The Positive Side

Winter 2015 

The Diabetes Drill

Dietitian Doug Cook on how to keep your blood sugar in check.


People who need help managing their diabetes have become the bread and butter for many dietitians and with good reason: The number of individuals being diagnosed with diabetes continues to climb. As a dietitian, I routinely see clients who have just been diagnosed walk through my door, wanting to know if they need to follow a special diet or how they can cut back on their sugar intake.

According to the International Diabetes Federation, 382 million people are living with diabetes worldwide and that number is projected to increase to a staggering 592 million by the year 2035. An additional 344 million people are estimated to have pre-diabetes, meaning that their blood sugar levels are high but not high enough for a diabetes diagnosis. Here in Canada, of the more than nine million who are living with either diabetes or pre-diabetes, almost half remain undiagnosed and are not getting the vital education, facts and care needed to manage this serious disease.

Art Zoccole knows all about it. The executive director of 2-Spirited People of the 1st Nations—an organization that provides counselling and social services to Aboriginal two-spirited, lesbian, gay, bisexual and transgender people—Zoccole was diagnosed with diabetes in the summer of 2003, just days after learning that he had HIV. “I knew something wasn’t right,” he says. “I was outside shivering in July and I had night sweats in the evening.” So he admitted himself to St. Michael’s Hospital in downtown Toronto, where he was diagnosed with HIV and, soon after, diabetes. Up until that point, he had no idea that he had either disease.

With effective HIV treatment allowing people to live longer, more and more cases of diabetes and other metabolic disorders are being detected in people with HIV as they age, not unlike the general population. Plus, certain factors specific to HIV—the virus itself, certain HIV medications, and HIV/hepatitis C coinfection—put a person at greater risk for developing diabetes.

What’s the big deal?

We’ve come a long way with how diabetes is managed. There are now insulin protocols, such as insulin pumps, that more closely mimic the way the pancreas (our insulin-producing organ) functions normally. Despite this, diabetes remains a serious disease. In my practice I’m continually surprised by the casual attitude many people have with respect to their diabetes, believing that they just need to watch their sugar intake and take their medication. The truth is, if left untreated or poorly managed, diabetes can have serious long-term consequences, including increased risk for blindness, kidney disease, nerve damage, heart disease and stroke. Diabetes is the leading cause of amputations and a significant contributor to erectile dysfunction.

But a diabetes diagnosis doesn’t have to mean a lifetime of health woes. Like HIV, this chronic condition can be effectively controlled with a holistic approach—a healthy diet, regular exercise, medication, stress reduction, addressing any underlying psychological issues like depression or anxiety, smoking cessation and routine monitoring of health issues with a family doctor and other specialists as needed.

Who Is at Risk?

Traditional risk factors

  • having a parent or sibling who has diabetes
  • being Aboriginal, Hispanic, South Asian, Asian or of African descent
  • having metabolic syndrome – three of the following symptoms: high blood pressure, high fasting blood sugar, large waist size (greater than 102 cm for men, 88 cm for women), high LDL or “bad” cholesterol and triglyceride levels, and low HDL or “good” cholesterol levels
  • having sleep apnea
  • being diagnosed with pre-diabetes or insulin resistance
  • being over the age of 40
  • being overweight, especially if you carry extra weight around your waist
  • having polycystic ovary syndrome (PCOS)
  • lower socio-economic status

HIV-specific risk factors

  • HIV infection, especially when accompanied by a low CD4 count and a high viral load
  • certain older HIV meds – some nukes, such as d4T (stavudine, Zerit) and ddl (didanosine, Videx EC) and some protease inhibitors, such as indinavir (Crixivan) and nelfinavir (Viracept)
  • being coinfected with HIV and hepatitis C, which makes people over the age of 40 far more likely to develop diabetes than people who are monoinfected with HIV

Keeping it under control

Controlling your diabetes and blood sugar levels is best achieved using a combination of lifestyle changes and, if needed, medication, such as insulin and/or an oral anti-diabetic drug like metformin. No medication can make up for a sedentary lifestyle or unhealthy diet. Nothing can substitute a diet rich in fruits and vegetables, omega-3 fats, fibre and protein and low in trans fats, refined carbohydrates or added sugars, but medication can certainly help many people.

Following his diagnosis, Zoccole went to diabetes school at St. Michael’s Hospital. For two days, he sat in a class learning how to read food labels, how different foods can affect your blood glucose levels and how to manage diabetes. This education was the beginning of a series of major lifestyle changes.

A small army of healthcare professionals has helped along the way. Zoccole now sees his diabetes doctor, heart specialist and kidney doctor every six months. And his HIV doc acts as his primary care physician. Zoccole makes sure that all of his doctors know what’s going on with him—when he starts taking a new drug, when he stops a drug, and so on.

Zoccole used his experience with antiretroviral therapy to guide him with his diabetes management. He points out that when you’re not feeling well or when you start a new treatment, you assume that this is how it’s going to be forever, but that’s not necessarily the case. For example, Zoccole experienced gastrointestinal problems during the first year of taking antiretroviral therapy, but when his doctor switched one of his meds, those side effects disappeared and never returned. “It was a process of trial and error,” he says. He took a similar approach to managing his diabetes.

