Diabetes: Active Management is the Key

Develop a plan

A diagnosis of diabetes is serious. Many people feel overwhelmed at first. They feel angry, scared, or even depressed. These reactions are natural. But a diagnosis of diabetes is not a death sentence.

The person you care for is not alone. There are many diabetics. And people with diabetes can lead happy, healthy lives despite their condition. Certainly, they have to change their daily habits. And they have to monitor their health more closely than they did before their diagnosis. But active management can keep the condition in check so your relative can fully engage with his or her regular activities.

Fortunately, a lot of support is available. And if the person you care for will create and then follow a plan, he or she will have more energy.

• Work with the diabetes team. Diabetes affects many organ systems. As a result, your relative will benefit from having a team approach to care and treatment. Ask the primary care physician about who should be on the team. For instance, diabetics often need special care from an internist or endocrinologist, an eye doctor, a foot doctor, a dietician, a pharmacist, and a dentist. Also be sure to request a referral to a diabetes educator. These educators can weave all the pieces together. They can help your relative come up with a set of realistic daily routines that are most likely to keep his or her blood sugar under control. Plans frequently have to be adjusted, so it’s good to stay in touch with the team and ask questions, especially if something changes. It’s also important to be honest. Better for your relative to create a plan that is realistic than to be polite and agree to things he or she won’t really do.
• Connect with other diabetics. Find out if there is a diabetes support group nearby. Support from family and professionals is helpful. But talking to others who are going through the same process is invaluable. Support group members share practical tips. A support group is also a place to talk about some of the more emotional aspects of being a diabetic. If your relative uses the Internet, you might suggest online groups, such as those sponsored by the American Diabetes Association.
• Talk about how you can best be of help. Nagging doesn’t work. It will only create tension. But you can ask about what he or she finds difficult to do and how you could be most supportive. Perhaps you can help with preparing diabetes-friendly meals or finding the best place to buy low-sugar foods. Maybe the person you care for would like help keeping track of questions for the doctor. Or someone to accompany him or her on daily walks. Sometimes it’s nice to just have a sympathetic ear about how hard it is to stay on top of all the things that have to be managed. In addition to asking what you can do to help, don’t forget to also ask if there are things you are doing that are making it harder. One never knows.

Avoiding crises. Your relative may have large swings in blood sugar levels, depending on the severity of his or her condition. The goal is to keep those swings to a minimum. Once the person you care for gets a routine in place, it will be easier to recognize when there is an imbalance brewing and how to take quick action.

Talk to the diabetes team to find out the symptoms of too much sugar and too little sugar. They can teach you and your loved one about simple and quick remedies. Serious extremes don’t happen often. But find out what to do if the person you care for were to have a dangerous spike.

Have a plan for sick days. Illness makes it hard for anyone to keep up with daily regimens. Even brushing teeth or bathing can be too much of a chore. This is true for diabetics, too. But diabetes doesn’t take a holiday during illness. In fact, the stress of being sick can cause blood sugar levels to rise and increase the chance of a serious problem, such as a coma. Not good!

It’s important to have a plan for sick days so your loved one has supplies and knows what to do. For instance,

• check blood sugar more often during illness;
• check the urine for ketones. Work with the team to determine how often to take these measurements;
• ask for an alternate meal plan in the event of nausea, diarrhea, or fever. These conditions can make it difficult to keep to the regular eating schedule or to keep food down;
• clarify any changes in medication and any medicines to avoid (e.g., is it okay to take aspirin or cough syrup?);
• know the signs of a problem and when to call the doctor or team.

Emergency preparedness. Just as your relative needs a plan in the case of illness, it’s also good to have one in the case of a disaster. To begin with, the person you care for should

• wear a diabetic ID bracelet at all times. This will give emergency personnel important information in case your loved one is unconscious or forgets to mention his or her condition;
• have an emergency kit. It should include at least three days worth of diabetic supplies. Be sure to check the kit regularly and rotate out any supplies with expired dates. Include in the kit a list of all the diabetes team members and their contact information. There should also be diabetic-friendly foods and some emergency foods that contain sugar. Diabetics often have problems with dehydration, so be sure there is also plenty of water and noncarbohydrate fluids in the kit.

