Type 2 Diabetes, the Basics

By Editor |

Monday, April 4, 2011

This article is still being written, but it is mostly complete.  Diabetes is a complex disease, and the statements made in this article apply to most type 2 diabetics, but not all.  There are topics that I haven't covered, and you should do further research.  I am a diabetic, not a doctor or medical expert.

If you are not interested in the causes of your diabetes, you can jump right to the section "A Step-by-Step Guide for Newly Diagnosed Diabetics" at the end of this article.

I am constantly revising and updating this article.  Consequently, you should check back every few months to see the changes.  As a result of the constant updates, redundancies sometimes creep into the article.  I suggest that you also read the companion article on this blog about injecting insulin.

What Is Type 2 Diabetes?

Sugar, in the form of glucose, circulates in every person's blood and provides energy to all parts of the body.  The sugar comes from the foods we eat, mainly from carbohydrates (starchy foods and sweets) but also from proteins.  An organ called the pancreas secretes the hormone insulin, the role of which is to take excess glucose from our blood and store it as fat in our fat cells, and as glycogen (a form of starch) in our liver, kidney and muscle cells (and a couple other places).  When a person's body is unable to remove all the excess glucose from the blood, and the glucose level rises above normal, that is called diabetes.  Normal glucose levels range from 70 mg/dL (3.9 mmol/L)* (before eating) to 130 mg/dL (7.2 mmol/L) (after eating).  Slightly elevated glucose levels (10% to 20% higher than normal) are diagnosed as "pre-diabetes", and anything higher is diabetes.  When your blood-sugar levels get into the 200 to 300 range (11.1 to 16.6 mmol/L), you will need medication and/or insulin injections to get your blood sugar down.  If you allow your blood-sugar levels to get to 500 to 700 (27.7 to 38.8 mmol/L), it's time to go to the emergency room at the hospital!  (But before that happens, you will have lots of unpleasant symptoms.)

* mg/dL (milligrams per deciliter) is the American system; the rest of the world uses mmol/L (millimoles per liter).

There are several things that cause or contribute to diabetes:  a high-carbohydrate diet (which in itself may be caused by metabolic processes that create a taste for sweets and starches), a lack of exercise, overweight, poor genes, and advancing age.  As a person gets older, or as the result of eating a high-carbohydrate diet for years (which most of us do), the cells in the pancreas that produce insulin (called "beta cells") may start to die.  Another thing that can happen is that your body may become insulin-resistant, meaning that the areas of your body where blood sugar is stored (fat cells, liver, etc.) become resistant to taking in more glucose.  Obesity is a major cause of insulin-resistance, since an obese person's fat cells are already "full up".  Another cause is a sedentary lifestyle, and genes also play a role.  If your body is insulin-resistant, your pancreas will produce more and more insulin to force the glucose into your cells.  At a certain point, your pancreas can't keep up, and your blood sugar becomes elevated.  Indeed, you may have more insulin in your blood than most non-diabetics, but it won't be enough to force the glucose into your cells.

Regarding genes, some ethnic groups, such as American Indians, have a "thrifty gene" that makes their bodies less tolerant of concentrated carbohydrates, and the incidence of diabetes in these groups is very high.  Such ethnic groups are not able to handle a modern diet, which is based substantially on grains.  For the rest of us who are diabetic but don't have the thrifty gene, our lifestyle choices (eating a high-carbohydrate diet and not exercising) bring on diabetes.  My own personal theory is that we have gotten too far from our animal heritage.  Early man exercised strenuously and ate a wholesome diet with meat as the main ingredient.  Biologically, we are not equipped for modern life.

Type 1 diabetes is the result of an auto-immune disease in which the body attacks and kills the beta cells, and it usually develops during childhood (although it can occur later in life and may be mistaken for type 2 diabetes).  Typically, type 2 diabetics produce insulin, but not enough to overcome their insulin-resistance, and type 1 diabetics produce no or very little insulin.

Are You to Blame for Your Diabetes?

No, you are not to blame, even if you are overweight and eat a great deal.  Many overweight people lack the physiological signals that tell them when they are full, so they experience more hunger than normal people do.  In addition, over-eating causes the release of a neurotransmitter called serotonin in the body, and serotonin acts as a natural tranquilizer.  Some over-eaters (myself included) are essentially serotonin-addicts who eat to get a tranquilizing effect.  About 20% of diabetics are not overweight at all, and in those cases, genes (or environmental factors) seem to be the culprit.  Indeed, a person with good genes will develop a stronger pancreas in response to insulin-resistance, rather than a weaker one.

If you are carrying around a load of guilt because you are fat and diabetic, then you need to let go of it, as it will make it harder for you to deal with your diabetes.  Also, if there are people in your life who blame you for your weight or diabetes, then you need to either education those people or distance yourself from them.  Sadly, some doctors blame their overweight patients for causing their diabetes.  If you have such a doctor, you need to find a new one.

The Treatment

Diet and Exercise

Unless you have a genetic predisposition to diabetes, you can generally avoid it by eating a moderately low-carbohydrate diet all your life (150 grams of carbohydrates per day or less), by getting adequate nutrition, and by exercising regularly.  The fewer carbohydrates you eat, the less sugar enters your blood, and the less insulin your body must secrete.  Unfortunately, our American diet is becoming increasingly carbohydrate-rich, and Americans routinely eat 200 to 350 grams of carbohydrates a day.  Once you have diabetes, and if your blood-sugar levels do not exceed 200 mg/dL or so (11.1 mmol/L), you can possibly gain control of your diabetes by eating a diet which is low in carbohydrates (50-100 grams per day, depending on your body) and higher in fat than a normal diet.  (By controlling, I mean getting your blood-sugar levels down to normal or near-normal.)  Losing weight and exercising will definitely help (indeed, limiting yourself to 50-75 grams of carbohydrates a day will probably cause you to lose weight).

Eating an overall nutritious diet is important.  If the carbohydrates you eat are mostly refined (white bread, white rice, pasta, sugary cereals, soda, desserts, etc.), you will have larger spikes in your blood sugar than if you eat whole grains and other unprocessed carbohydrates (whole wheat bread, brown rice, whole-grain cereals, yams, fruit, fresh or frozen vegetables, etc.).  However, even whole grains are bad for most diabetics.  Nuts, olives, low-carb vegetables, beans (unsweetened), yams and some low-carb fruits (especially berries) are the best carbohydrates.  Fiber is important because it will slow down your digestion, which will lessen the blood-sugar spikes after meals.  Fiber also contributes to good cardiovascular health.

The one concentrated carbohydrate that I think may be good for diabetics is oatmeal (regular oatmeal, not instant).  Oatmeal contains fiber, and seems to reduce bad cholesterol in one's blood very effectively.  When you eat it, have a small serving (e.g., 1.5 oz.), and sweeten it with a sugar substitute.  Personally, I like to add cinnamon, vanilla extract or almond extract, and then half & half.  It can be cooked easily in the microwave.  (Put 1.5 oz. in a cereal bowl and add 2/3 to 3/4 cup water.  Cook on the low or defrost setting for 9 minutes.  If it boils over the edge of the dish, use a lower setting or a larger dish.  Then add sweetener, flavorings, milk, etc.)

