Diabetes: Maintaining Control -- Karmeen Kulkarni, MS, RD, CDE -- 11/26/03
By Karmeen Kulkarni
Nutritional therapy is a major key to controlling your diabetes. But playing such a big part in your own disease management can be a daunting task! We talked about it with Karmeen Kulkarni, MS, RD, CDE, co-author of the ADA's Complete Guide to Carb Counting, as part of the WebMD University: Take Charge of Your Diabetes.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome to "Take Charge of Your Diabetes." Our instructor today is Karmeen Kulkarni, MS, RD, CDE, co-author of the ADA's Complete Guide to Carb Counting, and vice-president of health care and education for the American Diabetes Association.
Support for this WebMD University course provided by GSK.
Member question: After being on the Atkins diet for three weeks, and in addition to losing weight, I have been able to reduce the amount of metformin I take (from 2,000 to 1,000 milligrams per day. My fasting glucose count is now from 97 to 113 (previously it was 140 to 160). I feel great, have energy and am able to do my 30-minute walk each day. However, since I have been trained over the years to cut the fats in my diet, I am concerned about cholesterol. My cholesterol count has always been good. What is your advice as to the Atkins diet?
Kulkarni: Congratulations on your weight management, physical activity, and also the improvement in blood glucose control. If the Atkins Diet is working for you, and your blood glucose control and your lipid profile, which would include your cholesterol level, improve, and it's working for you, that's very promising.
But, we don't have long-term studies to know what the long-term effects of a high-protein, high-saturated animal fat intake has on the body, so at some point I would encourage you to consider meeting with a registered dietician and start re-including carbohydrates into your food choices. All through that period continue to monitor your blood glucose levels, and every six months monitor your lipid profile. Hopefully this will help you to stay healthy in the long term
Member question: When I check my blood glucose just before breakfast, it is usually 10 points higher than it was at bedtime. I don't understand how that can happen. I'm not one for "midnight snacks" and never have been.
Kulkarni: This occurs commonly in some people with type 1 or type 2 diabetes. Though you probably are not a midnight or a bedtime snacker, what happens, at around 3 or 4 a.m. is all of us have what we call counter regulatory hormones, like glucagon, which work opposite to insulin, and they typically stimulate the liver to produce glucose at this time, causing the fasting to be higher in some individuals than their bedtime glucose.
If your blood glucose continues to stay high fasting, check with your physician regarding your oral bedtime medication or insulin, as the dose may need to be adjusted.
Member question: I have tried the Atkins also, but I still utilize low-fat eating methods, as well as cut out the carbs. I try to only eat those of a low carb, low on the glycemic index. Why don't our nutritionist train us on this?
Kulkarni: Let me preface your question by stating that nutrition does go through fashion cycles, and the Atkins diet and the glycemic index are not new concepts. The glycemic index has been around since 1980 and Atkins since the late 1970s.
The glycemic index needs to be individualized for each person and if you are doing frequent blood glucose checks about six to eight times a day, and you see the impact of certain carbohydrates on your blood glucose, you can establish your own glycemic index, since each person's body is different. And low-, medium-, and high-glycemic indexed foods in a meal, meaning a meal that has protein and fat, may not make much of a difference.
I commend you for following a low-fat program and would encourage you to continue using some amounts of carbohydrates. If you notice, the low-glycemic index carbs are healthy ones that we recommend anyway: high-in-fiber fruits, vegetables, and grains. Best wishes for your diabetes control.
Member question: The glycemic index seems to be a very useful tool in glucose monitoring. Is there a book listing GI values of foods?
Kulkarni: There is a book on the glycemic index by Thomas Wolever I don't know the title, but if you go to any large bookstore they should find it for you.
Member question: So, what nutritional therapy would you suggest?
Kulkarni: I would encourage you to take time to visit with a registered dietician who has an expertise in diabetes, and individualize your meal plan based on your diabetes management and blood glucose control, and make it doable so it fits into your lifestyle.
Member question: My glucose levels remain within normal range, including morning fast, except after I eat, when they can go as high as 230 but fall back within the normal range within two hours. Is this a problem?
Kulkarni: I would pay attention to what you are eating and how much that's causing such a spike in your after-meal blood glucose. The problem arises any time you have those spikes; it's not that healthy for the body even though it comes down to a normal range after that. So I would pay attention to any elevated blood glucose levels.
