Standards of Medical Care in Diabetes 2017: Diabetes Medications

March 9, 2017 at 9:10 am | Posted in Health | 2 Comments
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Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I recently reviewed updates to the American Diabetes Association’s (ADA) Standards of Care for 2017.  In this post, I’ll review Section 8 of the standard that talks about different medications for treating diabetes. I will also discuss some of the newer medications used to treat diabetes.

Type 1 Diabetes is always treated with insulin, either through multiple injections or an insulin pump. Type 2 Diabetes can be treated with oral medications (pills by mouth), injections, or both.  The ADA recommends that people with Type 2 diabetes start patients start with the pill metformin, as long as it safe for them to take it.    Taking metformin for a long time may lead to not getting enough Vitamin B12, stomach symptoms, and can affect how well the kidneys work (your care team will monitor your kidneys to be sure they are working properly).

If someone is taking one oral medication at the highest possible dose but their A1C is still not at goal, providers should consider adding additional medications:  another oral medication, long acting insulin (injection), or a non-insulin injectable medication called glucagon-like peptide 1 receptor agonists (GLP-1 receptor agonists).

Examples of GLP-receptor agonists are exenatide (Byetta), liraglutide (Victoza), and dulagultide (Trulicity).  These medications cause food to move through the stomach slower so people feel full sooner. This leads to less glucagon (another hormone made by the pancreas) being released after meals and lowers appetite, which helps with weight loss.  These medications need glucose to work, so there is little chance of hypoglycemia.  Side effects include nausea, vomiting and acute pancreatitis. They may also cause medullary thyroid cancer in animals. It should be noted that these medications are expensive.

People with poorly controlled diabetes and atherosclerotic cardiovascular disease (ASCVD aka heart disease) may benefit from a new medication called empagliflozin (Jardiance), a type of medication called SGLT-2 inhibitor.  These medications work by preventing the body from reabsorbing glucose. This lets more glucose leave the body through urine.  People may have lower blood sugar values after eating and lose some weight.  Studies show empagliflozin helped reduce deaths caused by heart attack, stroke, and cardiovascular disease.  Empagliflozin is the only SGLT-2 inhibitor with these results, but other medications are being studied (liraglutide [Victoza] may have the same results, but other GLP-1 receptor agonists are not used this way).  Potential side effects include hypoglycemia, low blood pressure, dizziness, urinary tract infection, needing to urinate a lot, and increased LDL and creatinine (a waste product filtered out by the kidneys).  Again, these medications are very costly.

There are many medications available for the treatment of diabetes. These standards are general recommendations for medical care.  Always discuss questions about your care plan with your healthcare provider.

Standards of Medical Care in Diabetes 2017 (Part 2)

February 2, 2017 at 8:15 am | Posted in Health, Uncategorized | Leave a comment
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Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

This week is part two of my review of the revisions to the 2017 American Diabetes Association Standards of Care (click here to review Part 1).  First, a quick reminder that these are guidelines; always discuss questions about your personal health care plan with your health care provider.

Section 6: Glycemic Targets

The International Hypoglycemia Study Group has recommended that serious, clinically significant hypoglycemia be defined as a reading of less than 54 mg/dL. People who have experienced such measurements need to notify their health care providers immediately and be prescribed a glucagon emergency kit.

Hypoglycemia measuring less than 70 mg/dL is still treated by the rule of 15: 15 grams of fast acting carbohydrate with a blood sugar check in 15 minutes for an expected increase by at least 15 points. Repeat the process if the result doesn’t improve.

Section 7: Obesity Management for the Treatment of Type 2 Diabetes

The best blood sugar results occur with weight loss early in the management of Type 2 Diabetes, before beta cells begin to stop working. For this reason, metabolic surgery (formerly referred to as bariatric surgery) is now recommended for people with a BMI of 30 (or 27.5 for Asians with poorly controlled diabetes).

Section 9: Cardiovascular Disease and Risk Management

Any of the medications for managing high blood pressure can be used (except for beta blockers) as long as the person doesn’t have protein in the urine (albuminuria). One or more medications should be used at bedtime to improve blood pressure control.

The goal for blood pressure for pregnant women is 120-160/80-105.  When prescribing medications, providers should consider both maintaining the health of the mother and avoiding harm to the baby.

