Driving and Diabetes

December 18, 2014 at 11:42 am | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPPossessing a driver’s license is a rite of passage in our society.
A driver’s license is seen as a gateway to independence and is a necessity for survival in many instances since many places in the US don’t have adequate public transportation. Driving is such a huge part of our lives, but there are instances when the ability to drive competently is also at issue. The American Diabetes Association (ADA) published a Position Statement on Diabetes and Driving in the 2014 Clinical Practice Recommendations. I would like to summarize the key points of this Position to provide an overview to help both people with diabetes and their health care providers have the best information about driving with diabetes.

The process for identifying drivers with diabetes varies from state to state, depending on what type of vehicle the driver needs to be licensed for. In some states, questions such as “Do you have any medical condition that may interfere with the safe operation of a motor vehicle?” are asked at the initial application for license. These questions may then prompt the need for further medical evaluation. There is no need for a medical examination just because the driver has diabetes. Most often a medical evaluation would be requested when there has been a documented episode of hypoglycemia while driving. Visit the ADA Website for more information on specific rules for each state.

Drivers with diabetes that are commercial drivers in interstate commerce have different rules and follow a set of uniform federal regulations. ALL drivers are subject to an examination every 2 years to update the driver’s ongoing general fitness. Drivers with diabetes managed with diet, exercise, and oral medications do not have any further requirements. Drivers who use insulin often require a more detailed medical evaluation so an exemption to drive and medical certification can be granted. Drivers for commercial motor vehicles, such as school bus drivers and vehicles that transport passengers or hazardous materials are subjected to more strict evaluations that differ state to state.

There are many factors to consider when caring for the driver with diabetes. I want to be clear: a diagnosis of diabetes or the use of oral medications or insulin does not mean that driving ability is compromised. The ADA has determined that the single most significant factor associated with collisions for drivers with diabetes appears to be a recent history of severe hypoglycemia regardless of diabetes type or treatment. The ADA Workgroup on Hypoglycemia defines severe hypoglycemia as an event that disrupts cognitive motor function and requires the assistance of another person to treat the hypoglycemic event.

The plan of assessment and care of the driver with diabetes needs to be individualized. It is important to not only review hypoglycemia awareness, but to also review the other conditions that could interfere with safe driving. These conditions may include decreased visual acuity due to retinopathy or cataracts, neuropathy that diminishes the sensation of the right foot, or sleep apnea which can result in daytime sleepiness. Drivers that have had a hypoglycemic event will need much closer evaluation and education. The driver may need re-education to address issues with mealtimes and dosing of medications (or medications may need to be adjusted altogether), further education about hypoglycemia awareness, and the best methods of treating low blood sugars. Drivers who have had episodes with severe hypoglycemia may also need to perform additional glucometer testing.

People driving for long distances should have a good supply of glucose tablets easily available in the glove compartment or in the console. A supply of snacks such as packages of cheese and peanut butter crackers or nuts should also be stored in the front of the car with the driver and checked before each trip. Drivers who feel hypoglycemia occurring while driving should pull off the road immediately, put on their blinkers, and treat with a fast acting carbohydrate. Do not resume driving until blood sugar values are normalized.

Finally, I advise that all of my patients with diabetes have a medical ID with them at all times. Symptoms of hypoglycemia may appear as if driving under the influence of alcohol or drugs, which can lead to losing precious treatment time if there is an incident where you are unable to identify yourself as having diabetes.  First responders are trained to look for things like a bracelet or necklace, or a card in the wallet.

Healthy Tips for Managing Holiday Stress

December 11, 2014 at 10:49 am | Posted in Health | Leave a comment
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The holidays are a time of fun and excitement, but they can also be a time of added stress.

While stress is a normal part of life, it can have an impact on diabetes management. Stress hormones can raise blood sugar, and prolonged stress weakens the immune system and interferes with healthy self-care routines.

