Children’s parties and a diabetic diet

Your child can have parties.

Arranging a child’s birthday party if he has diabetes may demand some ingenuity, but can be readily done. If it is his own party you will not want your child singled out so that everyone else can have cake except him, so you will use only foods suitable for those with diabetes, and tell your child (beforehand if he is old enough, but unobtrusively if you are handing round the food at the time) how much he can have. In general you will rely on savory foods such as nuts, potato chips, party size pies and cocktail sausages. You may have to allow a little more carbohydrate at the party and make adjustment at the next meal. You can make a sugarless sponge or use diabetic jellies or an ice-cream cake as the birthday cake.

Coping with a diet when travelling

Try to keep the diet while travelling. Be prepared for delays.

Usually, when planning a trip it is possible to manage the schedule to fit in with usual meal times, and no special changes in diet are necessary. Always be prepared for delays, however, by carrying food with you, so that if it is not possible to keep to a timetable, the carbohydrate part of the diet at least can be given on time, and the risk of the glucose in the blood becoming too low is avoided. Even if you expect to be only a little late for a meal, it is best to give some of the carbohydrate at the right time and allow for this when the proper meal is taken later.

If your child is prone to travel sickness you may be wise to give an anti-sickness tablet before starting off, and your doctor will prescribe a suitable one for him. It is always essential to carry extra glucose or sugar (such as barley sugar) with you so you can cope with a possible hypo reaction or vomiting.

In long distance travelling, such as overseas air travel, it may be necessary to rearrange the meal plan to fit in with changes in local time. This can be quite easily done, but should be discussed with your dietitian or doctor when you know the flight schedule. Once again, a supply of dry biscuits or crackers will be a good precaution against unexpected delays.

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One, two or more injections a day?

Whether your diabetes is best controlled by one or more injections a day is a matter on which your physician will advise you. What may be best for one person may not be for another. Some people need two injections a day and some can get by on one, while others are best controlled on four.

Insulin, given by injection once a day, can never act in exactly the way that insulin which is naturally produced by the body. This is partly because the pancreas produces a rather steady flow of insulin throughout the day and night with extra amounts every time you eat. The extra amount depends on how much food is eaten. Considering this, it is remarkable that insulin injections work so well, but it is not surprising that we believe the ideal system would be to have insulin injections before each meal. This may not be convenient, but it may be necessary for someone who is seeking very precise control. It may also be necessary for some people whose diabetes is unstable with variable mealtimes and lifestyle.

Insulin antibodies

In the early years of insulin production, it was not as highly purified as it is now, and the insulin made from beef or pork was slightly different to human insulin. The body reacted to injections of insulin by producing antibodies to insulin. These antibodies were capable of reacting against the insulin and changing the way it worked, but usually this did not matter. The antibodies were provoked either by impurities in the insulin or by the beef or pork species itself. With modern techniques of purification and the use of human insulin, antibodies should not develop. This might be an advantage theoretically, but in practice the antibodies did not appear harmful.

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Recognizing hypos

Sometimes your toddler will behave in a way that resembles a hypo – but isn’t. This can be confusing for you. Perhaps she becomes tired and goes to sleep in the middle of a visit to her grandmother. Perhaps she throws a tantrum on the floor of the supermarket, or becomes cross and bad tempered on an outing. Is this just two-year-old behaviour or is the blood glucose level low?

With time and experience you will probably learn to recognize which is which, although sometimes both occur as the blood glucose value varies and influences her mood. If in doubt however, it is usually best to treat it as a hypo. It won’t do any harm to give a little sugar even if the blood glucose is not low.

If you are at home of course, it is sometimes best to do a blood glucose to help you to decide. If you give sugar every time your child has a tantrum it might seem like a reward for bad behaviour and encourage it!

Perhaps a compromise is to give an exchange as a drink for the hypo but then don’t react with any additional attention to her bad behaviour.

Have a break sometimes

Living with a toddler with diabetes can be a full-time job. If you get the chance, meet with other parents of a toddler with diabetes. Check if there is a local playgroup you can attend. Make sure your child is on the waiting list for your local kindergarten, and if there is a difficulty, discuss this with your doctor or social worker. Sometimes special consideration can be given to a child with a special problem like diabetes.

