It always amazes me to hear some of the pertinent questions asked by our patients with diabetes when in diabetes management sessions. I’m certain that many of you have similar concerns but may not have anyone locally to ask or be the person to write in to ADW diabetes. So, I intend to share recently asked questions to offer you the needed information. Here we go:

I see additives listed on food labels all the time and have no idea what they are. I do not know if they are harmful or helpful. What are they and what do they do?

Food additives are “any substance added to foods.” Food additives are used to “maintain freshness, improve taste and color, and maintain nutritional value.” On the other extreme, it is often said “they are commonly added to food but do not add value to your food.” I am not defending food additives or telling you that they are healthful. I am just making you more familiar with the information.

Some additives are stabilizers, thickeners and gelling agents which help processed foods have “structure, viscosity and stability.” They form stiffness or stabilize the food. Stabilizers/emulsifiers usually include pectin, lecithin (from egg yolk or corn) AgarAgar (algae) and carrageenan (seaweed). Foods like water and oil which do not mix, will require a stabilizer. Stabilizers are used in mayonnaise, margarine, dairy products and salad dressings. Thickeners are flavorless powders or gums that work under many conditions. Thickeners include starches, pectin and gums. They are used to thicken soups, sauces and puddings. Gelling agents include gelatin, gums, starches and pectin. Gelling agents are added to jellies, jams, desserts, yogurts and candies. These additives are identified on the label to help consumers. All food additives must be approved by the FDA prior to use. Most food additives are from natural products but up to 1% can be from synthetic ingredients.

How safe are additives? Although they are carefully regulated by the FDA, some individuals suffer from side effects especially if eaten in large amounts. People can experience nausea, bloating, gas or stomach pain. Certain additives can have food/drug interactions. Examples would be anticoagulants (blood thinners) and anti-hypertensives (blood pressure) may be affected by carrageenan and antibiotics/cholesterol drugs may be affected by pectin. There are over 3000 ingredients on the FDA list considered food additives. Some food additives which may be considered “riskier or questionable for health” include: high fructose corn syrup, MSG, food dyes, Trans-fat, sodium nitrate and BHA/BHT.

Snack FoodsHigh fructose corn syrup may “contribute to diabetes, inflammation and tissue damage”. It is a highly refined artificial sweetener and the number one source of calories in the US. It is often found in canned vegetables, cereals, bars, breads, and flavored yogurts. Some studies show it may “contribute to overeating and weight gain.” High fructose corn syrup tends to turn off the mechanism of feeling full. Food companies have begun to remove this additive due to bad press.

MSG is a flavor enhancer found in snack foods, Chinese food, cookies, frozen dinners and lunch meats. People often complain of headaches, being spacey, feeling fatigued and weight gain. Some people are highly sensitive to MSG and others are extremely allergic.

Food dyes like red, blue and yellow, are often found in cereals, sport drinks, snacks, American cheese, maraschino cherries, and fruit cocktail. These are artificial dyes and may cause behavioral problems or allergies, especially in children.

Sodium nitrate is added to processed and preserved meats including luncheon meats, bacon, hot dogs, and smoked fish. It may cause allergic reactions.

BHA/BHT is an added preservative in chewing gum, chips, cereals and Jello and may cause a neurological effect.

The best way to avoid food additives would be to eliminate bagged, boxed and processed foods and concentrate on whole simple foods like whole fruits, vegetables, lean grass-fed meats, fatty fish, no preservative whole grain bread and stick to “clean eating” as much as possible.

What is the best single therapy to sustain long term weight loss when you have diabetes?

Unfortunately, there is no single discipline, diet or way to achieve this. Positive ways for sustained weight loss would be to use portion control, eating on a schedule, making wise choices of foods, mindful eating, home food preparation, drinking calorie free liquids, counseling (when necessary) and daily exercise. Consider working with a registered dietitian who specializes in diabetes. In addition, some patients may need to utilize surgical procedures like gastric bypass, gastric band or gastric sleeve, weight loss drugs or other pharmaceutical interventions. What affects body weight/body fat? The medical world used to assume weight was completely dependent on “calories in vs. calorie expenditure.” Now we have increased knowledge and understand that hormones, metabolic rate, sleep quality and patterns, medications, age, genetics, chronic diseases, food quality, quantity and timing of food plus physical activity play a significant role.

What is the “weight neutral movement?”

The weight neutral movement is a “therapeutic approach to improving the health of individuals by focusing less on BMI (body mass index) and more on positive lifestyle behaviors.” This approach understands that focusing only on BMI may cause “weight cycling” which is the gaining, losing and regaining of weight which is more detrimental to health than being weight stable. “Weight cycling” has been associated with chronic systemic inflammation, insulin resistance, and bone fractures due to bone loss, emotional distress, cardiovascular disease, decreased metabolic rate and elevated cholesterol. Thinking in “weight neutral” terms should not give you a free pass to a poor lifestyle but should encourage positive physical, behavioral, and psychological interventions. Gaining, losing and regaining weight is bad for your general health and diabetes control.

