The problem with "diabesity."

Hey Dad,

Things continue to be busy with working on my dissertation, but the good news is I'm learning things that I can pass along.

Even health care providers and researchers
don't take the stairs.

A few weeks ago, I was at the American Diabetes Association scientific meetings in Chicago. This is the big annual event where researchers, industry, doctors and other clinicians all get together to learn about and discuss the latest and greatest in diabetes care, prevention, and treatment research--and you'd be amazed at the breadth of the stuff they're doing.

Something I heard a lot when I first started doing diabetes research was "diabesity."  The way that people said it just bothered me because it seemed like they were dismissing the seriousness of diabetes because a person was also obese and they were clearly less sympathetic, calling it a "lifestyle disease."  So I looked into it and found that the way most folks are using it comes from Francine R. Kaufman's book, which you can take a peek at here.  Originally, though, “diabesity” was a diagnostic category for type 2 diabetes that was directly caused by obesity in laboratory studies of animals (see this and this if you're curious).  The way it is used now is much more generic, a shorthand for talking about fat people who have diabetes or prediabetes--and it doesn't matter which came first.


The more I learn about diabetes and the more scientists I get to hear talk about this issue, the more I'm convinced that there's some underlying metabolic disorder that causes both diabetes and obesity independently of each other.  This explains why weight loss helps both issues, but is not enough to cure either.  The problem with "diabesity" is that there's a lot of cultural stigma in our society around obesity and to lump the problems together into a single word oversimplifies the causes of diabetes.  We tend to blame fat people for all of their health problems and they are treated poorly as a result.

Blaming obesity for type 2 diabetes hides the fact that it is possible for diabetes to be a cause of obesity (not the other way around) and that weight loss alone does not actually cure diabetes. If the issue were as simple as balancing energy consumed with the energy expended (“don’t eat more than you’ll burn off with activity”), then reducing carbohydrates would cure both diabetes and obesity.

In a recent TED Talk, Dr. Peter Attia did an excellent job of laying this out and describing how his belief that type 2 diabetes was the patient's fault affected the care he gave a patient and how his own experience with metabolic syndrome changed the way he sees diabetes.  Please watch this.

I wish every doctor who ever wrote off my bigger health problems because I was fat could have this awakening so that they would know how they hurt people and they wouldn't keep doing it.

Many people with diabetes are able to live with high blood sugars for their entire lives without complications and no matter what medications and lifestyle changes are made, they never achieve an A1C below 7.5.  There are others who have known genetic mutations within their families that create a condition that looks a lot like type 1 diabetes, but doesn't respond to conventional treatments.  There aren't any conclusions just yet and there aren't any changes being made to the way that diabetes care happens (like new tests and treatment plans), but I was glad to know that the research is happening.

Language matters in how we understand the world and how we relate to each other. I hope that as people who do diabetes care learn just how much they don't know, their language will change. Diabesity is inaccurate and it hurts people.  It is great for marketing and media soudbytes, but it is not a human diagnostic category.

So when it comes to weight loss, diet, exercise, and controlling type 2 diabetes, here's the jist of what I learned at ADA:

"We don't really understand the relationships just yet, but we're working on it.  

In the mean time, please eat some salad because it can't hurt."

I'm glad you're doing so great with weight loss and managing your blood sugar, but if that stops working so well, I want you to know you're not the only one.  It's so frustrating that the one behavior that is pushed over and over again for managing diabetes is not always under your control. I'm looking forward to when the scientists figure it out and they come up with new ways to treat it. For now, though, keep eating what you've been eating since it's working for you.  Also, never take that kind of abuse from a health care provider.  Just because you're overweight doesn't give anybody the right to bully you about it, least of all the people you trust with your health care.

Love,

Mel

Sad news and a plea.