Stay healthy and enjoy the season with these techniques for managing holiday stress:

  • Prioritize – A common cause of holiday stress is trying to do too much at once. Focus on those things that are most important to you, and don’t be afraid to say “no” to taking on new commitments.
  • Take “time out” (Find a distraction) – Take a break and do something to clear your mind. Spend time with or call friends. Engage in some other activity you enjoy (like a favorite hobby).
  • Get Moving – Exercise is a known stress reducer, and sticking with your regular fitness routine can help with maintaining good blood sugar control. Small steps make a difference! Go for a walk, put on a yoga video or dance to a song on the radio.
  • Relax – Mind-body activities like meditation, deep breathing or positive visualizations elicit the relaxation response, the body’s built-in counter to the stress response.

Losing or maintaining a healthy weight is another source of stress for many during the holidays. The added pressures of the holidays can also contribute to emotional or stress eating (eating for reasons other than hunger). Signs of stress eating can be turning to comfort food after a difficult day, or mindlessly munching on snacks to burn off nervous energy. The downside is many comfort foods are high in sugar (which can raise blood sugar), fat, and calories. Distracted snacking makes it easy to take in more calories than expected. Consider preparing some healthy snacks to have accessible.

The techniques above can help with coping with stress eating as well, but if you’re still craving a crunchy snack or Mom’s Mac and Cheese go ahead and have some – just do so mindfully. Keep track of portion size, and eat slowly so you can really enjoy the food’s taste and texture.

It’s not possible to avoid all stress completely, but one final thing to remember is the holiday season (and the stress that comes along with it) is temporary. Slow down and enjoy the best the season has to offer. If you’re still feeling overwhelmed or think you might be experiencing diabetes burnout, talk to your health care provider or a diabetes educator.

(Post content reviewed by the Benson-Henry Institute for Mind Body Medicine)

Easy Weekday Breakfast Ideas

November 28, 2014 at 1:25 pm | Posted in Nutrition, recipes | Leave a comment
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They say breakfast is the most important meal of the day.  Don’t skip breakfast if you’re pressed for time in the morning – instead try one easy breakfast ideas from Janelle Langlais, a dietetic intern with the MGH Department of Nutrition and Food Services.

Turkey, Butternut Squash & Nuts
Serves 1

3/4 cup Butternut squash
¼ cup or 10-15 almonds/walnuts/pecans sliced/chopped
1 tsp. cinnamon (as desired)
1/8th tsp. ginger (as desired)
2-3 oz. Turkey (or chicken) breast

Directions

  1. Combine squash, turkey (or chicken) and spices in a microwave safe dish.
  2. Microwave on high for 1 minute (keep an eye on things).
  3. Add nuts and spices.
  4. Enjoy with ½ cup of skim milk, soy milk or water as desired!

Calories: 365 • Carbs 22g • Protein 29g


Avocado and Egg Sandwich
Serves 1

1 Egg or 2 Egg Whites
2 Slices low-Carb whole wheat bread Or 1 Whole Wheat English Muffin
¼ Avocado sliced or ¼ cup Guacamole
2 slices of tomato
¼ cup spinach
1 slice low-fat cheddar/American cheese

Directions

  1. Microwave egg or egg whites in a microwave-safe dish for 1 minute or until egg is firm. Or conventionally cook egg in a frying pan on stove with Pam or canola oil.
  2. Toast English muffin or bread in toaster/toaster oven.
  3. Top egg with cheese, avocado slices/guacamole, add tomato and spinach.
  4. Enjoy!

Calories: 330 • Carbs 24g • Protein 23g


Blueberry Banana Overnight Oats
Serves 1

1/3 cup oats
2/3 cup Greek yogurt
1/3 cup soy milk, slightly overflowing
1/2 banana (1/3 if it’s particularly large)
1/4 cup blueberries
1/8 cup Granola and/or chopped nuts

Directions

  1. Mash banana and blueberries together in a bowl until blended together. Stir in oats, yogurt, and milk. Cover, and refrigerate overnight.
  2. In the morning, top with granola and/or walnuts, along with fresh berries/bananas, if desired.

Calories: 460 • Carbs 49g • Protein 20g

World Diabetes Day

November 14, 2014 at 9:15 am | Posted in Uncategorized | Leave a comment
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WorldDiabetesDay Cropped

Building a Better Breakfast

November 6, 2014 at 11:36 am | Posted in Announcements | Leave a comment
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Breakfast Flier

Save the Date: World Diabetes Day

October 30, 2014 at 11:30 am | Posted in Announcements | Leave a comment
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WDD candidAnnual World Diabetes Day Awareness Event

Thursday, November 13 10:00 am—3:00 pm MGH Main Lobby near Coffee Central This year’s event will focus on developing a healthy lifestyle and preventive care.

