Guidelines for Good Management of Diabetes
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Guidelines for Good Management of Diabetes

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Application of the advice given by this guide helps the diabetic treat him or herself so that minimal or no medication should be needed. Changing the life style for the better can reduce the risk of ...

Application of the advice given by this guide helps the diabetic treat him or herself so that minimal or no medication should be needed. Changing the life style for the better can reduce the risk of complications and slow down their development.

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    Guidelines for Good Management of Diabetes Guidelines for Good Management of Diabetes Presentation Transcript

    • GUIDELINES FOR GOOD MANAGEMENT OF DIABETES By Dr Matti Tolonen and Dr Pentti Raaste 1
    • It takes years to get accustomed to lasting life style changes. The first step is to abandon the idea of temporariness because the changes have to be life-long. A life-style change is not too late as long as one breathes. Claes Andersson (Finnish psychiatrist, writer, musician, ex-minister, and diabetic) ● Diabetes has become a world wide epidemic. The number of dia- betics is steadily increasing and it will probably double during the next 10 to 15 years, worldwide. There would appear something fundamentally wrong with our dietary habits causing this, as genetic changes are not this rapid in humans. ● Diabetes is usually defined as either type 1 or type 2. Type 1 is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to a deficiency of insulin. Genetically disposed children and youngsters tend to get type 1 diabetes, but some environmental factors are causing it to appear earlier in the life span. Type 2 is due to insulin resistance or reduced insulin sensitivity, combined with reduced insulin secretion. Nowa- days there is also a third, uncertain type, sometimes called type 1.5. ● The costs of diabetes are expanding rapidly as type 2 is contracted by younger and younger people. At least 2/3 of the costs are caused by preventable complications. Reducing the reading of HbA1C (for short A1C) by 10 per cent would lower the costs by 40 per cent. ● Increased blood sugar concentration damages tissues in very early stages, often years before the diagnosis of diabetes is set. Once the organ damages have started, they are not reversible; it is possible only to slow down their progress. Therefore the prevention of complications is of utmost importance. ● The treatment of diabetes has to rely on four pillars: Healthy nutri- tion, regular physical exercise, necessary medication and dietary supplements. ● Application of the advice given by this guide helps the diabetic treat him or herself so that minimal or no medication should be needed. Changing the life style for the better can reduce the risk of complications and slow down their development. 2 3
    • Figure 1. Diagnosis of dia- betes is based on the blood glucose values, both fasting blood glucose (left) and glucose tolerance test (right). WHAT YOU SHOULD KNOW ABOUT DIABETES In the UK the readings are given as mmol/l, while in Spain and USA the values are mg/dl. The co-efficient is 18. Between the health and diabetes there is a grey area, called pre-diabetes. Diabetes is a group of different conditions common than generally recognised. In a in which the concentration of the sugar healthy person, the fasting reading of glucose (glucose) in the blood increases to a too high in whole blood varies between 4 and 5.6 level. Diabetes does not appear by itself, but millimoles per litre (mmol/l), or 72 and 100 rather as a combination of genetic and life mg/dl. The person is considered to be pre- style factors. The reason for increasing diabetic when at least two fasting blood glucose concentration in the blood is the measurements yield readings between 5.6 cessation or inadequate excretion, or the and 7.0 mmol/l (100–126 mg/dl) and in a diminishing influence of the pancreatic two hour glucose tolerance test (GTT) one hormone, insulin. The latter condition is or more readings are 7.8–11.1 mmol/l (126– GESTATIONAL DIABETES called insulin resistance. Elevated blood 200 mg/dl). Then the person has “impaired (OCCURRING DURING glucose leads to glycation (caramelisation) glucose tolerance”, and consequently an PREGNANCY) of proteins and fats in the tissues, which in elevated risk of contracting diabetes in the turn causes pathologic changes in the micro In healthy women, the pancreatic beta cells future. Many of the present diabetics have and macro arteries, eyes, nerves and kidneys. (which excrete insulin) multiply during been pre-diabetics for 5–10 years before In other words diabetes reduces and limits pregnancy, and produce insulin adequately getting the diagnosis “type 2 diabetes”. That the quality of life, causes comorbidity and to meet the need for both mother and foetus. is why many of them already have alterations increases the risk of mortality. Comorbidity In women who contract pregnancy diabetes, in the arteries and the eyes at the time of refers to other diseases an individual might the beta cells do not multiply enough. The diagnosis. Pre-diabetes can best be observed have other than the primary disease. In cause is probably over expression of a by measuring the blood glucose about one addition to the generally known compli- protein called menin. It may also be the hour after a meal – instead of just fasting cations (eye, blood vessel, nerve and kidney reason behind type 2 diabetes in overweight blood glucose (before meal). damages), diabetes has been found to and obese people. Gestational diabetes may increase the risk of depression and some Pre-diabetes is a serious medical condition, harm the normal development of the child. cancers, such as pancreas and colon cancers. which has significant