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

Eating Healthy on a Budget

January 5, 2017 at 10:51 am | Posted in Nutrition, Uncategorized | Leave a comment
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By Josann Nichols
MGH Dietetic Intern

You don’t have to break the bank to have a healthy diet. Below you’ll find tips and tricks to eat well on a tight budget.

  1. Get produce in season. Buying produce in season and from local farmers is often less expensive. More corn on the market means competition, which drives prices down. For example: 4 ears of corn in season costs about $1 from local sources compared to $18 on Amazon during the winter. Produce you buy in season is also picked at peak ripeness, which packs in more flavor and nutrients.
  1. Try frozen fruits and vegetables. Frozen produce is a cheaper alternative to many fresh fruits and vegetables. They’re also picked at peak ripeness, meaning they have the same nutritional quality as fresh produce. You can also store it longer, leading to less food waste which saves money over time.
  1. Stock up on canned fruits and vegetables. Canned fruits and vegetables are a very cheap option and can be stored longer than either fresh or frozen produce. Make sure to buy fruit canned in its own juices to avoid added sugar. To reduce sugar and salt, rinse before eating.
  1. Don’t give up on meats. There are many cheaper cuts of meat available such as brisket, skirt, flank and top rump. Typically, these cuts are cheaper because they are a bit tougher but don’t be discouraged! Cooking meat like pot roast in fluid for a long period of time can make it so tender it falls off the bone! Another money saving tip: check with your local grocery store for sales on older meats. These should be used within a few days or immediately frozen.
  1. Substitute other protein sources for meat more often. Plant-based protein sources are inexpensive, contain fiber and higher-quality fat than meat and will last longer in the kitchen. Beans and lentils for example are usually purchased canned and/or dried. Use them as a substitute for meat in stews, salads, casseroles and side dishes to help your dollar go a little farther. Peanut butter, seeds and eggs are also excellent sources of protein. Add an egg to your breakfast for only $0.25!
  1. Try canned fish. A healthy diet includes seafood, which can often be pricey. Tuna is one cheap alternative, but if mercury is a concern try sardines. Not only are sardines rich in protein, they’re another source of anti-inflammatory fats. Again, watch out for added salt!
  1. Go whole grain. Fiber is your friend! It helps manage blood sugar levels and keep your digestive system healthy. Whole grains have more fiber than white flour products and can be affordable. Instead of expensive specialty grains, try switching to old-fashioned oats, whole wheat bread and brown rice.
  1. Buy in bulk. This can include frozen, canned or dried whole foods. The larger the quantity the cheaper the price per unit, so even though you pay more up front you end up saving money over time.
  1. Choose generic brands. These typically have significant price cuts. Check the ingredient list, though, to make sure you aren’t losing any quality of the product.
  1. Take advantage of sales and coupons. Stores frequently have deals on fresh, canned and dried foods.
  2. Don’t feel pressured to buy organic. Organic farmers do not use chemicals on their crops, but that doesn’t mean non-organic produce is full of chemicals. Many non-organic farmers use little to no chemicals on their produce and simply can’t afford to get the organic certification. Research has also shown that conventionally grown organic and non-organic produce does not differ in nutritional content. So you can be just as healthy eating non-organic foods while saving big bucks at the checkout line.
  1. Follow the Balanced Plate Model. Protein-rich foods tend to make the largest dent on your wallet, compared to starchy foods and vegetables. By maximizing plant-based foods and limiting your meat portions, you’ll improve the quality of your meals and make your dollar stretch farther.

Just follow the tips above to mix and match your protein, starch and vegetables to maximize your dollar and eat healthy!

Content reviewed by Melanie Pearsall, RD, CDE

Be Fit Basics: Clam Chowder

December 1, 2016 at 11:00 am | Posted in recipes | Leave a comment
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Warm up this winter with a bowl of this Be Fit clam chowder.  Pair with a salad to round out the meal.

