Saturday, July 31, 2010

Easier or harder?

This afternoon I put out on Twitter a request for Type 1s to make suggestions about anything they might like to see a Type 2 address. My friend Scott Johnson responded, "I often think you guys have it harder - depending more on willpower & dietary choices for BG control. Do you feel that way?"

It's a complicated question, or a simple question with a complicated answer. I've often thought about it, and I've been hesitant to address it. My basic reaction is "absolutely not!" However, I've rarely been angrier than the time I was listening to a podcast panel of Type 1 PWDs, and someone said that "Type 2 is easy!"

The first thing to remember, and I'll mention it again, is that Type 2 is a progressive disease. Type 2 covers people in many different situations: diet and exercise alone; a dizzying array of oral and injectable medication options, each with its own set of consequences; a combination of oral medication and basal insulin injections; and full insulin dependency. A Type 2 may be as healthy as a horse or a very sick individual indeed. A Type 2 may be dealing with the effects not only of diabetes itself but any or all the other conditions that tend to cluster with it: hypertension, elevated cholesterol, heart disease, apnea, and others.

I have to say that in my mind, it's the manner of treatment and how well it's working that affects what life is like far more than the disease mechanism. For the purpose of this discussion, by "Type 2" I'll be referring to someone on the diet/exercise regimen or oral medications.

I also want to note that my knowledge of what Type 1 is like to deal with is all second hand. I think I know more about it than most people, but I'm sure there are important things I don't understand. So, I hope my friends will forgive me if I'm missing something important.

I have some academic background in political philosophy, and it often helps me to go Aristotelian on the bit and break things down into parts. I see four areas to compare lifestyles for the two types: immediate health impact, daily management, complication avoidance, and the complications themselves.

Immediate health impact -- As I noted above, a Type 2 diabetic may be at many different places on the scale between healthy and sick on a day to day basis. In my own case, because I'm so fortunate in how well my medications work at present, I don't experience anything like the rollercoasters I see many of my T1 friends experiencing. I've never had a low, as I've noted elsewhere, and anything like reasonable choices in what I eat keeps me from getting too high to feel poorly in that respect. I do have days in which I feel ill because my metabolism hates me in general.

Daily management -- There are sort of two sides to this coin. There's absolutely nothing I currently have to do that's as intrusive as the daily routine of shots/pump management, diabetes arithmetic, many daily blood tests, etc. On the other hand, many of the folks that manage Type 2 without medication work vary hard, with very significant dietary restrictions and exercise routines that would make Richard Simmons blush. On the third hand (can you believe I'm not a lawyer?), Type 1's are not necessarily immune to the same genetic, lifestyle, and environmental factors that produce insulin resistance in Type 2 folks, and thus diet and exercise become critical for some of them, too. So, this one is kind of a toss-up to me, and depends on the individual's situation.

Some Type 2s feel a bit of envy for folks on basal/bolus regimens who "can just push a button" or "just take a shot" to prepare for a special meal or to treat a high. I'm not one who feels that way - I think it's way more complicated than that, and I don't want to minimize the difficulty and discomfort of managing boluses. Yes, it would be nice to have a tool (other than patience) to deal with a high that's beyond exercise being a safe option. But that might yet be down the road for me.

Complication avoidance

For people with all types of diabetes, the best chance of fending off the complications we can all list consists in good long-term control of blood sugar levels. (And, of course, complications may show up even when control has been good.) But, in order to achieve that control over the long term, many Type 2s must do their best to make very significant changes in their dietary and exercise choices. Most often, Type 2 is diagnosed in middle age or later, and habits have been built up over decades, and making those changes is very difficult. Plus, for those of us who are truly obese, there are often psychological issues that must be either addressed or somehow sidestepped for meaningful changes to occur. So, the challenges are considerable, and I for one am not even out of the foothills at the basis of this particular mountain. For most (I think) Type 1 PWDs, this is a set of issues that's not part of the equation. Again, however, Type 1 PWDs are not immune to this set of issues and may deal with them as much as anybody else.

