Doctorweblog. About Health & Medicine

Taking care with what you eat is essential if you have diabetes. For some people with type 2 diabetes, this is all they have to do to keep their blood sugar levels in the normal range of between 4 and 8 millimoles per litre. Others also need to take tablets or injections of insulin. People with type 1 diabetes must have insulin injections. But no matter what the treatment, everyone with diabetes must take care with what they eat in order to keep their blood sugar levels under control Keeping the blood sugar near the normal range helps prevent complications of diabetes such as blindness, heart attacks, kidney failure and amputations.

For over a hundred years, people with diabetes have been given advice on what to eat Many diets were based more on unproven (although seemingly logical) theories, rather than actual research. In 1915, for example, the Boston Medical and Surgical Journal advocated that the best dietary treatment for someone with diabetes was ‘limitation of all components of the diet’. This translated into a very low kilojoule diet interspersed with days of fasting. Unfortunately, malnutrition was often the result!

In the 1920s doctors began recommending high fat diets for their patients. Ignorant of the dangers of a high fat diet, they knew that fat, at least, didn’t break down to become blood sugar.

It was not until the 1970s that carbohydrate was considered to be a valuable part of the diabetic diet Researchers found that not only did the nutritional status of patients improve with a higher carbohydrate intake, but their blood sugar levels improved as well.

The only part of food which directly affects blood sugar levels is carbohydrate. When we eat carbohydrate foods, they are broken down into sugar and cause the blood sugar levels to rise. The body responds by releasing insulin into the blood. The insulin clears the sugar from the blood, moving it into the muscles where it is used for energy, so the blood sugar level returns to normal.

Some people think that because carbohydrate raises the blood sugar level, it should not be eaten at all by people who have diabetes. This is not correct. Carbohydrate is a normal part of the diet and at least half of our total daily kilojoules should come from carbohydrate. In fact, the more carbohydrate you eat the better because it automatically reduces the proportion of kilojoules you get from fat.

The secret to the diabetic diet is not so much the quantity but the type of carbohydrate.

Traditionally sugar was excluded from diabetic diets because it was thought to be the worst type of carbohydrate. The simple structure of sugar supposedly made it more rapidly digested and absorbed than other types of carbohydrate, like starch. This assumption was simply not correct. Even in the late 1970s, test meal studies showed that there was a great deal of overlap between the blood sugar responses to sugary and starchy foods. Fifty grams of carbohydrate eaten as potato caused a similar rise in blood sugar as 50 grams of sugar. Ice cream resulted in a lower blood sugar response than potato! Findings like these sparked research into the G.I. factor in an effort to learn more about how the body actually responds to different carbohydrate foods.

The emphasis through the 1970s and for much of the 1980s, was on the quantity of carbohydrate in the diet. ‘Portion’ diets were used to prescribe a set amount of carbohydrate to be eaten at every meal. (A carbohydrate portion* is an amount of carbohydrate-rich food which contains 10 to 15 grams of carbohydrate—depending on which country, or State of Australia—you lived in. So, not only was the portion system complicated, portion sizes varied throughout the world!).

An underlying assumption of the carbohydrate portions theory, was that equivalent amounts of carbohydrate, irrespective of the type, cause an equal change in the blood sugar level. This reasoning had no scientific backing and has since clearly been shown to be incorrect. Fortunately, good quality scientific research supports today’s dietary recommendations for people with diabetes. While the G.I. factor research has not negated the significance of the quantity of carbohydrate in the diet, it has shown us the importance of considering the type of carbohydrate food that we include.

The G.I. factor has shown us that the way to increase the quantity of carbohydrate in the diabetic diet, without increasing the sugar levels in the blood, is to choose carbohydrate foods with a low G.I. factor.

Our research has shown that blood sugar levels in people with diabetes are greatly improved if foods with a low G.I. factor are substituted for high G.I. factor foods.

*126\42\4*

The following lists some basic tasks and resources which can be used by the fat loss counsellor in exploring the psychological component of excess body fatness. More detailed therapy should be referred to a qualified professional psychologist.

Current attitudes.

1. Identify current thoughts, feelings and attitudes to fat loss: What for? Why now? How long for? What then? Ensure clients recognise that permanent fat loss means lifestyle change.

