After he had cancer, and was tested continually for metastases, his CT scans showed a ‘fatty liver.’ Our doctor sent him to a specialist, who said not to worry about it—that lots of people have it and never know it; the only reason Dave knew it was because he’d had cancer and was having all the follow-up tests. He said the cause is unknown, and he had no advice for improving the situation.

I have great respect for the liver! It is our largest single organ and the most complex. It is about the size of a football, weighs almost four pounds, and is nestled under our rib cage/lungs on the right side. The liver does hundreds of functions. It regulates (keeping track of glucose, bilirubin, and cholesterol levels), it metabolizes (processes nutrients absorbed in the intestine, makes bile for digestion, manufactures cholesterol, vitamin K for clotting and proteins), and it detoxifies (removing toxins, drugs, alcohol, and harmful chemicals). Everything you eat, drink, breathe, or absorb through your skin, is processed by your liver. In other words, the liver is life-and-death important to us.

I figured that if you aren’t an alcoholic or a drug addict and didn’t contract hepatitis, your liver would be fine. So we were baffled at Dave’s tests. We thought maybe when he used to use solvent with his bare hands to wash car/truck parts, it damaged his liver. (He is now very careful to use a good respirator and solvent-resistant latex gloves.) No one seemed to know.

What is a ‘fatty liver’? It simply means fat deposits in the liver that aren’t supposed to be there. It has no symptoms, and if it doesn’t progress, it probably is doing you no or little harm.

I do hate the name. Who wants to have a ‘fatty liver’ anyway? It reminds me of years ago when my nephew Adam overheard my sister and I talking about a ‘lumpectomy.’ He asked me, “What is the medical name for lumpectomy?” I said, “Well, I think that is the real name. That’s what they write on the surgical permits anyway.” (It means they remove only the tumor and not the surrounding tissue, usually said with breast cancer.) Adam grimaced and asked, “Isn’t that like saying you’ll be having a ‘slice-’em-open-urgery’?”

Actually fatty liver does have another name, ‘steatosis,’ but you rarely see that word. (‘Stear’ means fat.) If a fatty liver worsens and becomes inflamed, then the condition is called steatohepatitis. (‘Hepato’ means the liver, ‘itis’ means an infection or an inflammation.) Although the most common reason people have liver problems is alcohol, some, including Dave, don’t drink. Their fatty liver problem is labeled NAFLD, or non-alcoholic fatty liver disease. NASH is non-alcoholic steatohepatitis.

Dave trusted and liked the urology surgeon who removed his cancerous kidney, but he was frustrated that in the six-plus years of doctoring with him, this doctor never believed that Dave didn’t drink no matter how many times Dave reminded him. After he told Dave he was leaving the area, the doctor wished him well, and told him he really did need to consider quitting drinking… .

NASH patients’ livers are impaired with the inflammation to the point it is starting to interfere with the liver’s ability to function. Of course there are a hundred degrees of seriousness, but when the liver does so many different jobs, it starts to get scary.

What is really scary is ‘cirrhosis.’ When steatohepatitis worsens and the liver becomes cirrhotic—that means it becomes hardened and scarred—this damage is irreversible. Cirrhosis can advance to liver failure which means a liver transplant or death. Cirrhosis is usually caused from severe alcoholism or drug use or viral hepatitis, which is an infection of the liver. (Vaccinations are now available for Hepatitis A & B, if you are at a higher risk of exposure.)

Our livers are amazingly resilient! They repair themselves; they regenerate new cells. If we give our livers half a chance, they are the hardest workers in the body. Even if most of the liver is cirrhotic, the rest of it digs in and does its jobs. But it does need our help.

So why this discussion about livers in a diabetic blog? All these years, Dave and I have never connected his abnormal liver tests with diabetes, and no doctor has ever mentioned any correlation. Now I read listed in the Mayo Clinic’s risk factors of fatty liver: type 2 diabetes, along with high cholesterol and high triglycerides and obesity. (Gastric by-pass surgery can also cause it, maybe from the too-rapid weight loss?)

In contrast to the years of medical shrugs we’ve received, I’ve now read several studies that show weight loss helping NAFLD. In patients who lost 5% of their body weight, they showed improvement of ‘insulin resistance’ and steatosis and steatohepatitis. Patients who lost 9% or more of their weight showed reversal of liver inflammation. I was so excited to finally see there was some hope of turning it around!

The study recommended for treatment of fatty liver and steatohepatitis: 1.) slow weight loss as needed—rapid weight loss actually increases the problem, 2.) increased activity—even moderate amounts showed a good reversal of inflammation, 3.) healthy diet, 4.) avoid alcohol and unnecessary medications and supplements, and 5.) control diabetes and cholesterol levels. Is this advice starting to sound very repetitious?!

But back to the connection between NAFLD and diabetes, some estimate that 20% of the general US population has FL. (Obesity rates are much higher.) But an estimated 50-75% of diabetics have fatty liver problems. So there is a connection. We don’t know how long Dave had elevated glucose levels before he was diagnosed with type 2 diabetes—his test were borderline high/normal, but pretty good, we thought—but it makes me wonder if something with his metabolism had been out of whack for years.

He’s lost about 30#, and if my math is right, he’s lost 7% of his body weight, and for the first time in many years, his liver function tests are completely normal! Can you see me smiling? We had both long ago given up on normal liver function tests.

What about supplements touting liver health? Dave took ‘milk thistle’ (an ancient European thistle that’s a common supplement for the liver) and ‘alpha lipoic acid’ for quite a few months, but his tests didn’t improve.

If you take supplements, keep in mind that the liver has to process everything you throw down. Most of the studies I read showed supplements causing more liver damage. If your liver is already struggling, the more pills/higher dosages you give it to detoxify, the harder it has to work.