(Mini-rant: I just about lost my temper during last week's #dsma session. A number of folks talked offhandedly about lifestyle choices, as if it was a simple thing, like upgrading your wardrobe and grooming yourself a little more carefully to get a better job. If losing weight is so freaking easy to do, how come millions of Americans (and countless others) are unable to do it? Do you really believe all of those people are stupid, or have deeply flawed personalities? Or, just based on your own experience with blood sugar management, don't you think that human metabolism is way more complicated than we currently comprehend, and that we simply don't yet know how to actually help people rather than just lecture them? *ahem* Sorry.)

The Complications Themselves -- I think it's important to note that the long term effects of diabetes do not much vary between the two major types. The organs of our bodies that rely on intricate networks of tiny blood vessels don't care why they've been assaulted by excess blood sugar for many years. They're not concerned about antibodies, or insulin resistance, or beta cells, or artificial ingredients, or even cheeseburger consumption.

So, in summary, my answer to Scott is no, I don't think that Type 2 is harder, although distinctions between the two types fade as Type 2 advances. On the other hand, that's not to say that Type 2 is "easy", and involves issues and complications not common to most of my Type 1 friends. All diabetes is hard, all diabetes sucks, all diabetes needs to be cured.

Thursday, July 29, 2010

D-Feast Friday: Getting Started with Dried Beans

"Beans, beans, the wonderful fruit..." - every 8-year old in the US

Canned beans are very useful. They can turn some veg and/or a little meat into a fast, satisfying meal. I keep some on hand pretty much continually.

Cooking dried beans is a little more (though not a lot more) trouble. But they have four huge advantages over the canned:
1) They're really cheap, probably the cheapest available protein source.
2) Dried beans do not have the tons of sodium usually poured into canned beans.
3) By starting from dried, you've got the opportunity to build flavor INTO the beans, not just in whatever you add them to.
4) They're really, really cheap. (Yes, it's worth two reasons: do you consider two hands redundant????)

Cooking Beans

If you've never cooked with dried beans, here's enough to get you started.

The basic method I use is sort, soak, add liquid and flavor, cook.

Sort - It's a good idea (even though I usually skip it) to examine your beans for loose rocks and such not removed in processing. This almost never happens anymore, but think how you'll get to laugh when I break a tooth someday.

Soak - almost all beans, except tiny ones like lentils and split peas, benefit from soaking in water somewhere between four hours and overnight. I use a 2 quart pitcher for this (because the lid, designed to keep ice cubes from being poured out, make draining easy) for a 1 lb bag of beans. Give it plenty of water and room in whatever container you use, because the beans will get a lot bigger.

At the end of the soaking, drain off the water and give a quick rinse.

Cooking liquid and flavoring

It works just fine to cook your beans in plain water with no flavoring at all, but you may find the results a bit bland if you're not going to do a lot to the beans after cooking. I've gotten fond of using low-sodium cooking stock for my cooking liquid. I like to add some roughly chopped garlic and onions or some spices. maybe some fresh or dried chiles. (You're going for a fairly strongly flavored broth - the beans will soak in some of the flavor, but won't get nearly as strong as the cooking liquid.) I really think that the possibilities here are endless. I find that a quart of chicken stock (in the containers like large juice boxes) needs to have some water added to be enough to cook the beans.

Cooking the beans

Cooking is usually done on the stovetop or in a pressure cooker.
* The pressure cooker is FAST - if you've got one, you've probably got a little book with cooking times for beans.
* If you cook on the stovetop, put the beans a-simmering in plenty of water/cooking liquid (a good couple of inches above the beans) and keep an eye on it to make sure there's plenty of liquid. Cooking times depend on the variety and age of the beans and the humidity at which they've been stored, but most varieties of beans will average cooking times of 45-90 minutes. They're done when they mash fairly easily with fingers or a fork.
* My favorite method, actually, has become my slow cooker on "high". I'm not actually sure how long to tell you, since I just sorta let it go and check occasionally, but I'm guessing 2-3 hours.