Set up a routine

At first, active management of diabetes may seem overwhelming. But like most things in life, if you set up a routine, it becomes easier. Getting into a routine will allow these important health activities to become habits. The good news is, just like bad habits, good habits are hard to break once they are a regular part of daily life.

Weekly

• Plan and shop for meals and snacks that fit the diabetes program. Planning ahead will allow your relative to shop for the foods that are needed. That way he or she can conveniently prepare healthy meals and quickly grab snacks that fit within the prescribed food diet. (Similarly, making sure that foods outside the program are NOT in the house is a great way to reduce the temptation to eat them.)
• Replenish the “quick sugar” foods used for emergencies. Best to check once a week and be sure there is a good, fresh supply of high-sugar, low-fat emergency snacks on hand. Avoid chocolate. The fat in the chocolate slows absorption of sugar, which is the exact opposite of what you want if you’re reaching for an emergency sugar snack.
• Plan for exercise. Items that appear on one’s calendar are more likely to happen than those that don’t. Schedule time for exercise each day. A daily dose of 30 minutes is what most doctors recommend, but ask the doctor what’s best for your relative. Leaving exercise to chance greatly increases the likelihood that it won’t happen. (Exercising with a buddy, on the other hand, greatly increases the chance that it will!)
• Trim toenails straight across. Diabetics need to be careful not to get cuts on their feet. Weekly nail care and trimming toenails straight across will reduce the chances of a nail digging into a neighboring toe and causing an infection.

Daily
To help your relative more easily manage his or her diabetes, here are some habits to cultivate:

• Eat according to the plan. Diabetics need to pay attention to the types of food they eat, the quantities of food, and the frequency of meals. It’s hard on the body to skip meals because it results in wide blood sugar swings.
• Monitor blood sugar. Work with the diabetes team to determine the best time(s) of day to check levels. Together they can work with your relative to set a target blood sugar level. Be sure your loved one knows what to do if his or her blood sugar is too high or too low.
• Take other tests as directed. Other daily tests may be necessary, such as checking blood pressure, weight, or presence of ketones in the urine. Talk to the diabetes team to find out what should be checked, how often, and what to do if there’s a problem.
• Brush and floss teeth twice a day. Diabetics are especially prone to infections. For this reason, it’s important to remove bacteria and food particles from the gums soon after eating, before the gums have a chance to get infected.
• Take all medicines as directed. Certainly this pertains to insulin or other medicines for diabetes. But diabetes also makes people more prone to heart disease and stroke. If your loved one is taking medicines for high blood pressure or cholesterol, it’s important that he or she also take these medications faithfully, as directed.
• Examine feet. It is very common for diabetics to lose feeling in their feet. As a result, they can have infections and not know it. A blister or cut that would heal easily for a nondiabetic can quickly become infected in persons with high blood sugar. Without the “cue” of pain, infections can become very serious very quickly. Visually check for cuts, bumps, red spots, or other breaks in the skin. Diabetics should avoid wearing socks that are mended or have holes or ridges that could cause sores or blisters. Check shoes for sharp objects inside that could cause a cut.
• Wash and dry feet. Diabetics are at high risk for having a foot amputated if an infection goes unchecked. For this reason it is important to clean the feet daily. Using mild soap and warm, but not hot, water will remove any bacteria. Best not to soak the feet, though. Dry the feet thoroughly, including between the toes. Then apply lotion, but NOT between the toes. Too much moisture in those dark warm corners provides a great opportunity for infections to develop.

Make healthy food choices

Food has much more meaning than nutrition alone. Food reminds us of family and friends, our cultural roots, and often of enjoyable times and celebrations. That is why it can be difficult to change what we eat. But careful monitoring of sugars and fats is essential to keeping diabetes under control.