There is a discussion of new medications and the potential benefits for people with diabetes and cardiovascular disease: empagliflozin (Jardiance) and liraglutide (Victoza).

Section 10: Microvascular Complications and Foot Care

There is an increased risk for retinopathy in pregnant women with Type 1 or Type 2 Diabetes.  Thorough eye exams should be a part of preconception counseling as well as during pregnancy.

Anyone being treated for neuropathic pain should be evaluated for the addition of medication therapy with pregabalin (Lyrica) and duloxetine (Cymbalta). They should also be fitted for therapeutic footwear by a podiatrist.

Section 12: Children and Adolescents

Preconception counseling should begin in puberty to help to avoid the risk for birth defects in unplanned pregnancies.

When diabetic ketoacidosis appears in children, it is important to know if the child has Type 1 or Type 2 Diabetes as 6% of these cases are actually Type 2 Diabetes, not Type 1.

Section 13: Management of Diabetes in Pregnancy

Insulin is the preferred treatment for pregnant women.  Oral medications may harm the baby.

Targets for blood sugar are the same for gestational diabetes as for preexisting diabetes.

Section 14: Diabetes Care in the Hospital

It’s now recommended to use basal and/or basal bolus insulin regimes (instead of sliding scale insulin alone) when patients are admitted to the hospital.

2017 Standards of Medical Care in Diabetes (Part 1)

January 26, 2017 at 9:05 am | Posted in Health | 1 Comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

The American Diabetes Association (ADA) publishes guidelines each January to educate professionals about the best clinical practice for people diabetes. I will review the standards that have had changes made in them for 2017.  Section 8 (Pharmacologic Approaches to Glycemic Treatment) is a very important section with a great deal of information, so it will be covered in a separate post.

This year the Standards of Care have been updated to address psychosocial issues in all aspects of care.  This includes the importance of assessing self-management capabilities, mental health status, and complications and comorbidities.  These standards are meant to provide general treatment goals and are not meant to replace clinical judgment.   This post is a brief overview of the changes to the standards; click here to access a full list and descriptions.  Please remember, that these are in no way meant to replace the individual care that you are participating in with your health care team.

Section 2: Classification and Diagnosis of Diabetes

There is a new consensus on staging Type 1 Diabetes. Three stages have been identified:

  • Stage 1 – no changes in the blood glucose values and no symptoms are present
  • Stage 2 – some impaired fasting blood glucose and possibly some impaired glucose tolerance, too
  • Stage 3 – the stage that most people are diagnosed. They may appear with dangerous hyperglycemia and have symptoms such as excessive thirst, hunger and urination

Investigators hope to use this staging system as a research road map to help better plan intervention strategies.

A new risk test has been developed to help to identify people with prediabetes and undiagnosed diabetes as soon as possible. Click here to see the test and share with loved ones.

Dentists are also are important in identifying people with diabetes. One study shows 30% of people over 30 that are treated for periodontal disease have abnormal glucose levels. Educating dentists to refer these individuals to their health care providers for formal assessment will be helpful in identifying at-risk people sooner.

Birth weight of infants is no longer a risk factor for Type 2 Diabetes. Women who had gestational diabetes should have their fasting glucose test done 4 to 12 weeks after having their baby (instead of 6 to 12 weeks).  The hope is that most women will have the test done before the 6 week checkup so they can discuss results and implications with their provider.

Section 3: Comprehensive Medical Evaluation and Assessment of Comorbidities

This is a new section highlighting screening for, and management of, comorbid conditions in people with diabetes. Assessment of sleep pattern and duration has been added as well as HIV, autoimmune diseases, depression and anxiety, and disordered eating patterns. Please refer to the full standards to see the entire list of conditions.

Section 4: Lifestyle Management

People following a flexible rapid acting insulin schedule should work closely with a registered dietician for education on counting fat and protein values as well as carbohydrates to be sure they are using correct insulin amounts.

Sitting is the new smoking! Stand up and move a little every 30 minutes. Aim for 150 minutes of exercise per week and try to do strength training 2 to 3 times a week. Balance and flexibility are priorities for older adults, and activities like yoga or Tai Chi are recommended.  There is also a table providing information about situations that may require referral to a mental health professional.

