid regimen to an individualistic approach. “In earlier days we took the fun out of exercise,” See said, but much has changed since then. “It’s not so prescriptive anymore,” he explained. “We’re the coach now, not the expert.” In other words, the trainer will not tell you exactly what to do, but will make sure that you are performing safely whatever is your chosen activity. The exercise recommended for all adults will also apply to those with diabetes — 150 minutes a week of moderate-intensity exercise, such as brisk walking, and two or more days a week of muscle strengthening exercises. A part of the problem is the misperception of exercise. People think they need to sweat or lift heavy weights to benefit. That myth was put to bed with the Diabetes Prevention Program Study, when researchers discovered that just 30 minutes a day of moderate exercise can prevent or delay the onset of diabetes. Even 10-minute intervals of exercise are beneficial. Some people with diabetes, however, may have to take precautions before initiating an exercise program.

The 2008 Physical Activity Guidelines for Americans provide general recommendations to increase physical activity.

150

minutes of moderate-

Michael See, M.S., R.C.E.P., C.D.E. Exercise physiologist Photo courtesy of Joslin Diabetes Center

Those on insulin therapy, in particular, may have to test their blood sugar 30 minutes before exercising and 30 minutes later to make sure it is safe to continue exercising. They should have handy a carbohydrate source, such as juice or an energy bar in case their glucose drops too low. One benefit of monitoring one’s level before and after exercise, according to See, is that people can see the significant impact of exercise. Those with diabetic peripheral neuropathy — tingling and numbness in the feet — may do better with low-impact or non-weight bearing exercise. Diabetics with blood sugar measuring 400 or higher are advised to postpone a workout until blood sugar drops to a safe pre-exercise level, which ranges from 100 to 250, according to Mayo Clinic. Exercising is one of the most difficult lifestyle changes a person must make. See offers advice. “Think of exercise as medicine. Find something you enjoy,” he said. That can be anything from walking, biking, swimming or even dancing. Start slowly and gradually increase intensity and time. The key is realistic and specific goals. “Don’t be so hard on yourself,” he said. And whatever you choose, stay with it. “It takes three months to adopt a habit.”

intensity of aerobic activity a week and muscle-strengthening activities on two or more days a week that work the legs, arms and trunk. Example activities are: • Walking fast • Biking • Dancing • Mowing the lawn …

minutes of vigorous-intensity aerobic exercise a week and muscle-strengthening activities on two or more days a week that work the legs, arms and trunk. Example activities are: • Jogging or running • Biking fast or on hills • Swimming laps • Playing basketball

xamples of muscle-strengthening activities are:

• • • •

Lifting weights Calisthenics—push-ups, sit-ups Heavy gardening Yoga

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