Exercise is important, primarily because it reduces your insulin-resistance, but also because it increases your muscle mass.  (Studies have shown that the more muscle mass a person has, the less likely he or she is to get diabetes.)  As to whether you can eliminate insulin-resistance entirely with exercise, there isn't a clear answer.  Insulin-resistance seems to increase with age.  A middle-aged person may be able to eliminate insulin-resistance entirely by becoming very athletic, but moderate exercise may not be enough.  Once a person reaches old age, all that may be possible is to reduce it.

As for the type of exercise, any will do -- both aerobic and non-aerobic.  A mixture of both is probably best.

I think it is worth explaining more about why a low-carbohydrate diet stops (or slows) the progression of diabetes.  Researchers have discovered that high blood-sugar levels kill the beta cells in your pancreas that make insulin.  Thus, if you have high blood-sugar levels for an extended period of time, your beta cells start to die out.  As your beta cells die, there is less insulin in your blood to handle the high blood-sugar levels, and you eventually reach a crisis point where you must take dramatic action to get your blood sugar down (by injecting insulin, reducing your carbohydrates to a very low level, and/or taking medication).  Also, if you have insulin-resistance, your beta cells have to work overtime manufacturing insulin to overcome the resistance.  If you go on a low-carbohydrate diet at the time of diagnosis, your beta cells may stop dying, and they may continue to make enough insulin to handle your body's needs into old age (if not into old age, then certainly longer than if you eat a high-carbohydrate diet).  Even if your diabetes is fairly advanced, a low-carbohydrate diet along with Metformin (see below) may be all you need.

So how low do you have to take your carbohydrates?  That depends on how early you catch your diabetes.  The FDA considers 225 to 300 grams of carbohydrates a day to be a normal diet, but in my opinion, 300 grams constitute a daily binge, even for a large man (that's enough to eat a half-gallon of ice cream!).  If you catch your diabetes early, when your blood-sugar levels are just starting to rise, eating 150 grams of carbohydrates ("carbs" for short) a day may be low enough to get your blood sugar to a normal level.  If you've had diabetes for a few years, 100 carbs a day may do the trick.  But if you let your diabetes worsen over many years, you may have to eat 50 grams a day (or less) to normalize your blood sugar (i.e., if you are trying to treat your diabetes with diet alone).  It all depends on how much insulin your pancreas is producing, and how much insulin-resistance you have.  You'll have to experiment with your diet.

So can it be said that eating a low-carbohydrate diet is a "cure" for diabetes?  Yes and no.  If your body has a tendency towards diabetes, that tendency will still be there.  If at some point you start to eat more carbohydrates, your blood sugar will go up again.

Allowing your blood-sugar levels to remain high can lead to some very unpleasant complications:  cardiovascular disease (with an increased risk of heart-attack and stroke), neuropathy (resulting in pain and numbness, usually in your extremities, but sometimes in your groin area), amputation of your feet (from advanced neuropathy), sexual dysfunction (from neuropathy), and blindness.  Believe me, it's not pretty.

But What If You're Not Fat?

Probably more than 80% of diabetics are overweight, and this article is directed primarily at them.  Overweight diabetics are generally caught in a vicious cycle:  overeating and weight gain, accompanied by a sedentary lifestyle, lead to insulin-resistance, which makes insulin less effective, which leads to an over-production of insulin to overcome the insulin-resistance, which causes stress on the beta cells, causing them to die, which results in higher blood-sugar levels, which further damages the beta cells, leading to even higher blood-sugar levels, etc.

If you are not overweight, your problem is most likely genetic and/or age-related.  In other words, your beta cells may naturally begin to die with advancing age.  Also, advancing age alone may bring on insulin-resistance, especially if your lifestyle is mostly sedentary.  However, even if you are a slender diabetic, the treatment is the same:  reduce your carbohydrates, exercise more, and take medications and/or insulin.

Medications

When people find out that there are medications for diabetes, they are relieved because they think that diabetes can now be treated with pills.  Really, it can't.  The pills have one of three effects:  They stimulate the pancreas to produce more insulin, they partially block the release of sugar into the blood by the liver, and they reduce the insulin-resistance of your cells.  However, the drugs that stimulate your pancreas do so indiscriminately, and your pancreas may end up producing too much insulin at times when you don't need it.  The drugs that block the release of sugar from your liver do so only partially.  And the drugs that reduce your insulin-resistance do so only slightly.  To overcome insulin-resistance, more insulin is what is really needed (although, as stated above, a low-carbohydrate diet and exercise will reduce insulin-resistance).  This is why insulin injections are probably the best treatment.  Having said this, however, if your diabetes is mild, and if you reduce your overall carbohydrates, the judicious use of medications may keep your diabetes in check for many years.

The best of the medications is Metformin (Glucophage).  Metformin reduces your cells' insulin-resistance, and it also reduces the amount of sugar that is released from the liver.  However, it won't work very well if you eat a high-carbohydrate diet.

I don't recommend any drug that stimulates your pancreas to produce more insulin.  There is some concern that such drugs may cause the pancreas to "wear out" more quickly.  In my personal opinion as an informed consumer, I believe that Metformin is the only safe drug.  (Please note that Metformin will cause diarrhea and general intestinal discomfort for the first 2-4 weeks that you take it, but your body will eventually adapt to it.  If your doctor is going to prescribe Metformin, ask for the extended-release version.  The pills are much larger, but you should have less intestinal problems.)

No matter what drug you take, it won't work very well if you don't reduce your dietary carbohydrates.

Injected Insulin

Injected insulin is essentially the cure for diabetes.  It replaces the substance in your body which is missing in the needed quantities (insulin), and it is very effective at getting your blood-sugar numbers to normal or near-normal.  However, even with injections you will have to keep your carbohydrates to a moderate level, and you will also have to match the amount of your injections to the amount of food you eat.  (If you inject a lot of insulin so you can eat a lot of carbohydrates, you will gain weight.)  Because insulin is injected into fat, and because it takes time for the insulin to make its way out of your fat, injected insulin cannot be taken as an exact replacement for the insulin which is secreted from your pancreas, which acts much faster.  Simply put, the technique for injecting insulin is to inject the amount needed to cover the carbohydrates you'll be eating, and then to be sure that you don't eat more carbohydrates than you injected for. You also need to spread those carbohydrates out over the time that the injection will be effective.

There are two kinds of insulin:  basal (long-acting) and bolus (short-acting).  Basal insulin is injected once or twice a day, and bolus insulin has to be injected 30-45 minutes before meals.  The basal insulins that are generally considered the best -- Glargine (band-name Lantus) and Detemir (brand-name Levemir) -- are about twice as expensive as the cheaper insulins.  The less-expensive basal insulin -- NPH (brand names Humulin N and Novolin N) -- does not have a smooth action in the body (by that I mean that it peaks in your system about 4-5 hours after injecting).

