Monday, December 09, 2013

The 5 Stages of Kidney Disease

The kidneys are the body's filtering system. They pull waste and extra water from the blood and take it out of the body as urine. The filtering parts of the kidneys are called nephrons. Nephrons have many small blood vessels in them. High blood sugar levels and uncontrolled high blood pressure can damage these small blood vessels.

Damage to the nephrons is called nephropathy. In the early stages of nephropathy, the body doesn't give any warning signs that the damage is happening. The earliest sign of diabetic kidney disease is an increased excretion of albumin in the urine. This is present long before the usual tests done in the doctor's office show evidence of kidney disease, so it is important for diabetics to have this test on a yearly basis. 

As a diabetic's kidneys fail, their blood urea nitrogen (BUN) levels will rise as well as the level of creatinine in the blood. Diabetics may also experience nausea, vomiting, a loss of appetite, weakness, increasing fatigue, itching, muscle cramps (especially in the legs) and anemia (a low blood count). Diabetics may find you need less insulin. This is because diseased kidneys cause less breakdown of insulin. If a diabetic develops any of these signs, they should call their doctor.

Signs of kidney disease in patients with diabetes include but are not limited to the following:
-- Albumin/protein in the urine
-- High blood pressure
-- Ankle and leg swelling, leg cramps
-- Going to the bathroom more often at night
-- High levels of BUN and creatinine in blood
-- Less need for insulin or antidiabetic medications
-- Morning sickness, nausea and vomiting
-- Weakness, paleness and anemia
-- Itching

Stages of Kidney Disease
Diabetes can lead to changes in the kidneys that happen in stages. In the early stages, stages 1 through 3, the kidneys are able to make up for the damage and there aren't any obvious signs that the damage is happening. When enough damage occurs, in stages 4 and 5, the kidneys lose their ability to filter and cleanse the blood.

Stage 1: In this very early stage, the blood flow through the kidneys increases and the kidneys get slightly larger. Good blood pressure and blood sugar control are very important at this stage to help prevent any more changes. Remaining kidney function: 90% or more. Glomerular Filtration Rate(GFR):  90+%

Stage 2: The kidneys start showing damage in stage 2, as small amounts of protein (albumin) begin to leak into the urine. The kidneys will normally try to keep from filtering protein into the urine because protein is such an important building block for the body.

Albumin in the urine in this small amount (200 micrograms or less per milligram of urine) is found by a test called the microalbumin urine test, done at the lab. Remaining kidney function: 60% or more.
Glomerular Filtration Rate (GFR): 60-89%

At this stage, treatment includes quitting all tobacco products, controlling high blood pressure, keeping blood sugar levels as close to normal as possible, and, if really necessary, using an ACE inhibitor or similar drug. Doing these things can protect the kidneys against any further damage. (But, keep in mind that extended drug use can damage the kidneys over a period of years).

Stage 3: The loss of albumin into the urine is more than 200 micrograms per milligram at this stage. This is enough protein to be found by using a urine dipstick test, which can be done at your doctor's office. Treatment will still focus on controlling high blood pressure and keeping blood sugar levels as close to normal as possible. Remaining kidney function: 30% to 59%.
Glomerular Filtration Rate (GFR): 30-59%

Stage 4: By stage 4, also called advanced clinical nephropathy, the kidneys have become badly damaged from poorly controlled diabetes. Large amounts of protein leak out into the urine and signs of kidney damage start to show. These signs can include swelling in the legs and feet, high blood pressure, and high cholesterol and triglyceride levels. Remaining kidney function: 15% to 29%.

Treatment will include supporting remaining kidney function, controlling blood pressure, and keeping blood sugar levels as stable as possible.

Stage 5: By the time a patient gets to this stage, called end stage renal disease, the kidneys have failed. The patient will need expensive therapy and medicine as well as kidney dialysis. When kidneys fail, waste products have to be regularly removed from the blood by a dialysis machine that does the filtering work of the kidneys. Remaining kidney function: Less than 15%.
Glomerular Filtration Rate (GFR): <15 font="">

Some people might benefit from getting a kidney transplant, but most will have to wait years for a donor kidney. After having a kidney transplant, people need to take many different medicines to make sure the body doesn't reject the transplanted kidney. 

Kidney Health Tip: Your kidneys will work better and last longer if you:
  • Eat a plant-based diet (such as the Death to Diabetes Diet)
  • Control your diabetes and blood sugar (with diet and lifestyle)
  • Control high blood pressure (with diet and lifestyle)
  • Get treatment for urinary tract infections
  • Correct any problems in your urinary system
  • Avoid any medicines that may damage the kidneys (especially OTC pain medications)
Note: About 30 percent of patients with Type 1 (juvenile onset) diabetes and 10 to 40 percent of those with Type 2 (adult onset) diabetes eventually will suffer from kidney failure.

The 5 Stages of Kidney Disease Chart

Stage
Description
GFR
1
Kidney damage with normal or raised GFR
≥90
2
Kidney damage with mild decrease in GFR
60-89
3
Moderate decrease in GFR
30-59
4
Severe decrease in GFR
15-29
5
Kidney Failure
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The 5 Stages of Kidney Disease



Saturday, November 23, 2013

Causes of High Blood Pressure

High blood pressure is a complex condition that has many causes and contributing factors. These factors are associated with your physiology, diet, lifestyle, stress level, environment, genetics, and other factors.

Here is a list of the many causes and co-factors associated with high blood pressure. Use this information to help figure out what is causing your high blood pressure so that you can implement the necessary corrective actions.

Biological/Physiological
High blood glucose
High insulin levels
Insulin resistance
Cellular inflammation
Oxidative stress
Hormonal imbalance
Being overweight or obese
Narrowing of the arteries (large blood vessels) supplying the kidneys
High blood viscosity
Enzyme deficiencies
Impaired digestion
Impaired immunity
Toxicity

Diseases
Diabetes
Kidney Disease
ObesityHormonal conditions, such as Cushing's syndrome 
Conditions that affect the body’s tissue, such as lupus
Obstructive sleep apnea
Adrenal gland tumors
Thyroid problems

Nutritional/Dietary
Macronutrient imbalance
Vitamin deficiency (A, B, C, D, K2)
Mineral deficiency (magnesium, potassium, calcium)
Excess salt
Other nutrient deficiency(Omega-3 EFAs, probiotics)
Excess processed foods, trans fats, HFCS, etc.
Smoking
Drinking large amounts of alcohol

Nutritional Supplements
Synthetic vitamins
Herbal remedies, such as herbal supplements

Drugs/Medications
Steroids
Painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen  
Recreational drugs, such as cocaine, amphetamines and crystal methamphetamine
Other  medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs

Lifestyle
High stress environment
Lack of exercise

Mental
Emotional stability
Stressful work environment
Financial problems
Lack of knowledge

Family
Race (being of African or Caribbean origin)
Genetics
Certain defects in blood vessels you're born with (congenital)
Family cooking habits

Societal
Racism, sexism, etc.
Other isms

In most cases, most people will have multiple causes and co-factors that contribute to their high blood pressure.

Note: For more information about high blood pressure, refer to the Death to Diabetes book, Heart Disease ebook, training program, online training course; and, the Death to Diabetes website, blog and Facebook Page.

Additional References:
http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/causes/con-20019580
https://www.kidney.org/atoz/content/hbcauses
http://www.webmd.com/men/guide/high-blood-pressure
http://www.drging.com/conditions/root-of-causes-of-high-blood-pressure
http://causes-of-highbloodpressure.blogspot.com/2011/04/root-causes-of-high-blood-pressure.html
http://www.huffingtonpost.com/2015/01/14/causes-of-high-blood-pressure-surprising-_n_6445366.html
http://www.medicalnewstoday.com/articles/159283.php
http://www.webmd.com/hypertension-high-blood-pressure/guide/hypertension-in-african-americans
http://news.stanford.edu/news/2005/january26/med-hypertension-012605.html
http://www.clickondetroit.com/lifestyle/good-4-you/mens-health/African-American-men-and-risk-of-high-blood-pressure/19474654
http://www.lindbergnutrition.com/common/news/news_results.asp?task=Headline&id=13429&storeID=1C7A08050B8F4419BFFBA945004CA5D1
http://www.gallup.com/poll/180329/blacks-suffer-disproportionately-chronic-conditions.aspx
http://www.kevinmd.com/blog/2014/01/unidentified-mans-hypertension-racism.html 

Friday, November 22, 2013

High Blood Pressure -- The Number 1 Silent Killer

High blood pressure is the Number 1 silent killer disease. This silent killer is characterized by subtle symptoms that often go undetected.

High blood pressure (or hypertension) is a silent killer because it is deadly and has no early significant symptoms.

The American Heart Association estimates that up to one third of people living with high blood pressure are unaware of the fact that their blood pressure is high, and many people are unaware of the risks of high blood pressure.

