Lima Bean Soup

Ingredients:

• 1 cup dried baby lima beans
• 1 onion, chopped fine
• 2 medium carrots, sliced
• 2 celery stalks and leaves, chopped
• 1 yam, diced
• 1 cup green beans
• 1 cup chopped kale (can substitute chard or spinach)
• 1 bay leaf
• 3 cloves garlic, minced
• 6 cups vegetable stock or water and Harvest Sun vegetable bouillon cube
• ¼ cup chopped fresh parsley or 2 tbsp dried
• 1 tbsp fresh dill weed or 1 tsp dried

Pick through the lima beans, removing any little stones or debris. Rinse thoroughly. Place beans in a large bowl and add twice as much water to soak. Leave beans to soak 6-8 hours or overnight.

Drain beans and put them in a crock-pot and add 6 cups of filtered water, bay leaf and bouillon cube. Put on low setting and let cook for 8 hours. This is a great way of preparing beans while at work.

Meanwhile, chop onion and mince garlic. Chop carrots, celery, yam, and kale. Break cauliflower into small flowerets.

Saute onions and garlic in 1 tsp olive oil on medium low heat until soft. Add vegetables and quickly saute these as well to absorb flavors. Add beans and all of the stock.

Add chopped parsley and dill. Simmer soup for 15-20 minutes or until vegetables are tender. If you like soup more brothy add a little water. If you want the soup to be a little thicker, you can puree 1/3 of the soup and return it to the pot. Season with salt & pepper to taste.

Alternative Stovetop Method For Preparing Beans Put beans and stock into pot, bring to boil, then reduce to simmer for 45 min-1 hour or until beans are tender but not mushy.

Fast And Easy Biscuits (dairy and sugar free)

Ingredients:

• 1 ¾ cup whole-wheat flour
• ¼ cup wheat germ
• 3 tsp aluminum free baking powder (available in health food stores)
• ½ tsp salt
• 1/3 cup olive oil
• 2/3 cup organic soy milk (look for a brand without added sugar)

• Preheat oven to 475° F.
• Mix dry ingredients well.
• Pour the milk and oil over the dry ingredients (no need to mix them first)
• Stir with a fork until mixture comes away from side of bowl.
• Drop from a spoon onto an ungreased pan.
• Bake for 10-12 minutes or until golden
• Spread with a little flaxseed oil/butter mixture.

Note: Mixing flaxseed oil with your butter boosts your intake of omega 3 essential fatty acids while adding a nice nutty flavour to the spread. If you make this in advance, be sure to keep it refrigerated and in a dark container to keep the flaxseed oil from going rancid. You can add more flavour with chives, minced garlic, cayenne or paprika.

Round out the meal with a crunchy fresh green salad sprinkled with flax oil and you have a satisfying meal which is low in fat and sugar, high in fibre, vitamins & minerals.

Organics or Not — There are those who insist on organics while others feel it is just a waste of money. Some favour the idea yet feel they just can’t afford it. Those who do buy organics may do it for health, ethical or environmental reasons or all three. If you are concerned about pesticides on/in your fruits and vegetables you can avoid those that are known to be the worst when it comes to pesticide residues or buy these items organic. Here is a list of the worst offenders for pesticides when purchased non-organic.

The post Wishin’ For Nutrition appeared first on BC Diabetes Foundation.

Type 2 diabetes is typically the result of the following breakdowns in glucose regulation :

• increased insulin resistance in the body tissues
• decreased insulin output by the pancreas
• excessive glucose output by the liver.

Therapies for type 2 diabetes are varied and will change over time as the disease progresses. Insulin resistance, insulin production and excessive liver glucose production all change over time and require adjustments in therapy. As discussed in the last issue the nature of the diabetes therapy will determine the degree of risk of low blood sugars and the necessary precautions to take before exercising. We will get to that later but first let’s elaborate on the benefits and risks associated with exercise.

Benefits Of Exercise

There are numerous benefits of a regular exercise program and they are listed in table 1. I will highlight a few of my favorites here. One of the immediate benefits, besides having fun and feeling good, is the reduction in blood sugar. There is typically an immediate reduction in the blood glucose levels towards normal in response to exercise. The immediate reduction of blood glucose levels with exercise can actually be used to help regulate blood sugars on a daily basis and can lead to long-term improvement in diabetic control. Exercise can also produce a long-term improvement in insulin sensitivity and decreased fasting/after-meal plasma insulin levels when performed on a regular basis (3-5 times a week).

Another benefit is the potential for improved cardiovascular fitness, decreasing the risk for heart disease and increasing energy levels and stamina. In turn these can result in an enhanced sense of well-being and an improved quality of life. Exercise can also result in an improved lipid profile (cholesterol) with research showing lower levels of bad cholesterol (LDL and triglycerides) and higher levels of the good cholesterol (HDL) with a minimum of 10-12 miles per week of moderate intensity jogging. Often there is a reduction of hypertension (high blood pressure). This can occur independent of weight loss or changes in body composition, although these typically occur as well. One of the greatest benefits, however, is the potential to reverse the underlying mechanism of insulin resistance that can lead to diabetes in the first place. Exercise tends to reduce this resistance and increase insulin sensitivity enabling the body to regulate blood glucose (BG) levels more effectively with less insulin. This can be important in the prevention or the delay of onset of type 2 diabetes as well as the treatment.

It was back in the 1970’s that researchers first proposed exercise as a way to treat insulin resistance associated with type 2 diabetes. What they found was that physically active people with diabetes had lower fasting levels of insulin as well as lower insulin levels following a glucose challenge when compared to untrained diabetics of the same age and weight. The exercise resulted in increased sensitivity to insulin and therefore the pancreas didn’t need to produce as much insulin to achieve a similar glucose level. Exercise has been shown to increase insulin-stimulated glucose disposal by 30-35% and this correlates with increased aerobic capacity and is known to be a result of increased uptake of glucose by skeletal muscle and not as a result of reduced liver output of glucose. Glucose disposal refers to the removal of glucose from the circulating blood and into body tissues.

The beneficial effects of insulin sensitivity associated with exercise are lost when exercise is discontinued. The time frame is not entirely clear. There is some evidence indicating that much of the effect is lost after 60 hours while other studies indicate it can last as long as 5 to 7 days. It has even been shown that a single bout of exercise in untrained individuals can increase insulin sensitivity for 2-5 days. So although the effect doesn’t last forever it does last for a while and this can reduce the total insulin requirements and improve overall blood sugar management. The mechanism is not entirely understood but is believed that it may be related to increased capillary density in skeletal muscle, increased oxidative capacity of skeletal muscle and increased skeletal muscle GLUT 4 glucose transporter content. In other words the muscle has more blood vessels, can burn glucose more effectively and has more shuttles to move the glucose out of the blood and into the muscle tissues.