It is important to understand that basal insulins were designed to keep your fasting blood-sugar levels normal -- i.e, your blood sugar level when you are not eating.  They were not designed to compensate for the rush of sugar that enters your blood after meals.  Thus, basal insulin should be used in addition to bolus insulin, not in place of it.  However, if your consumption of carbohydrates is extremely low, one shot of basal insulin a day may be all you need.  But if you are eating a standard diet, you will need to inject bolus insulin to cover your meals.

(Note:  NPH contains a substance from cows which at least one well-known doctor says may cause a mild allergic reaction, although that allergic reaction only seems to affect the speed with which NPH is absorbed into your body.  Also, there is some concern -- very preliminary at this time -- that Lantus may be carcinogenic.)

Bolus insulin comes in two types:  regular (identical to human insulin) and fast-acting.  Regular insulin (brand names Humulin R and Novolin R) is effective for 4 or 5 hours, and fast-acting insulin is effective for 2 or 3 hours.  (In both cases, there is a delay of 30-45 minutes before it takes effect.)  The fastest-acting insulins are Aspart (brand-name Novolog), Lispro (brand-name Humalog) and Glulisine (brand-name Apidra).  Like Lantus and Levemir, these "engineered" insulins are more expensive than regular insulin or NPH.  (I do not have much to say about these fast-acting insulins because your doctor is not likely to prescribe them for new diabetics, and this article is directed to the new diabetic.  Also, I have not taken any of the fast-acting insulins myself.)

Now, it is important to understand the difference between natural and injected insulin.  As stated above, insulin that is secreted by your pancreas is released directly into your blood, and it will immediately lower your blood-sugar level.  Insulin which is injected into your fat will drip into your blood over a period of hours.  So even the fastest-acting insulin is slower than insulin released by your pancreas.  As a result of this, diabetics must "eat to their injections".  In other words, if you take an injection of, say, 25 units of insulin, which you know from experience will cover, say, 75 grams of carbohydrates; and if you know that it will take 6 hours for the insulin to be completely absorbed into your body, then you will want to eat those 75 carbohydrates over a five-hour period to keep your blood sugar levels even (leaving one hour at the end for your blood sugar to get back to normal).

You may think that it would be more effective to inject insulin directly into veins or into muscle so as to mimic the natural action of your pancreas, but your pancreas may release insulin a dozen times a day, and you don't want to take so many injections.  Furthermore, coordinating your injections with your food intake would be very difficult, if not impossible.  In addition, injections made into veins or muscles can be dangerous if you accidentally inject a bubble of air.  (Bubbles of air injected into fat will not harm you.)

How Painful Are Injections?

As I stated above, you'll want to try to get your diabetes under control before it is necessary to take injections; that's because it is harder to control your blood-sugar levels with injections than it is for your body to do it naturally.  Nonetheless, injections may become necessary.  Modern needles are very thin and sharp, and they hurt much less than needles did just 20 years ago.  You may have heard that they are painless.  Well, that's true for some people but not for all.  I take two injections a day, and sometimes I don't feel the needle at all.  At other times, I feel it, but it doesn't hurt.  At other times, it stings slightly, and at other times, it definitely hurts.  It all depends on whether I hit or miss the nerves.  Each person is different.  Apparently, for some people it never hurts (lucky them).  Even if the needle doesn't hurt, the insulin may sting going in (especially if you are taking more than 5 or 10 units of insulin).  Again, however, some people never feel any discomfort as the insulin goes in.

The important thing for you to remember is:  If the injections sting, you'll become accustomed to them, and eventually they will become a routine part of your life.

Please note that there is only one way to inject yourself.  Insert the needle into your fat as fast as possible from a distance of 2 to 3 inches (make sure you are inserting it straight).  The faster the needle goes in, the less it will hurt.  Dr. Richard Bernstein, a well-known diabetes doctor, talks about throwing the needle into your fat like it was a dart, but that can be awkward if you are throwing the needle at your belly (rather than, say, at your thighs).  Also, if you don't throw it straight, or if the syringe flops to one side after being thrown (which it will), you may experience pain.  I've never tried throwing, and I never will.

You should inject your insulin into a large pad of fat, and the best place is usually the stomach (under the ribs down to the groin area, avoiding the area around the belly button, which has more nerves).  You can also inject in your arms, but only if you have a lot of fat there and you are sure the insulin isn't going into your muscle.  You can inject into your thighs or hips if you have a lot of fat there, but I found the thighs to be more painful.  You should not exercise the area where you just injected because that will make the insulin leave your fat more quickly.  Don't, for example, do situps after injecting into your belly.

Using a good needle makes a great deal of difference.  I use BD syringes, which cost 30¢ to 40¢ each.  At one point I searched the internet for a cheaper syringe, and I purchased Easy Touch syringes, which cost 10¢ to 20¢ each.  Even though they have the same specifications as the BD syringes, the Easy Touch syringes seem to be more painful (to me; you may react to them differently).

When you buy your first syringes, you'll want to get syringes with 6mm or 8mm needles that are 31-gauge thick (the thinnest needles available).  There are also syringes available called "pens" that have even smaller needles, but I have no experience with them.  I believe, although I am not sure, that the pens come pre-loaded with insulin, and only the more expensive insulins.

How Many Shots Will You Have to Take?

The number of shots that you'll need to take can vary from two to five per day, but most will need two or three shots.  If you are a type-2 diabetic, that means that your pancreas is still producing insulin -- but exactly how much can vary from one person to the next.  You may only need to cover the carbohydrates in your meals, which would mean two or three shots of bolus insulin each day (two shots if you don't eat carbs for breakfast). If your pancreas is producing very little insulin, you may need to take one or two shots of basal insulin (NPH, Lantus, Levemir) in addition to bolus insulin.  You may be able to get away with taking just one shot of Lantus (the longest-acting basal insulin), but only if you eat a low-carbohydrate diet.  Lantus will not cover your post-prandial needs if you eat more than about 20 carbohydrates per meal.

NPH (the older basal insulin) comes in a mixture with regular insulin in the ratio of 70 (NPH) to 30 (R).  That mixture last about eight hours in the system.  Most people tend to eat a full meal after taking a shot, so in my opinion the ratio of NPH to R should be reversed:  30/70 instead of 70/30.

Note:  Regular insulin is available without a prescription in 49 of the 50 states, so taking insulin is something that you can try yourself without getting a prescription from your doctor.  If you try it, be sure to start with very small shots (5 units or so) and then work your way up to larger doses; otherwise, you can give yourself a hypo (see next paragraph).  Always inject 30-60 minutes before you eat.  You'll know how much of the insulin to take by what your meter tells you.  If 5 units is not enough, gradually increase the dosage one or two units a day until you are taking an amount that results in decent blood-sugar numbers (as given in this article).

As already stated, all insulin is injected into fat.  If you injected it into your veins or muscles, you would have an episode of low blood-sugar which could be life threatening.  Such episodes are informally called "hypos".  Also, if you accidentally injected a bubble into a vein, it could kill you (bubbles injected into fat are not harmful).  When injecting insulin into fat, it is always possible that you may accidentally inject it into a vein, so please read "Avoiding Hypos" below.