Healthy New Year’s Resolutions

January 19, 2017 at 9:15 am | Posted in Health | Leave a comment
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By Annabella He
MGH Dietetic Intern

It’s 2017! At the start of year, you may be making a New Year’s resolution to better manage your diabetes by eating healthier and exercising more. In order to stick to the plan, your New Year’s resolutions should be specific, measurable and reasonable. The following are some specific tips to get you started. Pick one or a couple to work on!

  1. Cut down on portion size: The amount of food you eat for each meal has a huge impact on your blood glucose and weight control. Having a smaller meal keeps your glucose and insulin levels more stable. Also research shows that lowering total calorie intake helps with long-term weight loss, so portion control is the key. Use food labels and measuring cups to accurately gauge your intake.
  2. Eat breakfast: Have a filling breakfast to keep yourself full for longer. Eating breakfast reduces your hunger levels later in the day. A balanced breakfast like whole-wheat cereal with low fat milk and nuts, or scrambled egg with some vegetables are good options. Instead of topping the toast with butter, try avocado to make it tasty and healthy.
  3. Make a balanced plate: Fill half plate with fruits and vegetables, especially brightly colored ones, ¼ plate protein, ¼ plate starch.
  4. Eat more non-starchy vegetables: We always say eat more vegetables, but the kinds of vegetables we eat also matter. Starchy vegetables like corn, green peas, winter squash and potatoes are high in carbohydrate. Eating too much of those will increase your blood sugar, so it’s important to moderate the portion size of these vegetables. Non-starchy vegetables like carrots, broccoli, salad greens and beets contain little or no carbohydrate. Eating more of those vegetables not only stabilize your blood sugar level, but also help fill you up without gaining much weight.
  5. Choose healthy snacks: It’s okay to have some snacks throughout the day to keep your blood sugar stable and promote energy levels. Again, make sure to control the portion size and make healthy choices. Here are some examples of healthy snacks: whole fruits, cut vegetables, almonds, Greek yogurt and low-fat popcorn.
  6. Learn a new healthy recipe every month: Search for new healthy recipes and practice. Cooking at home is fun and it saves money. You are in full control of what’s in your meal. Also, by December, you will master cooking 12 recipes. How exciting is that?!
  7. Drink more water: The daily recommendation is 8 cups of water or other non-caffeinated beverages. Drinking enough water helps you stay hydrated and energetic. Sometimes you may feel hungry, but actually you are dehydrated. Drinking water helps you to not get hunger and thirst confused.
  8. Go to bed early and get enough sleep: Going to bed early keeps you from eating too late at night. Also, getting a good night sleep helps your body process carbohydrate and has a positive effect on weight control.
  9. Exercise more: Try different types of exercise such as walking, running, hiking, yoga or a group class at the gym. Get a pedometer or use phone app to record your steps while walking. Recording your steps can motivate you to try to reach a higher goal by walking more miles.
  10. Stay up to date with medical appointments: See your provider regularly to make sure everything is going well with your diabetes and that you are up to date on your health screenings (including eye exams).
Content reviewed by Melanie Pearsall, RD, CDE

Blood Sugar: What Does It Mean for Your Health?

November 23, 2016 at 9:01 am | Posted in Health, Nutrition | Leave a comment
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By Felicia Steward, Dietetic Intern

Blood Sugar Defined

Blood sugar is the measurement of the amount of glucose, or sugar, in your bloodstream. This is important because it tells us how much energy our cells and tissues are receiving from the food we eat. Some foods affect blood sugar more than others. Any food that is mostly carbohydrates will affect blood sugar levels. These include dairy (milk and yogurt), all fruits and fruit juices, starches (pasta, bread, rice, and tortillas), and starchy vegetables (corn, peas, beans, potato, and butternut squash). Eating more carbohydrates at a meal can raise blood sugar, so it’s important to think about portion size along with when we eat and what food items we choose to eat together.

Why Care About the Amount of Sugar in My Bloodstream?

 Glucose provides our body with energy, and is needed for the brain to properly function and process information. Therefore, it is important that we choose foods containing small amounts of carbohydrates whenever we have a meal or a snack throughout the day so there’s enough glucose to support our tissues and cells.