Interestingly enough the research seems to indicate that even though there is improved insulin stimulated glucose uptake as a result of exercise there doesn’t appear to be any improvement in fasting blood glucose levels. There is however, a reduction in the HbA1c indicating that overall blood glucose management is improved as a result of regular exercise. For those of you who may not be familiar with the HbA1c it stands for glycosylated hemoglobin and represents an approximation of the 3 month average of the blood glucose levels weighted more heavily on the more recent levels. It is proposed that the improved HbA1c is the result of frequent episodes of lower blood glucose levels associated with exercise and the after effect of prolonged reduced blood sugars which results in a lowering of the average blood sugar.

For those of you who enjoy weight lifting you’ll be glad to know that a recent study (3) showed a significant reduction in HbA1c as a result of high-intensity resistance training.

A group of 47 type 2 diabetics, men and women, were randomized to either 1. modest weight loss or 2. modest weight loss in conjunction with high-intensity resistance training. The group was 60-80 years of age and used diet and/or medication to manage their diabetes. They were all overweight, sedentary, were not taking insulin and had a HbA1c between 7-10%. All research participants were placed on a healthy eating plan with the intention of a weight loss of 0.25 kg per week. The exercise group attended the gym 3 non-consecutive days per week. Each session included a 5 minute warm-up and cool-down with 45 minutes of high-intensity resistance working both the upper and lower body. Instructors supervised the workouts to ensure proper technique and to assess the workload.

After 6 months both groups had similar changes in terms of weight loss, reduced waist circumference, reduced energy intake, no change in blood lipids, no change in fasting insulin and glucose.

The benefits seen in the training group were a greater reduction in HbA1c, increased strength, a greater reduction in blood pressure and increased lean body mass. Keep in mind this was the result of a high-intensity workout program and perhaps would have yielded even greater improvements had the training group done some other activity on the days between workouts. This type of workout may not be for all individuals as we will discuss shortly in the Risks section and should only be pursued with the approval of your physician or diabetes specialist.

Risks of Exercise

The risks of exercise are listed in table 2. Yes it is a rather large list and for that reason it is highly recommended that you consult your physician and/or diabetes specialist before starting an exercise program. You can even present them with this list if you wish to be sure they are aware and they can tell which risks apply to you. Exercise can increase the risk of having a low blood sugar either during or after the activity. We will discuss this in much greater detail shortly. It is important to mention that individuals with proliferative retinopathy (eye damage) should be cautious with respect to certain exercises which may cause retinal or vitreous hemorrhage. Exercise with the head lower than the rest of the body (eg. sit-ups, certain yoga moves etc) should be avoided as should extremely strenuous exercise or exercise that raises the blood pressure beyond levels recommended by your doctor. Also exercise that results in rapid or jarring head movements should be avoided because of increased risk of hemorrhage or retinal detachment.

Type 2 Diabetes Therapy

If you have peripheral neuropathy be cautious of high-impact exercising and always keep an eye on the condition of your feet. Watch for any blisters or lesions and treat them appropriately. Frequent and generous foot care should be part of the daily routine of anyone with diabetes.

If you have any heart problems be sure to get specific instructions from your doctor regarding maximum heart rate, maximum blood pressure and symptoms to watch for such as extreme breathlessness, chest pain, joint pain etcetera. With an appropriate choice of exercise and a bit of planning most of these complications can be avoided.

A common risk that presents the most immediate concern for many individuals will be hypoglycemia (low blood sugars), either during or after exercising. To better understand this risk we need to understand the approaches to type 2 diabetes therapy. Perhaps a better understanding will eliminate some of the mystery and result in safer and healthier routines before, during and after exercise.

Last issue we categorized type 2 diabetes therapies based on the risk for low blood sugars. I have listed them on the following page as a reminder, and we will now discuss them in more detail in relationship to exercise. Refer to Table 3 for a list of symptoms associated with low and high sugars.

1. This first category representing the lowest risk will include individuals taking any of the following:
   1. No Diabetes Medications
   2. Metformin
   3. Acarbose

   Generally speaking when someone is first diagnosed with type 2 diabetes their physician or diabetes specialist will recommend a period of lifestyle modification (ie. diet and exercise); a minimum 6-8 weeks to see if average blood sugars can be reduced, that is a lowering of the HbA1c. Historically, prior to the discovery of insulin and the development of oral diabetes medications, this was the only way to treat type 2 diabetes. If lifestyle modification fails it will be recommended that some form of medical therapy be introduced. Typically this will be a drug called metformin that acts by reducing sugar output from the liver to help reduce the average blood glucose (BG) levels, especially morning fasting sugars which are often high as a result of an overactive liver during the night.

   A second drug Acarbose may also be used, either alone or in conjunction with metformin. This medication acts by reducing glucose absorption from the small intestine thereby reducing the blood glucose rise associated with food intake. In any of the above circumstances there is no danger of ever having a serious hypoglycemic reaction. In some rare circumstances the BG levels may go as low as 3.5 mmole/litre but the body would certainly respond by turning up sugar production and reducing insulin secretion to avoid a further decline in blood sugars. Therefore, if your therapy falls into this category you should never let a fear of low blood sugars deter you from pursuing physical activities. Also do not use the fear of a low blood sugar as an excuse for bingeing during or after exercise. You may get hungry during and/or after exercise but that is no reason to overreact or take in excessive carbohydrates. Take in healthy balanced nutrition, not just carbohydrates.