(I don't mean to scare you when I say that injecting a bubble into a vein could kill you.  "Could" is the operative word here.  You will not definitely die if you accidentally inject a bubble in a vein.  Rather, there is a small chance that you could die if the bubble made its way to your lungs or your brain.)

There is something called an insulin pump which remains attached to your body.  Insulin pumps have both advantages and disadvantages.  I have no experience with them, so I'm not discussing them here.

A Two-Shots-a-Day Program

In my opinion, regular (or "R") insulin is the best.  If you are horrified at the thought of taking 4 injections of insulin a day (one basal and three bolus to cover your meals), then you can probably get away with injecting R insulin just twice.  This is how:

About 45 minutes before eating breakfast, inject enough R insulin to cover your breakfast and your lunch.  The insulin will remain in your system for about 5 hours, which should give you enough time to eat two meals (if you eat them close together, such as at 8:00 a.m. and noon).  If you get hungry in the mid-afternoon, eat a low-carb snack (cheese, nuts, etc.).  Then, about 45 minutes before dinner, do the same thing:  Inject enough insulin to cover your dinner and a bedtime snack.  If you are a typical type-2 diabetic, your pancreas will be able to secrete enough insulin to handle your fasting needs overnight.

If you want these shots to last a little longer than 5 hours, then mix in some 70/30 insulin.  Mixing in 50% 70/30 will give you a shot that contains 35% NPH to 65% R, a good proportion.  When mixing insulins, draw the R into the syringe first.

In my opinion, two insulin injections a day is the least that a type-2 diabetic can get away with and also eat a near-normal diet.  If you take just one shot of Lantus a day, you will have to eat a low-carbohydrate diet to make it work.

Avoiding Hypos

The word "hypo" is shorthand for an episode of hypoglycemia, or extremely low blood sugar.  Hypos can be caused by certain medications (such as medications that stimulate the pancreas to release more insulin), and by accidentally injecting insulin into a vein or muscle (instead of into fat).  The one medication that I recommend -- Metformin -- does not cause hypos.

If you accidentally inject your insulin into a vein or muscle, about ten to 20 minutes later you will develop a set of symptoms that will be very alarming.  Your heart will start to pound, and you will start sweating as if you were exercising.  You may also feel faint.  If you experience these symptoms, immediately do a glucose test.  If your glucose is low (anywhere from 30 to 70 mg/dL [1.7 to 3.9 mmol/L]), do the following:  Take one or two glucose tablets or candies made primarily from dextrose (another name for glucose), such as SweeTarts.  (If you don't have either of those, eat a teaspoon of sugar.)  Then wait ten minutes and measure your blood again.  If your blood is still low, take the glucose, candy or sugar again.  Repeat this procedure (testing and then eating) until your blood sugar returns to normal.  Once it returns to normal, continue testing every 10 to 15 minutes for the next hour, just to be on the safe side.

It is not necessary to continue to eat sugar until your symptoms subside.  The symptoms -- sweating, heart pounding -- are caused by a hormone called epinephrine (also called adrenaline) which your body pumps into your system to alert you that your blood sugar is dangerously low.  It takes less time to get your blood sugar back to normal (about 15 minutes) than it takes for the epinephrine to leave your body (45-60 minutes). So if you continue to eat as long as you have symptoms, your blood sugar will go way too high.

It is a good idea to always have SweeTarts with you when you inject insulin.  In the three years that I have been injecting insulin twice a day, I have had two hypos.  I marked those spots on my belly, and I will never inject there again.

I said above that the first thing you should do when you experience the symptoms of a hypo is to test your blood sugar.  However, if you've just taken an insulin injection, it might be wise to take a SweeTart first and then test your blood sugar.  If your blood sugar is plunging rapidly, you are in danger of blacking out if your blood sugar gets below 30 or 40 mg/dL (1.7 or 2.2 mmol/L).  (SweeTarts can be bought at almost any candy counter.)

Testing Your Blood Sugar

As a diabetic, you will have to test your blood sugar several times a day (whether you are taking insulin or not).  The results of your testing will tell you which foods to avoid, whether your medication is strong enough, and/or whether you are injecting enough insulin.  You'll want to avoid foods that cause you to have sharp blood-sugar spikes after meals.  The blood-sugar levels you should try to achieve are 85-110 mg/dL (4.7-6.1 mmol/L) when "fasting" (i.e., 3 or more hours after eating) and 130-150 (7.2-8.3 mmol/L) in the 2 hours after a meal (the lower the better, in both cases).

Testing your blood sugar by pricking your skin stings more than the needles do.  You can minimize that sting by getting a blood-sugar monitor that requires only a small tiny of blood, so that it can be used on your forearm (where there are fewer nerves).  However, even on your forearm, the pricks are likely to sting (at least sometimes).  The skin-pricker (called a lancet) works on a spring-loaded action, so you position the lancet in the right spot and then press a button.  The needle jumps out, pricks your skin, and then jumps back.  You can control the depth of the prick by dialing a number (on my lancet, 1 is the shallowest prick, and 5 is the deepest prick).

Important:  Testing your blood sugar on your arm is less accurate than testing on your hands.  Firstly, there is a 15-minute delay when testing on your arm (meaning that the reading you get at any particular moment reflects your blood-sugar level 15 minutes ago).  Second, peaks in your blood sugar are not always reflected in your arms.  Thus, if you slip and overeat on carbohydrates, and your blood sugar rises to 250, the highest reading that you get from your arm may be 180.  To get the most accurate readings, you must test on your hands, and the least painful spots are the fleshy outer palm and the fleshy mound at the base of the thumb.  It is especially important that you test on your hands if you suspect you are having a hypo.

Let me give you an example of how you would use your meter:

Let's say that you eat a meal that contains 80 carbohydrates, and your blood sugar peaks at 180 to 200 after that meal (10.0 to 11.1 mmol/L); and let's say that this happens on several occasions so you know it is a pattern.  180 (10.0 mmol/L) is really too high, so it is then up to you to take some action to get that number down.  Now, the action you take would depend on how you are treating your diabetes.  The first and best course of action (no matter what your treatment) is to lower your carbohydrates to 40-50 grams per meal.  If you are taking Metformin, you could ask your doctor for a higher dosage.  Or, if you are injecting insulin before your meals, you could inject more of it.  The problem might also be that the carbohydrates you are eating are very high-glycemic, meaning that they enter the blood stream quickly and raise your blood sugar quickly.  (For example, sugar, bread and rice enter your blood quickly, whereas pasta enters the blood a little slower, and beans [cooked without sugar] enter the blood even slower.)  So you might choose to eliminate the fast-acting carbohydrates from your meal.  Which course of action you take in getting your blood sugar down depends on your experience using your meter, your judgement, and the judgement of your doctor.

The Dawn Phenomenon

In the morning your blood sugar may always be elevated.  That is due to something called the "dawn phenomenon".  As your body approaches the time of waking, your liver will release glycogen into your blood, and you will wake with your blood-sugar level elevated (the elevation is usually in the range of 20 to 40 points [1.1 to 2.2 mmol/L).  Once you are awake, your blood sugar may continue to rise.  Eating something and/or taking a shot of insulin will stop the rise (although if you eat something, your blood sugar may rise further before it drops).  The "dawn phenomenon" occurs in most diabetics and cannot usually be avoided.  However, having said that, you may be able to control it with an injection of basal insulin before bed, or by eating a very low-carbohydrate diet.  Personally, as long as my waking number is 140 or below (7.8 mmol/L), I don't worry about it.