Hey Dad,

I am sorry it's taken me a while to write.  The last thing I wrote about was trying to find public diabetes education and information events.  I did attend the Chicago ADA Diabetes Expo and collected some samples for you and got to talk to folks who do different community-based work, but I've not felt much like writing about it.  You see, just a few hours after I got home from that event, my family got the call that another one of our dads was dying and that we needed to get down to Missouri immediately.  So we packed up the car and arrived in time to sit vigil with even more family for L's last hours.  We were only home for a few days before heading back down for the memorial mass.  It's been a long couple of weeks and I'm just now trying to get back to work.

L was diagnosed with type 2 diabetes over 30 years ago and had managed the disease, when he managed it, pretty well with diet and oral medications.  He wasn't a model patient--we toasted him with bourbon, after all--but he did pretty well considering the lack of resources that were available when he was diagnosed.  In fact, it wasn't until the last year that he needed insulin, which only started after he went on dialysis for kidney failure.  L had been investigating transplant options for a kidney when he developed other complications with his gall bladder.  When his recovery from gall bladder surgery became severely complicated by the dialysis, they discovered he had liver cancer.  There was less than a month between diagnosis and his passing, nowhere near enough time to process the reality of the situation before it was time to say goodbye.  L was only 67 and he will be missed dearly.  

You would have liked L and I am so sad that you never had the chance to meet.  He had a generosity of spirit and acceptance that put the people he welcomed into his life at ease and he laughed loudly and easily.  I smiled when I heard his laugh from 3 rooms away the same way I do when I hear you laugh like that.  He reminded me of you.

So, Dad, I am so grateful that you've been doing well with keeping your blood sugar in check.  Please do what you can to spare us from suffering this kind of loss again, even if it means going in for regular checkups when you feel just fine.  Just do it, please.

Meanwhile, I'm gonna do what I can to help improve access to meaningful help for people with diabetes.

I love you.

-Mel

In search of diabetes events.

One of the things I do for my research is I attend conferences and educational programs about diabetes care.  Those meetings are targeted for health care professionals, industry, and researchers and cost quite a bit of money to attend--especially if you are not a member of a big professional organization like the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE).  These folks are really excited to travel to spend several days with people who do the type of work that they do so they can geek out together share ideas about diabetes care.

No joke, I took this picture at the AADE conference in Indianapolis last year.  I swear it was for an opening plenary session around 8:45 a.m. and not an evening rock concert.  I had not had enough coffee for the blaring conference theme song, but now that I've seen the video I kind of wish there had been a big dance number on that stage.

Normal folks would be lulled to sleep by most of the stuff they talk about in these conferences.

I might have been a lot like that woman in the second row who is slouched so far down the seat that she might startle herself awake when she falls off if I weren't studying the audience as much as the stuff they were talking about.

Even so, I have learned a lot about the state of diabetes treatment, new technologies, and information that diabetes educators are using to help their patients bring down their A1Cs and keep them there.

You should have access to this information, too.  The industry assumes that patients will get information from their health care providers and diabetes educators, but if you can't make, keep or afford those appointments, it cuts you off from really important information that coud make a big difference in how you live with diabetes.

So what sorts of educational events do the big diabetes organizations put on for the general public?

So far, the only widely publicized event I have found from the major organizations is the ADA's Diabetes Expo where they do health screenings, activities, cooking demos, product samples, etc.  They even have family activities programming so that folks who wouldn't be able to attend due to child care issues can bring their kids along.  They have these events in various cities throughout the year and I will be attending it in Chicago this Saturday (4/13).

A smaller not-for-profit organization, Taking Control of Your Diabetes also has one-day events in several cities.  These aren't free, but they are pretty inexpensive if you don't have to travel to get to them.  I hope to attend one of these conferences because it looks like their approach is much more tailored to the needs of the attendees by having two different tracks for people with type 1 vs. type 2 diabetes since their experiences are different.

I keep searching for big community health events around diabetes and it leads me back to the ADA and the National Diabetes Education Program at the NIH that offers free resources for community organizations to do diabetes education events in their communities.  So I think this means that if you're looking for a chance to talk about diabetes or to be screened for it free of charge, your best bet is to look for local clinics and health centers to see if they have any upcoming events.  You might also find that your local park district or department of public health has events.