When someone with diabetes eats large portions of carbohydrate-rich foods, too much sugar is released into the blood stream and, because there’s either not enough insulin or they have insulin resistance, their body is unable to use this sugar for energy effectively.  It builds up in the blood stream, causing damage to the body.  Over an unhealthy extended period of time, the body will eventually store much of the excess sugar as fat, which can lead to weight gain. Therefore, it is important to be aware of how the food we eat influences the amount of sugar in our bloodstream and how it affects our weight.

How is Blood Sugar Managed?

helthy-plate

 A healthy eating pattern that includes balance and portion control is an important part of managing the amount of sugar in the bloodstream.  Pairing whole grain, carbohydrate-rich foods with protein and fiber helps maintain healthy blood sugar levels. Eating a meal or snack that contains foods that increase blood sugar with those that do not affect blood sugar means the glucose is absorbed slowly into the blood and prevents blood sugar from spiking too high. Paying attention to portion size will also ensure that we are providing our body with exactly what it needs each time we eat. What the body doesn’t use for energy right away can be stored as fat and cause weight gain.

Balanced Lunch Examples:

  • PB&J on whole wheat bread + 1 cup carrot and celery sticks dipped in plain yogurt
  •  2 cups tossed salad + 3 oz. grilled chicken + oil/vinegar dressing + 1 banana
  •  3 oz. salmon + 1 cup brown rice + 1.5-2 cups cooked green beans
  •  2 oz. tuna salad (with light/mayo), lettuce, and tomato on whole wheat bread + 1 small apple + 8 oz. of skim milk
 Content reviewed by Melanie Pearsall, RD, CDE

 

 

Why Medical Appointments are like Math Tests

November 17, 2016 at 9:30 am | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

A medical appointment is a really big investment.  It takes time from our busy lives that may impact our employment or family commitments.  It costs us financially through transportation costs, parking fees, childcare expenses and copays.  It also can cause anxiety and uncertainty because of worry about the outcomes of tests (on top of all of the other things I mentioned).  Even so, a medical appointment is the single best investment you can make in your healthcare. The best way to gain the most from this investment is studying the night before. That’s right, just like preparing for that all important math test it’s worthwhile to prepare for your upcoming medical appointment.

Remember, you and your health care provider are teammates working for the same goal: the best health you can achieve.  Using the tips below to prepare for your appointment will help you both get the most out of your time together.

  1. Review your prescriptions and see if you need any refills on medications or supplies.  It is also important to have updated pharmacy contact information so your prescriptions are not delayed, and check to see if you need any specialty referrals.
  2. Make sure that you have your updated insurance information and photo ID with you. Medical offices do not automatically receive insurance changes, so it is important to check this information at each appointment to prevent issues with bills and referrals. You can update your address and phone number at this time if they have changed since your last office visit.
  3. Allow plenty of time to get to your appointment and park so you are not late. We try to accommodate people who are late but sometimes it can’t be done.
  4. Please be patient with me if I am running late. I work very hard to keep on time because I value YOUR time, but if I have a very sick patient, I may run behind. I promise that I will still give you the time you need for your care.
  5. Don’t forget to bring any results from home such as blood pressure, weight, and blood sugar checks. The information I get during the office visit is just one snapshot in time; seeing it along with your home results gives me a clearer picture of your health.
  6. Write down any questions and concerns you want to talk about during your appointment.
  7. Take notes during the appointment and use the same notebook for each visit. This will help keep all of your information organized and in one place if you need to review something you’re unsure about.

I know being a patient is a full time job for many people, and it can be daunting to keep track of everything that goes into good self-care and good health.  I think that preparing for your appointment, just like studying the night before the math test, can make this process less overwhelming and as successful as possible.

Summer 2016: The Tale of the Mosquito

August 5, 2016 at 10:41 am | Posted in Health | Leave a comment
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By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I have lots of fond summertime memories from my childhood. We could play outside really late, Hoodsie® Cups were allowed even if it wasn’t a birthday party, and mosquito bites made me scratch so much I got the evil eye from my mother because I was so annoying. That was the extent of thought anyone gave to bug bites. So what has changed? Playing tag until dark has been replaced with my commuter rail commute and Hoodsie® Cups are too hard to find in the supermarket these days. But the biggest change is that now if I get a mosquito bite it doesn’t itch so much as cause anxiety.