Let me add that the dawn phenomenon is apparently a natural process which has gone awry in diabetics.  The assumption is that the liver releases sugar into the blood to help wake the person up and to give him or her energy for the day.  The diabetic's body, however, is unable to control the process, and the blood sugar goes too high.

The Action of the Liver

As I stated above, sugar can be stored in the liver, the kidney, the muscles and a few other places in the form of glycogen.  The liver can complicate things when you are trying to get your blood sugar under control because it may release sugar into your blood at unexpected times.  Indeed, when you first start a low-carbohydrate diet (or when you first start injecting insulin), your liver may dump sugar into your blood every day for the first several days or weeks.  Thus, you will start to wonder why your diet (or your insulin injections) are not working.  Eventually your liver will achieve a stasis in which it is not dumping sugar into your blood frequently, and you'll see your blood-sugar numbers drop.  Thus, it is very important that you be patient after starting a new regimen of either diet or injections.  If you choose to eat a very low-carbohydrate diet, such as 50 grams a day or less, this period won't last that long (a week or less), and you may eventually get to the point where so much glycogen has been taken from your liver that it no longer affects your blood-sugar readings very much.  However, if you eat more than 100 carbs per day, that may be enough for sugar to continue to be stored in your liver, and the action of the liver may continue to cause unexpectedly high BS readings from time to time.  Taking Metformin will help to ameliorate these "liver dumps".

Ketosis

As I stated above, the glucose in your blood is used for energy throughout your body.  However, there are substances called "ketone bodies" that can pinch hit for blood sugar.  If you do not eat any carbohydrates, and if you do not eat much protein (some of which is converted to glucose), your body will use fat for energy.  It breaks down the blood lipids (i.e., blood fats, which come from your diet and your fat stores) into smaller components, one of which is the ketone body (or "ketone" for short).  Ketone bodies can be used in place of sugar throughout the body.  When your body is using ketones for energy, it is said that you are in "ketosis".

There is a good kind of ketosis and a bad kind of ketosis (called "diabetic ketoacidosis").  The bad kind of ketosis occurs when a diabetic has inadequate insulin in his body (which is necessary to metabolize sugar), so the body produces ketones to use as a source of energy.  The body will then have both an excess of blood sugar and ketones (this is a dangerous situation and requires immediate treatment).  However, ketones in your blood are not harmful if they are at moderate levels and if insulin is present to regulate your glucose.  Indeed, a ketogenic diet is a good way to lose weight, since your body gradually eats up your fat deposits.

If you eat a diet of 50 carbs a day (or even more for some people) your body will go into ketosis and will use your fat deposits for energy.  Your liver will release most of its glycogen stores into your blood, so you will stop having "liver dumps" which raise your blood sugar.  This kind of low-carbohydrate diet (the same thing that Atkins recommended) used to be controversial because doctors associated it with diabetic ketoacidosis, but it is now understood to be perfectly healthy.  Indeed, ketosis may be a normal state for the human body.  There are some populations, such as Eskimos, which eat mostly meat and fat, and their bodies are in ketosis all the time.  In centuries past, many populations ate carbohydrates only during warm weather (when fruits were available), and their bodies were in ketosis during the winter months (when only meat was available).  Thus, a low-carbohydrate, ketogenic diet is perfectly normal and healthful, and may be the best diet to treat diabetes.

Carbohydrate Addiction

Most people in our country eat a high-carbohydrate diet, and the evidence is increasing that it is the cause of the diabetes epidemic.  You may have eaten a high-carbohydrate diet all your life, not because you love carbohydrates so much (although they are addictive), but simply because you were taught to eat that way.  Some people, however, (and I am one of them) develop a true addiction to carbohydrates.  As stated above, eating a large quantity of carbohydrates will cause a release of a natural tranquilizer in the body called serotonin, and people can become addicted to the serotonin effect.  (A release of serotonin is also caused by some narcotics.)  Also, people who frequently overeat may be lacking certain chemical signals in their body that tell them that they are full.  If you've been eating a high-carbohydrate diet over the years simply out of habit, then giving up the carbs may not be that difficult for you.  But if you are addicted to carbohydrates, it will be much harder.

There are two strategies for giving up carbohydrates:  immediately going to a low-carb diet (this is the "cold-turkey" approach) or gradually reducing your carbohydrates.  A diet of 50 carbs a day (total) is low enough to be considered "cold turkey", whereas a more gradual approach will start you at 175 to 200 carbs a day (a level that will allow you to have a dessert a day, or a couple servings of whatever kind of starchy food you love).  Then, over time, you should decrease the amount of carbohydrates you eat to, say, 100 or 125 grams.  200 carbs is actually pretty high, and you should start at a lower level if you can.  200 carbs is high enough that it will be hard to keep your blood sugar under control.  For me, 150 carbs seems to be the magic number.  If I keep my carbs to that, my health seems to be good, and my blood-sugar fluctuations are not extreme.  Eventually I hope to get to 125 carbs a day, which would be my maintenance level.  A diet of 75 carbs a day will be better for your diabetes than 125 carbs a day, but we do what we are able to do.  On a forum that I frequent, there are quite a few people who eat 125 carbs a day and manage to control their diabetes quite well.

If you decide to go cold-turkey off carbs, it is my understanding that once you've been dieting for 2-3 weeks, you stop craving them.  This, then, is the problem with the moderate approach:  If you eat 100-150 carbs a day and allow yourself to have sweets and starches, that may keep your taste for sweets and starches alive.  In other words, you may never reach a point where you don't crave them.

Another strategy is to go on a very low-carbohydrate diet (50 grams a day or less), and then, after you lose your weight, to increase your carbohydrates gradually to a more moderate level.  What will work for you is a highly individual matter, and you must work it out for yourself.

Incidentally, starting insulin injections may help to decrease your craving for sweets.  That is what happened to me.  There was something about my high blood-sugar levels that was keeping my craving for carbohydrates alive.  When the insulin began to reduce my blood-sugar levels, my cravings decreased also.

But for me, the craving always comes back.  Periodically I will buy (always as the result of an impulse) a box of ice cream bars.  I will then have the ice cream bars as my only carbohydrates for the rest of the day, eliminating all bread and other starches.  It doesn't seem to hurt me at all to do that (in that my blood-sugar levels are often good during such binges), but it might not work for you.  Knowing that I can have ice cream if I really want it helps me on those days when I am being good.  If you try to deny yourself forever the foods you want, that may just lead to failure.  ...  But not always.  You may, instead, have success at completely changing your diet.