Arrange for a relative, perhaps a grandparent, to learn about diabetes so that you can get a break sometimes. Try to have some time off from your toddler each week to relax. Check with your doctor or social worker whether you are eligible for a government allowance which would help with baby-sitters and extra help in the house.

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HbAIc is the chemical abbreviation for a compound of glucose and hemoglobin in the blood. Hemoglobin is the red pigment inside red blood cells, and some of it has glucose attached, though most of it does not. We measure this substance in blood as a regular check on young people with diabetes.

The test for hemoglobin A1c

The purpose of the test is to help estimate the quality of control of diabetes over the previous 4-6 weeks. This is helpful in deciding if we should be satisfied with the way we are looking after you or your child with diabetes. We believe that trying to obtain good control is an important way to protect health in later life.

The test measures the quantity of hemoglobin in red cells that has glucose attached to it – glycosylated hemoglobin.

How does the glucose become attached to hemoglobin?

Glucose circulates in the blood, and some passes into the cells in the blood where it attaches to various proteins including hemoglobin. Some of this glucose becomes fixed to the hemoglobin and gradually accumulates over a period of several weeks. The amount that accumulates depends on the average levels of blood glucose concentration over that period of time.

In people who do not have diabetes there will only be a small proportion of glucose hemoglobin. For those with diabetes whose control is not good there will be a high proportion. In this way the proportion or quantity of glucose hemoglobin indicates how close glucose levels are to normal values over the period of time.

Why don’t blood tests at home tell you the same thing?

Blood glucose levels can vary a lot during the day and night, and although we usually only test before meals, they can be quite high after meals or during the night.

The blood tests at home tell us only part of the picture. They are very important however in helping with the day to day management of diabetes and in preventing hypos.

The relationship of HbAlc test and blood glucose tests at home

Both HbA1c and home blood tests tell us about how well we are controlling diabetes. Usually someone who can keep blood tests at home within a satisfactory range (most between 4 to 8mmol/l) will also have a satisfactory level of HbA1c. Sometimes however, the blood tests at home don’t match up with the HbA1c level. There are several possible reasons for this. Perhaps the blood tests at home are inaccurate: the test strips may be out of date or improperly stored. The meter may need calibrating. The child may not be putting enough blood on the strip. It is also possible that blood glucose levels done before breakfast and evening meal are not representative of other times. Thus, someone with a satisfactory HbA1c value, may have high blood tests during the day but low blood glucose levels during the night.

Sometimes teenagers get so fed up with doing blood tests and the disapproval from their parents when the tests are high, that they just make up their results and write down normal values of blood glucose on a test record. Even adults do this sometimes!

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Exercise helps control diabetes

Energetic activities play an important part in the healthy life of the child with diabetes. Activity increases the use of glucose formed from food, and helps insulin in maintaining a correct balance of sugar in the blood.

Exercise also helps insulin work properly by increasing its efficiency. It may also help in the absorption of insulin, particularly if the physical activity involves the part of the body where the injection had been given that morning.

Plenty of exercise is good

Your child should be encouraged in outdoor play, and in joining in sport and games with other children. With regular activity, insulin dosage will be kept lower and good control will be easier. It is important, of course, that exercise should be as regular as possible. Some children are naturally active, and this is no problem. Others prefer to watch television and sit around in their spare time, and if your child is like this he should be encouraged to spend some time each day in outdoor activity. Walking, cycling and skipping are good forms of exercise. Swimming is excellent, and although you will want to arrange that he is with someone responsible when swimming, you should certainly allow him this recreation. Do not restrict school sports, such as ball games, athletics, swimming or P.E. Encourage sports that can be continued through adult life.

Take extra carbohydrate before strenuous activity

Very strenuous sports, or unusual activities (such as a sports day or football match) will use up unusually large amounts of glucose for energy. You will need to give extra carbohydrate.

The type of carbohydrate used will depend on the type of activity.

For strenuous activities of short duration

For strenuous activities such as swimming, sprinting – some form of sugar which is absorbed rapidly should be taken just before the activity. For example, fruit juice, barley sugar or soft drink. Extra amounts may be taken during the activity – e.g. at half time at football.

For activities of longer duration

For longer activity, e.g. hiking, long distance running or jogging, additional complex carbohydrate or a combination of simple and complex carbohydrate which will be absorbed and enter the blood stream at a slower rate is more suitable.