Ingredients

2 bacon slices
2 small onions, chopped
1¼ cups chopped celery
¼ tsp kosher salt
½ tsp dried thyme
2 garlic cloves, minced
6 (6½ ounce) cans of chopped clam
5 cups diced potato
32 ounces bottled clam juice
1 bay leaf
3 cups low fat milk
½ cup all-purpose flour

Instructions:

Cook bacon in a large saucepan or Dutch oven on medium heat until crisp.  Remove bacon and set aside.  Add onion, celery, salt, and thyme to pan and cook for 2 to 3 minutes; add garlic and cook until vegetables are tender, 1 to 2 minutes more.

Drain clams, reserve the liquid, and set the clams aside.  Add clam liquid, potatoes, bottled clam juice, and bay leaf to the pan and bring the mixture to a boil.  Reduce heat and then simmer until the potatoes are tender, about 15 minutes.  Discard bay leaf.

In a medium bowl, combine milk and flour, stirring with a whisk until smooth.  Add flour mixture to the pan and bring to a boil.  Cook for 10 to 15 minutes more, or until the mixture thickens slightly; stirring occasionally.   Add clams.  Crumble bacon and divide among soup bowls.

Yield: Serves 6

Serving Size: 2 cups. 

Nutrition Information Per Serving:
Calories: 345 • Protein: 20g • Sodium: 675mg • Carbohydrate: 40g • Fiber: 4g • Fat: 9g Sat Fat: 2g

Recipe adapted from Cooking Light.  Originally posted on clubsatcrp.com.

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.

Pasta with Beet Greens, Goat Cheese and Raisins

November 3, 2016 at 9:26 am | Posted in recipes | Leave a comment
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The addition of greens, raisins and almonds to pasta is a healthy new spin on a quick dinner.  Beets are in season in Massachusetts from June to October. Beet greens are often thrown away after beets are removed.  Instead, save the greens: they are a good source of many nutrients, including vitamin A, vitamin C and vitamin K.  If beet greens aren’t available, you can substitute any dark green like Swiss chard or spinach.

Ingredients:
8 ounces (1/2 of a 1-pound box) whole wheat penne pasta
¼ cup sliced almonds
1½ tbsp olive oil
1 clove garlic, minced
2 cups chopped beet greens
¼ cup raisins
3 oz goat cheese (soft variety, such as Chevre)
½ tsp salt
Black pepper to taste

Instructions:
Prepare pasta according to the directions on the package. While pasta is cooking, toast the almonds in a large, dry sauté pan over medium heat until they turn golden brown (about 3 minutes). Remove almonds from pan and place in a small bowl. Add olive oil to the pan and add garlic, greens and raisins.  Sauté for about 3 minutes, until greens are tender and wilted. (If necessary, once greens are fully cooked, remove sauté pan from heat until pasta is cooked.)

Once pasta is cooked, reserve ½ cup of the pasta water and add it to the sauté pan with the greens.  Let mixture cook for about 1-2 minutes until slightly thickened.  Meanwhile, drain pasta from remaining water. Add pasta, toasted almonds, goat cheese, salt and pepper to the greens and toss to combine.

Yield: 4 servings (about 1 cup each)

Nutrition Information per Serving:
Calories: 375 • Protein: 15 g • Sodium: 380 mg • Carbohydrate: 53 g • Fiber: 7 g • Fat: 14 g Sat Fat: 4 g

Recipe adapted from Cooking Light

Are you newly diagnosed with diabetes, or struggling to control your blood sugar? If so, DMSE/S programs can help!

October 17, 2016 at 9:43 am | Posted in Announcements | Leave a comment
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Diabetes is a chronic, complex disease. Self management is key, but what does that even mean?  Where do you start? Self Management is the ‘taking of responsibility for one’s own behavior and well being.’   Living well with diabetes means you need to learn new skills and behaviors. This can seem overwhelming during an already stressful time.  DSME/S programs teach you the self management skills you need to truly thrive.

You will first see a nurse or nurse practitioner (who is often usually a Certified Diabetes Educator or CDE).  You will either continue to see that clinician by yourself or attend group classes with other people just like you. Group classes are a great way to learn and be supported by people who know what you’re going through. You are not alone! During appointments or classes, you will learn about important topics like nutrition, exercise, medications and more.  You will also set specific behavioral goals to work towards between each visit.

Research has shown that DSME/S works. It can lower your A1C and stop complications from happening or getting worse. Attending can also improve your quality of life and keep you out of the hospital. Major organizations like the American Diabetes Association, American Association of Diabetes Educators and the Academy of Nutrition and Dietetics all believe that everyone with diabetes should have DSME/S at some time in their life.