Being overweight can make it difficult for the body to keep blood sugar in balance. When creating a list of good foods to eat, your relative will need to think in terms of limiting calories as well as emphasizing diabetes-friendly nutrients. This can be challenging. But the rewards are worth it.

Everyone can benefit from a diet low in sugar and saturated fats. But diabetics have especially powerful incentives.

The combination of wise food choices and daily physical activity can often be enough to avoid the need for insulin injections. And a diabetic who keeps his or her blood sugar in balance feels better and has more energy to do the things he or she likes to do.

It is important for your relative to work with a diabetes educator or a dietician. Diabetes professionals can help your loved one come up with an individualized eating plan that is healthy and realistic.

Here are some basic tips:

Carbohydrates
These are the nutrients in food that raise the level of sugar (glucose) in the blood. Your relative will want to work with his or her diabetes team to determine the right balance over the course of the day, spread across these three categories:

• Sugar: Sugars are called the “simple carbohydrates” because they send sugar directly into the body. They can be naturally occurring sweeteners, such as those found in sugar, fruit, and milk. Naturally sweet drinks, such as fruit juice, send a big spike of sugar very quickly into the bloodstream. A single glass of apple juice has twice the sugar, two thirds again the number of calories, and only one tenth the fiber that a single apple has. It is much better to eat the piece of fruit than to drink the juice. Artificial sweeteners can substitute for sugars. By themselves, they will not create a rise in blood sugar, but they often come in high-calorie, processed foods. Stevia, a natural plant-based sweetener, has been generally recognized as safe by the FDA. Like artificial sweeteners, it has no calories itself and it will not cause a rise in blood sugar.
• Starch: These foods may or may not taste sweet, but they break down into sugar once they go through our digestive system. They are sometimes called “complex carbohydrates.” Think of them as “delayed sugars.” Corn, peas, dried beans, and potatoes are examples of starchy foods. Grains are also high in starch, although less so if you eat whole grains. For instance, ounce for ounce, there is more starch in refined grains (white rice or white flour) that have had their natural coverings removed. Brown (unrefined) rice or whole-wheat flour includes the high-fiber portion of the grain and counterbalances the starch.
• Fiber: This is the indigestible portion of plant foods. It is also called “roughage.” It passes through the digestive system untouched. But it also helps the digestive system stay clean. It helps us feel full and avoid constipation. Fiber also blocks the absorption of cholesterol. Beans, nuts, whole grains, and fruits and vegetables (especially those with edible skins and seeds) are all good sources of fiber.

Overall, your loved one will want to balance the amount and types of carbs eaten during the course of the day. The goal is to avoid big spikes in blood sugar.

Fats
People with diabetes are at much higher risk of developing heart disease and dying of a heart attack. This gives added reason to follow a heart-healthy diet. Fats are an integral part of some foods (for instance, red meats). But how we prepare foods can also add fats (fried foods have more fat than steamed or baked foods). And then there are the sauces we put on our foods. Cream sauce is an obvious source of fat. Less obvious, but equally high calorie, are salad dressings, butter, and mayonnaise.

Not all fats are created equal. Some fats are hard on the heart. They are high in calories, which makes it hard to maintain a healthy weight. They can also cause blockages in blood vessels.

• Saturated fats tend to be solid at room temperature. Butter, cheese, lard, red meats, and poultry skin are all examples of foods that are high in saturated fats. Cream, half and half and “whole” milk are liquids with high concentrations of saturated fat.
• Trans fats are fats that are usually liquid but have been chemically altered to become solid at room temperature. Examples of foods that tend to be high in trans fats are margarine and shortening. Many processed or fast foods are also high in trans fat and should be avoided whenever possible. Foods high in saturated and trans fats have been shown to increase cholesterol levels.
• Cholesterol is known to contribute to heart disease. Cholesterol exists in many of the animal products we eat. Our bodies naturally make cholesterol, so we don’t need to add more through the food we eat. Try to limit high-cholesterol foods whenever possible, especially foods that are also high in saturated fats or trans fats.