Some supplements listed as possibly helpful are licorice extract, dandelion, artichoke, chamomile, garlic, Coenzyme Q 10, etc. besides the milk thistle and alpha lipoic acid, but no studies have so far shown that they work. Milk thistle at least showed it did no harm, even if no proof of improvement. (It doesn’t sound like there’s been good studies performed; so this doesn’t necessarily mean none of these help.)

Some listed as harmful to the liver are kava, pennyroyal, and skullcap. Acetaminophen (Tylenol) is also especially hard on the liver.

There is a lot of information on the internet on supplements. Check out several sources of anything you might want to try. Stay away from the sites selling them—there are a lot of very convincing snake oil salesmen out there. In the 1900 Sears Roebuck catalog, it sold ‘Wonderful Little Liver Pills’ that made you ‘always feel well and look the picture of health.’ Or how about ‘Dr. Hammond’s Nerve and Brain Pills’ that were ‘positively guaranteed to cure any disease.’ My favorite was Dr. Rose’s Obesity Powders. He started his sales pitch with: “Listen up, Fat Folks … .” Guess there wasn’t quite as much political correctness going around back in 1900, but some of the claims on the internet today sound terribly similar.

The Food and Drug Administration (FDA) has approved six artificial sweeteners, and new ones keep popping up. They are big business. Saccharin (Sweet’N Low, Sugar Twin) came out first, in 1957. Aspartame (Equal, NutraSweet) came out in 1981, and sucralose (Splenda) in 1998. Others approved are acesulfame-K (Sweet One, Sunnette,) neotame, and tagatose.

Diabetics were told for decades that they couldn’t eat any sugar. (I would be so furious if I had been one of those sweet-deprived diabetics, then told it hadn’t really mattered after all.) Now they realize that all carbohydrates turn into simple sugar in the bloodstream, so eating sugar is all right in moderation. Dave is very careful to eat sweets only right after a meal, and he’s had no problem with glucose spikes. He won’t even wait 20-30 minutes any more—he’s tried it. With little or no nutrition in goodies, they are not something he eats daily, but if others are eating birthday cake or whatever, he does, too. And I am making healthier versions of sweets for him to eat occasionally. He eats only half of the serving size he used to.

The bulk of artificial sweeteners used in the US are not consumed by diabetics. People want to eat something with little or less calories for weight control. Lots of controversy surrounds this idea. I have read—and I can not find where now that I want to verify it—that artificial chemicals confuse the body which treats anything ‘unidentified’ as a carbohydrate, just in case, so it pumps out insulin. I’ve asked our doctor, and the class dietitian about this, but neither had heard this theory.

My sister’s friend Mike says that Splenda does not spike his blood glucose, but the other artificial sweeteners do. I wonder if this is because Splenda is made from actual sugar. Dave isn’t using artificial sugars, so we don’t know the effect on his glucose levels.

If you see ‘tol’ words on nutritional labels, like sorbitol, mannitol, xylitol, lactitiol, or maltitol, these are sugar alcohols, non-sugar sweeteners. I’ve read conflicting information about their effect on the glucose levels. Since it seems to be more an individual thing, if you want to eat the sugar alcohols, just test yourself and be aware that different ones may affect you differently. They may cause cramps and diarrhea. (Dave and I well remember experimenting with some sugar-free fudge at a candy shop in Portland many years ago, then our sprint to the bathroom minutes later!) ‘Sugar-free’ candy does not mean calorie-free, unfortunately. My cousin’s wife gave Dave some candy made with maltitol that tasted good and didn’t cause any problems.

High fructose corn syrup (HFCS) is a food additive in soft drinks, many processed foods, salad dressings, and lots of other things. It’s cheaper and sweeter than sugar, hence its popularity. Before 1966, the average American had never consumed any HFCS; in 2001, the average person ate 63 pounds/year! Some think this alone accounts for a lot of the obesity problem in the US. Another thought—the years we have greatly enlarged our waistline as a country are the same years that artificial sweeteners have been around. (From 1987 to 2000, artificially-sweetened products consumed in the US rose from 70-160 million, and obesity in those years rose from 16% to 30%.)

A study listed in ‘Circulation’ magazine pointed to a 50% rise of the metabolic syndrome rate in those consuming one or more soft drinks (either regular or diet!) per day. This was shocking and brutally sad news for a Diet Coke lover like me who has thought, ‘I know the stuff isn’t good for me, but I don’t drink more than one or two a day….’ (I have quit almost entirely now. Besides for my health, Dave has cut out all pop, so I am trying not to tempt him either.)

If you like rat studies, researchers (Feb. 2008, Swithers/Davidson with Behavioral Neuroscience) fed rats food containing a sugar substitute. Even though the food had less calories, the rats ate more and gained more weight than the group of rats eating sugar-sweetened food higher in calories. In addition to eating more, the bodies of the rats eating the substitutes adjusted their metabolism/body processes to burn fewer calories. Man.

Lest we get on too high of a soapbox here about eating regular sugar, unless you are gnawin’ on a hunk of sugar beet/cane, you are eating a processed sugar whether it’s labeled ‘natural’ or ‘organic’ or not.

Besides table sugars, there are natural sugars such as honey, molasses, fructose (fruit sugar,) lactose (milk sugar,) etc. These all break down into simple sugar, so they will all raise the glucose level like any sugar does. There is more nutrition in some of these, so worth using for that alone.

Stevia (PureVia, Truvia) is a South American plant used in other countries for centuries as a sweetener. It is ‘natural,’ but the US has said the plants can be toxic. Now they’ve recently decided that the amounts ‘probably used’ will be small enough to not be toxic if people abide by their RDA guidelines. (As a citizen of an obese country obviously failing miserably at the following-guideline part, I can’t say I find this all that reassuring.) In the US, stevia has been sold in health food stores as a ‘dietary supplement.’ Last fall (2008) the FDA approved it as a ‘food additive,’ which means it will soon be showing up in processed foods. And in pop—Coke is coming out with Sprite Green, sweetened with stevia. Dave’s cousin’s wife says she hates the taste of it. I tried a bit by itself—it almost tasted like a very bland cough drop to me. Not particularly bad or good.