2. The natural progression of diabetes is such that BG control may deteriorate over time and another medication is often added, typically an insulin secretagogue. There is a wide range of these currently available but the underlying principal is the same. These drugs stimulate the pancreas to secrete more insulin. This second category of therapy includes the addition of a secretagogue, typically with metformin but sometimes without and poses an additional challenge in terms of BG management. The challenge is that when taking a secretagogue it is possible that the pancreas may produce too much insulin relative to the blood sugar and results in a severe decline in BG for which the liver cannot compensate. In this scenario BGs may go so low that a coma and possibly death can result.
3. Eventually there may be further deterioration of BG control and the addition of another medication called an insulin sensitizer (eg. Avandia) which makes the body more sensitive to the insulin it produces. This class of medications is proving to be an excellent therapy for many type 2 diabetics. In some cases it has been found effective as a first line medication. An insulin sensitizer taken alone poses little risk for a severe hypoglycemic event but if taken in conjunction with an insulin secretagogue, as is often the case, it will increase the possibility of a low BG since the body will now be more responsive to the insulin it produces.
4. Many people with type 2 diabetes eventually require or may even choose insulin injections to help them manage their blood sugars effectively. I say choose because some individuals would rather inject a hormone that would occur naturally in the body than introduce a variety of drugs that the body’s liver must process. Insulin may be taken with or without oral diabetes medications. When taking insulin subcutaneously the risk of having a low blood sugar is increased, especially if it is fast-acting mealtime insulin. Even more so if insulin is taken with an insulin sensitizer such as Avandia.

These represent four therapy categories and if you have type 2 diabetes you will fit into one of them. Review your diabetes therapy and decide which category applies to you. This is meant to provide a guide for knowing what your relative risk is for hypoglycemia, especially during and after exercising, but also for activities such as driving and day to day living. Knowing what your risk level is helps you to take the necessary precautions for safety and also lets you manage your blood sugars effectively. Equally important you can live life to the fullest knowing your blood sugars are safely in range and you are prepared if they should dip into the unsafe range.

You should consider yourself at risk for low blood sugars if you are using either a secretagogue or injecting insulin. If by chance you are at risk for severe hypoglycemia during exercise be aware of what your blood sugar is before you start exercising and take appropriate action if you feel you are at risk of low blood sugars during your activity. Appropriate action may include a snack before the workout or simply having some carbohydrates with you just in case of a low or a severe low. If you have an exercise partner it is wise and considerate to inform them that you’re diabetic and the appropriate action to take if a low BG occurs. Generally speaking you should pay attention to any symptoms of a low BG that you experience and take action early rather than waiting until a mere low BG becomes a severe low BG. Let past experiences be your guide. Do your low blood sugar episodes come on gradually or do they happen rapidly with only a small amount of warning time? Do you manage things better with a solid snack or does a liquid carb source seem to enable you to deal with the crisis better and avoid the overcompensating as often happens after a low blood sugar? Learn from your experiences and let the lessons empower you to manage your blood sugars effectively so you can enjoy exercise and life to the fullest.

Eric Norman is a research scientist investigating heart disease in post-menopausal women and in individuals with type 2 diabetes.

References

1. Exercise in patients with Type 2 Diabetes Mellitus. Horton, E.S.. Chapter 77 in Diabetes Mellitus: A Fundamental and Clinical Text. Second Edition. Editors Derck LeRoith, Simeon I. Taylor, Jerrold M. Olefsky. Lippincott Williams and Wilkins. 2000.
2. Fuel Metabolism, Exercise and Nutritional Needs in Type 1 Diabetes. Franz, M.J.. In Canadian Journal of Diabetes Care 22:4 pp 59-63.
3. High-Intensity Resistance Training Improves Glycemic Control in Older Patients With Type 2 Diabetes. Dunstan, D.W. et. Al.. 2002. Diabetes Care Vol. 25, No. 10. 1729.

The post Exercise and Blood Sugar Management In Type 2 Diabetes appeared first on BC Diabetes Foundation.

ACCORD is a large multicentre clinical trial being funded by the National Heart Lung Blood Institute in the United States. There are approximately 70 centres though out North America and 12 centres in Canada including one in Vancouver. They will be recruiting a total of 10,000 volunteers to take part in this 7 year study of diabetes care including 132 volunteers at the Vancouver site.

The key comparisons in the study are:

1. Standard blood sugar management (HbA1c 7.0-7.9%) vs intensive blood sugar management (HbA1c less than 6.0/)
2. Standard blood pressure control (135-139 mmHg systolic BP) vs intensive management (systolic BP less than 120)
3. Cholesterol: Standard therapy of 20 mg simvistatin vs intensive therapy of 20 mg simvistatin and 200 mg fenofibrate.

The post ACCORD Study appeared first on BC Diabetes Foundation.

For starters you’ll find the second half of the type 2 diabetes and exercise article begun last issue. Be sure to discuss this one with your doctor if you are planning on introducing any new and intensive activities into your daily routine.

Cheryl Wertman has returned with Wishin’ for Nutrition and provides us with a couple of recipes to combine for a healthy meal.

A new research study has started called Action to Control Cardiovascular Risk in Diabetes. Take the time to read the available information and perhaps you or someone you know may be eligible for the study.

Next issue you can look forward to a commentary on controversial contraception which extends the length of the menstrual cycle for as long as three months.

Bye for now.

The post From the Editor appeared first on BC Diabetes Foundation.

It is often said that you either have type 2 diabetes or you don’t. Your physician may tell you that you can’t have just a touch of diabetes or be a little bit diabetic. Why is this? The main reason is that there is a definition of diabetes based on several strict criteria and you either meet the criteria or you don’t. The criteria are as follows:

1. Fasting blood sugar > 6.9 millimoles/litre (mmol/l)
   Individuals are asked to refrain from eating for 12 hours prior to going to the lab to have a blood sample drawn and the sugar concentration of blood plasma determined. A normal fasting blood sugar is < 6.0 mmol/l.

   or

2. Fasting blood sugar between 6.1 and 6.9 mmol/l and a 2 hour post-glucose load blood sugar >11.0.
   The Oral Glucose Tolerance Test (OGTT) is used to determine the latter criteria by having individuals consume a drink containing 75 grams of pure glucose and then measure the blood plasma glucose concentration 2 hours later.

Health care professionals use these diagnostic criteria in order to make decisions regarding patient care. If diagnosed as diabetic you will be referred to a doctor who specializes in diabetes care and possibly sent for education and counseling at a diabetes clinic.

What if you almost meet the criteria?

Individuals who have a fasting blood sugar between 6.1 and 6.9 mmol/l but who have OGTT values between 7.8 and 11.0 mmol/l are referred to as having Impaired Glucose Tolerance. They are not defined as diabetic but it is estimated they have a 5% annual probability and a 35% lifetime probability of becoming diabetic. They are walking around with blood sugars higher than normal much of the time and this can affect their health. Many of these individuals are on the road to becoming diabetic.

A second group that almost meets the criteria are those who have a fasting blood sugar between 6.1 and 6.9 mmol/l but their OGTT result comes back < 7.8 mmol/l (normal). These individuals are referred to as having Impaired Fasting Glucose (or Impaired Glucose Homeostasis). Although the probability of these individuals becoming diabetic may not be as high as the Impaired Glucose Tolerant group it is usually a warning sign.