Some of the statistics associated with high blood pressure and its impact include the following:
  • 67 million American adults (31%) have high blood pressure—that’s 1 in every 3 American adults.
  • 69% of people who have a first heart attack, 77% of people who have a first stroke, and 74% of people with chronic heart failure have high blood pressure. High blood pressure is also a major risk factor for kidney disease.
  • More than 348,000 American deaths in 2009 included high blood pressure as a primary or contributing cause.
  • High blood pressure costs the nation $47.5 billion annually in direct medical expenses and $3.5 billion each year in lost productivity.
  • About half (47%) of people with high blood pressure have their condition under control.
  • Almost 30% of American adults have pre-hypertension—blood pressure numbers that are higher than normal, but not yet in the high blood pressure range. Pre-hypertension raises your risk of developing high blood pressure.
  • Reducing average population sodium intake from 3,300 mg to 2,300 mg per day may reduce cases of high blood pressure by 11 million and save 18 billion health care dollars annually.
  • About 1 in 5 (20.4%) U.S. adults with high blood pressure don't know that they have it.
  • About 7 in 10 U.S. adults (69.9%) with high blood pressure use medications to treat the condition.
  • Team-based care that includes the patient, primary care provider, and other health care providers is a recommended strategy to reduce and control blood pressure
The chart below shows normal, at-risk, and high blood pressure levels.
Blood Pressure Levels
Normalsystolic: less than 120 mm Hg
diastolic: less than 80mmHg
At risk (prehypertension)systolic: 120–139 mm Hg
diastolic: 80–89 mm Hg
Highsystolic: 140 mm Hg or higher
diastolic: 90 mm Hg or higher

The danger from high blood pressure is the extra load on the heart, leading to complications such as hypertensive heart disease, a heart attack, a stroke and congestive heart failure. High blood pressure can also seriously damage the kidneys.

And it does all this silently, without any major symptoms, except when the high blood pressure gets extreme.

Always get your blood pressure checked to rule out hypertension as part of regular medical checkups. 

High blood pressure affects millions of people around the world. This condition goes unnoticed for years unless we have the insurance to receive annual physicals and blood tests from our primary care physician.

For the people who are able to afford insurance and get annual physical exams, they end up "controlling" their blood pressure by taking drugs that mask the real problem and give us the false sense of security that everything is fine. But, over a period of years, we find ourselves having to take more and more medication to 'control" our blood pressure. Until one day, you discover that you have problems with your kidneys, liver, or heart due to taking these medications for so many years.

What to Do
So, what if you have high blood pressure, but you don't know it? We recommend that you visit your primary care physician at least once a year for a complete medical exam. A complete medical exam will uncover a problem such as high blood pressure. At that point, your doctor may recommend one or more medications to help lower your blood pressure.

Blood pressure checkup

However, we don't believe that you should rely solely on medications because they don't help to get rid of the disease in your body that is causing your high blood pressure. As a result, you would be required to take high blood pressure meds for the rest of your life.

Please Note: Recent studies show that long-term use of these medications can lead to more health problems, so, be careful. 

Next Steps
Once your physician has diagnosed you with high blood pressure, ask him/her to identify what type of high blood pressure you have. For example, if the systolic number is high and the diastolic number is normal, this is an indication of atherosclerotic hypertension -- a pre-cursor to atherosclerosis and heart disease. In that case, you may need to modify your nutritional program to help heal and repair your arteries.

Other types of high blood pressure include: Secondary Hypertension, Isolated Systolic Hypertension Diastolic Hypertension, Malignant Hypertension, Renal Hypertension, Pulmonary Hypertension, Resistant Hypertension.

If your physician can't identify what type of high blood pressure you have, then, whatever medications he/she recommends will be just a wild guess. And, once you start on medications, it will be difficult to get off the medications. In fact, the number of medications and their dosages will increase over time as your body becomes more dependent on the drug's effects.

When you see your physician for your annual exam, get your blood tested for other factors so that you have a broader picture of your overall health state. Some of the additional tests include: fasting blood glucose, hemoglobin A1C, inflammation markers, lipid panel, kidney tests, hormone levels, vitamin levels, mineral levels and other blood tests listed in the Death to Diabetes book and on the Death to Diabetes website.

It is very important that you make sure that you do not have any (marginal) nutritional deficiencies, i.e. macronutrient, vitamin, or mineral. Some of the key nutritional deficiencies that may affect your blood pressure include: magnesium, potassium, calcium, Vitamin D, Vitamin A and fats.

Next, change your dietary program to a plant-based diet such as the Death to Diabetes Diet. Start eating a lot more vegetables, drinking raw juices and avoid eating the major "dead" processed foods, and a regular exercise regimen of brisk walking, stretching, and resistance training 4 to 6 times a week.

And, based on your blood tests, add the necessary nutritional supplementation -- but, make that you use wholefood-based supplements and avoid synthetic supplements.

Some Additional Steps to Consider:
  • Get a home blood pressure monitor so that you can check your blood pressure on a regular basis.
  • Make sure that you're getting 8 hours of quality sleep every night.
  • Address the stress in your life and learn how to control your emotions -- getting upset over events that you have no control over will raise your blood pressure.
  • Use meditation techniques to change the way you think about the world around you.
  • Educate yourself about diabetes, blood pressure, nutrition, etc. Without education, we live with a lot of anxiety and uncertainty. This, in turn, leads to fear, which creates anger and more anxiety and raises your blood pressure.
Please Note: The Death to Diabetes Diet is not just for diabetics! Non-diabetics can also use this diet program.

Please Note: Because of their impact on our health, nutritional deficiencies will be discussed in more detail in a future blog post.

Warning! More than 87% of people who end up in the hospital because of high blood pressure, do not change their eating habits or lifestyle. As a result, 91% of them return to the hospital or end up in the graveyard.

FYI: Ironically, this top silent killer disease is fueled by what the author calls the "triple-killer foods" along with the 5 "dead" foods. So, make sure that you avoid these foods, especially if this silent killer is stalking you.

Laboratory and Other Tests

If a physical examination indicates hypertension, additional tests may help determine whether it is secondary hypertension caused by another medical disorder) and whether organ damage is present.

Blood Tests and Urinalysis. These tests are performed to check for a number of factors, including potassium levels, cholesterol, blood sugar (to screen for diabetes), infection, kidney function, and other possible problems. Measuring blood levels of the protein creatinine, for example, is important for all hypertensive patients in order to determine kidney damage.
Tests to Evaluate the Heart. These tests include:
  • An electrocardiogram (ECG) is performed on most patients in the doctor's office.
  • An exercise stress test may be needed for patients who also have symptoms of coronary artery disease.
  • An echocardiogram is needed when it would help the doctor decide whether to start treatment. Most of the time this test is not necessary for patients who have only hypertension and no other symptoms.
Tests To Evaluate the Kidneys. These tests include:
  • A Doppler or duplex test may be performed to see whether one of the arteries supplying blood to the kidney is narrowed, a condition called renal artery stenosis.
  • An ultrasound may also be performed to examine the kidneys.
References:
  1. Kochanek KD, Xu JQ, Murphy SL, Miniño AM, Kung HC. Deaths: final data for 2009. National vital statistics reports. 2011;60(3).
  2. CDC. Vital signs: prevalence, treatment, and control of hypertension—United States, 1999-2002 and 2005-2008. MMWR. 2011;60(4):103-8.
  3. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–220.
  4. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-44. Epub 2011 Jan 24.
  5. Palar K, Sturm R. Potential societal savings from reduced sodium consumption in the U.S. adult population. American Journal of Health Promotion. 2009;24(1):49–57.
  6. Hing E, Hall MJ, Ashman JJ, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Outpatient Department Summary. National health statistics reports. 2012; no 28.
  7. Guide to Community Preventive Services. Cardiovascular disease prevention and control: team-based care to improve blood pressure control. 2012. Accessed July 27, 2012.
Note: One of the key risk factors for developing cardiovascular disease is high blood pressure.

Cardiovascular Disease Risk Factors (incl. High Blood Pressure)





Kidney Dialysis

When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. Almost 200,000 people in the United States are living with kidney failure as a result of diabetes.
Kidney dialysis diagram

Dialysis works well in the short run, but, it takes a toll on the person with diabetes -- physically and emotionally. Unfortunately, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of diabetes—such as damage to the heart, eyes, and nerves.

Dialysis is a treatment that removes wastes and excess fluid from your blood. Like healthy kidneys, dialysis keeps your body in balance. You do not need dialysis in the early stages of chronic kidney disease. If your kidneys start to fail, you will need a kidney transplant or dialysis to stay alive.

Your doctor will help you decide when to start dialysis, based on results of lab tests that measure how much kidney function you have left and on your symptoms.

Dialysis is done with a unique liquid called dialysate. This fluid is a combination of pure water and carefully measured chemicals. It removes wastes from your blood without taking out any of the substances you need to stay healthy.

A semi-permeable membrane (having minuscule holes allowing only specific types of particles to pass through) keeps your blood separate from the dialysate. This lets the wastes and fluid in your blood travel into the dialysate. Blood cells and proteins that you need cannot fit through the holes.

In hemodialysis, an artificial kidney (hemodialyzer) is used to remove waste and extra chemicals and fluid from your blood. Your doctor will make an access point into your blood vessels using minor surgery. This access point allows your blood to travel to the hemodialyzer for flushing. Sometimes access is created by joining an artery to a vein under your skin, making a bigger blood vessel or fistula.

If your blood vessels are not the right size for a fistula, the doctor may use a soft plastic tube to join an artery and a vein under your skin. This is called a graft.

Sometimes, access is made using a narrow plastic tube called a catheter, which is inserted into a large vein in your neck. Your blood is then cleaned and returned to your body. This type of treatment needs to be done several times a week and usually lasts about three to four hours.