The amount of carbohydrate required will vary not only with the type and duration of the activity but also between individuals: some young people seem to need a lot of extra sugar, and some hardly any at all. Your child will soon work out what is best by experience and discussion with you and your doctor. Follow these rules until you have this experience.

As a general rule allow approximately 1 carbohydrate exchange per hour of activity.

All children with diabetes should have an extra exchange of sugar in some form before swimming. Make sure that such people as the sports teacher and swimming instructor know your child has diabetes, and know what to do if a hypo should occur.

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Double bonds contain unpaired electrons, and polyunsaturated fats contain the most double bonds. This means they make the oil highly unstable whereby it can easily become rancid or oxidized. Polyunsaturated fats easily react with oxygen, light, water and various molecules in the body. If they become oxidized, such as through heating and exposure to oxygen (such as in processing and frying), polyunsaturated fats act as free radicals in the body. They can cause a great deal of harm in our bodies by damaging cell membranes and DNA. Damage to DNA may promote the development of cancer; free radical damage to our skin promotes wrinkles, and damage to blood vessels can promote the development of atherosclerosis. For this reason polyunsaturated fats should never be used for cooking; yet these are precisely the oils sold in the supermarket specifically labeled for cooking!

All fats and oils in nature contain a combination of saturated, monounsaturated and polyunsaturated fatty acids. Animal fats like butter, cream and tallow contain mainly saturated fatty acids and plant fats contain mainly monounsaturated fatty acids, or polyunsaturated fatty acids. In their natural state, that is, when found in raw nuts and seeds, polyunsaturated fats are very healthy. However, when turned into vegetable oil via processing, polyunsaturated fats can do more harm than good.

Various health authorities claim that the typical Western diet is too high in omega 6 fats (present in most vegetable oils) and too low in omega 3 fats (present in fish, flaxseeds and walnuts). This imbalance may promote inflammation, contribute to weight gain, suppress the immune system and promote depression.

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•     Learn about PMT. Become aware of your body. Keep a diary of any symptoms you have at any time in the month for at least three or four months so that you understand what is related to your menstrual cycle and what is not.

•     Find a PMT club or group to join -other women’s experiences can be very reassuring and even curative.

•     Keep a note on the family’s calendar so that the rest of the family knows why you are behaving strangely and can make allowances.

•     Having learned by self-observation when to expect symptoms, do the following from ten days before their onset until the day you start bleeding:

1. Stop eating added sugar, sweet foods, refined-flour products and between-meals sugary snacks.

2. Stop adding salt to your cooking or to your food at the table. This will help reduce the amount of fluid you retain and could make you feel a lot better.

3. Stop drinking coffee and cola drinks. Drink only weak tea or other non-caffeine-containing drinks.

4. Reduce or cut out alcohol and smoking.

5. Start eating six small, high-protein meals a day rather than two or three big meals-don’t eat more over the day; simply spread it out evenly so you don’t go for long periods without eating.

6. Increase your intake of foods rich in magnesium. These include millet, corn, brown rice, potato, cashew nuts, peanuts and tomatoes. Reduce your intake of dairy foods because, being rich in calcium, they interfere with magnesium absorption.

7. Take brewers’ yeast tablets (two a day) to improve your sugar metabolism.

8. Take six capsules of evening primrose oil a day. This is especially useful for women whose main complaint is breast swelling.

9. Reduce your intake of fats, avoiding particularly animal fats and hydrogenated margarines. Consume only high quality margarines, high in polyunsaturates.

10. Take daily exercise, preferably out-of-doors. Walking and running are ideal, as are aerobic exercises and swimming.

11. If you are a PMT-H type restrict your fluid intake and beware of hidden salt in your diet as well as obvious salt. Pickled foods, preserved foods, cured meats, spinach and celery all contain large amounts of salt, so be careful. PMT-A women seem to improve with the addition of vitamin B6.

12. If this preventive regime doesn’t work then progesterone (a natural hormone made from inedible yams) can be given by a doctor. Progestogens, the synthetic versions of progesterone used in the contraceptive pill, tend to make PMT worse. Natural progesterone is best, given as a vaginal pessary or as a suppository. For some women even quite a short course of progesterone can stimulate their hormone production to normal levels.