  • Talk to an exercise physiologist about your fitness goals.
  • Ask our dietitians questions about food and nutrition.
  • Learn about stress reducing techniques and get a free massage.
  • Plus trivia, games and prizes!

Tomato Chutney and Whole Wheat Tortilla Chips

October 23, 2014 at 1:20 pm | Posted in recipes | Leave a comment
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Snacks should be satisfying and nutritious: this recipe works on both accounts. The spices add interest and also offer up beneficial antioxidants. You may even want to make a double batch of the chutney to freeze for when you need a quick condiment to spice up chicken or pork.

Ingredients:

8-8″ whole wheat tortillas
2T olive oil, divided
1/4 tsp salt, plus a pinch for the chips
1 tsp cumin seeds (can substitute ground cumin, if necessary)
1 tsp mustard seeds
1 medium onion, chopped
1 T fresh ginger, peeled and minced
2 garlic cloves, minced
1 jalapeño pepper, chopped (removed seeds to decrease spiceness, if desired)
1 tsp curry power
1 tsp tumerick
2 (14.5. oz each) cans diced tomatoes, no added salt
1/3 cup raisins
2T brown sugar

Instructions:
Preheat oven to 400 degrees. Cut each tortilla into 8 wedges and place wedges on baking sheet. Lightly coat wedges with 1 tbsp olive oil and sprinkle with salt. Bake for about 7 minutes or until wedges are crisp and golden.

Meanwhile, heat cumin and mustard seeds in a large sauce pan until seeds become fragrant, about 2-3 minutes. Remove seeds from pan and add in remaining tablespoon of oil. Add onion, ginger, garlic and jalapeño to pan and sauté until onions become translucent; add in ½ tsp salt, curry powder, turmeric, cumin and mustard seeds. Add tomatoes and simmer for about 10 minutes; add in raisins and sugar and simmer for an additional 5-10 minutes, or until mixture thickens (If mixture starts to thicken too much simply add a little water to the pan). Cool to room temperature or refrigerate until needed and serve with toasted chips. Chutney can be made ahead of time; prepare chips the day you plan on serving them.

Yield: About 12 servings (serving size: about ¼ cup chutney and 5 chips)
Nutrition Information per Serving:
Calories: 170 • Protein: 4 g • Sodium: 310 mg • Carbohydrate: 25 g • Fiber 2.5 g • Fat: 5 g •
Sat Fat: 0.5 g

Recipe adapted from Cooking Light

Diabetes Care for Older People: Is It Different?

October 16, 2014 at 1:43 pm | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

The Americans Diabetes Association has addressed the care of the older person living with diabetes  in their 2014 Clinical Practice Recommendations Standards of Medical Care. These recommendations do not define “older” by any specific numerical reference but instead are based on a person’s medical conditions. Quite honestly, this makes it easier for me to interpret these recommendations when I am caring for patients because I do not know what is considered “older” anymore. I think age is just a number that I personally hope keeps getting higher and higher, especially those decade celebrations because those silly cards are my all-time favorites.

The average lifespan of Americans is approximately 76 years for men and 81 years for women. This expectation has been slightly increasing over the years and everyone has an opinion as to why this is. I believe people are living longer due to a combination of better medical care, use of technology, and (quite frankly) attitude. I have been practicing for 30 years and I see people both living longer and living younger. I’d like to discuss this recommendation and offer some suggestions to help you and your family better understand and manage diabetes across your lifespan. I also want to remind you that these practice recommendations are just that: recommendations. Each person’s care should be individualized with their health care provider.

The Standards of Medical Care from the American Diabetes Association was developed because older adults with diabetes have a greater chance of premature death, cognitive impairment, and coexisting illness such as hypertension and heart disease. However, there are not many long-term studies available about the benefits of intensive control of blood sugar and blood pressure in the older population. The ADA has determined that people with few coexisting illnesses and intact cognitive and functional abilities should have similar goals for treatment as the general population. Those with multiple coexisting illnesses and some impairment (cognitively and /or functionally), end stage chronic illnesses, and/or severe cognitive impairment should have less stringent goals for treatment per the same recommendations. Health care providers need to consider that the goals for blood sugar management need to be directed to be sure that the acute complications of hyperglycemia, such as poor wound healing, dehydration, and coma, are avoided. It’s also important for health care providers to remember to screen for complications across the lifespan and individualize this screening to be most aware of complications such as visual and lower extremity injury that can develop quickly and seriously impact functional status.

