During certain times of the year I like to share interesting questions which have been asked during our one-on-one diabetes management sessions. It is easy to learn from other people’s questions especially when they are general and may offer information to everyone.

Diabetes Management

Question 1: I’m so confused about taking calcium supplements. My internist wants me to take them but I read they may cause heart disease or other problems. Can you explain? Also why should I add vitamin D?

Answer: Calcium is required for bone and tooth enamel health as well as helping your heart, muscles and nerves work more efficiently. It also plays a part in blood pressure regulation and may decrease insulin resistance. Your body produces no calcium so it must be ingested. The preferred way of obtaining calcium is through food sources. Dairy foods are excellent calcium sources including milk, cheese and yogurt. Dairy sources are more biologically available compared to non-dairy foods. Some people suffer from lactose intolerance and can not tolerate regular dairy foods. Non-dairy sources of calcium include canned seafood, especially the soft bones in salmon and sardines, as well as green leafy vegetables including broccoli, kale, mustard greens, collard greens, Swiss chard and Bok Choy. Other non-dairy calcium sources include almonds, almond butter, Brazil nuts, white beans, oranges, dried figs, firm Tofu and soy milk. Common foods fortified with calcium include instant oatmeal or Cheerios. Cooking with ground, dried spices including thyme or basil can boost calcium intake.

Many people do not get enough calcium from food sources; those who are vegan, lactose intolerant, suffer from osteoporosis, have celiac disease or inflammatory bowel disease, or are on long-term steroid use generally do not ingest enough calcium. These individuals should consider taking calcium supplements. The most common calcium supplements are calcium carbonate or calcium citrate. The cheapest variety is calcium carbonate which is also the one that causes the most constipation; other side effects may be gas and stomach bloating. Most people need between 1000-1200mg a day, but the dosage should be divided in half since it is difficult to absorb more than 500mg at a time. It may be easier to tolerate and absorb liquid or chewable calcium as compared to tablets or capsules. Watch out for calcium flavored chews which are filled with sugar. Take your calcium at a proper time since it may interfere with other medication and absorption. Synthetic thyroid hormones, certain blood pressure medications, antibiotics, calcium channel blockers and bone medication called bisphosphonates should not be taken at the same time. If taking a calcium supplement, combine it with a vitamin D supplement since calcium needs vitamin D to be absorbed. The required amount of vitamin D is usually 600 IUs daily but first check with your health care provider to evaluate your D level with a blood test. Yes, there still remains controversy about too much calcium supplement intake and its effect on heart disease and the inner lining of the blood vessels. The studies are still not clearly defined but if you stay within the guidelines of calcium/vitamin D amounts, you should not suffer from ill consequences. Always check with your health care provider prior to starting any supplement.

Question 2: Explain what resistant starch is and why should I eat it when I have diabetes?

Answer: Resistant starch is fiber and “resists the digestive enzymes in the stomach and small intestine”. Resistant starch can increase colon acidity which creates a better environment for “good bacteria”. Good gut bacteria may protect against colon cancer and infections. Resistance starch doesn’t digest so it lowers the glycemic response (rise in blood sugar) as well as concentrations of serum fat and cholesterol. Resistance starch contains both soluble and insoluble fiber which aids overall health and may help you maintain an appropriate body weight. Resistance starch can be very beneficial for those with diabetes. When eaten in proper portion size, resistance starch may prevent quick rises in blood sugar when compared to other carbohydrates. Sources of resistance starch include green bananas, artichokes, chicory root, beans and peas. Rice, oatmeal and potatoes become resistant starch when they are cooked, cooled and then reheated. Prepare a large pot of oatmeal and reheat it through the week for breakfast along with a protein source for a perfect meal. As always, aim for 2-4 servings of a carbohydrate per meal depending on your blood sugars and body size. Try to eat between 25-35 grams of fiber daily for a multitude of health benefits.

Question 3: I do not understand why my diabetes is getting worse and that it is more difficult to maintain my blood sugars. I still watch what I eat and I exercise so what am I doing wrong with my diabetes management?