Mosquitos are more than annoying. They potentially carry serious and life threatening disease.  We all have to try harder to avoid being bitten. The best way to avoid bug bites and the possible illness (as well as the associated anxiety they may cause), is being informed about the recent facts concerning mosquitoes.  What you need to know about illnesses spread by mosquitoes:

  • West Nile Virus (WNV): This is a virus that often causes no symptoms. It is most common between the months of June and September, but people are at risk until the first frost.
  • Eastern Equine Encephalitis Virus (EEE):  EEE is a rare and severe mosquito transmitted virus that carries a 33% mortality rate. EEE may have no symptoms, but in some cases it can cause serious inflammation of the brain that can lead to coma. EEE is also present until the first frost.
  • Chikungunya: This is a virus caused by mosquito bites that always causes some sort of symptoms; usually fever, joint pain and sometimes a rash. Chikungunya can affect people of all ages but the symptoms can be greater in the very young, the elderly, or those with chronic diseases such as heart disease and diabetes. Treatment is possible and people usually feel better within a couple of weeks. This illness has not been found in mosquitoes in the United States BUT it has been seen in many other countries including the Caribbean. People who travel to infected areas can be bitten and develop illness when they return home.
  • Zika Virus: Zika has been front page news over the last few months, but it was first identified in 1947 in monkeys in Uganda. It is now frequently mentioned by the media as it has been accompanied by a rise in cases of microcephaly (a birth defect that affects the growth of the brain that is spread to the fetus during pregnancy and possibly at birth) and Guillain-Barré syndrome in South America. This past week CDC announced that infected mosquitoes have been located in parts of Miami, Florida and published guidelines for travelers to the area. Visit the CDC website for more information about Zika. The possible symptoms are very nonspecific, such as feeling tired, fever, rash, and conjunctivitis. People may be infected and not know it. There are tests available to see if Zika is the cause of the illness, but they are performed under very specialized circumstances. Ask your healthcare provider for more information. There is no treatment for Zika, but the symptoms can be treated as needed.

The best treatment for any of these viruses is PREVENTION:

  • Mosquitoes breed in moist spaces. It is important to remove standing water such as watering cans, wading pools, or rubbish cans.
  • Mosquitoes are known to be most active at dawn and dusk. However, Zika infected mosquitoes are mostly DAYTIME biters. It is still the best idea to make sure that window screens are intact. Close windows and use air conditioning if possible.
  • Wear protective clothing (e.g. long sleeves, pant legs tucked into socks) when outside during potential peak activity hours.
  • Use mosquito repellent. Products that include DEET, picaridin, oil of eucalyptus, or para-menthane-diol are appropriate to use. It is important to read the directions as many of these products are harmful to infants and children.
  • Zika presents another challenge as far as prevention. Zika can be spread through sexual activity, so it is necessary to observe safe sex practices if there is any chance of infection.

This is a beautiful time of year in the Northeast and sooner than I care to think about, I’ll be worrying about ice dams. I hope that you will all join me and go outside and play. Just don’t forget to add the right clothing and some bug spray in your backpack.

Group Visits: Best Practices in Team-Based Care at MGH Back Bay

June 16, 2016 at 9:10 am | Posted in Health | Leave a comment
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In April of this year, MGH Back Bay began trying out a new model for delivering care and education for their diabetes community: shared group medical visits. Led by a nurse practitioner, a diabetes nurse educator and a registered dietitian, these shared visits are offered to people with prediabetes or Type 2 Diabetes (newly diagnosed or anyone needing a little extra help bringing blood sugars under control). Visits are divided into two sessions, two weeks apart. The first session focuses on diabetes basics and nutrition; the second covers nutrition in more detail and reviews complications.