2. Clarify expectations of fat loss: What problems are anticipated that it will solve? How else could these problems be dealt with? If any of these expectations are perceived negatively, how else could the problem be managed?

3. Clearly define a lifestyle which is both acceptable and achievable, which will maintain a lower level of both fat intake and body fat level.

History.

1. Explore previous experiences of fat/weight loss: What worked, What didn’t? What lasted? How were relapses dealt with? Understand what went wrong or right and how this time is different.

2. Deal with family leftovers, experience of fatness in the family, food messages, how eating, drinking and exercise played a part in the family life and what impact these still have.

Obstacles.

1. Identify which important aspects of lifestyle keep the client from losing fat: food choices, feelings/experiences which seem associated with inappropriate eating, time pressure, stress, lack of regular exercise, food knowledge?

2. Identify times during the day/week which represent the most difficult times to control eating: Mealtimes? Snack times? Going to work? Going home? Eating out?

Knowledge.

1. How good is the client’s knowledge of what is in food? How is this used? What else is happening at times when fattier food is deliberately chosen?

2. Increase knowledge of low-fat shopping, cooking, recipe modification and food skills associated with developing palatable, low-fat foods.

Stress management.

1. Identify possible connections between perceived stress and eating behaviour.

2. Develop effective stress management techniques which do not involve the use of food, in conjunction with other regularly used ’self-nourishing’ activities.

3. Plan and use time consistent with lifestyle aims (i.e. incorporating deliberate and incidental exercise, food choices and meal planning).

4. Develop and practice assertiveness, with self and others.

Habit management.

1. ‘Reframe’ eating habits which contribute to overfatness as ‘curious and interesting’ as opposed to ‘immoral or bad’.

2. ‘Stalk’—describe eating, drinking, exercise avoidance habits or routines and develop strategies for interrupting these. Monitor self-talk, identify triggers for over-eating and thinking patterns associated with these. Challenge beliefs about self body image.

3. Evaluate social environment for social support. Develop ways to protect self from ‘high risk’ situations.

Relapse management.

1. Identify and develop a clear strategy for dealing with relapses. This includes strategies for dealing with celebrations and festivities, times of high stress and pressure, times of boredom alone and negative mood states.

*190\186\4*

There is some inter-conversion between nutrients such as protein being converted to glucose (gluconeogenesis) for release into the bloodstream, but under normal conditions, the capacity to convert one nutrient into another for storage is very limited. Also, humans have little capacity to ‘waste’ extra energy by burning it off. This process, which has been termed luxuskonsumption, is common in animals such as rats but is very limited in humans. Therefore, the examination of each macronutrient as a separate entity is necessary and is summarised below.

Alcohol. There is an inconsistent relationship between reported alcohol intake and body mass index, with many studies showing that drinkers of large amounts of alcohol have lower body weights. This has led to hypotheses that alcohol calories may be subject to inefficient oxidation, thereby diminishing the impact of alcohol calories on energy balance. In heavy drinkers, there does seem to be an inefficient burning of alcohol because the addition of alcohol to a weight maintenance energy diet does not result in weight gain. Virtually all ingested alcohol is metabolised in the liver and this process produces energy. None of it is converted directly into fat. The main pathway is via the enzyme alcohol dehydrogenase and this should theoretically produce 7kcal/g of alcohol. However, alcohol also appears to induce another series of liver enzymes to burn it and this pathway produces far less energy for use than the usual one.

Alcohol, perhaps because of its toxic potential, is the top priority fuel for burning and, if present, displaces fat and, to a lesser extent, carbohydrate and protein as fuel sources for energy needs. Hence, while alcohol does not directly turn into body fat, it will certainly send any spare fat in the diet into storage. So it appears that the so-called ‘beer gut’ may not be full of beer calories, but rather full of the chips and nuts that accompanied the beer which have been sent to the fat cells for storage. A sobering fact though is that although alcohol does stimulate its own burning, it does not satisfy hunger, and indeed may stimulate appetite. The nature of beer is such that the type of food that is likely to be eaten with it will probably be high in fat (can you imagine beer and fruit rather than beer and nuts?). The sugar which is in the beer, wine and mixes may have an effect on reducing appetite and therefore counter the stimulation of appetite by the alcohol. Overall, we could consider alcohol as ‘half-balanced’ as a form of energy in the body and a potential promoter of weight gain.