From a diagnostic perspective you either have diabetes or you don’t based on these criteria.

From a physiological perspective there is a gradient from the normal individuals where glucose is well controlled to the type 2 diabetic where glucose levels are out of control. The nature of the disease is such that you don’t go from one end of the gradient to the other overnight. It is a gradual process as the body becomes more resistant to insulin and the pancreas is unable to provide adequate amounts of insulin to overcome the resistance. The liver can also play a role producing excessive amounts of glucose resulting in elevated blood glucose levels.

How prevalent is undiagnosed diabetes and glucose intolerance?

In 1998 a group of researchers asked this very question with regards to the Canadian population¹. They designed a program to have family physicians screen their patients (over 40 years of age) for diabetes. The physicians were randomly selected to ensure accurate representation of the Canadian population, balancing proportions between provinces as well as between rural and urban settings and between men and women. They enrolled 9,042 patients in this study.

What did they find?

They found that 2.2% of the group they screened had diabetes and didn’t know it. Another 3.5% of the group screened had either Impaired Glucose Tolerance (0.6%), Impaired Fasting Glucose (2.5%) or were probably diabetic (0.4%, based on incomplete information). These numbers are close to a previous estimate² that 3-5% of Canadians are walking around with undiagnosed type 2 diabetes. Hyperglycemia (high blood sugars) associated with type 2 diabetes develops gradually and type 2 diabetes is often only recognized 5-12 years after hyperglycemia develops³. Prior to a type 2 diabetes diagnosis, prolonged hyperglycemia may have already caused some damage to target tissues⁴ (heart, eyes, kidneys, nerves). This can occur in the absence of the classic symptoms of diabetes (see the list below). This is why early detection is critical and why screening programs for diabetes are rapidly expanding.

Equally important is the early detection of impaired glucose tolerance and impaired fasting glucose. Detecting these warning signals can permit early intervention and halt the damage caused by persistent hyperglycemia. Typically these physiological states are warning signs that your diet and exercise habits aren’t suited to your genetic make-up. They may be suited to your friend Fred down the street who eats and does exactly what you do and yet stays slim and trim; but you aren’t Fred. Genetics plays a huge role in determining our susceptibility to type 2 diabetes and the stages preceding it. The accumulating evidence suggests that there are as many as ten or more genes that may play a role in the onset of type 2 diabetes. If you are diagnosed with type 2 diabetes or any of the stages preceding it you will have to learn to modify your lifestyle in order keep your genes happy.

Is type 2 diabetes preventable?

In most cases type 2 diabetes is a preventable disease. It has been said that type 2 diabetes is the result of a “clash between genes and the environment”.⁵ Since we can’t change our genes, not at this point in time anyway, we need to change the environment, more specifically our diet and exercise habits. But does it really work? A Finnish research group decided to try to answer that question.⁶

The Research Study. They recruited 522 middle-aged, overweight subjects with impaired glucose tolerance. This population was chosen because they have a greater probability of developing diabetes making it possible to show significant effects of the study intervention in a relatively small study population in just a few years.

Volunteers with impaired glucose tolerance were randomized to either a control group or an intervention group. The control group was given general oral and written information about diet and exercise at the start of the study and at each annual visit thereafter. There were no individualized programs offered to the control group.

The Intervention. The intervention group was more intensive. They were given detailed advice about how to achieve the goals of the intervention; the goals being 1. a reduction in weight of 5% or more 2. total intake of fat less than 30% of energy consumed 3. saturated fat less than 10% of energy consumed 4. increased fibre and 5. thirty minutes of exercise a day. Nutritional advice was tailored to each subject based on food records. Volunteers in this group had 7 sessions with a nutritionist during the first year and every three months thereafter. These volunteers also received information on increasing their level of physical activity including both endurance training and strength training.

Did it make a difference?

At baseline the characteristics of both groups were identical in all respects. They observed that during the trial (mean follow-up of 3.2 years) the cumulative incidence of diabetes was 58% lower in the intervention group (63% for men and 54% for women) compared to the control. But this is conservative since not all those in the intervention group adhered to their recommendations, and for ethical reasons, the control group also received some guidance.

In the assessment they went one step further and looked at how successful the individuals were in achieving the goals of the intervention. This adherence was assessed for all 5 recommendations listed earlier. In those individuals who achieved 4 or 5 of the goals there was no one who developed diabetes after a mean of 3.2 years follow-up. Alternatively, when none of the goals were achieved, diabetes appeared in 38% and 31% of the intervention and control group, respectively. The message here being you can join as many gyms as you want and see a dietician regularly but unless you are willing to actually make the changes it is not going to help you. It is important to remember that a weight loss of as little as 5% can make a huge difference in the incidence of diabetes. In other words, the changes don’t have to be overwhelming. Setting reasonable goals and taking small steps in the right direction can pay off.

A publication last year by the Diabetes Prevention Program Research Group⁷ recruited a similar population of glucose intolerant individuals (3234 non-diabetic persons) and implemented a lifestyle intervention similar to that of the Finnish study. They had goals of 7% weight loss and 150 minutes/week of physical activity along with a reduction in fat intake and total caloric intake. In this large group they found a similar 58% reduction of the incidence of diabetes compared to their control group. This effect occurred in all subgroups of men and women of all ages from all racial and ethnic groups. The interventions work!

Medications

The above mentioned study also had a medication arm that involved taking 850 mg of metformin twice daily. Metformin is a diabetes medication that reduces the production of glucose by the liver and is effective in that it effectively reduces fasting blood glucose. In the research study metformin was found to reduce the progression to diabtes by 31 percent relative to the controls. While not as effective as a lifestyle intervention, it was significant. There are now several large research studies underway recruiting a similar glucose intolerant population and treating them with other diabetes medications. Some of these medications stimulate insulin release from the pancreas while others increase insulin sensitivity. The results of these studies are not yet available but should prove interesting. In the meantime we already know what works and it doesn’t require a prescription. Lifestyle changes!

Screening is important? Before getting screened you should consider risk factors for type 2 diabetes. Some risk factors to consider are:

1. Greater than 40 years of age
2. Central obesity
3. Has a parent sibling or child with diabetes
4. High risk ethnicity (Hispanic, aboriginal Canadian, Asian, African-Canadian, Pacific Islander)
5. Had gestational diabetes
6. Has given birth to a baby weighing more than 10 pounds.