I would suggest doing a Google search on:  diabetes event <city> <year> (fill in the city and year; if there's nothing for your city, try a nearby city, county, or state).  Doing that search for Chicago 2013, I was able to find listings for a few other events that are happening in the area, including Living Well with Diabetes at the University of Chicago Medicine Kovler Diabetes Center.

Also, event organizers often leave fliers at coffee shops, cafes, grocery stores and other public bulletin boards.  If you're looking for an event, just take a moment to read the signs that you see posted. If you can't make it to the event that's advertised or if you just missed it, you might be able to call or email the organizers to find out about other opportunities that will be in your area.

What do you find when you search for diabetes events in your area?

Retooling for the job.

Hey Dad,

You have information about diabetes care and have blood glucose testing down.  You have information about good food choices and a restocked pantry.  Unfortunately, cooking still takes time and energy, especially if you don't start with boxed something.  Very often I'm happy to order takeout even though I actually like cooking because I am too tired or too lazy or too unmotivated to do all of the food prep and cleanup that happens when cooking.  I get it.

Imagine trying to install a fence when the only tool you have for sinking the posts is a garden spade.  Sure, it would get the job done...eventually.  But it would also be tedious and shoddy and I hope you would abandon the job pretty quickly.  On the other hand, if you have PHD, the useful kind, (not the type I'm working on, as you've pointed out), those posts will go in much faster.  Having the right tools for food prep and storage makes a huge difference in the time it takes to prep meals and in practicing good portion control--and they don't have to be expensive.  Let's get you better food tools.

So I went to a dollar store and a large discount store to collect quite a haul.  What's here:

• Baking sheets (because you'll be baking more of your foods)
• A composition book and sticky notes (to write down notes about things you do and don't like, ideas you have for foods to try, nutritional information you figure out with a nutrition counter book, and to add notes to pages of your cookbooks)
• Plastic shoeboxes and small tubs (for keeping your tools, spices, snack packs, etc. neat and easily accessible)
• Cutting boards (it helps to have at least two when you are prepping food for more than one meal at a time)
• Measuring cups
• Food thermometer
• Small kitchen gadgets (tongs, lettuce knife, basting brush, egg slicer, small grater, strainer)
• Food storage bags and containers
• Portioned spill-proof, microwave safe bowls
• Digital food scale (for portioning)

The majority of these items costs $1-3.  The food thermometer and covered sectioned bowls were a little more.  The only splurge item here was the digital food scale and you can get those for about $20 if you poke around online.  You can use an analog scale, but it is way, way easier to do this with a digital scale that you can reset (tare) with the push of a button.  Here's a good review of an analog vs. digital scale that also shows you how to use them.

So now what do you do with all this crap?  This is going to sound like a lot of trouble, but I promise it will save you time and energy in the long run.

First, measure your food. It's amazing how much we underestimate how much we eat when we aren't accustomed to  measuring it.  To keep measuring from becoming tedious, I highly recommend writing down portion weights and using the scale to make portioning easier in the future.

Pre-portion snacks and meals that you can make ahead of time.  If you measure out the portion by following the food label (How many grams are in one serving?), then you can weigh it.  If there isn't a weight on the label, just a volume, measure out the volume and then put it on the scale to see what it weighs (subtract the container).  Write down that weight in the composition book so that you don't have to do it again.  Now when you go to portion your snacks out, just put the container on the scale, reset it to 0, and then fill up the container until you get to the weight you are looking for for the portion.  It's cheaper to get a large bag of baby carrots than to buy packs of the small bags, so if you do it this way you can make several little packs using snack size bags and the scale to measure. If you portion out snacks so that each pack has 15g of carbs, it's a lot easier to count the carbs.

When it comes to controlling portions at dinner, put your plate on the scale, reset it, and then portion foods out by weight if you can.  If it's a liquid and you don't yet know the weight, then use measuring cups and spoons (and write the weight down on a sticky note on the recipe!).  If you made enough for leftovers, portion them out into food storage containers while you plate your dinner.  This way it's more difficult to get seconds since you've already put the food away and you will know how many carbs are in tomorrow's lunch or dinner because you already did the math.