Now, how can we break this down so people living with diabetes can use this information to stay well? As we age, we may be faced with challenges such as multiple medical conditions, decreased memory ability, decreased agility and mobility, and financial challenges. People with many medical conditions have to manage multiple medications and medical appointments. It’s helpful to bring a friend or family member to appointments to be sure all important information is provided to the health care provider, and make sure that the provider’s suggestions are understood. A visiting nurse home evaluation may be in order to help with medication safety.

People who are struggling with memory issues may forget when their appointments are. They may also forget if they took their medications which could have life threatening implications, including hypo or hyper –glycemia. Family members may be able to set up simple reminders like Post- it® notes on the bathroom mirror or the kitchen counter. A simple large calendar may help with the appointment reminders.

People with mobility issues may not be able to exercise as they once did, so glucose control may be hindered. They may also be at greater risk of injury from falling. A safety assessment of the living space may be needed to avoid falls. Osteoarthritis can make checking blood sugars, administering insulin, and food preparation difficult or even unsafe. They may actually not be able to do frequent glucometer checks, meaning medication dose(s) may need to be adjusted to ensure safety.

Financial needs are very important to identify and address as costs of medications, testing supplies, and food can definitely impede people’s health. Health care providers need to inquire about these issues as people may be too embarrassed to bring it up themselves. Referral to social services for assistance is an important piece to try to work on a solution to this problem.

These are complicating factors on their own, but people with diabetes may also have severe visual impairment as the chance of developing retinopathy increases across the life span. This factor alone can be a huge negative impact on a person’s health status. Diabetes is difficult to manage at times. It takes time and dedication for the person living with diabetes, their family, and their providers. Aging is another unavoidable bump in the road of management. Adjustments in your diabetes care plan are sometimes needed because of this unavoidable fact, but the goal of these changes is to continue your good health. I think that the best approach is not to get caught up in the A1C values, but rather continuing to do all you can to stay healthy and keep collecting those silly birthday cards!

On Insulin and Weight Gain

October 2, 2014 at 2:28 pm | Posted in Uncategorized | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

Does my insulin make me look fat? The answer to this question is …it might. That would make it the wrong answer because none of us want to take a medication that may cause weight gain, especially as maintaining a healthy weight is such a crucial aspect of good diabetes management. The purpose of this post is to discuss how insulin works and how it may affect your weight. I hope after reading this you’ll have fewer reservations about using insulin if it becomes necessary.

Maintaining a healthy weight is so important for general health and is particularly important for people with chronic diseases such as high blood pressure, high cholesterol, heart disease, arthritis, and diabetes. A healthy diet and weight may mean fewer daily medications or a lower dose of medications you still require. Many medications have the potential for side effects; diabetes medications are no different. Weight gain IS a possible side effect of insulin, but it may also happen with oral medications.

Let’s talk about insulin as a first step. It is, simply put, a lifesaving medication. Insulin was discovered in 1921 at the University of Toronto and has been extensively studied and improved upon since. The job of insulin is to move the glucose from the food we eat into our cells so they’re able to stay healthy and work well. It then takes the remaining glucose from the bloodstream and stores it so it can be used for energy later. People with Type 1 Diabetes are totally dependent upon this medication for survival as their pancreas does not produce insulin. People with Type 2 Diabetes can manage their disease many different ways: diet, exercise, oral medications, and insulin. Diabetes is a progressive and chronic disease that as yet does not have a cure. That is why so many people with Type 2 Diabetes will require insulin as part of their management over time.

Two common symptoms of poorly controlled diabetes are significant weight loss and excessive urination. The weight loss happens because stored fat gets broken down to provide enough fuel for bodily functions (heart and lungs, for example) to operate and maintain life. You may start to notice the numbers on the scale decrease, regardless of what you eat or drink. This is because calories consumed aren’t being properly metabolized but rather directly excreted with urination.