I am really diligent during the daytime about avoiding and snacking on chips and desserts, then I fall apart when the TV goes on after dinner. I go to bed with high blood sugars and I feel stuffed and uncomfortable. I wake up full and refuse to eat breakfast, because today “I will be good”. Then, pattern starts again! What can I do to break this pattern even if I am eating only sugar-free treats?

Food ChoicesSo many patients have this same question. They often interrupt a decent night of sleep by overeating and causing gastric reflux. Cortisol hormone levels rise with poor sleep habits which increases the hunger cycle again. Although there is no easy or guaranteed way to prevent this behavior of evening bingeing, the most important thing to do is eat properly throughout the day. Do not skip meals and try to eat meals between 4-5 hours apart. Include protein, fiber and water which will lead to satiation. Many people eat in the evening due to hunger, boredom, depression, anxiety or habit. Start by figuring out the cause and then come up with a solid plan. Brush your teeth right after dinner which may help prevent you from eating until your small bedtime snack (protein and carbohydrate) which should be eaten 30 minutes prior to bed. If you have a roommate or partner, let them know you may need help with self–control. Try not to keep snacks in the house. Make eating “intentional “by only allowing yourself to eat in the kitchen and not in the family room/den with the TV or computer. Don’t sit down in front of the TV or computer with a bag of chips and eat mindlessly. If you need a snack focus on one serving size, about 8-10 chips. Avoid processed foods, sugary foods, salty foods, alcohol, caffeine and saturated fatty foods which may trigger a bigger appetite. Never bring food into the bedroom. Try sipping a zero calorie beverage like flavored sparkling or flat water, herbal tea or decaf coffee. Drinking may help fill you up and satisfy a craving. “Fiber and water activate stretch receptors that signal you are not hungry anymore.” Light a candle, take a bath, get a fragrance diffuser and curl up with a book. The stress level will fall and lower your cortisol level and the lower cortisol level will decrease your hunger.

What is the real story about saturated fat and how much should I eat?

Now “they say” it is good for me! Not a session goes by without this question being asked. All the reports are confusing and “eating saturated fat” still remains as a heated debate in the medical world. No one is really sure what the daily optimal level of dietary fat is, including the government’s official guidelines. Top physicians in the nutritional world state that, “The emphasis should not focus on a single food or food group but on the whole diet.” Fat intake is only one piece of the puzzle. According to Dr. Walter Willett, MD, PHD, affiliated with Harvard School of Public Health, “an occasional piece of buttered toast isn’t going to kill anyone, but opting for poly-and mono-unsaturated fats is likely the healthier choice.” Saturated fats are animal based foods such as lamb, beef, pork, poultry skin, cream, butter, milk and cheese. Saturated fats should not be replaced with more carbohydrates but with additional mono, poly–unsaturated fats. Eat olives, avocados, olive oil, canola oil, tree nuts, and sunflower and safflower oil. Remember, fats are high in calories so even healthier ones can add calories and weight. Eating a diet higher in mono-poly-unsaturated fats will lower your LDL cholesterol and the risk of heart disease.

What are the best practices for insulin/GLP1 injection techniques?

The Forum for Injection Technique {FIT} was established in 2009 in the UK by diabetes nurse specialists. Injectable therapies include all types of insulin and GLP1 Injectables. Currently, a 47 page document is utilized for the best practice along with a final chapter summarizing key aspects called the “Golden Rules”. Included are psychological aspects offering counseling for those who fear injections, knowing to use the smallest needle possible (4mm) even when overweight, understanding the need to inject into the subcutaneous tissue (fat) instead of intramuscularly and rotation of sites to prevent lipohypertrophy (skin puckering with less insulin absorption). It also contains suggestions and recommendations designed especially for children with diabetes. Reported in Diabetes Forecast in 2014, “7 billion sharps get thrown away in the US.” The document discusses proper needle and lancet disposal. Check with your own state for guidelines on proper needle disposal at http://www.properneedledisposal.org/search/. Find a CDE/nurse educator to help with your injection technique for best results.

What is the current most popular and utilized diabetes app used by patients with diabetes?

According to Dia Tribe, a well-known website for diabetes professionals and patients, the most popular app is MySugr. It offers “coaching and tools to track blood sugar, medications and exercise” and gives the patient the confidence they need to help manage their disease. Many on the team who created the app also live with diabetes and know what is needed on a daily basis. MySugr is free but can be upgraded for $ 2.99 a month, less than a daily cup of coffee. It includes photos of meals, blood sugar reminders, shareable PDF and Excel reports. Over 1 million US registered users utilize MySugr. It is available on the iOS App Store and Google Play. They are constantly working on device integrations but it already integrates with Aviva Connect, Free Style Libre and Dexcom G4/G5 CGM.

There is so much to learn when you have diabetes since technology, drugs, advice and treatments keep changing. Stay informed and up to date by reading all you can.

Have a question or comment? Then post below, no registration required. I would love to hear from you!


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