Member question: Regarding the morning reading, the only leeway my doctor has given me is eat three meals a day and inject Novolog with each meal (16, 20, and 18 units), or don't eat a particular meal but also don't inject. At night I inject Lantus (30 units). Sometimes I just don't feel like breakfast and the morning reading is, for example, 123. Two or three hours later, still no food and no Novolog, the reading has jumped to 170. Is this the same phenomenon from the liver's glucose?
Kulkarni: I will answer your question in two parts: One, it's appropriate to take Novalog before each meal; however, I would encourage you to discuss with your MD an individualized insulin/carb ratio so you can vary your Novalog dose based on the number of grams of carbs you plan to eat or not eat at a meal. That will provide you more flexibility and control with regards to your blood glucose.
Regarding the second part of your question about your blood glucose going up even though you haven't eaten: Our body needs glucose for energy and survival, so when it's not fed it looks for a source in the body, and that source is the stored glucose in the liver. A message is sent to the liver for glucose. That causes the blood glucose to go up.
Member question: Should our blood glucose level remain at a steady number throughout the day?
Kulkarni: Well, it's going to be typically lower before a meal and higher after a meal, based on what you eat, and each person should establish their target of blood glucoses before and after meals for themselves, with the help of their health care team.
Member question: I seem to avoid sugar spikes if I eat bread and carbs during the early hours of the day. Is this common with diabetics?
Kulkarni: This may be an individual situation, and if you've noticed this and how to take care of it, and keep your blood glucoses in the optimal range I would continue with that.
Member question: I have type 2 diabetes; if I include some kind of fat in my all meals will that help in not raising glucose levels fast and give meds time to work?
Kulkarni: We all need or require a certain amount of carbohydrate, protein, and fat in our meals, so I would encourage you to include a small amount of fat, but focusing on low-fat choices overall.
Member question: What snacks can I travel with to eat between meals? Most things have too many carbs.
Kulkarni: This depends on how many calories you want to work within for the day, what your medication regimen is for your diabetes, and whether you're focusing on weight management.
Some options could be low-fat/nonfat cheese, nonstarchy vegetables, small amounts of fruit, or whole grain crackers, even though crackers have carbs.
Member question: What's considered a nonstarchy veggie?
Kulkarni: I'll give you a short list of starchy vegetables that's easy to remember:
The rest of them are all nonstarchy.
Member question: I exercise every day to keep my sugar levels normal. But there are days when it's very high due to another chronic illness that I have. I've read not to exercise if your sugar is 300 or over and asked my doctor why, and he didn't know. Can you answer this for my doctor and me?
Kulkarni: It depends whether you're on insulin or not, and the recommendation is not to exercise if the blood glucose is 250 or higher. The reason being that at that time the body doesn't have enough insulin on board and so the muscles don't have the opportunity to get the glucose or energy they need. So again, the body goes to another source for energy, which is the liver and the stored glucose is released.
At a time like this the recommendation is to not exercise, and if you're on insulin to take either Humalog or Novalog to bring it down.
Member question: What is the proper range for the readings? My doctor tells me 80-120 nondiabetic, 100 - 140 for type 2. Are these good numbers or are there others?
Kulkarni: Each person with diabetes should establish theirs before and after meal targets with a discussion with their health care team. It is encouraged to be as close to normal as possible, but the overall health and quality of life also needs to be taken into consideration.
Member question: I am type 2. I have a hard time understanding carbs. Seems everything is a carb. How can I most easily choose them? I always looked at calories and glycemic index.
Kulkarni: Carbs are an essential part of everybody's food intake. They provide fiber, vitamins, minerals, and phytochemicals, which are all important for our health. I agree it is a confusing time with regards to nutrition and diabetes. Your carbs are basically from sugar foods and starch foods. Your starchy carbs are:
Your sugar carbs are from:
You'll find these foods in the glycemic index, and basically it's the amount of carbs and the quantity and the consistency at meals that you need to pay attention to.
Member question: So I can still have some carbs just not a whole lot?
Kulkarni: You've answered your own question, because we, as a nation, are overall eating a whole lot, and as a person with diabetes you can eat most anything in small amounts.