Fats

How dangerous are fats?  For years the medical establishment has been telling us that a high-fat diet is dangerous.  Well, that isn't entirely true.  Fats are fattening only when they are accompanied by high levels of carbohydrates.  That's because insulin not only ushers sugar into your fat cells, it also ushers blood lipids (blood fats) into your fat cells.  By lowering your blood-sugar levels, you will also lower your insulin levels, and there won't be excess insulin available to store your blood lipids in your fat cells.  Of course, it is still a good idea to avoid large amounts of saturated fats, although there is disagreement on this point.  Recent research seems to indicate that saturated fats are not as dangerous as was thought, especially when insulin levels are low.  I'll write more on this as I learn more about it.

One thing is certain:  oils contain all kinds of nutrients that we need, especially the omega-3 fatty acids found in fish oils.  They also contain vitamins A and E and sometimes D.  Oils and fats are used in tissues throughout the body, and they also slow down the absorption of carbohydrates from our intestines.

The fats which will be the best for you are mono-saturated oils, such as olive oil.  Other oils besides olive oil are problematic, even other mono-saturated oils.  Oils undergo a great deal of processing.  It is common for food manufacturers to use rancid oils and then heat them to extremely high temperatures to deodorize them.  Rancidity is bad for your body.  Canola oil, the new "healthful" mono-saturated wonder oil, is even worse than the others.  Canola stands for Canadian Oil, Low Acid.  It is mostly rapeseed oil, which contains a toxic substance which is only partially removed from the oil.  It is best to stick with extra-virgin olive oil, which, I believe, is processed less than other oils [I need to check this].

Buying your oils at a health-food store might get you a better quality of oil, especially if it says "cold pressed" on the label.  However, my experience is that the price for such oils is astonishingly high.

More on Diet

I have already said a great deal about diet in the paragraphs above, so I'll try not to repeat myself.  As a diabetic, the best way for you to lose weight is to go on a low-carbohydrate diet.  Eating a high-carbohydrate, low-fat diet is the wrong approach.  Restricting your carbohydrates to 50 grams a day will cause the vast majority of people to lose weight, and some men may be able to lose weight on 75-100 grams per day.  If you are overweight, losing weight is the single most important thing you can do, as it will lower your body's insulin-resistance, and you may find that you can go off both medications and insulin (as long as you do moderate exercise and keep your daily carbohydrates to a moderate level).

Let me give you some examples of low-carb eating so you'll know what I'm talking about.  Here is a day's menu (with alternatives given) that has less than 50 grams of carbohydrates:

Breakfast

Western omelette (eggs, ham, peppers, onions); or eggs with bacon; or a bacon, egg & cheese sandwich on low-carb bread.  (Almost all other breakfast foods -- cereal, pancakes, toast, juice, etc. -- have too many carbs.  If you don't like eggs, substitute dinner foods, such as steak or chicken.)

Snack

Nuts, cheese, olives, antipasto, celery sticks or other low-carb vegetables, Vienna sausages or any kind of meat.  Personally, I like to spread lox cream cheese on ham slices, add cucumber sticks, and roll them up like appetizers.

Lunch

Salad with oil & vinegar or low-carb dressing (no croutons); or cole-slaw made without sugar.

Any kind of meat, fowl or fish (not breaded) on low-carb bread with lettuce, tomato & mayonnaise.  Meat salads with mayonnaise (tuna salad, chicken salad, ham salad) are all acceptable.

- or -

Chef's salad or other meat salad, or meat and vegetable soup, or cream soup (not thickened with starch).

Snack

(same as above)

Dinner

Large salad with oil & vinegar or low-carb dressing (no croutons).

Any kind of meat, fowl or fish (not breaded) with butter, low-carb gravy or cream sauce.  Cooked low-carb vegetables with butter or cream sauce.  (No rice, potatoes or pasta.)

Snack

(same as above)

Daily Dessert

If you need a daily dessert, you could have any sweet thing which has 20 carbs or less, such as:  Chobani yogurt (20 carbs), Slim-Fast (20 carbs), a Hershey's dark chocolate bar (22 carbs), berries of various kinds (strawberries, blueberries, raspberries, blackberries) with heavy cream and artificial sweetener.

What I just gave you is one example of a day's diet.  It may sound monotonous, but there are all kinds of ways that you can make it tasty.  Keep in mind that you don't need to restrict fats, so you can actually eat a lot of rich foods.  How does asparagus with lemon butter sound?  Or broccoli and pearl onions with hollandaise sauce (or a thick cheese sauce)?  Or chicken with Thai red curry sauce?  Or peppers, cabbage or grape leaves stuffed with seasoned ground meat?  If you enjoy cooking, the variety of delicious low-carb foods you can make is limitless.

Making Substitutions

Reducing your carbohydrates is all a game of substitutions.  Let me give you some examples:

(1)  If you like sandwiches, you will find that the name-brand breads can have as many as 20 carbs per slice, whereas the supermarket-brand breads usually have about 10 carbs per slice.  If you really want to reduce your carbohydrates, you can buy low-carb breads made by Pepperidge Farm, Arnold's and Sara Lee (which generally have 7 grams per slice).  (Please note that Pepperidge Farm's "Carb Style" bread tastes of soy, so you might prefer the taste of their "Light Style" bread.)  A company called Joseph's makes low-carb pitas which have only 4-5 carbs per loaf (one loaf makes a sandwich).

(2)  On your sandwiches, use mayo or mustard instead of ketchup.  Use regular mustard instead of honey-mustard.

(3)  Instead of rice, potatoes or pasta with dinner, have two or three cooked vegetables with butter.  Instead of mashed potatoes, try pureed cauliflower or squash.

(4)  If you like potato salad, substituting cole slaw will bring your carbs down (though cole slaw is often made with a lot of sugar).  Making your own cole slaw with artificial sweetener will reduce your carbs even more.  Better yet, a green salad with low-carb dressing is the most nutritious.

(5)  Many brands of Greek yogurt have 1/3 less carbohydrates than Dannon or Yoplait.  To make them sweeter, stir in a packet of Nutrasweet or Splenda.

(6)  If you can't live without ice cream, a pint of Hershey's ice cream will have fewer carbs than Ben & Jerry's or Haagen-Dazs.

(7)  This one is obvious:  Substitute diet drinks for sugary drinks.

Important:  Diet drinks can cause you to eat more because they keep the taste of food in your mouth, thereby stimulating your hunger.  I strongly recommend that you stick to ice water as your only beverage.  Coffee and tea can also stimulate your hunger if they contain artificial sweeteners.

(I'll add more examples as I think of them.)

Don't Be a Hero

Having told you to reduce your carbs, I now must say that restricting your diet more than you can stand may backfire.  If you feel comfortable eating 150 grams of carbs a day, trying to eat just 50 grams may cause you to abandon your diet altogether and go on a binge.  If you love carbs, try starting with 200 grams of carbs per day and reduce your carbs gradually by substituting lower-carb foods for higher-carb foods.

What Parents Can Do for Their Children

Parents should not permit any of the following foods to be kept in the house:  sugary sodas; artificially sweetened drinks of any kind such as Cool Aid or Sunny D; low-quality desserts such as doughnuts, Twinkies and Ring Dings; candy; chips of any kind; sugary cereals, pastries, waffles or pancakes; and white bread or rolls.  Children should be taught to quench their thirst with milk or ice water.  Juices should be served at breakfast only.  Table sugar should be used sparingly.