Answer: Diabetes is a progressive chronic disease and even if you continue to make positive lifestyle changes, you may eventually need to take diabetes medications. This response varies between individuals since each person’s beta cells (where insulin is made in the pancreas) may have a different life span. Many people may have had pre-diabetes or diabetes for up to 10 years prior to diagnosis. During this stage, the beta cells overproduce insulin trying to lower blood sugars. After a while, the beta cells slow down or stop producing insulin. This is when you may require a diabetes pill or a combination of pills, injectables (which are not insulin) or insulin injections. This does not mean you have not been diligent or that you should give up on your exercise or eating plan; good lifestyle habits should always be maintained and may allow for less diabetes medication in the future. The general ADA goal is to maintain an A1C level below 7% or according to what your physician suggests specifically for you. Many internists and primary care doctors are well versed in all the latest diabetes medications but if you do not achieve improved blood sugars, consider going to an endocrinologist, who is a specialist in diabetes management. If and when you are started on medication, find out the correct way and time to take it since this will make a huge difference in your control.

Question 4: What about artificial sweeteners, can I use them?

Answer: The purpose of artificial sweeteners is to offer an option to regular sugar with a sweet taste without the calories and carbohydrates. Since artificial sweeteners are much sweeter than regular sugar, brown sugar, honey or Agave, you will only need to use a small amount. They are made from either chemicals or plant based substances and generally have little effect on blood sugars. The most common sugar substitutes (same as artificial sweeteners) are Splenda (good choice for baking), Equal, Nutrasweet, Truvia, PureVia and the old standby Sweet and Low. Using sugar substitutes for baking may not give you the same taste, texture or cooking time so be aware of that when you are baking. As with most things there are studies suggesting these sweeteners are completely safe and others suggesting they may cause problems in large quantities. There is discussion about a “rebound effect” stating that too much sweetness from these artificial products may lead you to crave even more. This could lead to eating an abundance of sugar-free foods which are not calorie-free and could lead to weight gain. Sugar alcohols are another artificial sweetener and are often found in sugar-free candies, ice cream, cookies and cake. They contain half the calories and carbohydrates compared to regular sugar. The most common ones include sorbitol, xylitol and mannitol. These products eaten in abundance may increase blood sugars in some individuals and cause stomach issues such as gas, bloating, cramps and diarrhea. Remember, they are not calorie-free and could lead to weight gain when eaten in large amounts.

These are just a few of the latest questions which I wanted to share. Keep asking and learning so you can gain the knowledge and keep your diabetes management on track!

Always feel free to email me your questions at RKleinman@adwdiabetes.com if you would like to share them with ADW diabetes


NOTE: Consult your Doctor first to make sure my recommendations fit your special health needs.

Roberta Kleinman

Roberta Kleinman

Roberta Kleinman, RN, M. Ed., CDE, is a registered nurse and certified diabetes educator. She grew up in Long Island, NY. Her nursing training was done at the University of Vermont where she received a B.S. R.N. Robbie obtained her Master of Education degree, with a specialty in exercise physiology, from Georgia State University in Atlanta, Georgia.

She is a member of the American Diabetes Association as well as the South Florida Association of Diabetes Educators. She worked with the education department of NBMC to help educate the hospital's in-patient nurses about diabetes. She practices a healthy lifestyle and has worked as a personal fitness trainer in the past.

She was one of the initiators of the North Broward Diabetes Center (NBMC) which started in 1990 and was one of the first American Diabetes Association (ADA) certified programs in Broward County, Florida for nearly two decades. Robbie has educated patients to care for themselves and has counseled them on healthy eating, heart disease, high lipids, use of glucometers, insulin and many other aspects of diabetes care. The NBMC Diabetes Center received the Valor Award from the American Diabetes Center for excellent care to their patients. Robbie has volunteered over the years as leader of many diabetes support groups.
Roberta Kleinman

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