Agave (Xgave) nectar—it’s in syrup form—is from a plant in Mexico. It actually has more calories than sugar, but it is sweeter so people usually use less. Agave is said to cause fewer spikes in glucose levels than sugar. Dave hasn’t tried it.

So are artificial sweeteners safe? The jury is definitely still out, and I think will be out for many years yet. The National Cancer Institute has found no evidence they cause cancer in any of the studies they’ve done. Aspartame should not be used with PKU, a rare hereditary disease dealing with protein metabolism. The FDA lists a different recommended daily amount (RDA) for each sweetener. I’ve seen it recommended—if you consume quite a lot of artificial sweeteners—you should use different kinds to lessen the side effects of each one. Dave and I are choosing not to use any—except maybe the occasional one—because it seems like a lot of questions and worry when a teaspoon of sugar has sixteen calories.

‘Lipid’ means ‘fat’—so a lipid panel means several tests breaking down the cholesterol types.

The ‘total cholesterol’ is a simple test that gives a quick peek at your general health. You can even buy home test kits now. Doctors won’t make any diagnoses or treatments based on a ‘total.’ If could, after all, mean that your good cholesterol is almost nonexistent and your bad is not that good. I had a hard time figuring out what the numbers meant since nothing added up on my reports—and no one could tell me. I finally found a formula: LDL=Total-HDL-(trigycerides divided by 5.) Don’t ask me why that was important, but at least it wasn’t my math.

LDL (low density lipoprotein) is the ‘lousy’ one. VLDL is ‘very low density lipoprotein,’ also bad. HDL (high density lipoprotein) is the ‘heavenly’ one. (And that may be the only time you’ll hear the words ‘dense,’ ‘fat,’ and ‘heavenly’ in the same sentence.)

Oil and water don’t mix; therefore fatty cholesterol and watery blood don’t mix. In order for cholesterol to float along through the bloodstream, the fat (lipids) are coated with a protein, which makes a ‘lipoprotein.’ LDL  is mostly a big fatty inner part covered with a small amount (low density) of protein. This isn’t so good. HDL has a little ball of cholesterol with a ‘heavily dense’ coating of protein.  LDL promotes accumulation of fatty deposits (plaque) in your arteries. HDL clears the excess cholesterol out of your body, and keeps your arteries healthy.

Total cholesterol should be under 200 mg/dL.  LDL, under 100.  HDL, over 40 for men and 50 for women.  Triglycerides, under 150. If you have heart disease, doctors may tell you differently, such as the LDL under 70.

If your numbers are high, you may see the words hyperlipidemia or hypercholesterolemia/cholesteremia. ‘Hyper’ means above or too much, ‘lipids’ means fats, and ‘emia’ means a condition of the blood.

What happens when our (bad) cholesterol levels are too high? Our blood vessels start clogging up (think of bacon fat hardening along the drain pipes) and raises our risk of all coronary (heart) diseases including heart attacks and strokes, Peripheral Artery Disease (PAD), and pancreatitis. Cholesterol can accumulate abnormal deposits such as gallstones, and atheromas (fat deposits/plaque.) Cholesterol plaque deposits make bumpy irregular blood vessels; blood clots try to come to the rescue and smooth it over. These can plug up an artery, killing off what they are supposed to supply blood to, or if these break off, they can float to the lungs (causing a pulmonary embolism) or brain (stroke).

Triglycerides are one of the cholesterol components they test you for. They come from the fat we eat, and the body makes them. Triglycerides can rise from smoking, excess alcohol, stress, and illness. The body can change excess glucose to this fat—so triglycerides can rise on a fat-free diet if you overeat carbohydrates. Tricky.

Triglycerides can be an albatross around a diabetic’s neck. Normally after a meal, they go down in 4-6 hours. If you have type 2 diabetes, or you are ‘insulin resistant,’ it takes much longer to clear out. This elevated amount of triglycerides hanging around is bad because: 1.) They slow production of insulin and make it harder for insulin to work, raising your glucose level,  2.) Triglycerides stimulate your liver to make more glucose—somehow they get their wires crossed, 3.) Triglycerides accumulate in the liver, making fatty liver, 4.) And of course they, along with other cholesterol, increase your risk of heart disease and blood vessel damage.

If you have high cholesterol, chances are good that you’ve been told to eat a lower fat diet. Were you told that your liver makes most of your cholesterol? Seems like that’s a point hardly ever mentioned! People vary, but some researchers estimate between 75-85% of your cholesterol is made by the liver and the rest is made up from dietary sources. If you are starving or eating a very low-fat diet, your liver kicks in and manufactures the difference. Cholesterol is vital to our lives, so our amazing bodies make sure we aren’t going to die from lack of it.

Genetics plays a big part of your cholesterol levels. One source I read said, “Be very careful picking out your parents.” Dave’s doctor said the only way he’s seen people raise their good cholesterol is with medication, since it’s hereditary. (Dave’s has improved some, without medication, but it’s low. 34 and should be 40 or above. But he started years ago at 27!)

So if your liver makes most of your cholesterol, and your levels are at least somewhat decided by your family history, it doesn’t add up that the main medical advice we get is to eat a lower fat diet. (And most don’t even go into healthy and unhealthy fats we eat.) We probably all do need to eat less fat—I’m not arguing that at all. Eating healthy fats is one of the best things we can do for ourselves, diabetics or not. But putting the blame all on our diet seems an easy cop-out. Our efforts for reducing high cholesterol levels need to be in three directions: 1.) healthy eating (including low-moderate alcohol consumption if you drink), 2.) losing weight if we need to, and 3.) regular exercise. In general, to lower the lousy LDL, eat healthy fats and lose weight if you need to—to raise HDL, increase your activity level. If these efforts fail, medication is an option that will be strongly pushed at you by your doctor.