Finally, if you know you are going to need to chop vegetables to make 3 recipes over the next few days, it's a lot easier to do all of the peeling and chopping in one longer food prep session than to have to do it every time you want to cook.  Use the bigger food containers to hold the vegetables you pre-chopped.  Doing it this way also means kitchen cleanup will be easier since you already did the messy vegetable prep part days ago.

I hope that between these tools and making some new routines around food prep this will get easier and less time consuming for you.  It's a drag to have to measure food and to have to think about it so much, but if you're using the right tools for the job, you'll spend a lot less time having to do it.  After all, it's not like you would use a spade instead of a PHD because you really enjoy the process of digging holes for fence posts.  The point is to get through the tedious part so you can get to the stuff you enjoy faster.

Now, please go play with your new tools.

Love,

Mel

Restocking the shelves.

Hey Dad,

So at this point you've gotten a lot of information about diabetes.  That's excellent, but I worry that if you don't also get the stuff you need to make it easier to make healthier lifestyle changes, the information won't do much more than stress you out.  I think a mistake a lot of folks who write books about diabetes--and even some of the dietitians I've encountered in my own life-- make is that they assume that everybody has the skills, time, money, and equipment that would make huge dietary changes a no-brainer.  Even if the writers and dietitians are aware of these obstacles, there isn't really a list of the things you need to get motivated and to keep up the changes in the long run.

When I was growing up, you were the cook in the family and I'm glad you taught me how to work with what I have on hand to make something that is filling and tasty.  Your basic formula used to start with a boxed side dish like au gratin potatoes or dirty rice mix, some meat either on the side or cooked into the mix, and maybe a canned or frozen vegetable--usually corn or peas.  When I want comfort food, this is what I still do even as an adult.  Last night, I added some leftover chicken from the other night to some boxed macaroni and cheese and called it dinner.  It wasn't healthy, but it was delicious and filling and made me feel better at the end of an otherwise blah sort of day.

You're a great cook, but these foods are not the ones that will help you keep your blood sugar and blood pressure under control because they are so full of carbs, starches, sugars and sodium.  Even if you have low-carb prepared foods, there's still a good chance they're full of sodium and doing your blood pressure no favors.  The easiest thing to do is to cook all your own food from scratch so that you know what all is in it and can control it.  Problem solved.

Really?  Who actually thinks this is easy?  Maybe people who don't have to think about preparing healthy food, or those who grew up learning how to cook from scratch and actually like to do it.  Most of the working people I know don't have those luxuries.

It's not easy, but it can certainly be less difficult.  I have an idea.

Step 1:  Purge the pantry of most of the prepared foods.  Donate them to a food pantry or someone else you know who likes them.  As someone who buys macaroni and cheese in 2s, I understand how one can accumulate so much Hamburger Helper when it's on sale more frequently than it gets eaten.

Note that I didn't say you should get rid of all of it, since we all need a little junk food every once in a while.  Just don't keep enough of it in the house that it makes sense as your automatic dinner starter.

Step 2:  Get stuff that will make foods taste good so that you can buy meat and vegetables and cooking them will be easier.  If you stock up on meat and frozen vegetables when they're on sale, then you'll be able to pull together a meal with the stuff on hand just like you did before, but it will be much healthier.

I looked through the cookbooks I gave you and it occurred to me that while the ingredients are pretty basic, they're not so basic if you don't have them on hand.  Why would you have all of those herbs and seasonings when the food you usually make comes with its own seasoning?