In peritoneal dialysis, your blood is cleaned right inside your body. Your doctor surgically places a plastic tube called a catheter into your abdomen to create an access point. During your treatment, your abdominal area (or peritoneal cavity) is slowly filled with dialysate through the catheter. Your blood stays in the veins and arteries that line your peritoneal cavity while extra fluid and waste products are drawn out of your blood and into the dialysate. This is a daily form of dialysis, and can sometimes be preformed at your home.

Discussing with your doctor what dialysis option is the best for you will help you manage your chronic kidney disease and keep you feeling as well as possible.

Physical Side Effects of Dialysis and How to Prevent Them
Dialysis is a lifesaving treatment for those with end stage renal disease (ESRD). However, with both peritoneal dialysis (PD) and hemodialysis, there are occasions when a patient may have side effects from the treatment.

These side effects can be mild or severe, depending on the patient’s condition and whether or not they are following their dietary and fluid restrictions. Most of these side effects can be managed if the patient carefully follows their healthcare team’s recommendations regarding diet and fluid intake.

Side Effects of Peritoneal Dialysis (PD)
Infection. PD is a method of home dialysis. All three types of peritoneal dialysis—Continuous Ambulatory Peritoneal Dialysis (CAPD), Continuous Cycler-assisted Peritoneal Dialysis (CCPD) and Nocturnal Intermittent Peritoneal Dialysis (NIPD)—need a small rubber tube called a catheter. The catheter, a soft, straw-like tube is positioned both inside and outside of the body to allow dialysis solution into and out of the abdominal cavity. Exchanges (the process of filling, dwelling and draining dialysis solution) must be done carefully because there is a risk of infection from bacteria on the outside of the body.

The frequent handling of the catheter means greater risk for infection. Specifically, there is a chance of peritonitis, which is an infection of the peritoneum (where the catheter is placed in the abdomen.) This infection is the most common side effect of PD. Peritonitis can cause fever, nausea, vomiting and stomach pain. Patients may notice their dialysis solution looks cloudy. Treating peritonitis quickly is the key to stopping widespread infection. The doctor will likely prescribe antibiotics. 

Skin infections around the catheter insertion site are also common. If the area becomes red or inflamed, a visit to the doctor is recommended.

Preventing infection
To decrease the chance of infection, patients are advised to perform each exchange carefully. Exchange should be performed in a clean area. Keeping the catheter area clean and touching it with washed hands or sterile gloves can minimize the transfer of bacteria. Patients may also be advised to apply an antibiotic preparation at their catheter exit site to prevent infection.

Some patients have problems attaching or detaching the dialysis solution bag, which could put stress on the catheter, causing tiny tears that could allow in germs. If a patient has difficulties handling the bag, a renal nurse can provide tips on how to properly connect the bag to the catheter.

If a patient notices any sign of infection, it’s best to call the doctor immediately.

Hernias. A hernia is another potential side effect of PD. The muscles of the abdominal wall protect the internal organs and keep them in place. The insertion of a catheter can weaken these muscles. When patients do an exchange, the pressure from the dialysis solution in the peritoneum pushes against these already weak muscles. This pressure could cause a tear, and organs from the abdominal cavity could emerge through the opening.

Surgery is the only way to repair a hernia. Patients who have a history of hernias are advised not to exert themselves or participate in activities that could strain the abdominal muscles.

Eating Discomfort. Some PD patients find eating uncomfortable, because of the full feeling from the dialysis solution in their stomach area.  Although eating less feels better, it can lead to malnutrition.

The PD renal diet is designed to meet patients’ nutritional needs. If patients eat less, they may not get enough of the proteins and minerals that are important for good health. Timing exchanges (generally after meals) helps relieve some of the discomfort.

Bloating and weight gain. Bloating and weight gain are common complaints while on PD. Some of the weight gain is fluid bloat from the dialysis solution sitting in the peritoneum. The dialysis solution filters not only the toxins from the bloodstream, but also removes excess fluid. When the dialysis solution is drained, a patient will normally remove more fluid (dialysis solution plus the excess fluid filtered from the blood) than what was originally placed in the peritoneum.

Weight gain not associated with fluid bloat can come from the sugar in the dialysis solution being absorbed by the body. These extra calories could lead to extra pounds. Talking to a renal dietitian and nurse for some insight on how to balance nutritional needs and achieve comfort while on PD is advised.  

Side Effects of Hemodialysis
Low blood pressure. The most common side effect of hemodialysis is low blood pressure (also called hypotension). Low blood pressure occurs when too much fluid is removed from the blood during hemodialysis. This causes pressure to drop, and nausea and dizziness can result. Letting a dialysis team member know about these issue is highly recommended. The dialysis machine can be programmed so that the right amount of fluid is removed.

Medication for high blood pressure should usually not be taken before treatment, unless the doctor prescribes it that way. This could cause further drops in pressure and more discomfort. Watching and limiting fluid intake as recommended by the healthcare team may also prevent low pressure during treatments. Patients who drink more than what is advised usually need to have more fluid removed which can cause nausea and dizziness.

Muscle cramps. Patients sometimes experience muscle cramps while undergoing hemodialysis. These muscle cramps, usually in the legs, can be uncomfortable or sometimes painful. The exact cause of muscle cramps can vary from patient to patient. Sometimes when fluid is taken out of the body at a fast rate during dialysis or too much fluid is removed, the muscles react by cramping. A patient should alert a healthcare team member as soon as a cramp happens to get help in alleviating the discomfort. A doctor may be able to recommend some remedies if muscle cramps are making dialysis treatment uncomfortable.

Infection and clotting. Proper care for the access (either a fistula or a graft) is important in hemodialysis. The access can become infected or inflamed. Pressure on the access (from clothing or from sleeping on the side where the access is located) can cause the site to become irritated. Keeping the area clean can help prevent infection.

An access can become clotted with blood. Clotting prevents blood flow, so that a patient will not be able to get dialysis treatment. Patients are advised to monitor the access daily by checking for the thrill (the pulse feeling in the fistula or graft) to ensure it is working properly.

Itching. Many dialysis patients complain about itchy skin. There may be several causes, but it is commonly thought that high phosphorous levels are responsible for this side effect. Phosphorous is not effectively removed by dialysis. That’s why foods with phosphorus are restricted on the renal diet. Following the dietitian’s guidelines can help prevent this side effect. Remembering to take a phosphorus binder as prescribed (usually before every meal) is another way to help prevent or stop itching.

Dialysis patients are also prone to dry skin, which can be the cause of itching. Using very hot water for showers or baths can dry skin more. Harsh soaps can cause irritation and more itching. Moisturizing creams can alleviate some of the discomfort.

Sexual problems. Dialysis can affect a patient’s sex life. The sexual side effects can include loss of desire, erectile dysfunction and vaginal dryness. Loss of desire can be a psychological side effect. Patients on dialysis may deal with anxiety, depression and a change in self-image. These mental challenges can diminish the sex drive.

Hormone levels while on dialysis can also lead to a loss of desire, as well as physical side effects such as erectile dysfunction and vaginal dryness. Certain blood pressure medications can impair the ability to maintain an erection.

Other Health Problems Associated with Kidney Dialysis
Amyloidosis. Dialysis-related amyloidosis develops when proteins in blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints. The condition is more common in people who have undergone hemodialysis for more than five years.
 
Anemia. Not having enough red blood cells in your blood (anemia) is a common complication of kidney failure and hemodialysis. Failing kidneys reduce production of a hormone called erythropoietin, which stimulates formation of red blood cells. Diet restrictions, poor absorption of iron, frequent blood tests, or removal of iron and vitamins by hemodialysis also can contribute to anemia.

Bone diseases. If your damaged kidneys are no longer able to process vitamin D, which helps you absorb calcium, your bones may weaken. In addition, overproduction of parathyroid hormone — a common complication of kidney failure — can release calcium from your bones.
 
Fluid overload. Since fluid is removed from your body during hemodialysis, drinking more fluids than recommended between hemodialysis treatments may cause life-threatening complications, such as heart failure or fluid accumulation in your lungs (pulmonary edema).
 
High potassium levels (hyperkalemia). Potassium is a mineral that is normally removed from the body by the kidneys. If you eat more potassium than recommended, your potassium level may become too high. In severe cases, too much potassium can cause your heart to stop.
 
Inflammation of the membrane surrounding the heart (pericarditis). Insufficient hemodialysis can lead to inflammation of the membrane surrounding the heart, which can interfere with your heart's ability to pump blood to the rest of your body.
 
Sleep problems. People receiving hemodialysis often have trouble sleeping, sometimes because of breaks in breathing during sleep (sleep apnea) or because of aching, uncomfortable or restless legs.

Patients should talk to their social workers or doctors if they experience any of these problems.

Keep an open communication with the healthcare team. Let them know about any reactions to treatment so adjustments can be made. Side effects should not discourage a patient from continuing dialysis, especially since many of these side effects can be controlled.

Emotional Effects of Kidney Dialysis
Coping with kidney failure isn't just about managing the physical symptoms with treatment. It is a major life change that can cause a great deal of stress and can give rise to a range of emotional reactions:
  • Anxiety
  • Depression
  • Anger or a feeling of frustration about the illness
  • Sexual problems
Taking care of your emotional well-being is just as important as looking after your health. Please do not be afraid of discussing emotional or sexual problems with your healthcare team. They will be familiar with the kind of problems you may encounter and will be supportive. They may also be able to offer practical solutions to some of your difficulties.