Mass General DSME/S programs are offered at Chelsea, Revere, Charlestown, Internal Medicine Associates, Diabetes Associates and Bulfinch Medical Group. For more information, contact Jen Searl at jsearl@partners.org.

My Story: What I Learned Caring for My Grandmother with Diabetes

September 29, 2016 at 9:24 am | Posted in My Story | Leave a comment
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By Vanessa

My grandmother is a tenacious and vibrant woman who was diagnosed with type 2 diabetes earlier this year. She had uncontrolled blood sugar levels along with other health issues and limited mobility. With no formal educational background, she doesn’t know much about diabetes or possible complications. Her low health literacy makes it difficult for her to utilize diabetes related health care resources.  “There are too many rules in my diet!” she would exclaim in Twi, her native dialect.  She also has low nutritional knowledge and at times would reduce her consumption of certain staple foods. She assumed that eating less of these foods would cure her body from the disease. Her daily diet in Ghana is mostly starchy and sugary foods with low nutritional benefits.  One staple meal that she eats quite often is called fufu:  a soft dough-like mix of cassava, plantain, and other flours served with different types of warm soups full of meat and/or fish.  Fufu is relatively high in carbohydrates and has a significant and rapid effect on my grandmother’s blood sugar levels.

As my grandmother’s caregiver, I provided diabetes care management and education.  My goal was to help her avoid blood sugar spikes keep her blood sugar in a healthy range before she went back to Ghana. Every day I checked her fasting blood sugar in the morning and again two hours after eating.  These results were reviewed by her PCP and nurse case manager.  I modified my grandmother’s meals and incorporated more green leafy vegetables, fiber-rich foods, whole-grain breads and old-fashioned oatmeal with almond milk and honey for added sweetness. I also introduced her to cooked quinoa and cauliflower rice as substitutes for fufu, white rice, and other fufu-like foods to give her meals a nutritional boost. After a meal, I would encourage her to take a walk to the local shopping plaza or to circle around the neighborhood for an hour.  Despite her stubbornness and fiery temper towards changes to her diet, we were able to improve her eating habits by stressing the importance of portion control.

My grandmother does not know how to pronounce diabetes or manage her care on her own, but making sure she understood that her medications, changes to her diet, and daily walks to her favorite consignment stores are effective tools for managing her blood sugar levels were key components to her care plan.  My experience as a caregiver was a wonderful opportunity to spend time with my grandmother, and it also highlighted the importance of diabetes education in following a care plan and reducing risk of complications.  I also learned how that approaching care in a culturally tailored manner that respects individual preferences, opinions and ideas is necessary for reaching optimal health.

 

Be Fit Basics: Quinoa Parsley Salad

September 14, 2016 at 9:48 am | Posted in Nutrition, recipes | Leave a comment
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Celebrate Whole Grains Month with this easy grain salad.  One serving is a good source of iron.

Ingredients:
1 cup of water
½ cup uncooked quinoa, rinsed
3 tbsp fresh lemon juice
1 tbsp olive oil
1 tbsp honey
¼ tsp salt
¼ tsp black pepper
¾ cup fresh parsley, roughly chopped
½ cup thinly sliced celery
½ cup thinly sliced green onion
½ cup finely chopped dried apricots
¼ cup pumpkin seeds

Directions:
Bring water and quinoa to a boil in a medium saucepan; cover, reduce heat and simmer for 20 minutes or until the liquid is absorbed.  While the quinoa is cooking, whisk the lemon juice, olive oil, honey, salt and pepper together in a small bowl.

Fluff the quinoa with a fork and place in a bowl.  Add the parsley, celery, onion, and apricots.  Toss with the dressing to coat and top with pumpkin seeds.

Yield: Serves 4

Serving Size:about 2/3 cup.  Nutrition Information Per Serving:
Calories: 195 calories • Protein: 5 g • Sodium: 160 mg • Carbohydrate: 33 g
Fiber: 4 g • Fat: 6 g • Sat Fat: 1 g

Recipe adapted from Cooking Light.  Originally posted on mghbefit.com.
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