Using the beans

There are zillions of recipes for beans. Cooked beans can be used in soups, in one-dish meals or countless other ways. Don't be in a big hurry to throw out the cooking liquid, which can be a nice base for a soup or something.

Lately, I've been taking advantage of the fact that cooking beans in bulk is just as easy as cooking less. After I've portioned out the beans I need for whatever I was planning, I let the remainder cool and then put them in freezer bags. I put in about a cup and carefully make the package as flat as I can - they store efficiently and thaw more quickly. Several times I've broken a bag's worth of frozen beans straight into a hot pan with a little oil to thaw and heat.

A note in closing: The Great Soaking Controversy!
Soaking has traditionally been done to speed cooking time and to reduce the gassiness some folks experience with beans. (I don't, but maybe I'm used to a higher-fiber diet.) Among the science set, there's a lot of skepticism that soaking helps the gasiness. And others say that the beans are better and more nutritious without the soak. I'm not an expert, and there's no reason to believe me if you don't want to. I just report that when I don't soak, they never seem to get tender. If you want to try it without soaking, though, figure on increasing the cooking time by quite a bit.

Tuesday, July 27, 2010

Culinary Therapy for Diabetes

In a couple of recent posts, I've let my interest in cooking show. Since I think I'll continue to do that from time to time, I feel the need to justify the presence of those posts in a blog dedicated to Type 2 diabetes. While I'll never promise not to write about irrelevancies from time to time, I should explain a new recurring theme.

A huge, huge part of coming to terms with my diabetes is learning to eat a more healthy diet. For the past decade or so, I've prepared some of my meals at home (bland stuff, mostly) and eaten the rest out (fast food, mostly, or inexpensive sit-down places), or had pizza/Chinese delivered (maybe once a week). Given the realities of my cooking skills as they have been, there are really only a few possible approaches to improving my diet:

1) I could learn to not much care about the yumminess of what I eat. Plenty of wonderful people really enjoy delicious food when they get it, but eat the bulk of their meals only as fuel, to get their bodies through to the next meal. It's a sound approach, I think, if you can do it -- and I can't.

2) I could continue to eat out, but do so more healthily. The options for doing this are sadly limited -- I can only eat so much salad. This doesn't work for me either.

3) I can learn to cook well enough so that the food coming out of my own kitchen is usually the most attractive option. This is the path I'm trying to follow.

So, over time, I'm working hard on learning to work with unfamiliar ingredients (especially vegetables) and flavor enhancers like herbs and spices. My growth is limited by the fact that I hate to cook from recipes. But I watch a lot of cooking shows, and I'm finding that I can sometimes read several different recipes for the same item to get the essence of the thing and cook it off the top of my head.

I'm making good progress. OK, it has to be admitted -- some of my experiments are acceptable only because I live alone and don't have to talk anybody else in to eating what I've prepared. But most of what I turn out is acceptable, and occasionally I turn out something that's fabulous. I'd have been proud to serve one batch of chipotle chili to anybody. And, more to the point, I'm eating out in the evenings much less often and even taking my lunch less infrequently. Plus, when I want to indulge, I can make treats of types and in amounts far more modest than the pizza place would bring me.

Chipotle chili, anyone?

Thursday, July 22, 2010

Thoughts on healthy cooking

In commemoration of D-Feast Friday, I thought I'd offer some thoughts on healthy cooking. On the face of it, it would seem absurd to listen to me on this subject, but I've been working on it, and have some things I think are worth sharing.

1) If you're interested in making the food you prepare be more healthy, I suggest you expand your ability to use spices and herbs. Most people find that fat, sugar, and simple carbohydrates taste really good. If we're to reduce the role of those things in our food, we need to find other ways to make our food delicious. Spices and herbs can be a pretty easy (and usually cheap) way to make things tasty.

2) One of the current trends among the foodies is an insistence on fresh, high-quality ingredients. I have some quarrel with that. I believe that approach will improve the tastiness of our cooking, but I also believe that budget and circumstances necessitate compromise. I read a recipe the other day that called for "farmer's market turnips". I call "nonsense!" on that. Are they really saying that supermarket produce would not be acceptable? I know a lot of words for that, but I'm not putting any of them in a blog posting.