risk of tissue damage. Pregnancy diabetes typically resolves with Smoking, some medications (cortisone, beta The good news is that people with pre- delivery of the child, but unfortunately the blockers and antidepressants) may weaken diabetes can prevent the development of mother may contract diabetes type 2 later the effect of insulin and thus trigger on type 2 diabetes by making changes in their in her life. As a matter of fact, half of the diabetes. diet and increasing their level of physical women who have had pregnancy diabetes activity. The risk could be reduced up to 60% will become diabetic later on. They may by slimming 5 to 10% off their weight and reduce the risk by weight control, regular PRE-DIABETES walking or jogging daily ½–1 hours. Pre- exercise and taking certain dietary sup- Before people develop type 2 diabetes, they diabetics should begin changing their life plements, which prevent, suppress and almost always have "pre-diabetes", i.e., style already at this stage, according to the extinguish oxidative stress and chronic low- blood glucose levels that are higher than advice given in these guidelines. All adults grade inflammation. normal but not yet high enough to be who are overweight should be tested for diagnosed as diabetes. Pre-diabetes is more diabetes or pre-diabetes. 4 5
    • SELF-MONITORING months intervals for those under good monitors his or her blood sugar readings, the cooking of meat (like broiling, frying, OF BLOOD GLUCOSE glucose balance. Otherwise we recommend better the glycaemic control, and A1C stays roasting, and grilling). Caramel is a typical testing A1C every 2 to 4 months, or even below 7%. This is a good way to prevent the example of AGE products. Smokers have It is an essential part of proper treatment. The more frequently. According to research, only toxic effect of elevated glucose concentration high levels of AGEs in the blood due to the aim of life style changes is to get the blood one out of three diabetics is in good on the beta cells of the pancreas as well as AGEs that are added in the processing of glucose readings as close to those of non- glycaemic control, i.e., A1C is under 7%. other vulnerable cells in the body. tobacco. diabetics as possible, in other words the In two out of three diabetics, the balance is AGEs are produced also internally fasting (before meal) plasma glucose to less so poor that they run a considerable risk of WHAT DOES A1C TELL US? (endogenously) in the body, when the blood than 6 mmol/l (105 mg/dl). Glucose readings complications. sugar concentration increases, long before are often at highest about 30 to 60 minutes A1C is formed when glucose reacts non- Blood sugar levels may be monitored clinical signs of diabetes complications have postprandial (after meal), and then the enzymatically with amino acids on according to various strategies, for instance started. At present no routine method for readings start to decline. Glucose monitoring haemoglobin in the red blood cells. A1C once or twice a day. If you measure once a measuring AGEs in the blood has yet been after meals aims to discover those top represents an integrated measure of glucose day, you may take the reading on alternative developed. readings, so it is advisable to analyse blood concentration during haemoglobin´s days from fasting and postprandial blood sugar after about 45 minutes postprandial. lifespan, which is about 2–3 months. AGEs are brown, gluey substances which samples. We recommend that you take The readings should not exceed 8 mmol/l Because A1C concentration predicts the risk damage the endothelium of the arteries postprandial readings sometimes after (145 mg/dl). Self-monitoring helps you to for diabetic complications (Fig 2), it is used leading to stiffness and constriction of the breakfast, sometimes after lunch, sometimes choose your meals so that the blood sugar in the clinical setting to assess longer-term blood vessels. AGEs also produce cross- after dinner, in order to get familiar with the levels are under control. glycaemic control among people with linking of the proteins thus causing wrinkles effect of different meals on your blood sugar diabetes. Generally, A1C concentrations in the skin and other ageing changes. For diabetics who do not need medication levels, and you thus learn how to avoid and under 7% are regarded as acceptable. Furthermore, AGEs oxidise the “bad” LDL (i.e., who are in nutritional therapy only), reduce the intake of food items detrimental Regrettably, only one diabetic in three cholesterol, which in turn damages the the A1C should stay under 6%. Otherwise to yourself. In addition, you should take four complies with this reading. In non-diabetics arteries. That is the bad news. The good is the treatment needs amendment. For those readings or more on consecutive days, once the reading is usually 5–6% (33–40 mmol/ that benfotiamine and carnosine, as dietary under medication the A1C should stay under or twice a month. If you are on insulin, you mol). supplements, are able to block totally the 6,5% and for those using insulin, in general, should monitor frequently the effect of dietary and endogenous AGEs and their under 7,0%, but the individual goal may be different meals, exercise and mood A1C values over 7% increase the risk of harmful effects. tighter, e.g., 6.5%. For those using metformin fluctuations on your blood sugar levels and complications and visa versa: lowering of or glitazone A1C aim may be as low as below learn from the readings. It is known from elevated A1C reduces the risk and slows 6.0%. A1C readings should be taken 3 to 6 experience that the more often a diabetic down the progress. Lowering A1C from 9 to 7 reduces the risk of retinopathy by 60%, nervous and kidney damage by 50% and arteriosclerosis by 40%. A1C can be controlled by healthy eating habits, medicines, exercise and dietary supplements, as explained in this guide. ADVANCED GLYCATION ENDPRODUCTS (AGES) These are the main culprits for diabetic complications. AGEs are formed when Figure 4. Dietary and endogenous AGEs are built glucose forms irreversible bindings with when glucose reacts irreversibly with proteins, fats other substances, like proteins, fats and and nucleic acids. One of the results is the glycated nucleic acids. Many foods and drinks contain haemoglobin A1C. The greater the A1C reading, Figure 2. The higher the A1C AGEs. They are present in Cola drinks, the more AGEs are formed in the body, and the reading, the greater the risk of mayonnaise, butter, donuts, cookies and greater the need for anti-AGE-agents, such as diabetic complications. pastries, and they form in high-temperature benfotiamine and carnosine. 6 7