At the beginning of each session, the nurse practitioner meets with each participant for a short individual visit. A larger group discussion takes place afterwards. Although there is a curriculum with prepared material about A1C, blood pressure and cholesterol (LDL), the discussion is allowed to grow organically. Questions are encouraged and participants are welcome to share personal stories if they wish. Opportunities for hands-on learning are woven into the session, such as exercises on reading food labels or using rice in a shoe to illustrate symptoms of neuropathy. At the end of the second session, participants are asked to identify and write down one or two goals to work on. The diabetes nurse educator mails these goals two months after the group as a reminder of what was motivating them during the visit.

Response to the shared group visits has been very positive. The opportunity to talk about living with diabetes and learn tips from peers for overcoming every day challenges is a highlight for many. Much of the success of this visit model is the emphasis on team-based care. One of the reasons for offering shared visits was providing better access to nutrition education. Since a registered dietitian is there for the visit, participants do not need to schedule a separate appointment. The group setting also helps reduce anxiety some feel about seeing a dietitian. In addition to clinical outcomes (improved A1C, reduced weight), scheduling a follow up visit with a dietitian is considered a mark of success for this visit model.

More shared group medical visits have been planned for the fall. Given how well visits have gone so far, the practice is considering offering shared group visits for other chronic conditions such as hypertension

Another “Mini”Relaxation Exercise

December 3, 2015 at 10:03 am | Posted in Health, Uncategorized | Leave a comment
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Meditation picture

The holiday season is “the most wonderful time of the year.”  It’s also the time of year many feel the most stressed! The relaxation response is the body’s natural counter to the stress response.  If you’re feeling holiday stress starting to creep in, take a few minutes to try this mini relaxation breathing exercise from the Benson-Henry Institute for Mind Body Medicine

INHALE, pause- 1,2,3         EXHALE, pause, 1,2,3

  • After each inhalation, pause and count: 1,2,3 (breath is held in)
  • After each exhalation, pause and count: 1,2,3 (breath is let out)
  • Do this for several breaths.

Is Organic Produce Healthier?

October 29, 2015 at 11:10 am | Posted in Health, Nutrition | 1 Comment
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By Lauren Beth Cohen
Dietetic Intern

A lot of confidence is put in the word organic. When playing the word-association game, you might hear things like: health, nutrition, clean, natural, expensive, and safe. But is that always the case? Before we fully answer this question (spoiler alert: the short answer no), we should breakdown what “organic” actually means.

The United States Department of Agriculture (USDA) certifies and labels certain foods as organic if they are produced “using methods that preserve the environment and avoid most synthetic materials, such as pesticides and antibiotics.” Pesticides and antibiotics are used to extend shelf life in the grocery store, reduce plant spoilage and mutation, and prevent illness in livestock. They are GRAS, or Generally Recognized As Safe to consume by the Food and Drug Administration (FDA).

So, should you eat it? Well, the choice is yours.

Not a lot is known about the how these pesticides and antibiotics affect the human body. What we do know is that organic can be a great option, but is not always essential.

In an attempt to help you save some cash and become a more savvy shopper, let’s introduce you to the “dirty dozen.” These foods, tested by the Environmental Working Group (EWG), show a higher amount of pesticides than average and, if given the option, should be purchased organic. They include: apples, peaches, nectarines, strawberries, grapes, celery, spinach/kale/collard greens, sweet bell & hot peppers, cucumbers, cherry tomatoes, imported snap peas and potatoes.

Next time you head to the grocery store, go in armed with some of these helpful tips:

  • Buy organic for the “Dirty Dozen” and conventional for the “Clean Fifteen,” which includes; avocados, sweet corn, pineapples, cabbage, frozen sweet peas, onions, asparagus, mangoes, papayas, kiwis, eggplant, grapefruit, cantaloupe, cauliflower and sweet potatoes.
  • Prioritize buying local over organic. Often times, local farmers are producing products in an organic fashion but can’t afford the accreditation. Support your local farms!
  • Check the country of origin. The United States only imports certified organic foods from Canada, EU, India, Israel, Japan, New Zealand, Korea, and Switzerland. Any other country with “organic” on the label may be a trick to get you to spend more!
  • Milk and seafood do not need to be purchased organic.
  • Remember: A cookie is a cookie. Even if it’s 100% natural and organic – it doesn’t make it a magically healthy cookie.
(Post content reviewed by MGH Department of Nutrition and Food Services)
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