Coming to Terms with  the Diagnosis
People who are diagnosed with kidney failure are confronted with a range of emotions. Different people react in different ways. Even so, there is a pattern to the way that most people react.

It may help to know about the emotional stages that patients may go through:
  • Shock: Often, newly diagnosed patients (and sometimes their family members) go into a state of shock. This is the feeling that life is going on around you but you are not really involved.
  • Grief: People may feel overwhelmed by grief and loss, as if they have been bereaved. They may feel helpless and have difficulty thinking clearly or dealing with day to day life.
  • Denial: It's common for people to decide, at this stage, that they "won't think about it." This denial that the disease exists is like a "defense mechanism" that can help patients escape from feeling overwhelmed until they are more able to cope.
  • Acceptance: Gradually, reality of kidney failure is acknowledged, and people begin to be able to think about the implications and the changes that need to be made. At this point of acceptance, they begin to adjust successfully to their condition.
Stress
One of the main causes of stress is change. All human beings find change stressful - even change that we are looking forward to, like moving house, raises our stress levels.

As a person with renal failure you will have to deal with more change than most people do. Not just the initial change of lifestyle that comes with the diagnosis, but ongoing change as you deal with alterations to your diet, medication and forms of treatment.

All these changes will mean you have to take in a great deal of new information, make decisions, learn new practical skills. You also have to adjust to new ways of doing things, to doing less than you would like to, and to asking for help... This is all extremely stressful - and it comes in addition to coping with the physical effects of kidney failure.

Different people react differently to stress - some get anxious or feel overwhelmed, others may get irritable or hostile, others may deny there is a problem and keep pushing themselves to "cope."

The best way of coping with stress is to recognize that it can be a problem in its own right and that if you are suffering from it, it is with good reason. Accept that you need to actively take time to "de-stress". There are many ways of doing so and they can all contribute to helping you cope with kidney failure.

There are a number of ways of dealing with stress:
  • Talking to someone who understands
  • Doing an activity that you enjoy
  • Relaxing, perhaps by listening to music
  • Doing some physical activity (within safe limits)
  • Take a short break, a day off or a vacation
Anxiety
This can be a specific "worry" related to something in particular, or a more general sense of "being on edge" or "not feeling safe."

Specific anxieties that renal patients may have include:
  • Worries about how the illness will affect your relationships,
  • Your ability to work,
  • Your finances
  • Your quality of life
  • You may also be anxious about understanding your condition or managing your treatment.
Ways of reducing anxiety include:
  • To see if there is something practical you could do to help you feel better. Make that appointment to see the doctor/dietitian/social worker/counsellor about what is worrying you. Ask a nurse about that part of the procedure you don't understand.There will of course be things that worry you that you can do nothing practical about. Most patients will say, however, that they find it helpful simply to talk about their worries to people who understand. Whether it's another patient, a nurse, a family member or a counselor, don't keep yourself alone with your anxiety.
  • Generalized anxiety is just as difficult to live with as anxiety that has an obvious cause.
  • Feeling generally "unsafe" may have something to do with a sense of "having no control" over your own body and life.
  • Many patients find that they can regain a sense of control by learning as much as they can about kidney failure and its treatment. Becoming an "expert" enables them to participate more actively in making decisions and to feel that they are working with the medical staff to control the condition rather than being passive.
  • Other people find that setting reasonable goals for themselves, such as going out, exercising, or keeping up certain activities - and achieving them - gives them a feeling of control.
Depression
Like anyone else, you will have times when you feel a bit down and less able to cope with life in general. You may also feel sad and "need a good cry" sometimes. If, however, the sadness turns into a real sense of despair that goes on for some time, this is depression.

You may feel depressed because you are having difficulty coming to terms with some of the changes their condition is imposing on you.

These changes might include:
  • The loss of your previous lifestyle
  • The loss of independence and self-confidence
  • The changes to your body and appearance
  • Difficulties with sex or with having children
  • Awareness of your own mortality
If you are feeling depressed it may help you feel less isolated if you talk to others who understand. This may be one of the renal unit nurses, the renal social worker, a counselor or even a good friend. Sometimes a short course of anti-depressant medication may be useful to get over these acute problems.

Anger
It seems quite appropriate for people who are going through these experiences to feel angry at times. It can even be energizing, sometimes, to feel angry.

Where problems arise, however, is if you get "locked into" your anger in a way which makes you unhappy and you can't seem to move through it into some degree of acceptance.

Anger is also a problem when it is expressed in destructive or self-destructive ways - when the feelings of anger and frustration lead to rebellion against diet and fluid restrictions, for example, or to aggressive behavior towards friends, relatives and staff. When people are angry, they may tend to "push away" the people who want to support them.

Anger expressed in these ways is self-destructive because it puts your health at risk, and - on an emotional level - leaves you feeling even more isolated.

It can feel like the hardest thing in the world to reach out for support when you are feeling angry. Paradoxically, it may be the one thing you can do to regain a real sense of power and control in your life. 

Sexual Problems
Some kidney patients never have sexual problems, but many do.
The reasons for these problems may include:
  • Hormonal problems: The hormones that control sexual urges may be too high or too low.
  • Medication: Some of the medication prescribed to renal patients may inhibit sexual desire.
  • Tiredness: This can be caused by anemia or by not having dialysis sufficiently.
  • Emotional factors: When people feel stressed, depressed or anxious, they often do not feel like having sex.
  • Relationship difficulties: The stress of kidney failure on a relationship may affect the couple's sex life.
Sexual problems in men
Impotence (the inability to get or maintain an erection) may be a problem in male kidney patients.

There are various approaches to treating impotence. Initially, doctors will look at possible causes such as anemia, under-dialysis and medication, and consider the treatments for them. There are physical treatments for impotence that can be considered including physical techniques and drugs.

Sexual problems in women
When women patients experience a lack of sexual desire or inability to have orgasms, causes related to anemia, under-dialysis and medication can be investigated.

There may be changes in the menstrual cycle and there is no doubt that the chances of getting pregnant if the kidneys have failed are much reduced. If kidney function is only mildly impaired and the blood pressure is under control before and during pregnancy, it is likely that pregnancy will progress as normal, but there will be a close liaison between the kidney doctor and the obstetrician. Some drugs particularly ACE inhibitors will need to stop before pregnancy and the blood pressure will be checked very carefully.

If you want to know more about the effects of kidney failure on pregnancy then speak to your doctor. And discuss any changes in your periods so that things can be checked out.

Kidney dialysis

Kidney dialysis

Kidney dialysis diagram

Thursday, November 21, 2013

Diabetic Amputations

Our primary focus is to educate and provide health-related information about diabetes management and prevention. However, during the past several months, we have received more than the usual number of phone calls and emails about being people losing their toe or leg due to diabetic complications.
Diabetic amputation

During these phone calls, most of the callers tell us that they wished they had heard about our diabetes management and prevention program sooner. They all admitted that they didn't think they would ever face an amputation.

For those who were told that they would have to lose a toe, foot or leg, they called us looking for a miracle. But, we had to tell them that there is no miracle -- in fact, there is very little that we can do to prevent person from losing their toe, foot or leg once the doctor has identified the need for amputation.

High blood glucose levels are responsible for the biological  processes that impair the neurological, vascular, and immune systems, leading to damaged nerves, damaged blood vessels and a weakened immune system. Damaged nerves and blood vessels lead to circulatory problems in the feet and legs, which leads to sores, ulcers and deformed feet. A compromised circulatory system fails to bring enough fresh oxygenated blood, nutrients, and antibiotics to a traumatic wound, and the (weakened) immune system cannot resolve an infection by fighting bacteria and cleansing the wound site on a cellular level.

More than 80% of diabetics will develop one or more of the major diabetic complications (amputation, blindness, kidney failure, heart attack, or stroke) -- if they live long enough and fail to change their diet and lifestyle while relying solely on diabetic medications. Approximately 67% of people with diabetes will develop a mild to severe form of nervous system damage, which can lead to a toe, foot or lower leg amputation. Worldwide, there are more than 1 million amputation procedures performed each year, at the rate of one every 30 seconds.

The most common reason for an amputation is poor circulation. The lack of circulation is caused by narrowing of the arteries or damage to the arteries from diseases such as diabetes and atherosclerosis. When the blood vessels become damaged and the blood flow is impaired to the extremities, the tissue starts to die and may become infected.

Another reason for an amputation is the damage to the foot’s sensory nerves due to diabetic neuropathy. This contributes to foot deformities and/or ulcers that increase the chance of lower-extremity amputations unless treated.

Factors that predict the need for lower extremity amputation in patients with extremity ischemia include tissue loss, end-stage renal disease, poor functional status and diabetes mellitus. Patients with diabetes have a  10-fold increased risk for lower extremity amputation compared with those who do not have diabetes.

Foot ulcers and nerve disease caused by Type 2 diabetes is the leading cause of amputation of feet, toes, legs, hands and arms among diabetes sufferers. Collectively, the disorders which cause these amputations are called Diabetic Neuropathies. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in other areas of the body, including the digestive tract, heart, and sex organs. However, complications with the feet and legs are more common.

Treatments for leg and foot ulcers vary depending on the severity of the wound. In general, the treatment employs methods to remove dead tissues or debris, keep the wound clean, and promote healing. But, if the diabetic fails to change their eating habits and lifestyle, healing will either occur very slowly or will not occur at all.