    • INSULIN RESISTANCE or its effects in the cell are inhibited, so that the blood. Glucose will bind within these issued by medical organisations. Therefore the fasting and postprandial blood glucose cells to form AGEs which have the potential we feel that the guidelines should be up- Every overweight type 2 diabetic is insulin readings will rise. Extra blood sugar levels to damage the cells very early, in a few days dated, as we propose in this guide. resistant. It means that the effect of insulin are toxic to the pancreatic beta cells, which or weeks. It is therefore these organs which has become weaker. The disposition to Actually, diabetes and cardiovascular then consequently reduce the insulin excre- are especially vulnerable. The younger you insulin resistance is partly hereditary, but it disorders belong to the same family of tion. The less the pancreas produces insulin, are when diabetes is diagnosed, the more may be worsened by smoking, drinking, diseases. Diabetes causes myocardial the more fat cells liberate toxic free fatty serious will the complications get. long-term stress, hypertension, pregnancy, infarctions (heart attacks) and infarctions acids, which again damage the beta cells. One of the reasons for the organ damage is cause diabetes. Elevation of blood pressure fast, and use of cortisone and antidepressive Free fatty acids also accumulate in the liver, that a diabetic person burns glucose via a increases the risk of diabetes, as well as drugs. The reason of insulin resistance may where they fight the effects of insulin leading wrong way, called hexosamine pathway. It myocardial infarction (heart attack) and be a disturbed binding of insulin to the to increasing blood sugar concentrations. produces toxic free radicals, especially stroke. The reason behind all these condi- cellular receptor or its function, disturbance Insulin resistance can be detected by making super-oxide (O2–), in the small cellular power tions is disturbed glucose and fat metabolism in the glucose transporter proteins. The an insulin loading test at the same time with plants called mitochondria. Free radicals and latent deficiency of some vitamins, problem lies in the uptake of glucose into glucose tolerance test. It will show whether cause damage to the mitochondrial minerals, trace elements, biologically active the cell or in the glucose metabolism inside the person excretes insulin at all, normally, membranes which begin to leak, just like peptides and omega-3 fatty acids. the cell. or in excess. Pathological values in a type 2 oxidised batteries. This leakage causes The pancreas of an insulin resistant person diabetic may be normalised simply by pathological changes in the arteries, heart, Increasing blood glucose destroys cardiolipin may produce insulin in excess and thus the avoiding excess intake of starch. If you are eyes, nerves and kidneys. Free radicals cause (literally ”heart fat”), a special fat present in blood glucose may stay within normal limits. insulin resistant, we recommend that you damage to the mitochondrial membranes the heart. This destruction begins already However, every fourth insulin resistant start applying the guidelines given in this which begin to leak, just like oxidised during pre-diabetes. Cardiolipin is essential individual does not excrete insulin enough, leaflet. batteries. for the cardiac mitochondria, which produce energy for the heart pump. When the mito- CARDIAC CHANGES chondria begin to leak, their ability to pro- duce sufficient energy for the heart muscle The heart and arteries are most vulnerable declines. This weakens the pumping capacity COMPLICATIONS to elevated blood glucose. External and of the heart and simultaneously the free internal AGEs cause hardening, narrowing radicals continue to damage the heart cells. and eventually blocking of the blood vessels. This vicious circle may lead to a heart attack, Diabetes can cause many pitfalls and we feel than others. Nowadays, complications may be Over 80% of diabetics contract cardiovas- insufficiency and degeneration of the heart that it is important that you know the facts. controlled due to better ways to treat cular disorders and die from them – although (cardiomyopathy). Certain dietary supple- Acute complications (hypoglycemia, keto- diabetes. they are treated by the current guidelines ments can help break the vicious circle. acidosis or non-ketotic hyperosmolar coma) may occur if the disease is not adequately HOW DO THE controlled. Serious long-term risks include heart COMPLICATIONS DEVELOP, and arteriosclerosis (cardiovascular disease), AND HOW CAN YOU REDUCE and micro-vascular damage, which may THE RISK AND SLOW DOWN cause retinal damage (which can lead to THEIR DEVELOPMENT? blindness), nerve damage, chronic renal Figure 3. Mitochondria are tiny organelles, There is still some uncertainty about the failure, impotence and poor wound healing. reasons behind complications that develop which produce energy in the cells. An Smoking, elevated cholesterol levels, obesity, after many years of diabetes. However, it is organelle is a specialized subunit within a high