Dave’s doctor told us that in diabetics, three factors—blood glucose, blood pressure, and cholesterol levels—are tied tightly together, and it’s almost impossible to get one down without the other. So we’ve got to attack this three-fold braid all at once. (Dave is on blood pressure meds. I had hoped he could get off them once he lost weight, but so far he’s still needed them.  Maybe his last ten pounds off will help. One of the functions of the kidneys is to help regulate blood pressure, so with just one kidney, he may always need them.)

So why not take a cholesterol-lowering drug and take care of the problem? Personally, I’m not just mildly opposed to them, I’m intensely rather fanatically opposed to them. I suppose it started years ago when our neighbor in North Dakota, a healthy active woman in her 60′s, was told her cholesterol was a little high and went on Lipitor. She died. All her systems shut down and they simply couldn’t save her. I absolutely refused to have Dave on them for many years. They finally convinced him that his chance of a heart attack was strong enough (with his low HDL) to try a statin. I reluctantly agreed, not particularly wanting him to have a heart attack either. He didn’t notice anything until he had taken it for about 5 weeks. One day he said his legs were hurting for no reason, and I begged him not to take more Lovistatin. He decided to take another pill to make sure, saying he didn’t think that was it. (I think it’s called ‘Sisu’ which my aunt defines as ‘unbelievably stubborn.’) That night he called from work (on top of a D-11, a very big dozer) and said he didn’t think he could get off the machine or do anything. His legs felt like they were being pulled apart in all directions. He finally hobbled home after thinking he was going to die. Both his doctor and pharmacist told him to never ever take any form of a statin again.

To be fair, there are many people who credit cholesterol-lowering drugs with saving their lives—their cholesterol levels drop like crazy and they are happy campers with no side effects. This has to be a personal decision, of course.

Niacin in high doses (under a doctor’s guidance hopefully) is sometimes given to lower cholesterol. I’ve tried moderate over-the-counter doses and have noticed no difference. Red rice yeast (2400 mg/day) is another OTC one you can try. The ‘cholesterol nurse’ said that was one recommendation for Dave. We tried it, but no longer take it. Both of our levels have gradually improved over the years, but probably a combination of things. Psyllium husks is a very concentrated form of soluble fiber (that isn’t supposed to have any side effects)  touted for lowering cholesterol. Dave and I each take fish oil capsules daily. I don’t know if they work or not, but again, no side effects if you don’t take too much. (Our dr. says to take 1000 mg/daily.) And some say fish oil also helps arthritis, which we both have. There are dozens of wild claims about lowering cholesterol on the internet. And many products available to buy OTC in health food stores and pharmacies. Our chiropractor has pills available to buy that he says really  helped him, but we haven’t tried them. Everyone’s so different, it maybe doesn’t hurt to experiment with things as long as they don’t end up hurting anything more than your pocketbook.

The bad news is: Most of us eat way too much.  And we are eating a lot of the wrong kinds—saturated and trans fats.

Saturated fat is the animal fat like butter, milk (except fat-free, of course), meat, and eggs. Most saturated fats are solid at room temperature—butter, lard, the white fat on meat, etc.—but two plant oils are saturated, coconut and palm oils. Processed meat like salami, pepperoni, regular bacon, etc. are pretty loaded. (In the diabetic class about protein, the dietitian said that bacon is a fat, not a meat. The only note Dave wrote during the two-hour class was “bacon is fat.’ Traumatic statement for a bacon-lover like Dave.)

Eggs continue to be a controversy. Some argue the benefits of the yolk outweigh the cholesterol issue. Egg whites don’t have cholesterol. Our egg-eating is very sporadic—Dave loves big breakfasts for supper during his 7 night shifts a month, and we don’t eat them much otherwise. Our dietitian suggested a limit of 3-4 eggs a week; the American Heart Association says IF your daily cholesterol intake is fairly low, one egg a day won’t hurt you. There are cholesterol-free egg substitutes, but I haven’t tried them. We haven’t worried about eggs a whole lot—I think they’re a good food in moderation—but we’re trying not to overdo it.

In our 32 years of marriage, seems like about every five years the controversy over butter vs. margarine flip-flops as to who is the better guy. In the early ’80′s, it was butter, and we’ve stuck with it ever since.  Back then margarine was hydrogenated stick margarine, worse for you than butter, and some still is—check the labels. A month ago, I bought a tub of “Smart Balance-Light” margarine made out of flax oil etc. which Dave has yet to try. (It does have a half-inch list of other ingredients that I don’t know what they are, so it’s not sticking with my ‘real food’ plan here.) I think it’s pretty good, although having not eaten margarine for 30 years, I’m definitely not a good judge. (Dave has an old horror of margarine dating back to his childhood memory of  greasy white sticks that they mixed with little yellow coloring packets. I grew up on a farm so escaped all that. We made our own butter, and I never tasted margarine until college days.) We are still using butter, just pretty sparingly. Cheese is good for you, but does have saturated fat so need to limit. Some has less than others; check labels to make sure that lower fat versions aren’t adding sugar and chemicals.

Trans fats (trans fatty acids) are the worst guys. The Mayo Clinic calls them the ‘double-barreled whammy’ because they raise the LDL (bad cholesterol) and lower the HDL (good.) They are also thought to cause inflammation in the arteries and nobody needs that, especially diabetics. Originally thought to be a healthier option to saturated animal fats, trans fats are created by adding hydrogen to vegetable oil. This makes them firmer, and gives them a long shelf life, which is a boon for the food industry! Plus they are cheaper, another reason they are still widely used in spite of everyone agreeing they are bad for us. In the 1990′s, researchers were startled to find out this ‘healthy alternative’ is worse for us than saturated fat.