When the condition results in a severe loss of tissue or a life-threatening infection, an amputation is usually the only option. Unfortunately, when a doctor identifies the need for a (diabetic) amputation because the toe (or leg) is "dead", there is very little that the patient can do -- especially, if there is an infection that could spread leading to further damage and possible death.

For a foot or toe to be considered dead, the blood supply must be so completely impeded that infarction and necrosis (dead tissue) develop. Infarction results in dry gangrene, with nonviable tissue becoming dry and black in color (because of the presence of iron sulfide, a product of the hemoglobin released by lysed erythrocytes).

The method of toe amputation (disarticulation versus osteotomy) and the level of amputation (partial or whole phalanx versus whole digit versus ray) depend on numerous circumstances but are mainly determined by the extent of disease and the anatomy.

A surgeon removes the damaged tissue and preserves as much healthy tissue as possible. After surgery, the patient will be monitored in the hospital for a number of days. It may take four to eight weeks for the wound to heal completely.

Possible Complications After an Amputation
Patients with diabetes, heart disease, or infection have a higher risk of complications from amputation than persons without these conditions. In addition, persons receiving above-knee amputations are more likely to be in poor health; therefore, these surgeries can be riskier than below-knee amputations.

As with any surgical procedure, complications can occur. Some possible complications that can occur specifically from an amputation procedure include a joint deformity, a hematoma (a bruised area with blood that collects underneath the skin), infection, wound opening, or necrosis (death of the skin flaps).

A stroke, heart attack, or a pulmonary embolism (due to deep vein thrombosis (DVT)) are additional health problems that pose a risk after an amputation primarily due to blood clots, heart muscle strain, or prolonged immobilization after surgery.

If you have this operation under general anesthetic, there is a risk of complications related to your heart and lungs. The tests that you have before the operation will ensure that you have the operation in the safest possible way to reduce the chances of such complications.

The chances for heart or lung complications are higher for elderly people with other health problems such as diabetes, or disease of the arteries that feed the heart with blood.

Usually, it is important to have the operation as soon as possible. If you delay things then the condition of your toe will get worse and it might get infected and become necrotic. This can make you very ill and significantly increase the chances of complications because of the anesthetic or the operation.

If you have an anesthetic injection in the back, there is a very small chance of a blood clot forming on top of your spine. This can cause a feeling of numbness or pins and needles in your legs. The clot usually dissolves on its own and this solves the problem. Extremely rarely the injections can cause permanent damage to your spine.

Chest infections may arise, particularly in smokers or obese patients. Do not smoke. Being as mobile as possible and cooperating with the physiotherapists to clear the air passages is important in preventing a chest infection.

Another possible complication is the formation of clots in the deep veins (draining pipes for the blood) of your legs (deep vein thrombosis). Although this complication happens more frequently when the leg is amputated either above or below the knee, it can also happen after a toe amputation, especially if you stay in the hospital longer than expected and you are not particularly mobile.

A piece of one of these clots can get detached and travel to your lungs. There it can cause partial or complete obstruction of the blood vessels in the lungs, which can be lethal. Consequently, you will be given injections of blood thinners (heparin) after the operation to prevent a DVT.

In addition, being as mobile as possible and co-operating with the nurses and physiotherapists after the operation are very important in preventing a DVT.

Slow healing is a possibility and this will be apparent within the first week or two. The doctors will discuss this with you. Studies show that the chances of complete healing after a toe amputation are 40 to 60 per cent.
If complete healing doesn’t happen, you might need another operation to clean any dying (necrotic) tissue or tissue that is not healing. You might also need to have the leg amputated higher up.

Infection sometimes happens. This is usually localized in the wound area and very rarely spreads into your blood stream. You will be given antibiotics to prevent this and you will be given more if an infection actually occurs. The antibiotics take care of the problem in most cases, but there is a chance that you will need another operation to clean the infected tissues.

At the beginning, some patients feel that the leg or toe is still there (phantom leg/toe). It is also not uncommon for patients to also feel pain in the amputated area (phantom pain). This is usually mild to moderate and rarely severe pain and will usually get better over time. In some cases the pain can last for a long time. If this happens your doctors will discuss the problem with you.

Aches and twinges in the wound may be felt for six months or more but will usually settle down.
Occasionally there are numb patches in the skin around the wound that get better after two to three months.

Trouble with your circulation or diabetes causing the toe to be diseased needs to be watched very carefully.

Note: Because of a weakened immune system, you may be susceptible to other risks depending on your age, lifestyle, and specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Any Alternatives to an Amputation?
If you leave things as they are, your toe (or foot) will certainly get worse. Infection may spread to your other toes and foot. An operation to bypass or core out your leg arteries to improve the blood supply to the toe will not work in your case. Laser treatment and X-ray guided stretching of the arteries will not work for you. Injecting the nerve to your blood vessels will not work. Antibiotics are not enough by themselves.

An alternative to a toe amputation is an amputation higher up. This may help the healing process at the cost of loss of part of your limb. Unfortunately, most amputations through the foot do not heal very much better than toe amputations, but an amputation just below your knee would heal very well. Overall, usually your best plan is a toe amputation unless your doctor says otherwise.

Problems with the lower extremities respond best when treated by a multidisciplinary team of medical specialists. These specialists may include: endocrinologists, neurologists, diabetes educators, diabetes health coaches. vascular surgeons, orthopedic surgeons, podiatrists, nurses, pharmacists, infectious disease specialists, wound care specialists, nutritionists, and specialists in prosthetic and orthotic services, physical medicine and rehabilitation. Comprehensive foot care programs can reduce amputation rates by 45% to 85%.

The direct cost of an amputation associated with the diabetic foot is estimated to be between $30,000 and $60,000. Three years of subsequent care for individuals whose ulcer has healed without the need for amputation has been estimated to cost between $16,000 and $27,000. The corresponding cost for someone who eventually needs an amputation ranges from $43,000 to $63,000, mainly due to the increased need for home care and social services.

The mortality rate after amputations is about 40% at one year and 80% at five years. Five-year mortality rates after new-onset diabetic ulceration are between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease.

Next Steps After an Amputation
It is critical that you see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep  prevent more amputations.

It is also critical that the patient make some serious changes to his diet and lifestyle to better manage one's blood glucose level and strengthen the immune system. Otherwise, further amputations and other diabetic complications will occur such as infections, blindness, kidney dialysis, heart attack and/or stroke.

Prevention and early detection of future disease should be discussed with the patient. Education on pressure-area pathogenesis is useful for engaging patients. Efforts should be made to encourage regular visits with a podiatrist, who can assist with provision of well-fitted enclosed shoes. Thick cotton socks act as a barrier to both pressure areas and foreign bodies. Daily self-inspection of feet should be promoted. Informed content must be obtained.

Appropriate preventive care includes professional foot care for timely debridment of the keratosis, padding, accommodative insoles, or biomechanical orthotics with accommodations to offload the pressure sites. Shoe modifications, diabetic shoes or custom molded shoes may also be considered. Prophylactic surgical care to eliminate the bony pressure point is also an accepted method of care.

Too often, toenails are overlooked. The nails can become thick and deformed due to mold, yeast and fungal infections Shoe pressure against these deformed toenails can cause a subungual abscess. Additionally, a long, thick or deformed nail can lacerate an adjacent digit, which can trigger the process of infection that can lead to amputation.

Topical antifungal medications are not FDA approved and are ineffective against this type of nail infection. Oral terbinafine or itraconazole are effective against this type of infection, but patient selection is critical for the safe and effective use of these medications. Confirmation of mycotic nail infection before prescribing medication is essential to minimize costs and potential drug-related complications. Testing for nail mold, yeast or fungal infections should be done before prescribing an oral antifungal medication. Foot care specialists should consider nail debridement and ongoing foot care to decrease the risk of a triggering event, such as a digital laceration during self nail care, that could lead to amputation.


Psychological Impact of an Amputation
Loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one.

Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands.

Having an amputation can have an intense psychological impact for three main reasons:
  • You have to cope with the loss of sensation from your amputated limb
  • You have to cope with the loss of function from your amputated limb
  • Your sense of body image, and other people’s perception of your body image, has changed
It is common to experience negative thoughts and emotions after an amputation. This is especially true in people who had an emergency amputation, as they did not have time to mentally prepare themselves for the effects of surgery.

Common negative emotions and thoughts experienced by people after an amputation include:
  • depression
  • anxiety
  • anger
  • denial (refusing to accept they need to make changes, such as having physiotherapy, to adapt to life with an amputation)
  • grief (a profound sense of loss and bereavement)
  • feeling suicidal 
Talk to your care team about your thoughts and feelings, especially if you are feeling depressed or suicidal. You may require additional treatment, such as antidepressants or counseling, to improve your ability to cope with living with an amputation. 

People who have had an amputation have an increased risk of more amputations. Within one year after a diabetic foot amputation, 26.7% will have another amputation. Three years after the first diabetic amputation, 48.3% will have another amputation. Within 5 years of a diabetes related amputation, 60.7% will have another amputation.

If that isn't bad enough, diabetics with amputations don’t live very long. Approximately 50% of all diabetics with an amputation are dead 3 years after the amputation. About 65% of all of those with a diabetic amputation are dead within 5 years.