blood pressure, and lack of regular known that glucose causes pathological cell that has a specific function, and is exercise contribute to the complications. separately enclosed within its own lipid alterations in certain cells, which do not Different people are more or less susceptible membrane. Elevated blood glucose and tolerate elevated glucose content. These cells glucose burning the hexosamine pathway to developing these complications, probably – situated in the arterial walls, eye retinas, produce toxic free radicals which damage due to genetic reasons. In the past, diabetics brain, nerves, adrenal glands, kidneys – take the mitochondrial membranes. Benfotia- who developed heart disease or kidney in glucose without the help of insulin, in mine, carnosine, E-EPA and other dietary damage had about 12 years shorter lifespan direct proportion to the level of glucose in supplements protect the mitochondria. 8 9
    • DIABETIC RETINOPATHY – protein into the urine, called micro- DAMAGE TO THE BLOOD alburinuria, as a sign of early kidney damage. VESSELS IN THE RETINA One in two with the condition proceeds into kidney disease. One in five type 2 diabetics SELF-MANAGEMENT OF DIABETES Elevated blood glucose damages insidiously has albumin in the urine already at the time the retinal micro-vessels without giving any of diagnosis; after ten years the figure is 30. symptoms until too late. Almost all type 1 The conditions may be reversible. Annually, The goal is to find a way of treating your effective in helping people lose weight over diabetics develop retinal changes during the thousands of diabetics need dialysis diabetes effectively. The ultimate goal is to a year, according to the association. The first 20 years of disease. Those who contract treatment and kidney transplant. prevent, or at least slow, the rate of recommendations are intended to help diabetes before puberty get retinal changes development of diabetic complications: physicians guide their patients in diabetes sooner than those who are diagnosed WOUNDS IN LEGS AND FEET micro- and macro-vascular changes, nerves prevention and management. diabetics later. Every third type 2 diabetic Wounds heal badly in diabetics due to poor and kidney damage, depression and memory has signs of retinopathy at the time of blood circulation and zinc and carnosine impairment. There may be more than one Carbohydrates: Starch v cellulose diabetic diagnosis. Diabetic retinopathy is deficiency. Poor healing of wounds, particu- way of reaching this goal. Good glucose the most common cause of visual Carbohydrate intake needs to be managed larly of the feet, can lead to gangrene, which balance reduces significantly the risk of impairment in those of working age and the to control your blood sugar levels. For this may require amputation. We strongly complications, but it alone is not sufficient third most common cause in people over 65 purpose, we endorse the orthoglycaemic recommend dietary supplements as in the to prevent the complications totally. Glucose years. The risk of retinopathy can be reduced diet for all diabetics and other people alike subsequent section of this guide. balance is monitored by analysing blood and its progress can be slowed down by (http://tinyurl.com/2dnpb9). glucose values and A1C but it is necessary careful glycaemic control, laser treatment ERECTIL DYSFUNCTION AND to monitor other risk factors, like C-reactive Most of our carbohydrates come from cereals and dietary supplements. protein (CRP), cholesterol, triglycerides, and grains, both products of the agricultural IMPOTENCE DIABETIC NEUROPATHY homocystein, vitamin B1, magnesium, zinc, revolution. Also milk contains sugar, lactose When a male has diabetes, the main risk liver enzymes, creatinine, and urinary (5 g/100ml). Half a litre (one pint) a day of The nerves are damaged partly because of factors for developing erectile dysfunction albumin. Plasma fatty acid analysis gives milk is recommended for children for its arterial changes. Sugar enters also directly are nerve damage (neuropathy), blood vessel valuable information of the person´s omega- calcium content. to the peripheral and central nervous system, damage and poor blood sugar control. As 6/omega-3 ratio. Annual or biannual eye Our bodies are not genetically designed to where it turns into alcohols (sorbitol and many as 80% of men with diabetes develop examination is also appropriate. thrive on large helpings of fibreless complex polyols). They cannot per se come out of the erectile dysfunction, compared to about 25 carbs, starch. With the popularity of cereal- nerve cells, which are then damaged. The percent of men without diabetes. Erectile NUTRITION based and grain-based diets, carbohydrate higher the A1C, the greater the risk of dysfunction most frequently develops after Healthy nutrition is important in preventing metabolism has been upset in approximately neuropathy (Fig. 2). age 65. In men with diabetes, however, it diabetes as well as managing existing 3/4 of the population, including all diabetics, tends to occur 10 or 15 years earlier, on which simply cannot handle this large load About 8% of type 2 diabetics have symptoms disease. The goal of these recommendations average. Men in their 30s and younger with of carbs. A big portion of starch is stored as and signs of neuropathy at the time when is to make people with diabetes and health diabetes have also experienced erectile fat resulting in obesity. We endorse the diabetes diagnosis is established. After care providers aware of beneficial nutrition dysfunction. The longer you've had diabetes avoidance of starchy meals, such as potatoes, 10 years about 40% and after 15 years over interventions. This requires the use of up-to- and the more severe it is, the more likely corn, rice, banana, squash and all cereals 50% of diabetics experience neuropathy. The date scientific evidence while