3) A small amount of something really tasty can bring life to a pedestrian meal. I've been experimenting with quick pickles, a term used to refer to pickles that don't have to be "canned" and are ready to eat in a few hours or days. I have done kimchee, pickled roasted red peppers, pickled onions, and marinated cucumber. They're really easy to do, and a bite or two can liven up a plate, make a sandwich special...or even substitute for a late night snack.

4) Learn to roast vegetables. If you haven't had roasted cauliflower, you haven't had cauliflower. Don't quibble with me on this - Uncle Bob understands these things.

5) Speaking of veggies, there's a lot of very valid concern about how expensive healthy cooking can be. There are ways to alleviate this, though: cabbage is cheap, as are carrots and usually celery. Lots of other stuff is inexpensive in season. If you do well on beans (pintos and such), dried beans are really cheap and aren't hard to prepare.

6) Also on veggies, don't listen to people putting down the nutritional value of frozen veggies. According to the best info I can find, what kills the nutrients in produce is time off the vine. While the fresh produce in your marked may have been in transit or storage for many days, frozen veggies are flash-frozen within hours of picking.

7) Finishing up the veggie section, steaming produces a better-tasting result than boiling for many vegetables and does a better job of preserving nutrients.

8) Substitutions. The basic trinity of stuff most Americans could stand to eat less of is sugar, fat, and salt. The food industry has responded to interest in healthier eating by offering lots of products that has reduced amounts of one of these things or that are intended to substitute for other foods. From my standpoint, there are three things to be aware of here:
a) Most of the time, it seems, the manufacturer compensates for reducing one of the three "bad" ingredients by boosting one or both of the others. So, a low fat product, for example, might have increased amounts of sodium - maybe MASSIVELY increased amounts. Whether the approach they've taken is appropriate for you depends on just what you want in your diet. For example, I need to watch both carbs and fat. But, my blood pressure is well-controlled, so I'm willing to (selectively) accept increased amounts of sodium, even in careful choices.
b) The acceptability of substitutes as far as flavor is individual. I happen to like fat-free mayo, which many find to be horrible. On the other hand, I can't handle most fat-free cheeses. When I was a vegetarian for a while, I enjoyed some "veggie burgers", but the tofu "hot dog" I tried was one of the vilest things I ever put in my mouth. My point here is that if you choose to experiment in this area, don't be discouraged if the first product you try won't pass muster for you.
c) I don't know enough about this to speak knowledgeably. I do know, though, that some sugar-free foods (such as hard candies or gum) contain "sugar alcohols" that may raise blood glucose just as "real" sugar does. So be aware that "sugar free" doesn't always mean "good for diabetics". See this article from the Joslin Diabetes Center for a little more information.

That's probably enough ranting for now, don't you think?

Sunday, July 18, 2010

A (Non) Rolling Stone: An Allegory

Once upon a time, there was a man who, while on a certain part of his journey, found his path blocked by a large stone.

The man first tried around the stone, but the stone lay against a high cliff on one side and a steep cliff on the other. He also found that climbing over the stone was impossible.

So, the man dedicated himself to pushing the stone off his path. But, try as he might, he wasn't strong enough. Day after day, he pushed against the stone with no movement. Every few days, he was able to summon a little extra strength and move the stone a fraction of an inch, but when he exhausted himself and had to let go, the stone rolled back to its original position.

The man became deeply discouraged. He had known others who had been strong enough to push similar stones out of their way. He had known those who, though no stronger than he, had been able to push more consistently and been successful. He had also known people who never seemed to run into stones or who just didn't seem to mind when they did. He was sad that he couldn't be like these other persons.

But this man cared. As he either pushed or dropped in fatigue, there was rain, and snow, and (worst of all) presidential elections. His friends and family told him that he should push harder or that he must not really want to move the stone badly enough. (In truth, they rarely told him these things - he just thought they did, because that's what he told himself.) Eventually, he came to feel completely trapped, and divided his time between occasional pushes and trying to change his thoughts so as to be able to push harder or longer.