But, in spite of this, there is hope... most are preventable. Start eating healthier (i.e. vegetables, juicing) to better control your blood glucose level and to help heal your body. Check your feet every day and see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep  prevent more amputations.

Note: We hope this information is of some help and encourages you to take action before it's too late. If you have any queries or problems after surgery, please talk with your podiatrist, other doctors, and the other members of your healthcare team. 

Note: If you haven't had an amputation, refer to our blog post about preventing diabetic amputations.

Warning!! Don't think this can't happen to you! It can ... and, it will -- especially if you don't change ...

Leg amputation

Diabetic toes

Amputated toes

Amputated foot


Wednesday, November 20, 2013

How to Prevent Amputations

In people with diabetes, a trifecta of trouble can set the stage for amputations: Numbness in the feet due to diabetic neuropathy (nerve damage) can make people less aware of injuries and foot ulcers. These ulcers may fail to heal, which can in turn lead to serious infections.

Normally a person with an injury on the bottom of their foot, such as a blister, will change the way they walk. Your gait will alter because you are going to protect that blistered spot until it heals up. But, people with a loss of sensation don't do that -- they will just walk right on top of that blister as though it wasn't there. It can burst, become infected, and turn into a foot ulcer. That ulceration can go right down to the bone and become an avenue for infection into the whole foot. And, that can lead to amputations.

Foot injuries are the most common cause of hospitalizations
About 15% of all diabetics will develop a foot ulcer at some point and up to 24% of people with a foot ulcer need an amputation. You're at extra-high risk if you're black, Hispanic, or Native American. These minority populations are two to three times more likely to have diabetes than non-Hispanic whites, and their rates of amputations are higher. 

Unfortunately, some people with diabetes don't believe that they will face amputation . This belief by some people with diabetes is primarily due to fear, denial and ignorance about the science of diabetes and how diabetes actually rots out the inside of the body.

Check your feet daily
Taking care of your feet is very important. The nerves of the feet are the longest in the body and are often affected by neuropathy.

Foot careThe single most important thing that a person with diabetes can do to prevent a problem is to look at their feet every day, just as they comb their hair or brush their teeth.

Look at your feet every morning and every evening to check for cuts, sores, blisters, redness, calluses, or other problems. You can use a mirror to examine your feet or have a family member check your feet for you.

Here are some tips on preventing foot problems from the National Diabetes Education Program.
  • Quit smoking if you're a smoker. Smoking is considered a likely factor in diabetic foot disease.
  • Be super-vigilant about your controlling your blood sugar. According to results of the United Kingdom Prospective Diabetes Study, people with type 2 diabetes who lower their blood glucose through intensive therapy are at reduced risk for neuropathy.
  • Choose shoes carefully.
  • Cut your toenails carefully or have someone else do it if you already have numbness.
  • Note: An increase in the temperature of your foot, which can be detected with a special infrared thermometer, can be an early sign of trouble. The foot will get hot before the skin breaks down.
Additional Ways to Care for Your Feet [Ref: Death to Diabetes Book, Chapter 15]
  • Wash your feet in warm water every day. Do not soak your feet. Dry your feet well, especially between your toes. Rub lotion on your feet, but do not put lotion between your toes
  • If your skin is dry, especially the heel of your foot, use a salt scrub to carefully remove the dead skin. (Thanks, Cynthia!).
  • Cut your toenails once a week or when needed. Cut toenails when they are soft from washing. Cut them to the shape of the toe and not too short. File the edges with an emery board.
  • Always wear shoes or slippers to protect your feet from injuries.
  • Always wear socks or stockings to avoid blisters. Wear thick, soft socks. Do not wear socks or knee-high stockings that are too tight below your knee.
  • Wear shoes that fit well. Shop for shoes at the end of the day when your feet are bigger.
  • If you have neuropathy, talk to your doctor about orthotics to improve circulation and relieve pressure.
  • Check the temperature of bath water with your hand or arm before getting in the tub.
  • Do not cross your legs when sitting.
  • Make sure your doctor checks your feet at each checkup and performs the filament test by lightly rubbing a feathery filament across the bottom of your feet - to check for a loss of touch sensation.  If you do not feel the filament, it is imperative that you use your eyes to check your feet every morning and night.
  • Note: If your feet do not sweat at all, this may indicate a loss of sweating and eventually a loss of touch sensation.  Unfortunately, this may eventually lead to foot ulcers. Notify your podiatrist and endocrinologist.
  • Use one or more of the following therapies to help improve nerve health and the blood circulation in the feet: massage therapy, water therapy, acupuncture, magnetic insoles.
  • Other natural treatment options for neuropathy may include: relaxation training, hypnosis, biofeedback training, acupuncture, transcutaneous electronic nerve stimulation (TENS) therapy.
In addition, follow a nutrient-dense nutritional program such as the Death to Diabetes Super Meal Diet that will help to control blood glucose levels and prevent the onset of diabetic neuropathy. Key foods, herbs and wholefood-based supplements include green vegetables, bright-colored vegetables, raw juices, beans, wild salmon, Omega-3 EFAs, evening primrose oil, CoQ10, cayenne pepper, garlic onions, ginger, and nattokinase.

Note: For more information about preventing diabetic amputations, refer to the Death to Diabetes website.

Foot care

Foot care

Friday, September 06, 2013

How To Kill Your Addictions to Fast Food

How can you kick your addiction to fast food/junk food? Many of us have tried and failed, and tried and failed, and tried and ended up binging on Big Macs blended with ice cream, etc.Smile
You can kill your food addiction with the right information and motivation.

What we usually do is say, "After this bucket of KFC Chicken, I'm not eating this crap anymore!" Then we purge our house of all things sugary, we eat salads and lots of veggies for about 3 days and then cave in the first time we drive past a McDonald's or Taco Bell.

Where is the will power, the drive, the ambition you had a couple days ago?

That's because we try to stop eating fast food without thinking about it - without planning our escape. What we should do is worry about changing our habits. Forging new habits takes time and energy. If you want to kick your junk food habits you'll have to give both time and energy.

Consequently, you should:

   1. Only change one habit at a time
   2. Give each change at least 2 weeks to become ingrained

After all, we've spent years building up these habits, we can't expect to take them down overnight. We'll do it smart, slow and consistent and we'll kick fast food and junk food to the curb.

Let's separate the tasks into kicking bad snacks, kicking fast food and kicking soda pop. Pick whichever will be easiest for you and do that first. A taste of success is incredibly motivating. Then do the one that will be hardest second while you're on an upswing.

Kick the Soda Pop Habit
This one's probably the simplest. Not the easiest, but the simplest. You just keep downgrading every 2-4 weeks. Essentially switching terrible habits for bad and then switching bad for good.
  • Regular -to- Diet: First switch from regular to diet pop and leave it at that for at least 2 weeks. I know that some people say diet is just as bad as regular but we don't want to be fighting our caffeine addiction at the same time we're fighting our sugar addiction. Remember we want to change habits in stages to have the highest chance of success.
  • Diet -to- Caffeine Free Diet: If you do have a caffeine addiction this is where you'll find out. You're going to have about 3 days of feeling like a hangover mouth tastes while your body breaks the physical addiction. But stay on it for the full 2 weeks, we don't want to change too much too fast.
  • Caffeine Free Diet -to- Flavored Water/Water: If you can't stand drinking water I'm not going to lecture you. Just drink the flavored water with 0 calories they have now, it's just as good (if you don't mind paying for it).
  • Flavored Water -to- Filtered Water: Now we're moving into healthy territory. Now you can move to regular water but  filtered, not tap water. Eventually you should be losing weight and feeling better than when you were drinking pop.
Kick Fast Food
How do we beat crack for the single male? Yes, that's how hooked people are on this. How about this:
  •   Start by saving all your fast food receipts for one week
  •   Now, place a jar by your bed
  •   Each night, empty your pants, wallet, or purse of all the fast food receipts.
At the end of one week, you can add them all up and get a pretty good idea of how much you're spending on this junk. Round that up to the nearest $10 and cut it in half. That's how much you'll spend a week from now on.

Take that money and put it in a ziplock bag that you keep in your car. All your fast food will be paid for out of this fund, and when it dries up, that's it until next week. This will force you to ration and make choices.

Let it sink in for 2 weeks and don't forget to plan this out. Something has to replace all that fast food you're suddenly not eating. I suggest:
  • Keep something in your car to eat on the way home from work, like an apple or some nuts - something filling and always ready.
  • Have some frozen meals ready at home so you never wonder what you're going to eat tonight. If you can't make them yourself on the weekend, try those frozen skillets - something balanced and quick.
Then, when this new habit is a part of you, cut that dollar amount again, and again, and again until you're happy with how much (how little) fast food you're eating. I think under $10 a week is OK for most people.

Kick Bad Snacks
The first step to kicking bad snack foods is doing a food inventory. What do you have in your kitchen? Cookies, chips, candy? And what are you eating them for? Which are your comfort food? Stress foods?

Then we're going to make a chart of all these snacks and for each one list a replacement snack. For example instead of potato chips you could eat tortilla chips with salsa. Now you can switch a crappy snack for it's healthier replacement. But no more than one every two weeks (pacing). Make yourself eat the new food daily so it becomes a part of your lifestyle and remember to snack before you get hungry.