taking into you are to develop erectile dysfunction or and grains (therefore bread and porridges), symptoms include tingling, numbness, account treatment goals, strategies to attain impotence. Carnosine forms nitric oxide in cakes, and other pastries. Pizza meal will sensory loss and pain. Also the muscles may such goals, and changes individuals with the body, which is needed for erection. usually contain more bread than traditional atrophy. diabetes are willing and able to make. Therefore carnosine has become an increas- meal; therefore we advise you not to eat ingly popular dietary supplement amongst Achieving nutrition-related goals requires a DIABETIC NEPHROPATHY – coordinated team effort that includes the much of the crust. men with diabetes. KIDNEY DAMAGE person with diabetes and involves him or her Most people know how to avoid excess in the decision-making process. simple sugars, which are easily identified by Fifteen years after the diagnosis of type 1 diabetes, 20–30% of the patients have In 2008, the American Diabetes Association their taste: sweet. The same alarms do not developed damage to the walls of blood (ADA) voiced its support of low-calorie or go off when consuming potatoes or white vessels which cause increased leakage of low-carbohydrate diets, which are equally bread, although they should since these items 10 11
    • Photos: Osmo Lehtinen convert to simple sugar within minutes of human body distributes glucose to the areas lowered incidences of diabetes, hyperten- boiling and stewing instead of frying, consumption. Potatoes and rice are not very where it is needed for energy or stores it as sion, cancer, arthritis, etc. Examples are let- broiling, roasting or grilling. different in that respect. Pasta gives slower its own special polymer – glycogen, another tuce, broccoli and berries. Eat your fruits, rise in blood glucose than potatoes, which polymer of glucose. Excess glucose is do not juice them and drink them, unless FATS makes pasta more suitable for people with bonded together to form glycogen mol- you are on a juice fast. Eating the whole fruit diabetes. Macaroni gives a quicker blood ecules, which we store in the liver and results in the inclusion of natural fibre, which Our diet contains a complex mixture of fats glucose response than spaghetti, which muscle tissue as an "instant" source of energy. allows proper absorption of sugars. and oils whose basic structural components increases the blood glucose just as quickly Both starch and glycogen (animal type starch) are fatty acids. We generally consume at least as white bread and ordinary sugar. The starch are polymers of glucose. Excess glucose turns 20 different types of fatty acids, which are in vegetables increase the blood sugar into fat, which builds on the waist and PROTEIN classified as saturated, monounsaturated and content more slowly than other types of bottom. That is why we recommend avoiding polyunsaturated. They do not directly affect Meat, poultry, fish and eggs are examples of starch, as vegetables are high in dietary fibre. starchy foods. If you cannot stand the temp- blood glucose, but indirectly fats slow down good sources of protein. Protein keeps hun- We recommend you to increase your fruit tation, you may use Kilo-Stop capsules, the absorption of carbohydrates by slowing ger at bay. Protein does not directly increase and vegetable intake along with the which inhibit the activity of amylase, thus the rate at which the stomach empties. blood glucose, but it stimulates the release preventing the absorption of glucose Consequently, the blood glucose level rises “cellulose line”. It is more effective, also for of glucagon, which – in a process called molecules into your blood stream. more slowly. Therefore it is a good idea to weight control, than low-fat starchy diets. gluconeogenesis – helps to convert protein include several weekly servings of oily fish The “cellulose line “can help people with Complex carbs come in two varieties: high into glucose. If there is not enough insulin, in your diets or to take omega-3 capsules type 2 diabetes get their blood sugar under fibre and low fibre. The main item in high- the blood glucose may slowly increase as a with your meals. control when standard dietary changes and fibre, complex carbs, is cellulose. It cannot result. drug treatment have failed. be digested by human beings; therefore Not all dietary fatty acids are created equally. It is important to understand that excess People with diabetes should minimise the We will explain the rational as follows: cellulose passes through the digestive tract protein can be nephrotoxic. It increases AGEs intake of saturated and trans fats. Foods that When we eat starch, an enzyme that occurs without being absorbed into the body. in the blood through an excessive dietary contain large amounts of saturated fat in saliva and in the intestines, called amylase, Despite the fact that it cannot be used as an AGE content and an increased amino acid include dairy products and red meats. Trans breaks the bonds between the repeating energy source, cellulose fibre is essential in load. This enhances AGE formation in the fat is present for instance in margarines, glucose units, thus allowing the sugar to be the diet because it helps exercise the body. We recommend protein daily 0.8 g/kg pastries, cookies, ice creams and in most absorbed into the bloodstream. Amylase is digestive track and keeps it clean and with an emphasis on protein that has high restaurant foods. secreted by the salivary glands, which empty healthy. biologic value and is low in AGEs. Dietary into the mouth, and by the pancreas, which High-cellulose (high-fibre) vegetable foods AGE load can be minimised by consuming Even among dietary polyunsaturated fatty empties into the head of the duodenum. are the healthiest choices for human non-meat proteins (e.g., chicken, fish, eggs) acids (PUFA), there are different families of Once absorbed into the bloodstream, the nutrition, and the ingestion is associated with and prepare the food by steaming, poaching, compounds, and this is at the heart of the 12 13