The treatment for extreme hyperglycemia is insulin therapy. The insulin corrects the high blood sugar, correcting the excessive weight loss in the process. The insulin is helping the body work correctly; it’s not causing new weight but rather replacing what was lost when the body was in crisis. It’s a sign the body is healing and starting to work more normally again. This is a good thing, but it can also be frustrating for people who struggle with their weight regardless of their level of glucose control. If your weight is still creeping up after your blood sugar is better controlled, there are probably other reasons for this and further investigation is needed.

Frequent episodes of hypoglycemia (low blood sugars) can cause added weight. I’ve discussed hypoglycemia in more detail in the past, but I want to review a couple of points now. Under eating, over exercising, and both oral medicines and insulin are potential causes of this frightening and potentially life threatening condition. Proper treatment is key, but it’s common for people to over treat low blood sugars because they feel so poorly and think more is faster and better. This is not the case, and the extra calories may cause added weight over time.  The strategy I encourage my patients to use is trying things like glucose tablets and gels for treatment more often than juices or regular soda because they are pre-packaged for the correct carbohydrate (15grams). It can be hard to measure out 4 oz of juice or regular soda when you are feeling so poorly and anxious during an episode of low blood sugar. I also strongly encourage all of my patients to see our RD CDE on a regular basis to review meal plans and make any adjustments as needed to assist with better weight control. It is also important to be as active as possible as any type of movement will decrease insulin resistance and improve weight and blood sugar numbers.

Insulin initiation is a daunting prospect for some. Many of my patients, especially those who are really struggling with their weight, have told me the fear of gaining weight is why they refuse insulin. I hope that my explanation helps to minimize this fear. So, this brings us back to where we started. Does my insulin make me look fat? I prefer to answer this way: It makes your body healthy so you look marvelous!!!

Caring for the Caregiver

September 25, 2014 at 11:15 am | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

Living with diabetes is a full time job for the patient, but what about their loved ones and family members? How do they cope with this disease and all of its implications? I would like to address the concerns of the caregivers today and how everyone can work together successfully.

Many people living with diabetes are perfectly able to care for all parts of their disease independently. However people who are visually impaired, have arthritis (particularly if their hands are involved), the elderly, and people with impaired mental functioning may require assistance in managing their diabetes. Their caregivers may include family members with whom they live or people who come to their homes as needed. The patient may work with just one person or there may be a team of caregivers available to assist.

Allow yourself to think for a minute about all that goes into daily self-care for a person living with diabetes. There are glucometer checks, medications and possibly self-titrating of insulin, meal adjustments, and the chance of unforeseen complications like hypoglycemia or an illness. Now think how stressful and difficult these responsibilities may be for a caregiver, especially for someone requiring a high level of assistance. Just as the person with diabetes can get overwhelmed and fatigued by their daily care, so too can the caregiver. That is when the caregiver needs the care.

Hopefully, if there is a team of people pitching in, no one will feel overburdened. However, many times there is just one person closely involved with the patient and it may be more difficult to realize the caregiver is suffering. It’s important that all involved in the patient’s care, including the health care team, check in with each other to see how things are going. Try to pick up on subtle clues such as off handed comments by the caregiver(s) like “I don’t always have time to get everything done, there is so much to do” or “I’m so tired all the time.” Also try to be aware of any changes in demeanor such as being impatient or more withdrawn, possible signs of fatigue or depression.

Schedules are important as well, not just for the patient but for the caregiver. It helps to still do the things that are important in their daily life so that their health and well-being are maintained. It’s important for caregivers to know that it‘s perfectly fine to ask for help. It doesn’t mean that they’re doing a bad job or can’t handle the tasks — just the opposite. Providing the best care possible really does begin with a mentally and emotionally healthy caretaker. Having responsibility in someone else’s care is a difficult and stressful job. It’s important for all involved to realize this. Caretakers should feel able to discuss their feelings with the health care team. Referral to social services may be in order to assist with identifying what other community services may be available. Support groups in the area may also be a good outlet to help to cope with the situation.

Everybody needs a little help sometime. A clear channel of communication between all the parties involved will hopefully ensure a caring environment is in place for all.

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