Try to cut down on the stress in your life – this will help your PMT symptoms.

It is my own personal clinical experience, and that of several others who work in this field, that many women who suffer from PMT have emotional or marital problems that are the cause and not the result of their PMT. I find that there is often a substantial psychosexual element with many of these women and that they often give a history of troubled sexual or interpersonal relationships. I have cured many women of their PMT by psychotherapy alone and a lot of women have told me that they can date the onset of their PMT to a particular psychological, emotional or sexually-linked event in their lives. Prevention in these women involves sorting out their underlying psycho-sexual problems.

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By pursuing a disease-free lifestyle, you’re doing something about it before it happens. That’s a wiser strategy, Dr. Bortz maintains. It’s also a major act of heroism, given that you’re not exactly smothered with support from the prevailing culture.

Take, for example, the eat-right plank on your disease-free platform. But is there enough doctors’ advice in the world to offset TV images of Michael Jordan telling you how wonderful it is to eat hamburgers?

“We’re a cowboy culture,” Dr. Wurzelmann says. “There’s a deeply ingrained and continuously reinforced belief that our strength derives from eating cows. What it comes down to is that eating beef is seen as having a lot to do with masculinity.”

But that’s where taking control of your own lifestyle comes in. Here’s how to do it.

Remember what it’s all about. The best beginning for a disease-free lifestyle is understanding the end. “You have to know why you’re doing it,” says Ed Burke, Ph.D., vice president of the National Strength and Conditioning Association in Colorado Springs and co-author of Getting in Shape. “If all you want is to lose five pounds to look good when you go to Jamaica on vacation, then don’t bother.” Instead, Dr. Burke says, think about having more energy always, about feeling stronger forever, and about losing weight and keeping it off. “Your approach should be long-term,” he says. “Make it part of your life.”

Keep things underwhelming. All six disease-free lifestyle elements are essential. But if you suddenly get religion and resolve to change your diet, lose weight, start exercising, and quit smoking on day one, you’re going to be overwhelmed. “You can fail miserably if you try to do too much at one time,” Dr. Glynn says. “It should be a sequence of lifestyle changes rather than one big one.”

The slow-but-sure approach works best for any individual lifestyle element, too. “You can’t run a half-hour if you’ve never walked around the block,” Dr. Bortz says. “Take small steps of mastery.”

Rewire yourself. For weight loss, gradual and steady progress isn’t just easier. It’s what works. You didn’t gain the weight in two weeks, so you can’t lose it healthfully in that amount of time either. You have to learn new behaviors. “Once you got fat, the eating center of your brain became fixed on that,” Dr. Bortz says. “If you starve yourself and lose 20 pounds in two weeks, you haven’t had time to rewire your brain.”

Hence, you haven’t accomplished much, and you’re probably going to gain the weight back. “Short-term enthusiasm is wonderful, but until you get your behavior reprogrammed, your long-term results are going to be poor,” Dr. Bortz says.

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According to the textbooks, an eating disorder is a pronounced disturbance in the way someone eats. “Disturbance” means a change from the person’s usual pattern, or a habit that poses a danger to health.

But such a definition isn’t very helpful. Do people who switch to a macrobiotic diet, for example, have an eating disorder? After all, they have changed their eating habits. Moreover, for some people at least, such a diet may provide insufficient amounts of calories, protein, and other nutrients, thus putting their health in jeopardy.

Although there is some overlap between obesity and the other eating disorders, specifically in terms of problems with body image and self-esteem, the causes and treatment of this disorder are sufficiently different to require a separate book of their own. Experts generally consider obesity a physical disorder, not a psychiatric one, although it may have a psychiatric component to it.

The question of what is and what isn’t an eating disorder is a common and sometimes baffling one. There are many areas of confusion and misinformation. In an effort to sort out this confusion, let me try to answer some of the most prevalent questions about eating disorders that I encounter as a physician specializing in the field.

Are eating disorders a recent problem?

No. Ancient Greeks and Romans wrote about abnormal eating patterns. Medical reports from three hundred years ago describe patients with anorexia. Only recently, however, have doctors tried to define these illnesses precisely, in order to better recognize and treat them. Bulimia, in fact, was only identified as a distinct disorder in the mid-1970s, although the problem existed long before then.

