A Preventable Epidemic
Smart lifestyle choices keep Type 2 diabetes in check
Endocrinologist Dr. Joseph Prendergast says that diabetes patients are much more involved with their own treatment than in the past.
Photographs by Lane Johnson
Twenty-five years ago, after months of not feeling well and wondering what was wrong, my mother learned she had Type 2 diabetes. Her glucose level was over 400, a number high enough to cause many of the major health problems associated with elevated blood sugar: high blood pressure, vision impairment, and diseases of the heart, kidneys, and nervous system. With medication and a proper diet, my mother has managed her diabetes for many years, although she still has periodic episodes that land her in the hospital.
She is part of a growing epidemic. According to the Centers for Disease Control and Prevention (CDC), since 1990 the number of Americans diagnosed with diabetes has increased at the rate of 5 percent per year. The American Diabetes Association states that one in eight Americans has diabetes—a total of 25.8 million children and adults. The CDC projects that by 2050 as many as one in three Americans will have the disease.
Type 2 diabetes occurs when the pancreas does not make the right amount of insulin, or when the body does not respond properly to insulin, or both. This leads to abnormally high sugar levels in the blood. In contrast, Type 1 diabetes occurs when the pancreas does not produce any insulin. An autoimmune disease, Type 1 diabetes is typically diagnosed in younger people, which is why it is often called juvenile diabetes.
In the United States, Type 2 diabetes is nine times more common than Type 1, despite the fact that most experts believe that Type 2 diabetes is preventable.
The causes of Type 2 diabetes are generally attributed to three factors: a diet high in refined carbohydrates (sugar in all its various forms), a sedentary lifestyle, and stress. These are also major contributors to obesity, another American epidemic.
Christine Rosche, M.P.H., a Palo Alto-based, board-certified nutrition specialist and biofeedback therapist, says, “Refined carbohydrates, which include white bread, white rice, and other starchy foods, set up an addiction in the body. We crave the food that is worst for us, just like a drug.”
Rosche focuses on a balanced eating program to treat diabetes patients. “The first thing we do is look at the patient’s diet,” she says. “We eliminate refined sugar, flour, and rice. We design a program that includes small meals of protein, vegetables, and fiber.”
Dalia Perelman, a registered dietitian and certified diabetes educator at Palo Alto Medical Foundation, says, “It’s really important for everyone, and especially diabetes patients, to have a very well balanced diet. If you have a plate that is half filled with vegetables and you add some lean protein, then you can add some type of starch—but the starch can only occupy about a quarter of the plate.”
Perelman says the ideal formula, whether you are diabetic or not, is 50 percent vegetables, 25 percent protein, and 25 percent starch.
She adds that people who are most successful at this type of eating plan are those who learn to plan ahead. “They don’t just grab one thing and eat it. They combine foods carefully, like an apple with nuts, or a banana with peanut butter. They pack snacks to have ready when they get hungry,” she says.
Additionally, it is important for diabetes patients to learn about their individual bodies and what works best for them. “Everybody is different,” Perelman says. “Some people are more sensitive to sugar in the morning; some people are more sensitive at night.”
Because sugar comes in so many different forms, Rosche teaches her patients to look at the glycemic index of foods. “Brown rice, whole grains, turkey, chicken, and fish, as well as large amounts of vegetables, form the basis of our diet plan,” she says.
Rosche adds that eliminating refined sugars should not mean shopping in the “diet” aisle at your grocery store. “Diet soda causes an even higher rise in glucose than regular soda,” Rosche says. “And many so-called diet meals are loaded with refined carbohydrates.” These foods can cause unhealthy imbalances in blood sugar, leading to hypoglycemia or extremely low blood sugar. Symptoms of hypoglycemia include shakiness, anxiety, and a craving for more carbohydrates.
Endocrinologist Dr. Joseph Prendergast, who practices in Palo Alto, says that genetics also play a role in the onset of Type 2 diabetes. “It’s a genetic problem that tends to show up later in life. Younger people are easier to treat, since their habits are less ingrained,” he says.
Regular screening can identify diabetes’ early warning signs, and this knowledge provides the best chance of delaying or even preventing the actual onset of the disease. Current guidelines recommend that most people begin regular screenings at age 45, unless they have additional risk factors that warrant screening at an earlier age.
Certain ethnic and racial groups have higher incidences of diabetes than others, including Hispanics, blacks, and Asian Americans/Pacific Islanders. Martha Quintana, an RN and diabetes educator, works at the Pajaro Valley Community Health Trust in Watsonville. “Our population is over 70 percent Hispanic, with a high incidence of diabetes,” she says, “but a lot of the problems have to do with lifestyle choices. We teach patients to manage their own care, but they also need help. Diabetes is chronic.”
Quintana says that even among populations with a genetic disposition toward diabetes, education and outreach make an enormous difference. “Our approach to treatment is changing,” she says. “We used to have the doctor ‘do the driving.’ Now, we put the patient in charge.”
Perelman and Quintana both stress the importance of exercise for treating diabetes. “Diabetes patients just have to move their muscles,” Perelman says. “When they exercise, their muscles become more sensitive to the insulin. Both weight training and cardiovascular exercise are very beneficial. Cardiovascular exercise has immediate benefits; it lowers blood sugar immediately. With weight training it takes a little longer to see the benefits, but by lifting weights and increasing muscle mass, the muscle cells use sugar even while at rest.”
She adds that patients who lift weights tend to hold less fat in the abdominal area. “[Abdominal] fat is a very different type of fat. It secretes its own hormones, which leads to insulin resistance. People with extra fat in the abdominal area often don’t make insulin the way they should, and so their blood sugar levels aren’t regulated.”
Stress management also plays an important role in controlling diabetes. Rosche uses guided imagery, including images of a healthy metabolic system, to help her patients relax. “Stress increases cortisol, which raises the blood sugar,” Rosche says.
Perelman agrees. “Emotional and physiological stress have a big impact on blood sugar levels,” she says. “Some physiological stresses, like when you have a backache or the flu, can’t be avoided. But emotional stress can be managed.”
Perelman and other educators teach stress management classes to patients at Palo Alto Medical Foundation. “We teach patients about mindfulness and meditation. Practicing these techniques can have a very positive impact in terms of managing diabetes,” she says.
Dr. Prendergast says that patients are much more involved in their own treatment than in the past. “We work with our patients,” he says. “They constantly measure the outcomes, check their glucose levels, and report what makes them feel better.”
As a result, his patients’ need for insulin and other medications has dropped. “Overall, we use only 15 percent of the insulin we used to,” Prendergast says. “We spend a lot of time talking to our patients, understanding their perspectives, and finding out what works for them.