*51\186\4*

Bronchiectasis means that large infected cavities have developed in the lungs. It is a chronic disease, often starting during childhood and following on from an infection. Whooping cough, measles, bouts of influenza or pneumonia may have been the predisposing infection. Small cavities of the lung are infected, and this usually spreads gradually. Although the general health of the child may originally have been good, a chronic loose cough becomes established. At first it may be apparent only in the mornings or the evenings. When the child runs or exerts himself, there may also be some breathing difficulty. He gets out of breath easily. Gradually, as it develops, he may lose weight and also lose general health and vitality.

Older children tend to develop a cough and bring up large quantities of foul-smelling sputum. Often there is a mild fever which waxes and wanes. In long-standing cases the doctor notices that the fingers become clubbed. (This means the normal ends of the fingers are more rounded.) Many children become anaemic, pale and obviously in deteriorating health.

Treatment

Most doctors believe that bronchiectasis can usually be prevented by adequate treatment of any respiratory disorder. Upper respiratory tract infections, bouts of the flu, coughs and colds, bronchitis, pneumonia, removal of foreign bodies—whatever the cause and nature of the respiratory disorder—if this is treated adequately and completely until a full recovery has taken place, then the risk of this hapless and debilitating chronic disease is not nearly so high. It is salutary advice which parents would do well to follow.

Treatment must be under the proper care of a doctor or hospital where full facilities are available, and where ongoing care and advice can be offered. Lengthy hospitalization is usually not needed, and much of the care can be given at home by the parents.

In the early acute stages, when diagnosis is being established, hospital care may be needed. Antibiotics, aerosol bronchodilators, postural drainage and breathing exercises all form an important part of treatment. Adequate nutrition is also important. Sometimes diseased tonsils or adenoids may require surgical removal, or sinus drainage undertaken. In severe cases, when the disease is confined to a particular lobe of the lung, removal of the lobe may be advisable.

The crux of ongoing home treatment is the postural drainage and breathing exercises routine. This is aimed at removing as much debris from the lungs as possible, and opening up the air passageways to enable as much oxygenation as possible of the lung tissues. The routine may be continued for many months, for years, or possibly for a lifetime.

There is often no simple do-it-yourself cure for bronchiectasis. It usually is diagnosed in hospital, and treatment and ongoing care must often continue for a considerable period of time. Parents should make certain they carry out full instructions to the best of their ability. They should also explain to all their children (especially older ones) the nature of the problem and the need for continual co-operation. Without this, it becomes an even more difficult medical problem.

In early stages, moderate bronchiectasis is often completely curable. However, some cases continue for many years and require ongoing management under the experts.

*75\87\2*

Many speech problems may occur, from the child speaking indistinctly, to repetition of the same syllable, or to speech being delayed. Often overprotective parents may unconsciously retard their child’s speech ability by pursuing baby talk as their method of communication. This is no fault of the baby. Stuttering or stammering (in which certain words or syllables are compulsively repeated or there is a complete blockage of certain words) are almost always nervous in origin. There is usually nothing anatomically or physiologically wrong with the speech mechanism; it is simply because of tension and stress at the subconscious level.

Occasionally there may be a question of normal mental development, but this can usually be quickly evaluated. In most cases, this is not the cause. A changed attitude by the parents and their efforts at helping the child speak normally often helps, with avoidance of baby talk as the child gets older. Stuttering often starts in the 3-6 age group when the child is often subjected to emotional stresses or tensions.

Treatment

Like most other anxiety-induced symptoms, eliminating the cause, as much as possible, as early as possible, is the ideal. Special anxiety-producing situations and circumstances must be carefully sought out. It may take time to do this, for situations that are of little importance to a parent may be major to a child. A sense of being wanted, of security, warmth and affection, is important. Instilling confidence into the little person, reducing fears and dreads and removing frightening situations all assist. Stuttering and stammering in the older child and adult are often very difficult to treat. In recent years, considerable success has been achieved in older children with the use of medical hypnotherapy. This again indicates the emotional nature of the disability.

*26\87\2*