Don’t eating disorders affect only rich white people?

No. Patients can be black, Hispanic, Japanese. Many are by no means rich. A small number are male. In one sense, though, anorexia and bulimia are economic in origin. They occur where food is plentiful, as in the industrialized nations of Great Britain, France, the United States, Germany, and Scandinavia. The incidence in Japan, a “Westernized” nation, is increasing. In areas where scarcity of food is a problem, such as parts of Africa, eating disorders are extremely rare.

Are all anorexics and bulimics women?

Most are, but about 5-10 percent of them are male.

Is a man with an eating disorder gay?

Not necessarily. An eating disorder may be just one facet of a complex personality problem. Some men with these disorders struggle with issues of sexual identity, including homosexuality. Others feel pressure because thinness is highly valued in their professions, such as sports, dance, fashion, or entertainment.

Are eating disorders caused by parents?

Family problems can contribute to the onset and severity of an eating disorder. But they don’t cause it.

Aren’t all eating-disordered families alike: upwardly mobile, with dominating mothers, and no independence for the children?

No. Research has shown that children with eating disorders come from many types of families, including healthy, functional families. It is true, however, that after years of struggling, families may begin to develop problems because of the eating disorder.

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Verona Mucci-Hurlburt just loves the steak fries that are served in the cafeteria of the building where she works. But the 38-year-old chiropractor from Chicago knows that they’re no good for her figure. So when she sees them on the menu, she employs a strategy that helps curb her craving. She tells herself that she can have them later.

Postponing her indulgences in this way helped Verona end her lifelong battle of the bulge and lose 60 unwanted pounds—permanently.

Certainly, she has come a long way since the days when she carta j ried 212 pounds on her 5-foot-5i/2-inch frame. “I was chubby even § I as a child,” she recalls. “My mother put me on my first diet when I was just 4 years old “It was one of many that Verona would try over | the years. “Usually, I’d lose some weight,” she says. “But as soon as I went back to my old eating habits, the pounds returned.”

Then, in 1994, Verona enrolled in Weight Watchers. “I knew other people who had been successful on the program, so I decided to try it for myself,” she explains. She attended weekly meetings, in which she learned all about food choices and portion control. “The program gave me the structure and accountability that I needed to be successful,” she says.

Newly enlightened on the subject of nutrition, Verona realized that her love of certain high-fat foods, especially pizza and steak fries, could jeopardize her weight-loss efforts. She tried hard to stay away from them, but as she recalls, “I let myself say yes way too often.”

So she adjusted her game plan. Instead of forbidding herself her favorite foods, she simply delayed her indulgences. The steak fries are a great example. “The cafeteria served them every 2 weeks,” Verona says. “Instead of saying I couldn’t have them, I’d tell myself, ‘Wait until next time.’ Two weeks later, I’d ask myself if I still wanted them. Sometimes, I did. Other times, I could pass them up.”

The tactic worked so well that Verona applied it to other foods that didn’t fit into her eating plan. “I had to know up front that I could eat the food sometime in the future,” she explains. “The future could be 10 minutes away or 2 weeks away. The important thing was that I was taking time to think before I ate. That made all the difference.”

With practice, Verona found that she could extend her waiting periods even longer. “I went from 10 minutes to tomorrow to a special event next month,” she says. “I could pass up many fattening foods without feeling deprived.”

And it shows. In just 9 months, Verona was 60 pounds lighter. She has maintained her weight at 152 pounds ever since.

“For a woman of my stature, 152 pounds may seem heavy,” she observes. “But most of that weight is muscle because I’ve been doing strength training all along.” In fact, she became so enthusiastic about exercise that she now teaches aerobics classes on the side. “Working out and learning to say’later’ to fattening foods keeps me trim and fit,” she says.

WINNING A C T I O N

Postpone your indulgences. Three cheers to Verona for coming up with a fabulous craving buster. By telling yourself that you can have a “forbidden” food at a later time, you can turn your back on temptation without feeling deprived. And when the appointed hour arrives, you may find that you can pass up the food that, a few minutes, hours, or days ago, you couldn’t live without. If you still want it, go ahead and indulge. At least you’ve thought about it first.

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