If the results of your test indicate you are glucose intolerant based on any of the criteria you should take action early on.

Why wait? You can get started right now of course without even going to your physician or a clinic and it won’t cost you or the health care system a penny. Put on your shoes and go for a walk. Consider what you now know to be some steps of a diabetes prevention program as outlined in the research study I discussed. Think of how you can incorporate some or all of these recommendations into your life.

Why should I bother if I’m not at risk for acquiring diabetes? The interventions used in this study to prevent diabetes are excellent recommendations for everyone. They are fundamentals of what we know to be a health promoting lifestyle. They can make you feel better, sleep better, have more energy and prevent or delay other health problems such as heart disease and osteoporosis. This is true whether or not you have any form of glucose intolerance.

In summary the recommended changes in lifestyle should include changes in diet and exercise. More specifically I would recommend the following goals.

Dietary goals: Aim for a total fat intake of less than 30% of total energy consumed and reduce saturated fat to 10% or less. You may also want to reduce your cholesterol intake as well. Boosting your fibre intake to greater than 15 grams/1000 calories is a good idea. If you smoke then stop as soon as possible. Learn as much as you can about nutrition and incorporate that information into the fabric of your life.

Exercise goals: Strive to improve cardiovascular fitness. Brisk walks, cycling, swimming, running. It doesn’t have to be one big workout. Research has shown that you still benefit from a small number of shorter activities during a day. For example, two or three 15-20 minute walks during the day if you don’t feel you have time for one big 45 minute walk. Whatever works for you. Be sure to consult your physician if you have any doubts about whether you should engage in a fitness activity.

Strength training should also be considered given our current understanding of glucose disposal and muscle mass. It is also excellent for your bones. Be sure to consult an instructor if you are using weights for the first time and start slowly, gradually increasing your intensity as your strength increases and your body becomes accustomed to the activity. The combination of cardiovascular fitness activities and weight training should equal about 4 hours per week.

Eric Norman is a research scientist investigating heart disease in post-menopausal women and in individuals with type 2 diabetes.

References

1. Diabetes Screening in Canada (DIASCAN) Study. Leiter et al., June 2001. Volume 24 Number 6. Diabetes Care.
2. Tan H and DR Maclean. 1995.Epidemiology of diabetes mellitus in Canada. Clin Invest Med.. Volume 18:240-246.
3. Muggeo, M. 1998. Accelerated complications in type 2 diabetes mellitus: the need for greater awareness and earlier detection. Diabet Med 15 (Suppl. 4): S60-S62.
4. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus:Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. 2000. Diabetes Care Volume 23 (suppl 1):S4-S19.
5. Bloomgarden, Z.T. 2000.European Association for the Study of Diabetes Annual Meeting. Diabetes Care Vol 24, No 6. June. 1115-1119.
6. Tuomilehto et al., May 3, 2001. Prevention Of Type 2 Diabetes Mellitus By Changes In Lifestyle Among Subjects With Impaired Glucose Tolerance. Volume 344 Number 18. New England Journal of Medicine.
7. Diabetes Prevention Program Research Group. Feb 7, 2002. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Volume 346 Number 6. New England Journal of Medicine.

The post Preventing Type 2 Diabetes appeared first on BC Diabetes Foundation.

A Two-fold Benefit: By reducing the carbs in your snack you lower the total carb content (hence blood sugar rise) and the fat in the nuts reduces the glycemic index of the total snack since it slows the digestion of the carbs.

The post Nuts About Nutrition appeared first on BC Diabetes Foundation.

Let this video help you and your family better understand type 2 diabetes so you can live a long healthy life!

This 55 minute video takes you through the basics of type 2 diabetes symptoms, diagnosis and treatment. Specialists in diabetes care present the facts to enable you to better understand type 2 diabetes and to provide friendly encouragement to help you “Live Well With Diabetes”. Lifestyle modifications, medications and insulin are clearly explained as are the long-term complications associated with diabetes.

You can obtain the video order form through this website or contact our office at:

380-575 West 8th Ave.
Vancouver B.C.
V5Z 1C6

phone: (604) 875-5922
fax: (604) 875-5931

The post “Live Well With Diabetes” appeared first on BC Diabetes Foundation.

Type 2 diabetes is typically the result of the following breakdowns in glucose regulation :

• increased insulin resistance in the body tissues
• decreased insulin output by the pancreas
• excessive glucose output by the liver.

Typically these breakdowns occur gradually over the course of years. It is worth noting that this is different from type 1 diabetes where the primary problem is the almost complete absence of insulin production by the pancreas with the breakdown being immediately apparent as symptoms can be life threatening. The treatment for type 1 diabetes is relatively simple and the choices few; insulin. In some way some type of insulin will be delivered into the body as treatment. It may be a pen, a syringe, a pump or eventually inhaled but the same principal applies; the provision of insulin that the body’s pancreas no longer makes. With type 2 diabetes the options are varied and will likely change over time as the disease progresses. Insulin resistance, insulin production and excessive liver glucose production will all change over time and require adjustments in therapy. I emphasize this point since, as you will read later, the nature of the diabetes therapy will determine the degree of risk of low blood sugars and the necessary precautions to take before exercising.

Benefits Of Exercise

There are numerous benefits of a regular exercise program and they are listed in Table 1. I will highlight a few of my favorites here. One of the immediate benefits, besides having fun and feeling good, is the reduction in blood sugar. In addition there is the potential for improved cardiovascular fitness. I think one of the greatest benefits, however, is the potential to reverse the underlying mechanism of insulin resistance that can lead to diabetes in the first place. Exercise tends to reduce this resistance and increase insulin sensitivity enabling the body to regulate blood glucose (BG) levels more effectively.

Risks of Exercise

The risks of exercise are listed in table 2. Yes it is a rather large list and for that reason it is highly recommended that you consult your physician and/or diabetes specialist before starting an exercise program. You can even present them with this list if you wish to be sure they are aware and can tell which risks apply to you. The most immediate risk for the majority of individuals will be hypoglycemia (low blood sugars), either during or after exercising. To better understand this risk we need to understand the approaches to type 2 diabetes therapy.

Type 2 Diabetes Therapy

Let’s categorize type 2 diabetes therapies since these have a bearing on the potential for low blood sugars and therefore exercise and safety considerations. I will present them in order of increasing risk of low blood sugars.