    • difference between omega-3 fatty acids and DIETARY SUPPLEMENTS Benfotiamine Carnosine other dietary lipids. Omega-3 fatty acids Your doctor may have said that you do not Benfotiamine is a lipophilic analog of Carnosine is an endogenous protein generally account for a small fraction of the need any dietary supplements. As a matter vitamin B1 (thiamine), which reduces the risk (dipeptide), another anti-AGE agent, which total daily consumption of fatty acids in Western societies. Fish such as tuna, trout of fact, the average doctor has not had much of pathological changes in the arteries, eyes, reduces the risk of diabetic complications, and salmon are especially rich sources of education in nutrition or dietary supple- nerves and kidneys. Recently, researchers led such as kidney damage and erectile these fatty acids. Fish-oil supplements are ments. A doctor is usually so busy prescribing by Professor Paul Thornalley at Warwick dysfunction. The content of carnosine in the also a rich source. Small quantities of omega- medicines, which of course take priority with Medical School, University of Warwick, have body declines with age, but it is possible to 3 fatty acids are naturally present in meats them, that they do not have time to study shown conclusively that diabetic patients are restore the concentrations by taking like beef, pork and poultry. Despite preventive medicine, including the use of thiamine (Vitamin B1) deficient and that the carnosine as a dietary supplement. It containing small quantities of omega-3 fatty dietary supplements. Average doctors do not decreased availability of thiamine in vascular increases the beta cell mass in the pancreas acids, meats contribute to the overall intake actually know a great deal about them and cells is linked to micro-and macro-vascular and fights oxidation and carbonylation, two of these fatty acids simply because of the consequently do not advise them. complications. The decreased plasma pathologic biochemical reactions charac- large amounts consumed. thiamine concentration in clinical diabetes teristic to diabetes. Carnosine prevents the As a matter of fact, what is recommended is not due to a deficiency of dietary thiamine. glycation of LDL cholesterol thus keeping it The most important consideration when daily for the healthy average population does Rather it is due to 15 times the normal rate in a harmless state. Carnosine also speeds considering PUFAs is the ratio between not apply to risk groups and diabetics, of removal of thiamine from the blood into up wound healing. An adult diabetic needs omega-3 and omega-6 fatty acids. Vegetable because their need may be much higher! The the urine. Professor Paul Thornalley said: carnosine 800 to 1200 mg a day. The dosage oil is rich in omega 6 and fish oil in omega- reason is that diabetics excrete urine more "Supplementing diets could be an effective may be doubled during the time of wound 3. Some vegetable oil contains also omega- than non-diabetics and with the urine they way of minimising the risk of these healing. Zinc and Vitamin E enhance the 3 (alpha-linolenic acid, ALA), but its also excrete abnormal amounts of nutrients, complications." beneficial effects of carnosine. biological activity is far inferior to fish oil such as vitamin B1. If you are serious about The most effective and safe thiamine is called omega-3 (EPA and DHA). Because omega-6 managing your diabetes to the best of your E-EPA (ethyl EPA) benfotiamine. Professor Jaime Uribarri, at and omega-3 compete with each other, the ability, you cannot afford to do so without Mount Sinai Hospital Renal Center (NY), E-EPA is highly purified fish oil (omega-3), proper ratio between them is extremely dietary supplements. They prevent deficien- suggests that diabetics take benfotiamine which is recommended for diabetics, heart important. The ideal omega 6:omega 3 ratio cies, help balance blood sugar and prevent daily about 300 mg in long term use, as and mental patients (1000 to 2000 mg a day). is 1:1 to 2:1. This ratio is prevalent in Japan, glycation, thus reducing the risk of compli- benfotiamine is an excellent anti-AGE agent, E-EPA prevents the break down of cardiolipin where people eat a lot of seafood. The cations. Supplements of special importance able to block totally the harmful effects of in the heart and it protects the arteries against standard Western diet, in contrast, is high in for diabetics include omega-3-fatty acids, AGE products on the arteries. stiffness and hardening. E-EPA enhances the omega 6 and provides an omega-6:omega- carnosine, vitamins B, C and E, chromium, 3 ratio of between 6:1 and 30:1. That means magnesium, selenium and zinc. that the effects of omega-6 outweigh the Omega-3-fatty acids and carnosine suppress beneficial effects of omega-3s. Mediterra- expression of genetic flaws, oxidative stress nean diets contain a better ratio of the and chronic low-grade inflammation. Some omegas. Fish-oil supplements is an effective supplements, like alpha lipoic acid, benfo- way to increase omega-3 fatty acid intake tiamine, carnosine and vitamin B6 prevent without changing dietary habits; however, glycation of proteins and fats (e.g., LDL 1–3 capsules must be taken daily to achieve cholesterol). Folic acid and vitamins B6 and the recommended intake. Omega-3 fatty B12 prevent accumulation of homocystein. acids may lead to a general increase in the Uniquinone (Q10) and E-EPA prevent the overall health and well-being damages in mitochondria caused by When changing your dietary habits, cholesterol lowering medication (statins). remember to frequently self-monitor your The outlook for someone who takes blood sugar values. Reducing the gly- supplements is much brighter. caemic load of your meals may require reduction of your medication, in order to avoid hypos. 14 15