Trans fats are in processed foods—boughten cookies, snacks, chips. If the label says ‘hydrogenated’ or ‘partially hydrogenated,’ it means trans fat. But ironically, ‘fully hydrogenated’ products do NOT have trans fats. They’re still slugging out the ‘acceptable limits’ on trans fats, but sounds like around 2 grams or less daily. Our government allows food to be labeled ‘No Trans Fats’ if it has less than 0.5% trans fats. It may not be a huge amount, but I find that very sneaky. If a ‘small’ bag of ‘healthy’ chips contain 3.5 servings—doesn’t take long to add up 2 grams. The label of Crisco shortening says it has fully hydrogenated cottonseed oil and partially hydrogenated cottonseed and soybean oils—and it is listed as zero trans fats. They have improved it quite a lot I think, but I still rarely use any. Now that people are getting more trans-fat-smart, manufacturers are adding coconut and palm/kernel oils which sound healthier, but are saturated. To avoid a lot of these processed junk food, I try remember the advice: ‘Shop the perimeter of the store.’

If you eat out a lot, be aware that many restaurants use a lot of trans fats—anything fried or deep fried, biscuits, desserts, and even things that seem healthy choices like rice and vegetables. A large serving of fries has 5 grams of trans fats—ouch. Restaurants are not required (yet anyway) to list trans fats in their nutritional information. Probably the best solution is to buzz over to New York City for supper—the city has banned all restaurant use of trans fats.

Now to confuse the issue, the trans fats talked about so far have been artificial—the hydrogen added into the oil—but there are very small amounts of naturally-occurring trans fats in dairy and beef. A recent Canadian study showed that these natural ones have a very different effect on the body and may be beneficial. Stay tuned.

OK, now to the good guys. The healthiest fats are the monounsaturated fats. Not only do they not raise your LDL (bad cholesterol), they are thought to raise the good HDL!  They are found in olive, canola, and peanut oils, avocados, nuts, seeds, etc.  The only negative thing about these are that they taste so good! and quickly can add inches and pounds. One serving of oil is one teaspoon. A serving of nuts is 2-4 tablespoons, depending on the nut/seed.

Polyunsaturated fats are good ones, too, since they don’t raise the LDL. They are one step down from the monounsaturated fats since they don’t improve the HDL, but they include the good-for-you omega-3 and omega-6 you hear about.  Most food has combinations of the healthy fats, so it doesn’t pay to worry a lot about which has which. Oily fish like salmon is good, flaxseed meal, walnuts, almonds, and sunflower seeds. Many nuts have added oil, salt, seasonings—watch the labels.

I don’t add ours up, but recommended daily allowances (which vary a lot depending on the source) that I found were around 45-70 grams for women and 60-95 for men.

The fats we eat are important to everyone, but in diabetics, it’s particularly important because fat can increase the body’s resistance to insulin. (Even one high-fat meal can make it difficult, even if temporarily, for the insulin to allow glucose into the cells.) And because of damaged blood vessels, diabetics are more prone to heart disease, so there’s no sense in adding to the problem. And extra weight (the more you weigh, the more glucose/insulin is needed to support that weight) puts extra strain on that struggling diabetic pancreas which is already dog-paddling upstream as hard as it can.

The thing is aim for is: more healthy fats, less saturated fats, and no trans fats.

Protein, along with carbohydrates and fats, is one of the major food groups. The body breaks down protein to amino acids, which are used to make and repair organs, tissue, skin, bones, enzymes, and hormones. Some food sources of protein are meat, fish, poultry, eggs, cheese, tofu, dairy/milk, legumes, and nuts.

Most of us probably eat more protein than we need. Guidelines recommend only one-fifth of our diet be protein. Protein doesn’t directly affect the glucose levels, so we don’t have to count it in carb counting. But—excess protein is changed into fat by our always-helpful bodies and stored for a rainy day.

We are eating less red meat—not every day—although we love it and consider it a healthy food. Buy the leanest cuts with the least marbled fat in them, and cut off any visible fat before cooking. (Chicken skin is quite a disaster, health-wise.) Prime rib tastes so wonderful because it is one of the fattiest choices of beef. The ‘loin’ cuts like sirloin or tenderloin, are usually the leanest beef. We love fish, but don’t it eat the 2-3 times they recommend. I am trying to remember it more often.

Animal sources of protein are called ‘complete proteins’ because they have all the essential amino acids that we need daily. The vegetable sources are good, but ‘incomplete’ in themselves, so vegetarians need to be careful/knowledgeable when mixing proteins in order to get all the essential amino acids. Our bodies can’t stockpile protein like they do so beautifully with fat and carbohydrates: We need to eat protein daily.

The sample serving sizes look pretty puny to farm kids like us. Dave’s diabetic class recommended 3 ounces of lean meat (looking about the size of a deck of cards or a small hand’s palm); the Mayo Clinic recommends 3-5 ounces per serving.  Some examples given by Dave’s class, besides the 3 oz. of meat, were 1 egg, 1/4 cup cottage cheese, 2 tablespoons peanut butter, 1 oz. of cheese, 1/4 cup canned tuna or salmon, or 1/2 cup tofu. Daily recommendations are between 75 grams and 125 grams, depending on where you look.

I know Dave and I overeat protein, although I haven’t added it up.  Besides excess calories, protein is thought to create extra work for kidneys (disputed by some), so this is an extra consideration for Dave’s one kidney.

‘Insulin resistance’ is a condition when the pancreas is faithfully making insulin, but the body is reluctant to let the insulin do its job—open up the cells and let the glucose (sugar/energy) inside. In Dave’s diabetic class, the instructor drew a round cell. Floating around the cell were both ‘keys’ (insulin) and glucose. Normally, the insulin ‘key’ would unlock the door of the cell, and glucose would go in and be used for energy.