1. This first category representing the lowest risk will include individuals taking any of the following:
   1. No Diabetes Medications
   2. Metformin
   3. Acarbose

   Generally speaking when someone is first diagnosed with type 2 diabetes their physician or diabetes specialist will recommend a period of lifestyle modification (ie. diet and exercise); a minimum 6-8 weeks to see if average blood sugars can be reduced. Historically, prior to the discovery of insulin and the development of oral diabetes medications, this was the only way to treat type 2 diabetes. If lifestyle modification fails it will be recommended that some form of medical therapy be introduced. Typically this will be a drug called metformin that acts by reducing sugar output from the liver to help reduce the average blood glucose (BG) levels, especially morning fasting sugars which are often high as a result of an overactive liver. A second drug Acarbose may also be used, either alone or in conjunction with metformin. This medication acts by reducing glucose absorption from the small intestine thereby reducing the BG rise associated with food intake. In any of the above four circumstances there is virtually no danger of ever having a serious hypoglycemic reaction. In some circumstances the BG levels may go as low as 3.5 mmole/litre but the body would certainly respond by turning up sugar production and reducing insulin production to avoid a further decline in blood sugars.

2. The natural progression of diabetes is such that BG control may eventually deteriorate over time and another medication is often added, typically an insulin secretagogue. There is a wide range of these currently available but the underlying principal is the same, stimulation of the pancreas to produce more insulin. This second category includes the addition of a secretagogue, typically with metformin but sometimes without and poses an additional challenge in terms of BG management. The challenge is that when taking a secretagogue it is possible that the pancreas may produce too much insulin and result in a severe decline in BG for which the liver cannot compensate. In this scenario BGs may go so low that a coma and possibly death can result.
3. Eventually there may be further deterioration of BG control and the addition of another medication called an insulin sensitizer (eg. Avandia) which makes the body more sensitive to the insulin it produces. This class of medications is proving to be an excellent therapy for many type 2 diabetics. An insulin sensitizer taken alone poses little risk for a severe hypoglycemic event but if taken in conjunction with an insulin secretagogue, as is often the case, it will increase the possibility of a low BG since the body will now be more responsive to the insulin it produces.
4. Many people with type 2 diabetes eventually require or may even choose insulin injections to help them manage their blood sugars effectively. I say choose because some individuals would rather inject a hormone that would occur naturally in the body than introduce a variety of drugs that the body’s liver must process. Insulin may be taken with or without oral diabetes medications. When taking insulin subcutaneously the risk of having a low blood sugar is increased. Even more so if insulin is taken with an insulin sensitizer such as Avandia.

These represent four therapy categories and if you have type 2 diabetes you will fit into one of them. Review your diabetes therapy and decide which category applies to you. This is meant to provide a guide for knowing what your relative risk is for hypoglycemia, especially during and after exercising, but also for activities such as driving and day to day living. Knowing what your risk level is helps you to take the necessary precautions for safety and also lets you manage your blood sugars effectively.

In the next issue we will continue this article and discuss the specifics of what you can do to optimize safety and blood sugar control depending on your diabetes therapy.

Eric Norman is a research scientist investigating heart disease in post-menopausal women and in individuals with type 2 diabetes.

References

1. Exercise in patients with Type 2 Diabetes Mellitus. Horton, E.S.. Chapter 77 in Diabetes Mellitus: A Fundamental and Clinical Text. Second Edition. Editors Derck LeRoith, Simeon I. Taylor, Jerrold M. Olefsky. Lippincott Williams and Wilkins. 2000.
2. Fuel Metabolism, Exercise and Nutritional Needs in Type 1 Diabetes. Franz, M.J.. In Canadian Journal of Diabetes Care 22:4 pp 59-63.

The post Exercise and Blood Sugar Management In Type 2 Diabetes appeared first on BC Diabetes Foundation.

The second in a two part series on exercise and diabetes appears in this issue. This article provides some of the basic information which will help people with type 2 diabetes make decisions regarding how to incorporate exercise into their lives.

You may have already noticed the large ad opposite regarding the new diabetes education video, “Live Well With Diabetes”. Please contact the foundation office if you are interested in obtaining a copy. Alternatively you can call your local library and ask them to order a copy from us. Either way we really need to get the message out. People with diabetes must take responsibility for their health and being informed is a good start.

Bye for now.

The post From the Editor appeared first on BC Diabetes Foundation.

A Brief History

Did you ever wonder how type 1 diabetes was managed prior to the discovery of insulin? It turns out that diet and exercise were the main therapies although exercise was difficult because of the associated metabolic abnormalities. Once insulin therapy became available it was easier for type 1 diabetics to exercise but still blood sugar management was challenging since 1. acute or delayed hypoglycemia was common and 2. post-exercise hyperglycemia and ketosis could also occur. Keep in mind this was all prior to the home blood glucose (BG) monitoring devices that we take for granted today. Back then healthy active individuals with type 1 diabetes were often not permitted to participate in various sports because of the concerns regarding unknown blood glucose levels in conjunction with intermittent activities of varying intensity and duration. With the advent of simple portable BG monitoring and increased understanding of neural and endocrine factors regulating metabolism during exercise it is much safer but still challenging for individuals with type 1 diabetes to exercise.

At present many people with type 1 diabetes are achieving the same level of conditioning and success as non-diabetics, many becoming world class athletes. However, in the general population, type 1 diabetics are on average less fit and have lower aerobic capacity than their non-diabetic peers. Research to date suggests that type 1 diabetics respond normally to physical training and thus the primary obstacle is likely the manner in which type 1 diabetics are educated/encouraged with respect to the benefits and the safety of exercising. There are of course risks as well which need to be considered. When the risks and benefits are weighed, and these will vary for everyone, it is essential to keep in mind the reasons for exercising. They should be for the fun and the fitness primarily. In terms of blood sugar management for the type 1 diabetic, the research to date does not show a significant benefit of exercise and it can actually make blood glucose management poorer and certainly more challenging.

Benefits Of Exercise

Regular exercise has many benefits to health and these are listed in Table 1. These benefits hold true for everyone, not just type 1 diabetics. Most of these are self-explanatory but a few points are worth adding. Since people with diabetes are at higher risk for premature cardiovascular disease, retinopathy, neuropathy and nephropathy it may be particularly worthwhile to pursue some form of physical activity as a part of day to day living. There are also the psychological benefits including a better quality of life and improved self-esteem. This is especially important for someone who is faced with the challenges and restrictions of living with a chronic disease.