So I looked at the ingredients lists for the recipes in the cook books and made a quick list of the herbs, seasonings, etc. so that I could figure out what sorts of things you would need to have on hand if you wanted to try those new foods.  Here's what I came up with:

Dry stuff:

• garlic powder (not garlic salt)
• oregano
• chili powder
• dill weed
• basil
• cumin
• sage
• sea salt
• parsley
• onion soup mix
• steak grilling seasoning mix
• chicken grilling seasoning mix

Wet stuff:

• worcestershire sauce (reduced sodium)
• stone ground mustard
• vinegars (apple cider and white)
• oilve oil
• light italian salad dressing
• low sodium soy sauce
• spray canola oil

It also turns out that from those ingredients, you can make all sorts of marinades for meats.  In fact, that's why I included the light Italian dressing.  One of my favorite ways to marinate pork chops is to put them in a gallon plastic bag with half a bottle of a dark beer, a heavy squirt of that stone ground mustard, a teaspoon of minced garlic, a pinch of sea salt, and a splash of olive oil.

You can get those supplies at just about any grocery store and even some dollar stores.  I recommend that you go to an ethnic market or look for the ethnic foods section of your grocery store for the herbs and spices because they are a lot less expensive than the main US national brands.  In this case, the small bottles cost less than $2 each.  At some stores, you can get the spices and herbs in bulk and put them in your own bags/bottles.  I don't recommend buying a spice set because they are often much more expensive than getting individual bottles, you don't get to pick and choose what's in them (so you'll get stuff you don't want or need), and you have no idea how fresh or stale they are.  At least with individual bottles on a grocery store shelf, you can look at the dates.

If you can spare a few extra dollars for any one thing on this list, I recommend getting a nicer extra virgin olive oil.  A little goes a long way, so you don't need a huge bottle.

Step 3:  Restock the shelves with the new stuff so that it's in front of you when you are looking for food and so that you can find what you're looking for easily.

Now that you've got a good base set of seasoning ingredients, it won't be too expensive or annoying to pick up just one more if a new recipe calls for it--like the rosemary I forgot to include with this list.  Sorry about that!

Love,

Mel

Diabetes by the books.

Hey Dad,

What happened to February?  It was good to talk to you now that I've come out of my work productivity cave.  I was especially happy to hear that things have been going so well with the books I found for you and mom.  I tried very hard to find books that would give you information in plain language and not overwhelm you with too much information or long, dry chapters.  I think the set I came up with for you does a decent job of this.

I've seen a lot of books about diabetes and they tend to go over the same basic information about what happens with the disease and the guidelines of the American Diabetes Association (ADA) for treating it.  If you take a look at the guidelines, you'll see why it's so important that there are books that translate them into something that resembles English.  Every year they update the guidelines based on new research that has come out so that they are based on the most up-to-date information.

Here are the books that I think do the best job of giving you practical information about what you need to actually do with the information.  You might notice that three of them have the ADA logo, which means they are published by the ADA and you can purchase them directly from their website.  All of the books can be ordered from Amazon.com and that is where you'll find the most customer reviews for books.  Since books are expensive, it's always a good idea to give them a try before you buy them by checking them out at the public library.  If your branch doesn't have them, talk to someone at the circulation desk to find out how to request it from other libraries in the library system.  Usually you can check out a book from your local library even if the local library doesn't have it--you'll just have to wait a while for it to come in.

I know you like your meat and potatoes.  Usually when we think of health food we come up with images of twigs and tofu or, worse, the Weight Watchers recipe cards from the 1970s.  Fortunately, nobody is asking you to like tofu or kale and even Weight Watchers has long abandoned those crazy, gross recipes.  I think these books do a good job of showing you ways that you can eat foods that will taste good to you and make you feel like you've actually eaten a meal.

What Do I Eat Now?:  A Step-by-Step Guide to Eating Right with Type 2 Diabetes by Patti Geil and Tami A. Ross cuts directly through the guidelines to give you the information about the part of diabetes care that is giving you the most stress.  It's an easy read because it's broken up into chunks and they pull out the parts that you'll refer to in the future into tables and charts.  If they just did the tables and charts or just the text, I don't think it would be nearly as useful.  Of all of the practical guides I've read in doing my research, this is really the most useful that I've found.