It's a pretty straight forward process but here's a few tips to make it go smoother:
  • If you have a craving for a bad snack that you absolutely have to give in to, buy an individual portion or eat just enough to satisfy your craving and throw out the rest. Keeping it around is crap-snack sabotage.
  • If you have a sweet tooth, proportion something into bites and eat them after a healthy snack. For example cut a snickers bar into 8ths and keep each individually wrapped in the freezer, then eat one after you've filled up on popcorn. That gives you that sweet taste without having to fill up that sweet crap.
  • Get the Death to Diabetes cookbook or Food Tips ebook for healthy, tasty snacks.
  • Get the Food Cravings ebook to learn how to beat the two types of cravings and overcome junk food addictions.
  • Get the Juicing & Smoothies ebook to learn how to drink tasty smoothies that will reduce and eventually eliminate your cravings for junk food and fast food.
The four keys to kicking junk food are super foods, planning, pacing and sticking to it. Remember to take as long as you need to get these new habits ingrained, 2 weeks is a minimum. Better junk food free in 1 year than relapsing in 6 months.

In addition, don't forget that the super meals and snacks will help your body detoxify and remove the chemicals that are causing the addiction!

How to Enjoy Your Favorite Foods                                               

It's unrealistic to expect people to be deprived of all of their favorite foods for the rest of their lives! Here are some ways for you to enjoy some of your favorite foods and comfort foods and still maintain your blood glucose level within the normal range.

Apple Pie
Avoid store-bought apple pie because it contains hydrogenated oils (trans fats) and high fructose corn syrup. Instead make your own pie. Use reduced-fat sour cream to replace some of the butter found in traditional recipes to keep the dough moist and tender, without adding tons of saturated fat.

Use organic butter to avoid the chemicals and growth hormones from the conventional butter.

Use whole-wheat flour to add fiber for the crust, but blend it with all-purpose flour to get a less wheaty taste and keep the crust  texture tender.

Use plenty of apples, with a mix of McIntosh and Granny Smith. The McIntosh adds a nice tangy flavor while the Granny Smith also tastes good, but breaks down less when they cook, giving the filling a more toothsome texture.

Use a deep dish to allow much more room for filling: you can squeeze in about 1 1/2 more cups of fruit into a deep-dish pie pan vs. a regular pie pan. And, adding more apples means more soluble fiber.

Substitute egg white for egg yolk to cut down on cholesterol. Also, use xylitol or stevia powder in place of refined sugar.

Bacon
Everyone loves bacon! To enjoy bacon, obtain the organic bacon, or, even better, get baconnaise. Baconnaise™ is a spread that tastes just like bacon! Add it to sandwiches, salads, dips, sauces, chicken, fish, and any recipe that calls for regular mayonnaise.

Chili
Choose ground beef that is at least 90% lean and organic; or, substitute the ground beef with ground turkey or try a chicken chili with skinless, boneless chicken breasts. You can boost fiber by adding more veggies and beans. You don’t have to use kidney beans in chili — try adding black beans or great Northern beans for a change. Try a low carb, no-bean chili that's full of interesting flavors, such as cumin, cinnamon, and allspice.

Using generous amounts of spice in your chili is a great way to add great flavor without any added fat or calories. Classic chili spices include chili and cumin (and cayenne for those who like it really hot). Have fun experimenting with different seasonings; cinnamon and allspice can add wonderful depth of flavor.

Use more beans to add fiber and stretch your dish healthfully and inexpensively.

Desserts
When making brownies, replace the semisweet chocolate with unsweetened cocoa and the butter with a cup of pureed prunes, which keep the brownies moist.

Bake your own cakes, pies, and cookies to avoid the high fructose corn syrup and partially hydrogenated oil of these store-bought baked goods.

Replace the refined white flour with a whole grain flour; the vegetable oil with olive oil or rice bran oil; the refined white sugar with xylitol powder; and, the margarine with a vegetable spread such as Earth Balance or Smart Balance.

When making a chocolate cake, replace the chocolate with cocoa, use fewer egg yolks, and reduce the amount of butter by substituting some nonfat yogurt.

Ice Cream
Add a handful of walnuts and a half-cup of blueberries to your bowl of ice cream to provide some fiber and protein and slow down the absorption of the sugar.

Make your own homemade ice cream with a blender, low fat cream and frozen fruit.

If you purchase your ice cream, do not buy the low fat versions because they contain more sugar and are less filling. Instead buy the rich ice cream, but eat less of it with some nuts and fruit.

Create a green smoothie by mixing berries, almond milk, walnuts, spinach leaves, and sugar-free vanilla pudding or nonfat plain yogurt. Add ice to thicken the smoothie and turn it into ice cream. You won’t even taste the spinach!

Make your own ice cream with a high-speed blender, cream/nonfat milk, frozen berries, vanilla extract, and xylitol (optional). For a root beer float: Mix sugar-free, flavored syrup with seltzer water, and add one scoop of homemade vanilla ice cream.

French Fries
Using sweet potatoes or the crunchy vegetable called jicama (pronounced hik’-a-ma), you can enjoy crisp, salty fries now and then. And since white potatoes can raise blood sugar more rapidly than even table sugar, you’re wise to avoid them.

Peel sweet potatoes, and then slice them up lengthwise like steak fries. Toss gently with extra virgin olive oil and seasonings of your choice, then bake at 425 degrees F for 10 minutes on each side. Jicama can be sliced thin (like matchsticks) and made either in the oven the same way (cut the time in half) or fried in a pan with a high-heat oil such as extra virgin coconut oil or grapeseed oil. You can also slice jicama super-thin like potato chips. Experiment with different spices on your fries, such as onion or garlic salt, paprika, or taco seasoning.

You can also use regular potatoes, slice them lengthwise into thin (or thick) strips -- but keep the skin, which are packed with nutrients and fiber, and will help to make the fries crispy and crunchy. Mix olive oil, paprika, garlic powder, seasoning salt, onion powder and black pepper together in a Ziploc bag. Add potatoes and shake to ensure all potatoes are coated. Place on a foil-lined baking sheet. Broil for 3 minutes on each side in preheated 450° oven, or bake for 35 minutes or until golden brown.

Fried Chicken and Other Meats
If you would like to eat a healthier version of fried chicken, buy locally or organic (free-range) chicken breasts without the skin. Coat the skinless chicken with skim milk, egg whites, a small amount of organic nut flour, cornflake crumbs, herbs and spices; and, bake at 375°.

Another option is to coat the chicken, bake it, and then flash-fry the chicken for 30-45 seconds in a nonstick pan coated with a teaspoon of olive or rice bran oil to crisp the outside. Avoid frying with Crisco, Mazola, and other vegetable oils, which break down under the heat.

Note: For crispy, yet tender chicken that doesn't tie you to the stove, the night before soak the chicken in buttermilk to act as a tenderizer and start by flash-frying and finish baking the chicken in the oven. Another option for a crispy coating is mix Greek yogurt and multigrain cereal flakes with spices (i.e. parsley, oregano, thyme, rosemary, sage, garlic salt, black pepper, paprika).

Note: To make the coating stick well, dip the chicken in water and/or refrigerate the coated chicken, uncovered, for an hour before frying.

Note: Another option for a crispy coating is to coat the skinless chicken with finely crushed walnuts (or almonds/pecans) and egg white.

If possible avoid grilling, broiling or frying animal meat, especially red meat. Toxic compounds are created that have been linked to several cancers.

To reduce these levels of carcinogens, use lean cuts only, marinate them, and flip them frequently on the grill to reduce the cooking time.

Avoid smoked and processed meats such as bacon, sausage, ham, hot dogs, bologna, and lunch meats, which have been linked to cancer, multiple sclerosis, and Type 2 diabetes. Eat organic bacon and sausage if you really miss these meats.

If you eat beef, eat only the lean beef. The leanest cuts usually carry the label “USDA Select”. Select beef contains 40% less fat than “prime” and 20% less fat than “choice”. If financially possible, eat only organic USDA certified meat. Avoid the meat if it has a lot of marbling – this indicates a lot of fat. Cut away any visible fat before cooking the meat to reduce the fat and toxin intake. While broiling meat, let the fat drip off, but don’t let it drain on hot charcoal or a hot burner because this will produce undesirable fumes.

Use ground turkey or chicken in place of ground beef for lasagna, soups, stuffed peppers, burgers, etc. to reduce your saturated fat intake. If you really prefer the beef, then, use organic, free-range beef and use 20-25% less meat. Other meat options include wild game such as venison and bear because they provide Omega-3 EFAs and conjugated linoleic acid (CLA).

Marinade meat overnight in something flavorful, e.g. olive oil, garlic, ginger, and light soy sauce. Use olive oil as part of the marinade to “break down” the harmful saturated fats and to increase the flavor.

Sauté your meats with red and green peppers, onions, garlic, mushrooms, tomatoes, and other vegetables that you like to give the meat a better flavor and reduce the amount of meat that you would normally eat because of the extra vegetables.

Trim all the visible fat from the steak (to reduce the amount of arachidonic acid in steaks and roasts), then place it in a large resealable plastic bag along with a mixture of 1 cup of red wine and 1 cup of olive oil or light sesame oil. Allow the meat to marinate in this mixture in the refrigerator for a full 24 hours, flipping the bag and contents over a couple of times.

Take the steak out, drain it for an hour or so, discard the marinade, rub the beef with some pepper or other spices to taste, and then grill it.