Although exercise does lower blood sugars, at least temporarily, overall blood glucose control may not be improved. Some studies have failed to show any benefits while others have shown modest benefits. Post-exercise hyperglycemia as well as additional caloric intake during or following exercise could be two reasons why benefits may not appear. Those are the averages however and individuals who are meticulous about food intake, BG monitoring, and insulin adjustments before, during and after exercise may be able to improve their overall BG management. However for the majority of individuals Edward Horton said it very nicely:

Risks of Exercise

There are several risks associated with exercise as noted in Table 2. These have to be weighed against the benefits when deciding on whether an exercise program is appropriate and if so what type of program. Especially in adults and in particular when long-term complications of diabetes have begun to appear it is essential that these are properly assessed and appropriate precautions taken when planning an exercise program. Review the list in Table 2 and determine which warnings may apply to you. Ask your own doctor or diabetes specialist if you have any uncertainties about your status with respect to these risks. Although the list is long do not let that discourage you from initiating some type of an exercise program, however modest it may be.

Energy Production in Our Bodies

First let’s consider the fuels available for energy production and how they are regulated. The three possible fuels are carbohydrate (glucose), fat (fatty acids) and protein (amino acids). Since amino acids only make up 1-2% of our energy requirements in muscle tissue, whether at rest or exercising, we will not discuss them in any detail. With respect to glucose and fat use as a fuel, they will vary depending on the energy demands, whether at rest or exercising, exercise intensity and duration, the level of physical training, overall diet and of course meals taken before and/or during exercise which affect substrate availability.

At Rest In the body at rest in the fasting state the glucose concentration is kept relatively constant by the balance between 1. glucose utilization in all tissues and cells and 2. hepatic (liver) glucose production. In terms of a body budget for glucose utilization, approximately 50% is used by the brain, 30-35% by other tissues (blood cells, liver, kidneys, gonads etc) and only 15 to 20% by muscle tissues. In terms of potential energy sources (figure 1) you can see that metabolic fuels are made available by 1. breakdown of glycogen and triglycerides in the muscles 2. fatty acids released from adipose tissue (fat) and 3. glucose release from glycogen stores in the liver. The latter two are released into the blood circulation and delivered to where they may be needed, especially muscle during exercise.

If we consider just the muscles in the fasting state at rest only about 10% of the energy generated in skeletal muscle comes from glucose. That means that 85-90% is derived from the oxidation of fatty acids. This is an interesting fact and is often overlooked when discussing diet, weight loss and various forms of exercise. We tend to think only of glucose when we think of energy and foods while the potential energy reserves in fat tissue are not considered or even discussed. In terms of type 1 diabetes and exercise the reasons for this are the dangers of allowing the blood sugars to go too low (hypoglycemia) and hence the focus on blood glucose levels. In addition in type 1 diabetes there is also the inability of the bodies glucose/fat metabolism regulation to respond to the demands. The scenario for type 2 diabetics is different and will be addressed next issue.

During exercise. During exercise a number of cardiovascular, hormonal and neural responses occur in concert to ensure efficient delivery of fuels and oxygen to muscle tissue and removal of end products. The onset of exercise results in a rapid increase in glucose utilization but not as much as you might think. At 50% of our VO2 max (for most individuals this represents a brisk walk or what is called moderate intensity) our muscles are using about 50% fat and 50% glucose. Now you can see why walking, especially a moderate to brisk pace, is such a highly recommended form of exercise. It strikes a wonderful balance in terms of physical safety, cardiovascular fitness, burning fat and lowering blood sugars. And you can talk as much as you like while you’re doing it.

As the intensity of exercise increases to 70-75% of VO2 max carbohydrate becomes the main metabolic muscle fuel. This intensity of exercise is comparable to a moderate to brisk jog depending on your level of fitness. As the intensity increases to 100% VO2 max nearly all energy is derived from carbohydrate oxidation with a very small (1-2%) being derived from fats and amino acids. Typically the muscles use up their glycogen stores first and then start to draw on circulating blood sugars. Blood sugars are replenished by glucose production from liver glycogen breakdown and liver gluconeogenesis (glucose synthesis) and as a result the blood sugars are kept relatively constant (refer to figure 1). At a moderate intensity these proportions of energy utilization are reliable estimates. After 2-3 hours, however, the glycogen stores can become depleted and there is a shift back towards a higher proportion of fatty acids for muscle energy.

Highly trained individuals perform the same work at a lower VO2 max than less conditioned individuals and as a result utilize less carbohydrate and more free fatty acids. Even if the conditioned individual performs at the same VO2 max they will consume less carbohydrate and a greater percentage of FFA. This means that their muscle and glycogen stores will be depleted less rapidly, they’ll have greater endurance and burn more fat in the process.

Following exercise the body must replenish both muscle glycogen stores and liver glycogen stores. Therefore, even after exercise, the muscles continue to take up glucose and in this case convert it into glycogen. This will happen very slowly in the absence of food and more quickly with carbohydrate intake; normal glycogen levels being established within 12 to 24 hours. Muscle glycogen replenishment occurs more rapidly than liver glycogen replacement. This post-exercise demand for glucose is the cause of post-exercise hypoglycemia. The best solution is frequent BG testing and appropriate food intake. Some will recommend BG testing at 1-2 hour intervals following exercise in order to determine how your body responds to exercise. Accurate records of this information allows you to make the appropriate adjustments. A key piece of advice is to always err on the side of caution. That means taking in additional carbohydrate or reducing insulin and accepting a BG reading higher than target rather than going low. This is especially true for post-exercise in the evening and bedtime when a low BG can be more than just an inconvenience but can actually be lethal. Be particularly cautious if you are just beginning an exercise program or exercise irregularly since BG values and your body’s response are even more difficult to predict.

Regulation of all these metabolic processes during and after exercise is highly integrated and beyond the scope of this article. Even though we will focus primarily on insulin many hormones are involved and ensure that fluid and electrolyte balance is maintained in addition to fuel balance.

The Role of Insulin. As mentioned earlier hormones play a major role in the regulation of these metabolic processes. Insulin in particular has several roles. First of all, in the non-diabetic insulin secretion is actually suppressed during exercise thus reducing the amount of glucose uptake by non-exercising tissue. Secondly, since insulin suppresses liver output of glucose and inhibits lipolysis in fat tissue, falling insulin levels result in an increase in both liver glucose production and release of fatty acids into the circulation providing more energy for working muscles. Since little or no insulin is needed in exercising muscle a lower plasma insulin level does not adversely affect glucose utilization while exercising. A note of interest here is that there are glucose transporters in muscle tissue that do not require insulin which are activated during exercise. This partially explains the ability to exercise with reduced levels of circulating insulin.