(Diet drinks are a problem because, although they don't put sugar in your child's body, they teach your children to always want a sweet taste in their mouths.  However, I'm not sure about this, so I can't give definitive advice.)

My suggestions for breakfast are eggs, bacon or ham, whole-grain toast with sugar-free jam, yogurt, and whole grain cereal with artificial sweeteners.  Oatmeal is okay if it is not instant, and if it is artificially sweetened.  Grapefruits should be eaten without sugar.

Desserts can be eaten occasionally, but they should be a special thing, and they should always be high quality.  An example of a high-quality dessert would be a home-made carrot cake made with natural ingredients, and which isn't too sweet.  The point is that you don't want to be teaching your kids to like junky sweets, which are available everywhere.  If your kids have high culinary standards, they are less likely to eat foods that are bad for them (well, we can hope).  Fruit salad, solid chocolate, trail mix with chocolate, and Greek yogurts make good substitutes for more carb-rich desserts (and I think they all taste good enough to satisfy your kids).  Mixed fruit can be extremely delicious if you choose the right fruits.  Ice cream and pudding have some protein in them, so they will be better than cakes and pies.  If you are serving your kids ice cream, give them plain chocolate or vanilla or strawberry instead of Ben & Jerry's ice cream that has syrup and candy mixed into it.  If you enjoy cooking, you can learn to make reduced-carb desserts.  Egg custard made with artificial sweeteners can be very low in carbs.  Of course, artificial sweeteners may not fool your kids' taste buds, but egg custard made with 1/2 sugar and 1/2 artificial sweetener might fool their taste buds, and it's better than egg custard made with all sugar.

Parents should insist that their local schools not sell sodas or candy to their students.  In my opinion, any school which sells such items within its walls is abusing its students.  Many, if not most, school districts allow the sale of junk food in their schools because they make money from it, which is a shameful situation.

More on Neuropathy

The latest trend in the treatment of diabetes is to put diabetics on insulin injections earlier rather than later.  The longer you wait, the more likely you are to develop neuropathy in some part of your body (most commonly in the feet).  I learned this lesson the hard way.  I told my doctor in 2010 that I thought I should take insulin injections.  He didn't say no, but he wondered why I wanted to take injections before it was really necessary.  By the time I did start injections in March, 2011, I had developed significantly worse neuropathy in my feet.  It took five or six months of injections for the neuropathy to subside substantially; and now, when I go off my diet, the neuropathy comes back.  To a considerable extent, neuropathy can be healed, but nerves which have been damaged will always have a tendency to become re-inflamed, even if you drastically improve your diet.  It is important that you take your diabetes seriously before you suffer permanent nerve damage.

Generally, the symptoms of neuropathy include tingling, numbness, aching, spasms, and outright pain; and that can occur in your feet, your ankles, your hands, and your groin area.  You may lose your ability to become sexually aroused (speaking physically now, not psychologically -- i.e., no more erections for men).  The feet are usually the first to be attacked, and your ankles may hurt as if you had gout.  Your ankles may become weak and you'll feel like you are about to collapse, only to catch yourself (until the day comes when you do collapse).  Your toes may spasm in the oddest way (that was the most disturbing symptom for me).

Finding a Good Doctor

The kind of doctor that you, as a diabetic, need depends on what kind of person you are.  If you are informed and pro-active, you will need a doctor who is flexible and not threatened by an educated patient.  Such a doctor will be your partner in controlling your diabetes, and he or she will not expect to dictate your treatment to you.  If, on the other hand, you want to leave all the decisions up to your doctor, then you need a doctor who has the right ideas.  The right ideas, in this case, means that your doctor believes that you should eat a reduced-carbohydrate diet and get your A1c below 7.0.  In addition, beware of doctors who are drug-happy -- i.e., who prescribe several medications.  Many diabetes medications have problematic side-effects, and metformin (also called Glucophage) is the only one which is truly effective and safe.

Beware of Misinformation

The American Diabetes Association (ADA) has become infamous among knowledgeable diabetics because it appears to be spreading misinformation.  Several of their top executives are former food-industry lobbyists, and they recommend a diet that is fairly high in carbohydrates (though not excessively high).  Nonetheless, if you go to their web site, you will find recipes for cakes, cookies and other desserts.  Although a diabetic can eat moderate amounts of sweets, to encourage the consumption of sweets is highly irresponsible.  Years ago it was discovered that starchy foods (such as bread) are converted into blood sugar as quickly as table sugar is.  The logical conclusion was that bread and other starchy foods should be avoided.  Instead, the ADA concluded the opposite:  that it is okay to eat sugar (and eat it, and eat it, and eat it).  An organization called dLife has picked up on the misinformation spread by the ADA, and their site is also filled with an astonishing number of high-carbohydrate recipes.

Even if you can eat a dessert every day, is it a good idea for any diabetic to bake an entire cake or pie?  Let's look at the situation:  At the time of this writing, dLife lists a recipe for an Amaretto Pumpkin Pie that makes 8 servings that contain almost 61 grams of carbohydrates each (to be exact, 60.8 grams after fiber is deducted).  That is a total of 486 grams of carbohydrates.  I can tell you right now, unequivocally, that eating 61 grams of sweets at one sitting will cause the blood sugar of most diabetics to spike over 140 (7.8 mmol/L) (the cut-off for what is considered absolutely safe), and many (if not most) will see their blood sugar spike to 160 (8.9 mmol/L), 180 (10.0 mmol/L), or 200 or more (11.1 mmol/L) -- even if the diabetic first takes a shot of insulin.

In order for a single person to eat up such a pie, he or she would have to eat a slice a day for 8 days -- but of course, the pie may not last in the refrigerator that long.  For a family of three to eat it up, two members would have to eat a slice for three days in a row, and the third member would have to eat a slice for two days in a row.  That is a lot of sweets to be feeding your family, especially given the amount of sugar per slice.  In addition, with a delicious pie sitting in the fridge, there is a chance that the diabetic might lose control and eat more than one slice in a day. Also, pies are generally eaten as desserts, which means that they are eaten at the end of a meal.  If you have already eaten 20, 30 or 40 carbohydrates at your meal, eating a slice of this pie will take your total for the meal to 80 or more, which is a lot for a diabetic.

dLife has a rating system:  "Very Low Carb", "Low Carb" and "Carb Safe".  That recipe was not rated at all, which means that it is not "Carb Safe" for diabetics.  If that's the case, why is it listed on their site?

Let's look at one of their "Carb Safe" recipes, Almond Spice Pound Cake.  That cake has 12 servings, each of which has approximately 25 grams of carbohydrates.  25 carbs is a reasonable amount for a dessert, yet there are the same issues with this cake as with the pie:  A single diabetic person would have to eat it up over 12 days, before which time it would have spoiled.  A family of three would have to eat a slice a day for four days, a lot of carbohydrates for a family to be eating.  And this doesn't take into account that eating sweets every day will keep your taste for sweets alive.  A diabetic should endeavor to eat sweets on occasion, not every day.