Note: The wine acts as a solvent to leach out a fair amount of the fat in the steak, which is replaced in part by the fat in the olive or sesame oil. The oil permeates the steak, giving it a juicy succulent taste and makes it healthier. You can use this technique with roasts as well.

Note: If you really like fried foods, then, use a flash fryer that will sear the food on the outside and prevent the absorption of the oil into the meat. But, you should eventually transition away from fried foods, if possible.

Note: The best oils for frying include extra virgin coconut oil, then vitamin E-rich extra virgin olive oil, because it tolerates high temperatures without breaking down. Unfortunately, it's expensive. The next best oil for frying is peanut oil. Neither corn oil, safflower oil, nor sunflower seed oil can tolerate frying temperatures, so you shouldn't use them.

Frying Tips
With health consciousness at such a high point these days, many people do not deep fry foods. But sometimes some fried food is just what you want! If you're going to consume the calories, make sure that the food is perfectly fried with these tips.

Deep fat frying is a dry heat cooking method. It's considered dry because no water is used, unlike poaching, microwaving, or simmering. Here's how to do it:

To start, choose your cooking oil carefully. Oils with high 'smoke points, in other words, those which do not break down at deep frying temperatures, are best. Peanut oil, extra virgin coconut oil, safflower oil, and sunflower oil, are some good choices.

Choose a deep, very heavy skillet to fry with. Add oil to the cold pan, leaving a headspace, or space at the top of the pan, of at least two inches. This allows a safety margin when the oil bubbles up as the food is added.

Make sure that the food you're going to fry is dry. Letting it sit on paper towels, or coating it in flour or bread crumbs is a good way to ensure this. Let the coated food sit on a wire rack for 20-30 minutes so the coating dries and sets.

Begin heating the oil over medium high heat. If you have a deep fat frying thermometer, use it! The best temperature is 350 to 375 degrees F. If you don't have a thermometer, the oil is ready when a 1" cube of white bread dropped into the oil browns in 60 seconds; that oil temperature will be about 365 degrees F.

Don't overcrowd the pan! Carefully add the food, leaving lots of space around each piece so the food will cook evenly. If you add too much food at once, the oil temperature will drop and the food will absorb fat instead of instantly searing.

Watch the food carefully as it cooks, regulating the heat if necessary to keep that oil temperature between 350 and 375 degrees F. When the food is browned according to the time in the recipe, it's done. Remove it with a slotted spoon or a heavy stainless steel sieve with a long handle. Drop it onto paper towels to drain the excess oil.

Fried foods can be kept warm in a 200 degrees F. oven until all the food is fried.
Oil and water do not mix!! Keep water away from the hot oil. If you pour water on the oil, the mixture will explode. If the oil smokes or catches fire, cover it with a pan lid or cookie sheet. You can use baking soda to put out any grease fires, but be careful that you don't spread the flames around.

Always keep a fire extinguisher in your kitchen, just in case. Learn how to use it now, before you may need it.

Don't reuse the cooking oil. Some sources say you can strain it and reuse it, but the oil has already begun to break down from the heat, and undesirable compounds like trans fats have formed. Let the oil cool completely, then discard safely.

Fruit
Eat your favorite fruit with a handful of walnuts and almonds to offset the carbs from the fruit.

Pizza
You can make your own healthier thin-crust pizza at home with pita bread. Buy whole-grain or ground flax pitas, spread your favorite tomato sauce over it, and add a mix of vegetables, sautéed peppers and onions, mushrooms, broccoli, olives, plenty of herbs and spices, a drizzle of olive oil, and shredded mozzarella. Bake in an oven at 400°F for 7-10 minutes.

You can also make a great, crispy hors d’oeuvre by splitting the pita pocket, topping the two halves with pesto sauce and grated Parmesan, and baking.

Potato Chips
Potato Chips are a favorite comfort food, but they're unhealthy. To create healthy potato chips, make them yourself. Slice the potatoes crosswise 1/8-inch thick and toss them in a bowl or Ziploc bag with olive oil and thyme.

Then, arrange the slices in one layer on two nonstick baking sheets, and spray the slices lightly with olive oil and bake in a preheated 400° oven until the potatoes begin to brown on the bottom, about 15 minutes.

Turn potatoes over, continue to bake until brown and crisp, about 15-20 minutes. Transfer the slices to paper towels and sprinkle them with salt and rosemary, if desired, while they are still hot. For some zest, coat the slices with black pepper and cayenne pepper or paprika and chili powder before baking.

If you don’t want to make your own chips, you can find organic chips or baked potato chips in the health food stores. Other healthy alternatives include: baked plantain chips, roasted Moroccan-spiced chickpeas, and homemade granola.

Rice
Some people are still confused about whether or not white rice is good for you. For one, we are often told that the Asian way of eating is a healthy one, and we know they eat a lot of white rice (but, in small portions).

Also, we know (some) grains are important for health, and rice is very clearly a grain. The nitty-gritty can be found in the difference between a refined grain and a whole grain. White rice is a grain that has been refined – which means the nutrient-dense parts of it have been stripped away, leaving only the sticky, starchy center. This center, or endosperm, is essentially the nutritional equivalent of table sugar, and it has a similarly high impact on blood glucose.

The better choice is (organic) brown rice, which is a whole grain rich in beneficial phytochemicals and fiber. But, check your post-meal blood glucose level because rice can spike your blood sugar.

However, brown rice isn’t the only choice. When brown rice doesn’t fit your needs –– or if you just aren’t a fan of its texture and flavor –– there are other great whole-grain options. Try amaranth, barley, buckwheat (kasha), bulgur, or quinoa. Each of these grains has a slightly different texture and flavor, but all can be substituted for rice. They can be cooked on the stovetop in boiling water (or better yet, use chicken, beef, or vegetable broth). Read package directions for amounts and time. Always test in the last five to 10 minutes to make sure the grains don’t become mushy.

To reduce the glycemic impact of eating rice, eat it with beans, or mix it with vegetables/almonds as part of a stir-fry or casserole.

Stews and Casseroles
Comfort foods like starchy stews (and casseroles) are hearty, filling and easy to make with healthy ingredients. Traditional dishes often call for lots of starchy vegetables and binders high in fat and sodium, but a few simple tricks such as using lean meat sparingly and adding a wide range of colorful vegetables create a healthier dish.

Meat Stews
Lean meats, such as turkey and chicken, make healthy one-pot meals when combined with vegetables and whole grains.

Use brown rice or quinoa to thicken a stew, rather than potatoes, or use sweet potatoes, which are a good source of vitamins A and C.

Ground turkey is ideal for a healthy version of chili with beans, tomatoes, peppers and onions, or use shredded chicken with carrots, kale and rice for a lighter stew.

Lamb is a strong meat that flavors a whole stew without using a lot of it. Choose a lean cut and use no more than 2 ounces per person in a stew with carrots, sweet potatoes, onions, tomatoes and red wine.

Tofu
Tofu has very little flavor and absorbs the flavors of the other ingredients, and is a good protein for smoothies. [Thanks, Daughter!]

Regular tofu is not fermented and does not have bacteria and/or molds added as do dairy cheeses. It can be used instead of meat in vegetarian and vegan dishes, such as breakfast or other burritos, chili, enchiladas, lasagna, pates, salads, sandwiches, soups, on shish kebabs with vegetables and mushrooms, and stir fries, etc. It can also be scrambled with turmeric and/or nutritional yeast and other spices for a taste, appearance and texture similar to scrambled eggs.

Silken tofu is best for puddings, soups, dips and some desserts since it's smoother and less grainy. Silken tofu can be substituted for butter, cream cheese, whipped cream, or heavy cream in a variety of recipes., especially in sweet recipes ranging from breakfast smoothies to puddings and pies.

Soft tofu is usually too soft for stir-fries and firm tofu may be too grainy for some desserts and dips, etc.

Firm tofu can be marinated, fried, or sautéed. Heating tofu before marinating will help it absorb the marinade thoroughly.

Tuna Casserole

A few substitutions can make tuna casserole more nutritious. Teff noodles, plain yogurt and fresh, organic peas add nutrients while increasing the casserole's anti-inflammatory properties and lowering its glycemic index.

Use tuna packed in water, which is low in saturated fat, making it a heart-healthy choice and a good choice for those with diabetes.

Choose a low carb pasta to significantly reduce the number of carbohydrates per serving. But, not all low carb pastas are created equal. Soy based noodles, such as Shirataki Miracle Noodles, are made of soluble plant fiber contain zero calories and zero carbs. This particular variety comes in fettuccini, angel hair and rice noodle styles. If no low carb pasta is available in your area, you can search online supermarkets for a greater variety. Or, use whole-wheat egg noodles—they have more fiber than regular egg noodles.

Use Parmesan cheese, which is much healthier than other types of cheeses because its calorie content is much lower.

Use low fat cream of mushroom soup instead of lots of butter and cream. Or, make your own creamy mushroom sauce with nonfat milk thickened with a bit of flour.
Layer your casserole with fresh vegetables, beans and lean cuts of meat.

Please Note: Before you start eating these comfort foods, make sure that you go through all 6 stages of the Death to Diabetes program first to ensure that your blood glucose won't spike and remain outside the normal range.

Note: These tips were taken from the hundreds of food tips in the Death to Diabetes Favorite Foods ebook and the Death to Diabetes Cookbook.