If your body is resistant against insulin, it will use the insulin eventually, but only when you have extra insulin floating in the blood. The pancreas keep churning out more and more insulin (depending on how resistant you become) to keep up. Eventually the pancreas gets pooped and the glucose levels get higher—and a person is diagnosed with type 2 diabetes.

Not always, but usually an insulin-resistant person is overweight. In my mind, I see chubby little fat cells (with ornery expressions) holding the cell doors shut. The more little fat guys barricading doors, the more insulin ‘keys’ it takes to ram them out of the way to get the glucose inside the cell.

Doctors have gradually noticed a group of symptoms that make a patient more likely to develop type 2 diabetes and heart disease/strokes. These five symptoms are called the ‘Insulin Resistance Syndrome,’ or the ‘Metabolic Syndrome,’ or ‘Syndrome X.’ (I think it’s leaning more toward Metabolic Syndrome now.) The five symptoms are: 1.) abdominal obesity, 2.) triglycerides over 150, 3.) HDL under 50 for women or under 40 for men, 4.) blood pressure over 130/85, and 5.) fasting glucose level over 100.

You are considered as having Metabolic Syndrome if you have three out of the five.

‘Apple-shaped women’ in general show less tolerance for insulin. (Some think that the abdominal fat cells produce estrogen and make—and keep—us fatter.) A general guideline of a waistline measurement over 35″ for women and 40″ for men means you’re at risk. Even with so many body shapes/sizes, this is a fairly accurate guess. The waist-hip-ratio is also used. (Divide your waist measurement by your hip measurement. If over 0.8 for women or 1.0 for men, at more risk.) One doctor said she divides your triglycerides by HDL, and if over 3, she immediately suspects insulin resistance. Even though there is a lot of disagreement about the numbers/measurements, I think most of us have a pretty good idea if the ol’ gut is too fat.

Convinced I was insulin resistant, when I went in for a check-up last week, I asked my doctor if he’d order the blood work for it. He did—lipid profile, fasting glucose, and an actual insulin level test. I know my waist measurement is bad, so that checked off #1. #2, my triglycerides were good (107), and #3, my HDL was 42, so that wasn’t high enough to make the grade. #4. My blood pressure has been OK for years, and on Monday it was 152/110! I went back in on Thursday and it was 124/84, so I don’t know for sure about that one. #5. My fasting glucose was fine, 89. I’d say that I was leaning toward having it—but then my insulin level was 9.0 (normal is 1.9-23), so I am confused. And if you divide my triglycerides by my HDL, it’s not over 3. (I haven’t had the heart to do the waist-hip-ratio one yet.) But I still think I’m pretty borderline, and need to work on it.

Now for the good news! Insulin resistance is one medical condition that’s really in our hands! The four guidelines for the ‘cure’ are 1. exercise, 2. weight loss if needed, 3. healthy eating, and 4. if you smoke, quit. OK, maybe that’s actually the bad news—these are so hard! But exercise doesn’t have to be the hard killing kind. Walking 20-30 minutes a day at a moderately brisk pace reduces insulin resistance. And even if you don’t lose a single pound, exercise lowers your blood pressure and improves your cholesterol levels besides helping the insulin resistance.

If I eat like I have Dave eat—spacing out healthy ‘slow’ carbs throughout the day, pairing them with a fat or protein—I cut my cravings way down, and keep the waves of tiredness at bay. Hopefully healthy eating and good old walks will improve my numbers eventually.

Our main concern was his A1c (a three-month average of his blood glucose levels.) In the end of November it was 10.7, which is off the risk of damage chart. Now it was 6.3! I couldn’t have even dared to hope for that much improvement. His doctor said that being it is a three-month test (testing Dave for December, January and February), he guessed that right now, Dave’s level was more like 6.0. (Normal is 4-6%.)

This is so crucial to prevent further damage! There is no way to peek inside Dave’s blood vessels and assess the damage already done, but he still has some cramping (it is much better), and leg and arm pain, and poor circulation. His hands and feet get cold pretty easily. I haven’t found any real encouragement from my reading if these could be reversed—the ADA (American Diabetic Association) says they are not and the diabetic nurse says they can be. She said sometimes nerves can repair themselves if the blood levels are good, although the repairs take up to a year. But even if not, at least keeping his glucose under good control will stop the deterioration, or slow it way down.

I’ve read that for every 1% over 7% that the A1C is, there is a 30% more likelihood of developing complications. It’s a huge relief to know he’s no longer in that wicked 10.7% range. (And that’s why I was crying.)

Another case for excitement was his liver function tests. These were done regularly every few months after his cancer, since the liver, and lungs, would be where kidney cancer would first metastasize to. Dave’s liver tests have been abnormal for maybe 15 years. He saw a specialist about it once, who said not to over worry about it since he suspected a big majority of us have fatty livers and don’t know it; the only reason they knew about Dave’s was because of the continual cancer checks. No one has ever figured out any reason for Dave’s abnormal liver tests other than it could be from his fatty liver. No one has told us there is any connection between that and diabetes, but I’ve since read in several books that it’s from storing excess glucose in the form of fat deposits.

Anyway—for the first time in many years, Dave’s liver function tests were actually normal!

I wanted him on metformin (generic Glucophage), a diabetic pill, to make sure we got him, and his 10.7 A1c, under control as soon as possible. I’ve wondered that along with good blood levels, if metformin might help improve his fatty liver problem. We still have no way of knowing, but it seems like it might if his liver function tests are normal.