There are some good fats. Unsaturated fats, for instance, have been shown to lower blood cholesterol. Fats from nuts, avocados, olive oil, and canola oil are unsaturated. Omega-3 fatty acids have also been shown to protect the heart. These fats are found in certain fish (salmon, sardines, rainbow trout, herring, and mackerel). Plant sources of omega-3s include walnuts, tofu, soybeans, flax, flaxseed oil, and canola oil.

Fats are also high in calories. Although high-fat foods may not cause blood sugars to spike, eating foods high in good fats can still make it difficult to lose weight or keep weight down. Your relative should work with his or her diabetes team to figure out the right balance for his or her body.

The best foods for diabetics
It’s easy to get overwhelmed thinking about all the foods that shouldn’t be eaten. Instead, you can help your relative focus on the foods that are especially helpful, such as fiber-rich carbs, lean protein, and heart-healthy fats. Here are some examples:

• Dried beans, such as pinto, navy, kidney, or black beans. Although they are starchy, beans provide protein and fiber. As long as they are not fried, they are also fat-free.
• Fish high in omega-3s. Examples include salmon, sardines, and rainbow trout.
• Fat-free milk and yogurt. Again, another excellent source of protein, and also of calcium. Many dairy products are also fortified with vitamin D.
• Nuts are a good source of protein and fiber. They are also great for snacking. They do have fats, and therefore tend to be high calorie. But most of their fats are heart healthy. Walnuts and flax seeds are high in the good omega-3 fats.
• Whole grains provide fiber and some protein. They are far more nutritious than refined grains. Oats and pearled barley also help reduce cholesterol, adding to heart-healthy strategies.
• Dark green leafy vegetables, such as spinach, kale, and swiss chard, are high in fiber and in B vitamins.
• Other nonstarchy vegetables, such as carrots, broccoli, and green beans, provide assorted vitamins and minerals.
• Citrus fruits, such as oranges and grapefruit, are high in vitamin C.
• Tomatoes are also part of the citrus family and are high in vitamin C, iron, and vitamin E.
• Berries and apples have fruit sugar, but they also have fiber. Berries, in particular, include vitamins and heart-healthy antioxidants.
• Sweet potatoes can be used instead of regular potatoes. Although they are starchy, they are high in fiber and in vitamin A.

Some foods may be recommended over others. Talk with the doctor and the diabetes educator to confirm which are the best for the person you care for.

Eating away from home
Eating away from home can be challenging. The person you care for may or may not go out to restaurants much. Even when visiting at someone else’s house, your relative may have difficulty maintaining wise food choices. Low-sugar, high-fiber, low-fat options may be scarce. He or she may also be tempted by goodies not usually available at home.

When eating out at a restaurant,

• look for the “heart healthy” symbol on the menu. This will be a good start in terms of low-fat options;
• ask to substitute a green salad or cooked vegetables for potatoes, pasta, rice, or bread;
• ask the server about ingredients, or if a nutrition chart is available;
• choose baked, broiled, and steamed items over fried;
• forego high-fat extras, such as cheese or bacon;
• request that dressings and sauces be put on the side, then dip in lightly rather than pour it on the food;
• eat only half the portion served and take the rest home to reheat for another meal. One less meal that has to be cooked!
• ask for artificial sweeteners for coffee or tea;
• drink water, or sparkling water, instead of high-calorie sodas or juices;
• limit alcohol, which adds calories but no nutrition.

When visiting others
Many of the tips for restaurants apply for eating at someone else’s house, especially if it’s buffet style. If you don’t have options to make wise choices, here are a few other tips:

• Bring a high-protein snack bar or trail mix in case a meal gets delayed or the main dish is high in fat.
• Always have a quick sugar option available in case of low blood sugar.
• Bring your own artificial sweeteners for coffee or tea.
• Peel off the skin or breading on poultry or fried foods.

Become physically active

People with diabetes are at greater risk for heart disease. And heart disease is the number one cause of death in our country. Fortunately, physical activity can do much to prevent heart disease and keep it in check.