Member question: A recent column by a newspaper MD states that a glass of wine with meals can help reduce insulin resistance. Do you agree with that statement?
Kulkarni: The statements about wine/alcohol change on a yearly basis. If you enjoy a glass of wine with your meal and your diabetes control is where you want it to be, then you can work it in.
Member question: How do I know how many carbs are in foods served in restaurants or fast foods?
Kulkarni: Fast food restaurants typically will have a nutrient listing available, which will give you that information. For restaurant items, if you review the American Diabetes Association's Complete Guide to Carb Counting, or other ADA consumer books, for example, The Diabetes
Carbohydrate and Fat Gram Guide, which will familiarize you with the carb content of foods you would typically order at restaurants.
Member comment: There is a Palmtop download called CalorieKing that gives calorie and carbohydrate values for many fast food restaurants.
Moderator: Thanks for the info!
Member question: Are there dietary ways to deal with dawn phenomenon?
Kulkarni: No, there are not. It needs some medication adjustment.
Member question: Are sugars from fruits easier to consume and do less harm than other sugars?
Kulkarni: Fruits are healthy foods and so the carb in fruit is a healthy carb compared to carb from a brownie.
Member question: So if we get a craving for chips, going to get a banana or apple is better for you?
Kulkarni: Once again, you've answered your own question. Of course, the human side of diabetes is to want chips or a cookie or any other junk. You are the best judge of whether you can eat a small amount and stop, or you're the type who wants the entire bag.
Member question: How many proteins are required per day? And as a vegetarian how do I get them into my diet?
Kulkarni: The amount of protein recommended is .8 grams per kilogram of your body weight. Your sources of protein are:
Member question: Is that body weight to calculate amount of protein your weight now if you are say 50 pounds overweight or your desired weight?
Kulkarni: It's actual weight.
Member question: There are so many new products out in the market that seem conducive to effective diabetes management, such as low-carb shakes, sugar substitutes, etc. How do I know which are right for me? For example, am I better off having a small amount of actual sugar, as a sweetener, than those sugar substitutes? And, is there a good source for obtaining information about these new products as it relates to diabetes?
Kulkarni: You need to become an expert on reading nutrition labels. Always look at the serving size, the calories per serving, and total grams of carb and that will give you an indication of whether you want to use the product. If you need help in learning how to read a label, visit with a registered dietician
Member question: My husband just found out a week ago he's a diabetic. I'm here to learn a bit more about it. He went from 24.3 now he's down to 9.2 this morning. I feel like I'm starving him. He likes to snack in the evenings; is there anything "good" I can give him?
Kulkarni: Congratulations on the reduction of the A1C. Sounds like you're on the right track. I would strongly encourage you to set up an appointment with a registered dietician specializing in diabetes in your area to help with individual meal and snack ideas.
Member question: With my schedule it is hard for me to always take my medications and eat on a regular schedule. How important is it to be on a strict schedule?
Kulkarni: It depends how variable your schedule is, but your medications need to be taken just prior to your meals. I would discuss that regimen with your diabetes educator, because if you take your medications at the times that they are not effective, it does not help you with your diabetes control.
Member question: My doctor suggests eating more grapefruit and pineapple and less starchy fruits. Why? Does this help the sugar levels?
Kulkarni: There are no such things as starchy fruits. There's really no difference between the types of fruits; it's the quantity and the types of fruits you have to pay attention to.
Member question: I am doing the Weight Watchers program and not counting carbohydrates strictly. Is this program good for type 2?
Kulkarni: As long as you're able to stick with it, and it's working, and your blood glucoses are in the optimal range -- go for it.
Moderator: Do you have any final words for us, Ms. Kulkarni, before we wrap up our discussion?
Kulkarni: Enjoy the holiday season and remember there are many other sources of enjoyment and fun besides just the food. Pay attention to your diabetes through the holidays so you stay well and healthy to enjoy them.
Moderator: Our thanks to Karmeen Kulkarni, MS, RD, CDE, for being our instructor today. For more information, pick up a copy of her book, the ADA's Complete Guide to Carb Counting, or The Diabetes Sourcebook, by our course leader, Richard Guthrie, MD. And thanks to all of you for being here today and for participating in our WebMD University course.
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