Next, there's The 4 Ingredient Diabetes Cookbook by Nancy Hughes.  The recipes really do have very few ingredients (occasionally 5 or 6 ingredients due to spices, but mostly just 4) and very few steps in meal preparation.  When one of the reviewers wrote that the recipes were too simple for them, I figured this was a good cookbook for people who aren't used to cooking things from scratch.

Then there's One Pot Meals for People with Diabetes by Ruth Glick and Nancy Baggett.  This book is full of the sorts of recipes where you throw a bunch of ingredients into a pot and let it cook--a real time-saver when you think about the amount of clean-up that comes with cooking from scratch.  The ingredients are also pretty basic and you can do a lot of the food prep ahead of time so it's easy to pull a healthy meal together without having to think about it too much.  I know cooking a complicated dinner is not what you want to deal with after you've been at work all day.

Finally, there's The CalorieKing Calorie, Fat, & Carbohydrate Counter by Allan Borushek.  This is a tool that any person who is trying to eat lower fat, lower carb, etc. should have because it is a fairly comprehensive listing of nutritional values for not just raw ingredients that you'll cook, but for food that you buy already cooked.  It's hard to get an accurate count for restaurant foods or something at a potluck, but this guide can give you a rough estimate.  It's a small book so you can take it with you wherever you go.  For folks who prefer to access it online or through a smart phone app, the CalorieKing website has other options, including an online weight loss program.  You can get the nutritional counts for free on the website, even if you don't subscribe.

I am glad that you and mom have been giving these a go and I look forward to hearing which ones actually work for you.  Please let me know if any of these are dead wrong for what you need so I can keep looking.

Love, 

Mel

Please eat some carbs.

Hey Dad,

I promise you can eat foods you love.  I know you don't really believe me.

You are right that if you were to eat a bunch of potato chips or pizza it would raise your blood sugar pretty high, but that doesn't mean they're off limits.  It means that you need to eat smaller portions of them and you need to eat them with something else (like lean protein and vegetables) so that you feel fuller and have more than just carbohydrates in your system.

I've been talking to a lot of diabetes educators and from what they've told me about their patients' concerns, you are not alone.  A lot of folks believe that having diabetes means that they cannot have any sugar at all ever again.  I'm worried that by severely restricting your carbs to less than 20g per day, you are actually doing more harm than good for your body.  In fact, it's that kind of limitation that prevents you from eating the foods you love, not the diabetes itself.

I know there is a lot of information out there about super low carbohydrate and mostly- or all-protein diets and there are people who swear that it's the best way to cure type 2 diabetes, but I am highly skeptical for a few reasons.  

First, Dr. Atkins and his ilk have made a lot of money selling books and related products promoting their diets.  I doubt their science because it is motivated by profit.  If they were truly honest about the health benefits and risks, they would not just publicize the good, but they would also look at the other side and take a critical view of their own research.  Super low carbohydrate diets are controversial in part because they make huge claims with insufficient science to back them up.

Next, it isn't clear how sustainable an extremely low-carb diet is in the long-run.  Sure, they can help you drop weight quickly and pull your blood glucose under tight control in short order, but they also come with additional health risks like kidney damage--something you're already experienced when following Atkins when you were just trying to lose weight.  In fact, even Dr. Atkins warned that people who already have problems with their kidneys should exercise caution in using his diet plans and should do so under medical supervision.  Unfortunately, many people don't realize that there is a problem with their kidneys until the damage is done.

Another problem you, yourself, have experienced is hypoglycemia when you're doing physical work.  Like it or not, your body really needs carbs for energy.  If having diabetes generally means that one way or another your body's ability to use glucose is out of whack, then cutting it off actually works against your goal of restoring a healthy balance by pushing it further out of whack.

I know it's a lot to take in and what I'm saying is running counter to what you've believed for a long time.  For now, I think it would help if you made sure to add a little carbohydrate to every meal, preferably something whole grain or fresh fruit.  When you're back to work, please pack yourself some small carb snacks so you can keep from bottoming out. It's also a good idea to have some emergency sugar on hand, like a couple of sugar packets or hard candy that you can chew, so that you can head it off when you feel it coming on.

Love,

Mel