The benefits of physical activity include

• more energy. Being physically active gets the engine running;
• better glucose balance. Sugars are burned during exercise, and insulin is used more effectively;
• reduced need for insulin. With daily activity and wise food choices, many diabetics can avoid the need for insulin pills or injections;
• better sleep. Physical activity during the day helps the body move into a deeper sleep at night;
• weight loss. Activity combined with a good diet takes the pounds off and helps keep them off. Reduced body fat also leads to a lower risk of heart attack, stroke, and even some cancers;
• reduced cholesterol and blood pressure. Exercise helps burn the bad cholesterol (LDL) and raise the good one (HDL). It also makes the heart pump more effectively so blood pressure goes down;
• less stress, anxiety, and depression. Physical activity helps release tension. It also causes the body to produce natural endorphins, which keep us feeling better physically and emotionally.

Your loved one doesn’t need to become a jock to feel the benefits. We often associate the word “exercise” with working out in a gym. Instead, think in terms of “physical activity.” Physical activity is anything that gets the body up and moving. Breaking a sweat is optimal, but not required. Dancing, working in the yard, going for a walk with a friend all qualify as physical activities. And they all help with diabetes management.

Get approval from the doctor first. Almost anyone can benefit from being physically active. But it’s still wise to check with the doctor to see if there are any restrictions. For instance,

• should your family member exercise if his or her blood sugar is high?
• is it best to have a snack before physical activity or after?
• what foods would be best to have available during exercise?
• are there any signs of a problem brewing? If so, what should be done to counteract the problem?

Pick several activities: one for outdoors and one for rainy days; one with others and one that can be done alone. The idea is to have a few options to choose from. The activities don’t have to involve lots of sweat and exertion. They should just get the heart pumping a bit faster than usual.

Try for short, 10-minute segments at first. Then build up. The ideal is to be active for 30 minutes, five days a week. If three sets of 10 minutes is easier to squeeze in than a half hour all at one time, no worries. It is just as effective as doing the full 30 minutes all at once.

Support the feet. Diabetics often have problems with poor circulation and numbness in the feet. Be sure your family member has shoes that fit well and that he or she uses fresh, clean socks each time. After exercise, remove the socks and inspect the feet for redness or sores. Call the doctor if there are sores that do not heal.

Other tips that might help your relative:

• Create a plan. Schedule time for physical activity just as one might schedule an appointment with the doctor. Indeed, activity is like a doctor’s visit. It’s an investment in health.
• Exercise with a buddy. It’s more fun and makes it easier to stick with the plan.
• Know the signs of low blood sugar and what to do if it happens.
• Bring a snack just in case.
• Check blood sugar before and after to learn how the body is responding.
• Wear a medical ID bracelet.
• Drink 8 oz. of water beforehand to avoid getting dehydrated.

Walking is the easiest activity. It’s inexpensive. There’s no need for special training or special clothes. Clean socks and good-fitting shoes are all that are required. Plus it’s a great way to get in a visit with a friend.

A few tips for walking:

• Start with just 10 minutes a day and build up slowly. For instance, the first week, your relative might walk for 10 minutes a day. The next week maybe 13–15 minutes.
• Stretch first, walk at a brisk pace, and then cool down with a slower pace at the end. This helps avoid feeling sore the next day.
• Have an outdoor route and an indoor route. Fresh air is always good. But sometimes it’s rainy or too hot. As a community service to seniors, many malls allow walking in the halls in the morning, before shops open. A mile around the mall is still a mile.
• Consider a pedometer. This little, inexpensive device measures how many steps have been taken. Some people enjoy keeping track, setting goals, and competing with themselves to do more over time.

Get regular exams

Diabetes can be kept in check, but it requires active management. Ideally, the person you care for will have a team of professionals to help. The doctor and a diabetes educator are good for starters. The dentist and eye doctor are also members of the team. All these professionals help monitor your relative’s condition. After doing examinations and bloodwork, they can make recommendations for adjustments in daily diet, exercise, medication, and so forth.