Zoccole now checks his blood sugar level at the same time every morning. Because alcohol can affect your blood sugar, when first diagnosed he cut back on drinking, and six years ago he cut out wine, beer, anything alcoholic, completely. “I used to be a couch potato,” he says. But that changed, too. He started eating a light supper after work and then heading out for a two-hour walk. He now exercises as often as he can and gets plenty of sleep.

Zoccole also tries to eat healthy—lots of vegetables, brown bread and rice instead of white. He acknowledges that it can be hard to break old habits, but it helped that growing up in Northwestern Ontario his traditional diet included wild game (goose, rabbit and partridge), wild rice and fresh vegetables from the garden, so those healthier food choices were familiar to him.

Formerly a pack-a-day smoker, Zoccole has also cut down to having just four puffs five times daily. While such changes can seem impossible at first, most of them get easier with time and practice. After landing in Melbourne, Australia, for the AIDS conference last summer, he noticed that his fellow smokers were jonesing for a smoke after the long journey, but he was OK. “Your body adjusts.”

Change isn’t always easy. It’s one thing to know we should eat healthy, exercise and quit smoking, but it’s another to do it. We are complex creatures and our behaviour is influenced by many factors, including our culture, age, gender and religion, as well as our individual values, beliefs and attitudes. I’ve found that the greatest success starts with increasing one’s self-awareness. Before jumping into the nuts and bolts of serving sizes or grams of carbs, practicing mindfulness is one of the most powerful tools for making change.

What’s Your Type?

Type 1 diabetes usually starts during childhood or adolescence. Your body makes little or no insulin, the hormone needed to carry blood glucose to your cells and fuel them with the energy they need. This causes high blood sugar (or blood glucose) levels.

Type 2 diabetes, which typically develops during adulthood, is by far the most common kind of diabetes among the general population and among people living with HIV, accounting for an estimated 90% of cases. Your body produces insulin, but doesn’t use it properly. This is called insulin resistance and blood sugar levels rise as a result.

Gestational diabetes develops during pregnancy. Blood sugar levels usually return to normal after the baby is born.

Pre-diabetes is when your blood sugar levels are higher than normal but not high enough to be considered diabetes. The condition can be reversed but nearly 50 percent of people who have it go on to develop type 2 diabetes.

Seek support

Dealing with life’s challenges and stresses is something everyone faces but it can take its toll. Seek emotional and psychological support from a peer support group or a counsellor. Sharing your experiences with others can provide an opportunity to swap tips, relieve stress and prevent burnout as you learn to manage your condition.

Acknowledge the barriers

Deciding what needs to be changed to improve your health requires honest reflection about your situation and prioritizing what can reasonably be tackled. What might get in the way of you achieving your goal? What could help you overcome those challenges?

Start small

Research shows that people are more likely to be successful in making changes when they don’t try to make too many at once. Taking on one, at most two, big goals will likely be more successful than if you try to tackle three or more all at once. One easy way to get a sense of whether or not you’re likely to be successful at achieving your identified goal is to ask yourself: How confident am I that I can achieve this goal? Rate your confidence on a scale from 1 to 10. If you can’t rate yourself as an 8 or a 9, set that goal aside for now and consider trying another one.

Set SMART goals

Change doesn’t just happen on its own; it needs a clear plan to be realized. Simply saying, “I want to start eating better” will likely yield little. This is where SMART goals can help. The acronym stands for Specific (the objective is clearly defined, so I know exactly what I want to accomplish), Measurable (I will be able to evaluate whether or not I have met the goal), Attainable and Realistic (the action plan is achievable and not overly optimistic) and Timely (the timeframe is reasonable).

By taking the vague desire “I want to eat better” and applying these criteria, a SMART goal might look like this: “Starting next Monday, I will eat four additional servings of vegetables each week.” It’s specific (my goal is to increase my vegetable intake), measurable (four additional servings), attainable and realistic (I know I am capable of eating more vegetables) and timely (starting next Monday).

While the concepts of specific, measurable and timely are relatively straightforward, what is attainable and realistic will vary from person to person. This is where honest reflection, identifying barriers and rating how confident you feel about your objective come into play. There is no right or wrong goal, only what is right for you.

By choosing easier-to-obtain goals, you’ll be more likely to achieve them. Once you’ve achieved a goal and kept it up for three to four weeks, layer on another, and then another. Achieving a larger, longer-term goal is easy when it’s broken down into smaller, more manageable steps.

Using this approach, most people feel a sense of pride and accomplishment, which can motivate you to take things to the next level. As the saying goes, success breeds success. “You do see the benefits and rewards after a while,” Zoccole says. “As my doctor said, I’m guarding my health.” 

Doug Cook is a registered dietitian and holistic nutritionist and co-author of Nutrition for Canadians for Dummies.