Dave was discouraged at first when his fasting morning glucose numbers were the worst. The rest of the day, they were in the 90′s and 100+, but the morning was usually between 110-120. It didn’t make sense that after fasting, sometimes for 12+ hours, they would be worse than two hours after a meal. Then I read about the ‘Dawn Phenomenon.’ Our body works day and night, doing its best to regulate us around the clock. And one way is that even though we usually ‘fast’ all night, the liver—worried we won’t have enough energy in the morning—releases stored glucose (in the form of glycogen) to up our glucose levels by the time we wake up at ‘dawn.’ (Well, some of us anyway.) I must say that’s pretty thoughtful of a liver to even think of that. I told Dave rather than be discouraged, maybe it was a sign that his liver was clearing out some of that stored liver fat. Since he no longer is having routine MRI’s—he’s past the five-year-cancer-survival time, yay!!—we probably won’t find out anytime soon if his fatty liver has improved, but at least his blood work seems an encouraging omen.

Dave’s creatinine level (a blood test that tests kidney function) just sneaked under the normal-wire! That’s so exciting because that’s the normal level for two kidneys. His urology surgeon told Dave to expect his to always be a little higher than is normal for two kidneys. Also, his urinalysis showed no protein. (Anything over a ‘trace’  would be a sign the kidney is in distress/working too hard.) So his one guy must be doing extremely well. Diabetes attacks kidneys, so that’s a special cause for rejoicing when you have only one.

Dave has lost a total of 35# since last fall! (10#  of it were lost before his diagnosis.) Since Dave’s cholesterol tests—although improving—aren’t exactly stellar, the doctor wants him to lose another ten, thinking it may help them. Dave’s already looking thin, so we’ll see what happens…. At least his triglycerides are real good, and that’s the one related more to insulin resistance and diabetes. (Not that I think a too-high LDL is a plus or anything. Just trying to look on the bright side here.)

His doctor told him to halve his dose of metformin, and if his glucose levels remain where they have been, to eliminate it all together! Always some risks and side effects with meds, so that’s good.

Dave’s vision is back to normal! Finally—that took a lot longer than the two months they first had estimated. We had first jumped to the conclusion that his blurry vision was caused by retinopathy, one of the things they warn you about as a serious diabetic complication. Retinopathy is caused by damaged blood vessels in the eye. We were both pretty discouraged about that. But I’ve since read in several books that having blurred vision on diagnosis like Dave did indicates that the lens inside the eyeball is swollen, and can’t focus properly. The out-of-whack glucose levels messes up the whole body, most noticeable in the eye as it affects vision, as it desperately tries to ‘balance the sugar’ ratio of fluid:glucose. We are so thankful to learn that this is temporary, with no lasting complications.

Dave also had had a follow-up with the diabetic nurse a few days earlier. She used a monofilament (he said it was like a little fishing line sticking out of pen) to check the sensitivity of his feet. We weren’t that thrilled when he discovered an area about 3″ across on the ball of one foot that he couldn’t feel with the filament, although he can feel it if he pokes it with his finger. The doctor said he thought this was due to his back problems, not diabetes, since numbness caused by diabetes usually starts with the toes, not farther up the foot.

I’m always worried Dave is going to get tired of the changes in diet/timing and counting of carbs, testing etc. but he said today that he is ‘perfectly fine’ with doing this forever. He doesn’t resent it at all—in fact, is so happy it’s working. I’m thrilled (and a still a bit in shock) that he’s so diligent and serious about taking care of himself—and this checkup showed him it’s paying off. Instead of this being a life of ‘changes’ now, it’s just becoming a way of life. We are happy, and thankful, campers.

Fiber is especially important for diabetics. Too late for Dave, but it’s listed as one of the most hopeful things for preventing, or delaying the onset of, diabetes. Researchers are linking populations with the lowest amount of fiber eaten to the highest rates of diabetes. (Of course lots of other factors figure into that.)

There are two forms of fiber–soluble and insoluble.

Soluble fiber dissolves in water, and then forms into a thick gel. This gel is a wonder product! It slurps up the LDL cholesterol and triglycerides, and sends them down the tube and out. And the gel also slows down the glucose in your meal, so the glucose enters the bloodstream gradually, erasing those spikes.

Some examples of soluble fiber are oat bran, rice bran, barley, beans (dried/cooked), carrots, unpeeled apples, etc.

Insoluble fiber does not dissolve in water, and provides no nutrients, but it’s good stuff. It absorbs water and produces the bulk you eliminate in your stool, so it prevents constipation, and researchers are seeing links to increased fiber and decreased colon cancer. Having more amount of bulk, or ‘roughage,’ in your diet decreases your appetite, and indirectly slows down the speed of glucose hitting your system.

Some examples of insoluble fiber are wheat bran, legumes, fruit and vegetables. (Skins are very good for you, so leave on if possible. Of course I’m not talking about grinding down a banana peel, but when they talk about how good fruits and vegetables are for you, a lot of that goodness is the fiber  in the peeling.) Lots of food have both kinds of fiber.

How much do we need? I’m reading a range of 25-50 grams a day (total of both kinds). That’s enough that you have to be trying! But not terribly hard if you eat whole grain things and unpeeled fruits and vegetables, etc. I calculated the amount of old fashioned oatmeal I eat with flaxseed meal and walnuts: 14 grams, so makes a good start on the day’s amount. All-Bran cold cereal says it has 10 grams per 1/2 cup, and Fiber One has 14 grams per 1/2 cup. (I use them in lower-sugar muffins rather than eating straight.)

If you currently are eating little fiber, they recommend you add more gradually over a period of days/weeks, to prevent gas/bowel upset. (Or as Dave delicately puts it, the ‘runs.’) Good old fashioned beans–pinto, kidney, black, white, etc.–are wonderful. (And so is Beano.)