Medical visits at least twice a year
Know the Diabetic ABCs (A1C level, Blood pressure, and Cholesterol). At least once every six months, encourage your loved one to get the following tests:

• A1C level (a more long-term measurement of blood sugar in the body). Find out what your relative’s target A1C level is.
• Blood pressure. There are no outward symptoms of high blood pressure. This is why it is often called the “silent killer.” Diabetics are at much higher risk for high blood pressure. Depending on the health of your loved one’s heart, his or her blood pressure may need to be checked more often, at home. But at least twice year, the person you care for should have a medical professional check his or her blood pressure readings and write them down.
• Cholesterol. This is a blood test that should be done in the morning, on an empty stomach.

In addition:

• Have the doctor check feet for problems. The doctor can monitor the feet for poor circulation or signs of early infection.
• See a dentist. Diabetics tend to get infected gums, which can lead to infections in the heart. Infections anywhere in the body also tend to raise blood sugar. Be sure to tell the dentist that the person you care for is a diabetic so a thorough diabetic dental exam can be done.

Yearly medical visits

• Get an eye exam. Uncontrolled blood sugar is the leading cause of new cases of blindness. The changes are gradual but can be stopped if they are caught in time. Be sure the eye doctor knows your relative is diabetic.
• Test for kidney problems. The kidneys clean the blood of toxins. Too much sugar in the blood makes it difficult for them to do their job. Getting a yearly blood test can let the doctor know if the kidneys need help.

Quit smoking

Diabetics are at high risk of heart disease (heart attacks, stroke, and high blood pressure). For this reason, it is especially important to stop smoking.

Many diabetics worry about gaining weight if they quit cigarettes. Granted, it is common to put on a few pounds, but they can be lost later. A little weight gain now is worth the health benefits of quitting.

Here are some tips for avoiding weight gain when a person stops smoking:

• Get regular exercise
• Keep convenient, healthy snacks on hand
• Avoid alcohol and other empty-calorie treats
• Use medications to help with nicotine cravings
• Join a support group

Talk with your diabetes team about tips and local resources. Quitting cigarettes is one of the best investments your loved one can make for a healthy heart.

Get help for depression

There seems to be a strong link between diabetes and depression. People who have diabetes are more likely to become depressed. And, people who are depressed seem to also have a greater chance of developing diabetes.

It’s a vicious cycle. Depression makes it difficult to muster the initiative to manage the lifestyle changes of diabetes. And the stress of diabetes can contribute to a feeling of overwhelm, isolation, and hopelessness. Many people with diabetes say they feel they are losing control of their body and their life.

Everyone feels sad now and then. But depression is a sadness that rarely goes away by itself. It’s not a matter of simply willing oneself to feel better. There seems to be a chemical imbalance at the root of serious depression.
How do you know if the person you care for is depressed? According to the National Institute on Aging, having several of these symptoms every day during a two-week period warrants a senior going to the doctor to get checked for depression:

• Loss of interest in activities that once were pleasurable
• Feeling emotionally “empty”
• Feelings of excessive guilt or worthlessness
• Tiredness or a “slowed down” feeling
• Restlessness and irritability
• Feeling like life is not worth living
• Sleep problems, including trouble getting to sleep, wakefulness in the middle of the night, or sleeping too much
• Eating more or less than usual
• Having persistent headaches, stomachaches, or other chronic pain that does not go away when treated
• Frequent crying
• Difficulty focusing, remembering, or making decisions
• Thoughts of death or suicide, or a suicide attempt

Some of these symptoms may seem to be related to other conditions. All the more reason to go to a doctor for a check-up! By treating the depression, your loved one could be relieved of some of the discomforts and feel much, much better.
Many people think that depression is normal in older adults. Not so! Depression is a treatable condition and should be attended to, no matter a person’s age.

If you think your loved one is depressed, talk with the doctor. Untreated depression can make it very hard to maintain the daily management required to keep diabetes in check. And if diabetes is not managed, the consequences can be serious indeed.