The implications of this are immense in terms of exercise and type 1 diabetes. First of all, in type 1 diabetes this critical regulatory hormone is essentially absent yet is provided artificially by insulin injection. Hence decisions made regarding insulin injections associated with exercise must be done carefully. For example taking a normal dose of insulin just prior to exercising maintains suppression of liver glucose, inhibits fat tissue breakdown and would further increase glucose uptake in tissue that would normally reduce glucose uptake during exercise (i.e. Non-exercising tissue). All of these could contribute to a hypoglycemic condition and are counterproductive to successful exercising. The situation is further complicated by the fact that exercise will increase circulation and thereby increase the delivery of insulin to the peripheral tissues. This is most likely to occur if insulin is injected shortly before exercising and even more so if injected in a part of the body that is being exercised. Hence some degree of insulin reduction prior to exercise is always recommended.

How much should insulin be adjusted? There is no one correct answer since everyone is different and exercise goals also differ. What is provided here are guidelines that you can incorporate according to your fitness level and exercise intensity and duration. You should also document important information such as insulin dose, time and site of injection, time of day, prior food intake, exercise duration and intensity and pre and post-exercise blood glucose levels. This information can be used to learn and make adjustments where possible before, during and after exercise to safely maximize your performance and optimize your blood glucose control.

Some Guidelines As a rule, if blood glucose levels are below 5.6 mmoles/L then exercise should not be undertaken without first ingesting some carbohydrate. You should then make a record of the amount of carbohydrate and use the information for future adjustments of either food intake or insulin under similar conditions. An additional consideration is the rate of change in your BG. For example if a BG value of 9.7 is followed by a BG value of 6.3 one hour later just prior to exercise then you should recognize that your BG is rapidly dropping and the 5.6 rule does not apply. Take food before you exercise!

General Rules:

• Reduce your usual insulin dose
• Inject somewhere away from the exercising tissue if possible
• Inject mealtime insulin at least 2 hours prior to exercise
• If blood glucose is less than 5.6 mmoles/L supplemental feedings should be taken before and during exercise
• Take in carbohydrate during exercise if exercise is vigorous and of long duration (ie. Greater than 1 hour)
• Test blood sugars before, during and after exercise if needed and take in food when indicated to avoid low blood sugars
• Be sure to also take in adequate fluids while exercising
• Keep in mind that your blood glucose response will vary depending on the type, intensity and duration of exercise.
• Do your best to plan ahead if you know you will be exercising and incorpaorate as many of these suggestions as possible.

The timing of your injection as well as the type of insulin are factors to consider. It is safer to exercise immediately after eating when regular insulin has been injected since the insulin has a slower time of action. Fast-acting mealtime insulin has a faster and more intense onset of action. For this reason you should consider waiting at least 2 hours after eating before doing any exercise.

In terms of the insulin dose reduction, a short-acting mealtime injection can be decreased by approximately 30-50%. For the longer acting insulins, either individually or pre-mixed, you have to plan further in advance. For example you may want to reduce your morning injection of long-acting insulin if you plan to exercise that evening. During that day you may also consider moderating your food intake to accommodate the reduced insulin and still maintain reasonable BG control. You will have to determine what works best for you based on your pre and post-exercise blood sugar values.

The time of day is also critical. Studies have shown that the risk of hypoglycemia is reduced when exercise is done in the morning before the pre-breakfast insulin dose. This is because insulin levels are lowest at this time. In contrast, late afternoon or evening exercise can be trickier since insulin levels can vary depending on when lunch and/or dinner were eaten. Worse yet, since the post-exercise blood glucose lowering effects can last for 12 to 24 hours the risk of nocturnal hypoglycemic events is increased. This doesn’t mean you shouldn’t exercise in the afternoon or evening. Simply be aware of additional challenges associated with BG management and take precautions; frequent BG tests and snacks if needed.

Type of Carbohydrate. Carbohydrate in either a solid or liquid form work equally well. The liquid form has the advantage of providing fluid that is essential for optimum performance and recovery. You may also find the liquid form easier to digest especially if consumed while exercising. Depending on the nature of the exercise you may have to consume carbohydrate before, during and after. The type of carbohydrate can be chosen depending on the desired effect. For example, if you are trying to address a blood sugar you know is low and dropping you want a fast-acting carbohydrate. In this case you should choose a carbohydrate with a high glycemic index such as fruit juice,fruit, granola bar etc. There are energy drinks designed especially for this and in most cases you can safely dilute these sport beverages in half. As a reminder, glycemic index refers to the rate at a which a consumed carbohydrate appears as glucose in your blood (Quarterly Newsletter Vol.2 No.3). There are also tables listing the glycemic index for a wide variety of foods. For a meal prior to exercise that you know will be of long duration (e.g. a 2-3 hour hike or bicycle ride) you should consume a balanced meal with a relatively low glycemic index. This meal will continue to deliver glucose to your circulation over a prolonged period of time buffering the blood glucose lowering effect of exercise. Be sure your diet is balanced and nutritionally sound in order to optimize your performance and your recovery.

Post-Exercise Hyperglycemia

This is a common occurrence and is believed to result from the continued output of glucose from the liver and the absence of insulin. If you find this is an issue for you some people have success with a small (i.e. 2-4 units) post-exercise insulin injection, which can signal suppression of liver glucose production and enhance removal of glucose from the blood. Always test your BG and take appropriate action.

Conclusion

Everyone is different and will respond in a different way to food and exercise. Take this information and these suggestions and see what works for you. Always consider your safety first and be sure to enjoy whatever exercise activities you choose.

Eric Norman is a research scientist investigating diabetes and heart disease.

References

1. Exercise For the Patient With Type 1 Diabetes Mellitus. Horton, E.S. Chapter 46 in Diabetes Mellitus: A Fundamental and Clinical Text. Second Edition. Editors Derck LeRoith, Simeon I. Taylor, Jerrold M. Olefsky. Lippincott Williams and Wilkins. 2000.
2. Fuel Metabolism, Exercise and Nutritional Needs in Type 1 Diabetes. Franz, M.J… In Canadian Journal of Diabetes Care 22:4 pp 59-63.
3. Dietary Carbohydrate in the Management of Diabetes: Importance of Source and Amount. Woelver, T.M.S. In Endocrinology Rounds, St. Michael’s Hospital, U. of Toronto. May, 2002.

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