    • positive effects, and prevents the side-effects testosterone, which may contribute to bad clotting factor, Lp(a), that may cause Alpha lipoic acid of statins, and it improves the lipid profile in erectile dysfunction and impotence. Zinc is heart attacks. Combining nicotinic acid with Alpha lipoic acid has been prescribed the blood (lowering triglycerides and known to improve the lowered testosterone a statin will produce a greater reduction in successfully for diabetics in Germany since improving the omega-6/omega-3-ratio). E- levels and immune system against infections, cardiovascular risk than statin monotherapy 1966, the daily dose being 200 to 600mg. It EPA is an excellent anti-inflammatory agent. degeneration and ageing itself. Diabetics alone. Nicotinic acid is safe for use in has many actions similar to carnosine. It also balances stress hormones (cortisone need 15 to 30 mg extra zinc on a daily basis. patients with diabetes, with no evidence of and cortisol) and it fights insulin resistance. clinically relevant deterioration in glycaemic Ubiquinone (Q10) Selenium (Se) E-EPA reduces visceral fat, and it enters the control at recommended doses (less than 2g/ brain better than traditional omega-3s, thus Ubiquinone is a vitamin-like substance, Selenium is a versatile water soluble day). On review of the available evidence, preventing memory impairment, depression which participates in production of energy antioxidant which protects the body against the European Consensus Panel recommends and dementia. in the intra-cellular mitochondria. Q10 also oxidative stress. Organic selenium is more the combination of nicotinic acid and a acts as an antioxidant, like vitamin E. Q10 effective than inorganic. We recommend for statin, together with lifestyle modification, Chromium (Cr) is used to prevent heart attack, myocardial diabetics a daily dose of 200 micrograms. as a useful strategy to lower CHD risk in The daily intake recommendation for healthy insufficiency and cardiomyopathy. Q10 also patients with diabetes and metabolic people is 50–200 micrograms, but diabetics Vitamins C and E fights side effects of statins, e.g., muscular syndrome. Furthermore, niacin may improve need at least double, because insulin needs fatigue. These vitamins, too, protect the cells against A1C significantly. Some dietary supplements chromium as a co-factor. In a recent study, oxidative stress, which prevails in the body contain benfotiamine and niacin-bound 63% of the subjects with type 2 diabetes All the aforementioned dietary supplements of a person with diabetes. One can safely chromium (Cr trinicotinate). This triple responded positively to the Cr treatment can be taken continuously on a daily basis, consume vitamin C 500mg and vitamin E combination might improve patient (1000 mcg/day) as compared with 30% with and if need be, together with any medi- 200 to 500mg daily, long-term. These anti- compliance when compared with the three placebo. Adequate chromium supplemen- cation. These supplements do not cause any oxidant vitamins fight oxidative stress, pre- substances administered separately. tation may lower A1C by one per cent. In side effects, when used according to the vent arteriosclerosis and ameliorate cardiac However, some individuals are unable to addition, chromium prevents cravings for guidelines given here. failure caused by elevated blood sugar. These tolerate niacin. sweets. Organic chromium – e.g., as chro- vitamins intensify the beneficial effects of mium trinicotinate or picolinate – also other supplements mentioned in these reduces the risk of depression. guidelines. Magnesium (Mg) Folic acid, B6 and B12 vitamins Diabetics excrete magnesium in the urine Diabetics build up homocystein, a toxic more than non-diabetics, and consequently, sulphur containing amino acid, which up to half of diabetics are magnesium- increases the risk of retinopathy, deficient. Unfortunately, doctors do not arteriosclerosis, heart attack, memory analyse the magnesium content in red blood impairment, depression, dementia and cells, and therefore the deficiency remains osteoporosis. The laboratory reference values mostly unnoticed and untreated. The for homocystein are 5–15 µmol/l, but the risk deficiency increases the risk of arrhythmias, of diabetic complications increase already hypertension, myocardial infarction and from 7 µmol/l upwards. A combination of stroke. Diabetics need daily 350 to 700mg folic acid, and vitamins B6 and B12 prevent extra magnesium. B vitamins improve the accumulation of homocystein. absorption and effect of magnesium. Nicotinic acid (Niacin) Zinc (Zn) Nicotinic acid, another B vitamin, is the most Diabetics need extra zinc for prevention of effective agent currently available for oxidative stress and inflammation. According increasing levels of the “good” HDL to research, many diabetics are deficient in cholesterol. This is pertinent, as low HDL zinc, and the deficiency is an independent and high triglyceride levels are particularly risk factor of heart attack. Zinc deficiency is problematic in diabetic patients. Niacin also known to reduce the synthesis of lowers blood levels of triglycerides and the 16 17