In my opinion, organizations like the ADA and dLife are about as irresponsible as they can be.  They serve as examples that the food industry has long tentacles that reach into all areas of our life, even into supposedly objective non-profit organizations.

Let me add that there are also medical supply companies which advertise cookbooks to diabetics that are full of dessert recipes.  A company called HDIS is possibly the worst of them.  By convincing diabetics that they can eat virtually anything they want, these companies hope to get new business.  It seems that keeping diabetics addicted to sugar and then treating their high blood-sugar levels is quite a lucrative business.

Diabetes Research

It is important that you not accept as gospel the conclusions of every study that comes down the pike.  For example, a recent study has concluded that a high-fat diet can contribute to diabetes.  However, that study was conducted solely on rodents, which react to fats very differently from human beings.  Also, the rats were fed high levels of carbohydrates along with the fats, so the carbohydrates were probably the culprit.

Less recently, there was a study that showed that diabetics who kept their A1c's low had a higher incidence of stroke and heart attack.  However, many of the participants in the study were using Avandia and a couple other drugs that are known to cause cardiovascular problems.  Getting your blood-sugar low by eating a reduced-carb diet and taking metformin and/or insulin will not cause cardiovascular problems.

In the world of medicine, most studies are funded by drug companies and other corporations, and that undoubtedly colors the conclusions that are drawn.

Getting More Help

Other Sites

This site is very useful:  www.bloodsugar101.com.  It is run by Jenny Ruhl, a lay expert on diabetes (meaning that she is not a doctor, but rather a diabetic who has done a great deal of research in the area).  My only criticism of Jenny is that she can be ever-so-slightly alarmist at times, in my opinion.  But her advice is generally very good.  she also has a blog, the link to which can be found on her site.

The site www.mendosa.com is run by a journalist named David Mendosa (also not a doctor).  There are dozens of useful articles on his site.

Forums

I am hesitant to recommend any forums because you can receive bad advice.  There are a lot of differing opinions about how to treat diabetes.  One forum, which I won't name, has a large contingent of aggressive low-carbers who are intolerant of anyone who is trying to eat a more normal diet.  The advice that I offer here (to eat low-carb if you can, or otherwise eat a reduced-carb diet and take metformin and/or insulin if necessary) is moderate advice, and it will help the most people.  There is also a great deal of censorship on all the forums.  If you are even slightly outspoken, you will be reprimanded or have your posts deleted.  It can be very humiliating.

Books

Until I fill this section in, I am going to refer you to David Mendosa's page about diabetes books:  www.mendosa.com/books.htm .  However, Jenny Ruhl has written her own book, Blood Sugar 101, which I recommend, though it is not on David Mendosa's reading list.

A Word About Dr. Richard Bernstein

There is a prominent diabetes expert named Richard Bernstein who has written a well-known book entitled The Diabetes Solution.  Dr. Bernstein recommends a very low-carbohydrate diet accompanied by multiple insulin injections each day in order to keep one's blood sugar within an extremely narrow range (more narrow than normal).  Indeed, eating just the 20 grams of carbohydrates every day that he recommends may make it unnecessary for you to inject insulin at all, even if you are now taking it.  Although keeping your blood sugar right between 88 and 90 mg/dL will undoubtedly be better for your body than letting it range between 90 and 140, the higher range just given will keep most people in good health into old age.  Bernstein is very old, and he was a pioneer in understand the importance of normal blood-sugar levels, and in advocating self-monitoring by the patient.  When he was young, few people tested blood sugar levels (even doctors didn't), and syringes had big needles that must have been very painful.  Bernstein's obsessively tight control of his blood sugar is undoubtedly the result of his life experiences, and also a result of his public position as a diabetes expert.  In my opinion, your average diabetic doesn't want to be so persistently strict with their treatment -- in addition to which, injections are not painless, as Bernstein claims, which will make multiple small injections every day anathema to most people.  It is up to you how you treat your diabetes.  If you have an obsessive personality and are happy to eat almost no carbohydrates, you may be able to follow Bernstein's recommendations.

As to why Dr. Bernstein thinks that injections are painless, I assume he is comparing the sting of an injection to the much greater pain he felt in the early days when he was using those older needles.


A Step-by-Step Guide for Newly Diagnosed Diabetics

1.  Immediately buy a carbohydrate counter (a book that tells you the carbohydrate values of foods).  You can also find the carbohydrate values of foods on these sites:

http://caloriecount.about.com/

http://www.carb-counter.org/

2.  Start keeping a daily log of your foods, carbohydrate totals, and exercise.

3.  Start counting the carbohydrates in your foods, and eliminate the foods that have the most carbohydrates.  Your immediate goal is to get your daily carbohydrates down to 150, and then eventually to 100 (if possible).  Avoid sweets and refined starches (as much as possible), and eat some low-carbohydrate vegetables every day (salads with low-carb dressings are especially healthful).  The focus of your diet should be on poultry, fish, meat, cheese, low-carb vegetables, nuts, seeds, and low-carb fruits (such as berries).  Use butter and olive oil in place of other fats.  Take a multi-vitamin/mineral pill every day.  If you don't eat much fish, taking omega-3 fatty acid supplements is also a good idea.  If you must have sweets, try to be satisfied with a yogurt or small chocolate bar.

4.  Buy a blood-sugar testing meter.  A diabetes expert by the name of Richard K. Bernstein recommends the Roche Accu-Check Aviva meter as being the most accurate.  The Bayer Ascensia Contour meter is also fairly accurate.  At the time that you buy the meter, you will also need to buy testing strips for your meter.  Test strips will generally cost more than $1 each when purchased in a drug store.  On eBay you can find them for as little as 40 cents each.  (When making purchases on eBay, be sure to note the expiration dates of the strips being sold, and avoid sellers who don't have a rating of 99.8% or better.)

5.  Test your blood sugar at least three times a day:

- after waking -- eventual goal: 120 or less (6.6 mmol/L)

- 1-1/2 hours after your largest meal -- eventual goal: 140 or less (7.8 mmol/L)

- 3 hours after your largest meal -- eventual goal: 120 or less (6.6 mmol/L)

Continue to reduce your carbohydrates until you see better blood-sugar numbers.  Don't be upset if your numbers, initially, are not anywhere near the goals just given.  Remember that your liver will pump sugar into your blood for the first 1-4 weeks that you are dieting, so it may take time for your blood sugar numbers to drop.

6.  Begin to exercise four or five times a week for 20 minutes, even if that only involves walking.  Both aerobic and strength-building exercises are good.

7.  Keep it up.  Keep lowering your carbohydrates, exercising, and testing your blood until your blood-sugar numbers approach the goals mentioned in step 5.

8.  See your doctor and get an A1c test (your eventual goal is a 6, but going lower is better).  If your blood-sugar readings are over 200 (11.1 mmol/L), ask your doctor for extended-release metformin (but remember, metformin will give you intestinal discomfort for the first couple weeks.  Start with a low dose and work your way up.)

9.  If after a couple months of this regimen you are having trouble getting your blood-sugar numbers under 200 (11.1 mmol/L), consider injecting insulin.