I’ve had a hard time finding food charts for soluble fiber. Since it’s good for reducing cholesterol, I’ve been more interested in it the last couple of years for both Dave and me. If you’re into supplements, “psyllium husks” are one source of soluble fiber. I doubt they compare too well to actual food–seems every study I read, they’re saying more and more that supplements don’t give the results they claim–but as far as I know, psyllium husks has no side effects and isn’t terribly expensive. One of its characteristics–the forming of the gel and slurping up the bad cholesterols–does mean you shouldn’t take it with any other medications/vitamins, because it also slurps them up and whisks them out without absorbing. So if you take psyllium husks capsules, you need to have a two hour space in between them and other pills. And since soluble fiber forms a thick gel, the pill form is very concentrated so you have to drink a large glass of water with it, and they recommend not lying down right away. Metamucil and other brands of ‘natural laxatives’ that are highly advertised ‘for your health,’ are talking about the psyllium husks in them. (I tried Metamucil, once, about 35 years, to see why my patients were whining, and I wasn’t fond of drinking the slime-water myself.)

Putting fiber-eating into practice, even the order we eat our food in our meal is important. If you start with a salad/vegetables, you have a good fiber base to ‘catch and slow down’ the speedier things we throw at the stomach. Protein and fat also slow down the faster carbs, so leaving the carbs, especially anything more refined or potatoes, etc., until we’ve got some fiber/protein/fat in our stomach–makes our glucose levels much more even. Then even a smallish dessert at the very end isn’t that big a shock to our system. Dave is finding very good glucose readings by doing this.

If you’re interested in reading more, there is a lot of information on the internet! I googled in “fiber for diabetics” and got over 5 million results.

Sodium is a mineral that, along with potassium (K), regulates our body’s fluid balance, helps nerve and muscle function, etc. Our body runs on a very fine balance, fluid-wise. It demands that our percentage of sodium in water (called ‘saline’) is exact. If we eat extra salt, we get thirsty—that’s our body demanding enough water to equal out the salt to maintain a ‘normal saline.’ In a perfect world, inside a perfectly working body, we automatically adjust this balance constantly through the kidneys, excreting the excess urine/minerals. But years of overeating salt/sodium wears things out, and we might start to get out of balance.

Usually doctors tell us to cut back on the salt if we have high blood pressure.

Our blood pressure is two numbers: such as 120/80. The top number (systolic) is the amount of pressure in your veins when the heart is pumping/forcing out the blood from the heart. The bottom number (diastolic) is the amount of pressure in your veins when the heart is resting. Sodium, although it is necessary for muscle function including heart muscle, relates mainly to the bottom number. If it’s over 100, you probably have too much fluid/sodium (which demands enough water/fluid to make a normal saline) in your blood.

High blood pressure (hypertension) unfortunately has no warning signs or symptoms. We can go merrily along for years without having a clue. (Hopefully these years will include a trip or two to the doctor, where it’s routinely checked.) If the top number is consistently high, the poor heart muscle gets tired, and works less efficiently. (This is called ‘congestive heart failure,’ which I think is a dumb name. People immediately think they’re on their last legs just by saying it out loud, when in reality, we all age as we get older, and this includes our heart. Of course, the diagnosis CHF does mean you are having more problems than average aging.) If the bottom number is high for years, the blood vessel walls can never relax, and they become stiffer, thicker, and less elastic—more prone to heart diseases. (If you like big words, ‘arteriosclerosis’ is the name of it. If you throw some fatty cholesterol plaque into the picture, it’s called ‘atherosclerosis,’ which is a form of arteriosclerosis.)

If you have swelling of tissues (this condition is called ‘edema’), or if you have fluid in your lungs because your heart is struggling (CHF), etc.—these are serious conditions, and you do need to pay much more attention to the exact amount of salt you’re getting, and also probably be on medication to eliminate some of the fluid. (These meds are ‘diuretics,’ which unfortunately also rid the body of potassium at the same time, so potassium often needs to be added back with either food or medication.)

None of us want any of these problems, so the best way is to prevent them. So … back to the sodium we eat. Sources vary on the amount in our average diet (because it would be impossible to know) but our diabetic dietitian said the average American eats over 5000 mg. of sodium a day, which is about twice what we need. (Other sources say we eat even more.) It made me feel a little better when she said the average Japanese diet has over 9000 mg/day. At least we Americans aren’t the worst in everything.

One teaspoon of salt is about 2400 mg. which is the recommended amount for the day. (And this isn’t a low salt diet—some people are supposed to go way lower.) If you cook from scratch most of the time, and don’t pile on the salt, you probably are doing well. But if you eat out often, eat packaged food (anything–even cookies) or crackers, canned foods, frozen dinners, etc. you are most likely eating too much.

Salt is a preservative that they used before refrigeration, but that excuse is a little lame now days. We just have gotten used to eating a lot of salt because it does taste good. And because our taste buds grow so used to it, we keep adding more and more. The dietitian said this ‘salt insensitivity’ is reversible–if you make an effort to use less, pretty soon, canned chicken noodle soup is startingly salty.

Read the labels. Most of us know what food is salty—chips, pickles, jerky, soy sauce, deli meat, packages of things like Hamburger Helper. But some food is sneaky. I never used to think of cheese as salty. So we need to check the labels, aiming for 800 mg/meal.

Our dietitian said “throw away the salt shaker!” I have to say I disagree with that one. I am cooking with less salt, and some of my homemade soups, etc. I probably overdo it, using too little so it tastes rather bland. I’d rather cook that way, and add a little at the table if needed. (Dave likes less salt than I do in general, so this works better for us that way, too.) She also recommended an ‘herb shaker’ on the table instead of the salt shaker. I’m going to try this. I wasn’t overly fond of Mrs. Dash, but haven’t tried it for years–maybe my attitude has improved. (And maybe Mrs. Dash has.)  And you could combine your own favorite spices in a shaker. Winco, or any bulk food place, is great for experimenting with small amounts.

My sister uses a lot of fresh herbs she grows; she makes amazing salads using fresh basil, oregano, etc. That’s my goal for this summer–using more herbs, and watching our salt intake closer. Salt is not bad, but too much does have its consequences.