    • PHYSICAL EXERCISE blood sugar (hypoglycaemia), high blood 13.9 mmol/l (250mg/dl) or higher? Before Examples include: sugar (hyperglycaemia) and high urine exercising, test your urine for ketones. If the Two or three glucose tablets If you are not used to regular exercise we ketone levels (ketoacidosis). results show a moderate or high ketone level, 1/2 cup of fruit juice recommend that you start easily and add the Find out when it's safe for you to start don't exercise. Wait until your ketones test 1/2 cup of regular (not diet) soft drink intensity and time gradually so that you will exercising, when to check your blood sugar indicates a low level. The excess ketones Five or six pieces of hard candy not get any strain or damage (muscles, joints). and what to do if you experience symptoms indicate that your body doesn't have enough Recheck your blood sugar 15 minutes after Regular fitness motion improves your mood, of low blood sugar. If you've been inactive insulin to control your blood sugar and can this snack. If it's still too low, have another improves and keeps up your physical or have a medical condition, talk to your lead to ketoacidosis. serving and test again 15 minutes later, until condition, promotes cardiovascular health doctor before you begin your exercise your blood sugar reaches 3.9 mmol/l (70 mg/ and burns energy (calories) thus helping in 16.6 mmol/l (300mg/dl) or higher? No programme. dl) or higher. weight control. Exercise also fights insulin matter what type of diabetes you have, don't resistance, and it releases carnosine from Before you exercise: Check your blood sugar exercise. You need to bring your blood sugar After exercise: Check your blood sugar at your muscles thus preventing glycation of twice. Your goal is to make sure that your down before you can safely exercise because least twice. When you've finished exercising, proteins and fats. Regular exercise may blood sugar isn't too low before you begin you risk an even greater increase in your check your blood sugar again. The more prevent type 2 diabetes in persons with exercising and that it doesn't drop too low blood sugar, which can lead to ketoacidosis. strenuous the workout, the longer your blood impaired glucose tolerance. Diabetics have during and after your workout. sugar is affected. Check your blood sugar a During exercise: Check your blood sugar to learn to monitor the effects of exercise, To avoid swings in your blood sugar, test it couple of times after exercising to make sure every 30 minutes. It's especially important meals and medication on blood sugar 30 minutes before you start and then once you aren't developing hypoglycaemia, to check your blood sugar during exercise if readings, in order to prevent hypoglycaemia. again immediately before exercising. This which can occur even hours after you've you're starting aerobic exercise for the first The increased activity will often require can help you determine if your blood sugar stopped. Exercise draws on reserve sugar time, trying a new activity or sport, or lowered insulin doses, especially at bedtime. level is stable, rising or falling before you stored in your muscles and liver. As your increasing the intensity or duration of your start to exercise. Avoid problems by body rebuilds those stores, it takes sugar from workout. If you exercise for more than an following these guidelines: your blood, lowering your blood sugar level. MONITOR YOUR hour, especially if you have type 1 diabetes, BLOOD SUGAR Less than 5.6 mmol/l (100mg/dl)? No matter stop and test your blood sugar every 30 Be encouraged Adapted from Mayo Clinic.com what type of diabetes you have, eat a small minutes. You may think that testing your blood sugar carbohydrate-containing snack such as fruit If it's 3.9 mmol/l (70mg/dl) or lower, or if it's before, during and after you exercise requires We suggest that you monitor and record your or crackers before exercising. not that low but you have symptoms of low a lot of effort. Keep in mind that once you blood sugar before, during and after exercise. It can help you and your health care team 5.6 to 13.9 mmol/l (100 to 250mg/dl)? For blood sugar – feeling shaky, weak, anxious, and your health care team know how your see how your body responds to exercise. It most people, this is a safe pre-exercise blood sweaty, or confused – eat a snack that serves body responds to aerobic exercise, you can can help prevent dangerous episodes of low sugar range. as a fast-acting source of sugar. probably cut back on testing. THANKS We thank our friend Dr Timo Kuusela, a diabetic physician himself, for valuable advice in writing these guidelines. Dr Kuusela has long experience in management of his own type 2 diabetes following the ”cellulose line”, and avoiding intake of excessive starch. 18 19
    • Diabetes mellitus is a condition, which requires careful management in which the patient him/herself has to be the one who takes control. Although professionals in health and nutrition participate in the treatment, it is you who is mostly responsible for the outcome. It is only the diabetic person who can learn how to manage the conditions in the best possible way. You can control your diabetes rather than let your diabetes control you. It requires continuous observation, practising and recording the effects of the life style factors (exercise, nutrition and medication) on the blood sugar readings and well-being. Having diabetes means that you need to make yourself better informed than the average doctor. This leaflet has information you will not find anywhere else. Some of our ideas may not tally with those of some other doctors, but we would like to offer options to consider for those who must live with diabetes. We do not address the drug treatment, except briefly. Dr Matti Tolonen is a medical doctor Dr Pentti Raaste is a GP, and and Docent in Public Health at the a diabetic himself. He has a University of Helsinki, Finland. consultancy in Fuengirola (Málaga), He has more than 25 years experi- Spain tel 95247 5290 ence of Nutritional Medicine as a scientist and practicing physician. www.biovita.fi/english/tolonen.html Photos: Osmo Lehtinen Are you diabetic? Do you know someone who is? La Cala de Mijas Lions Diabetic Support Group in Andalucia, Spain, invites you to call Anne Bowles on the Helpline 607 879 450. Regular meetings enable you to meet other diabetics and their families and help you to increase your diabetic awareness through informative lectures. 20 21