After many years, our friend wearied of feeling bad all the time, and came to somewhat accept his situation. He wasn't a bad person, he reasoned, he was just a man behind a rock. He still pushed from time to time, but he also built himself a shelter from the weather, and planted some basil, and subscribed to digital cable. He was still sad about his situation, but slowly changed how he thought about it.

One day as he was writing idle thoughts in the dirt, he discovered that he had written these words:

"Personal change is more about strategy than psychology."

For several days, he often thought about those words. He thought about them while cooking ratatouille, and while washing his dish, and after "Monty Python's Flying Circus" reruns.

Finally, he got up, and went and looked at the rock and the surrounding areas, really looked at them, for the first time in many years. He noticed a few fist-sized stones around the base of the stone. After he thought about these things, he went and pushed against the stone with all has strength. As he had before, he moved the stone about half an inch. This time, however, he used his foot to move one of the smaller stones to wedge against the big one to prevent it from rolling back to its original position. A few days later, he did this again.

That's the situation now. The man is hopeful that his new strategy will enable him to move the stone out of the way. But he has glimmers of a couple of other ideas if that doesn't work.

At least the stone is moving.

Recipe - Black Beans and Rice

Recipe - Black Beans and Rice

I had some black beans I wanted to cook, and read several recipes for Cuban-style black beans, so this recipe is along those lines. As I went along, I did things that made it like Louisiana Red Beans and Rice.

This is not especially diabetic-friendly, though there is a lot of fiber. I don't think I tested after eating, but I didn't have any symptoms suggesting a problem, and I do know I do well on brown rice.

I'm not a food snob. I've only ground whole spices a couple of times, and this is the first time I ever toasted a spice. The result, however, was FABULOUS. This would probably be good with powdered cumin, but starting with the whole spice gave such a fabulous aroma to both my kitchen and the food.

* spice grinder, coffee grinder (that you don't plan on grinding coffee with again), or mortar & pestle.
* slow cooker, or just a large post if you prefer cooking the beans on the stove
* stick blender, food processor, or blender.

A teaspoon or so of cumin seeds
One pound black beans, soaked overnight in plenty of water and rinsed
1 qt chicken stock (I used reduced sodium)
One white, yellow, or Vidalia onion, roughly chopped
3 or 4 largish garlic cloves, chopped
Cooked brown rice or another grain you do pretty well on (optional)

1. Put the cumin seeds in a small, dry frying pan or sauce pan over low-to-medium heat. Toast until the aroma is pretty strong but not burnt. It doesn't take long.(I had to do this twice.)
2. After the seeds have been toasted and cooled, grind them. Do not forget to marvel at the aroma.
3. Put the black beans in the pot or slow cooker with the chicken stock and a couple cups of water.
4. Add the ground cumin, the onion, and the garlic (but not the salt, which some say does weird things to the beans if added at the front end)
5. Cook until the beans are tender, almost mushy. No way to predict how long this will take, but my beans took about four hours in the slow cooker. Check periodically and make sure there's always enough liquid to cover the beans - add more water if needed.
6. When the beans are done, allow them to cool. Important for safety
7. Remove maybe a quarter of the beans and mash them lightly, leaving them pretty chunky. Set aside.
8. Puree the rest until smooth. If you use a food processor or regular blender, step 6 is especially important.
9. Add the lightly mashed beans back into the puree. Add the amount of salt that makes it taste good.

To serve, reheat and put in bowls. Add the rice or other grain in a scoop-like shape in the middle of the bowl.

Wednesday, July 14, 2010

The Pursuit of Dailiness

Some of life's victories can be gained by one big effort. An all-nighter to do a big school project, two or three days of focused effort on a report for work, or an afternoon in a kitchen to prepare a wonderful meal are often the best ways to approach those types of tasks.

However, most things worth doing are best accomplished by a modest effort applied consistently over time. No all-nighter will overcome a semester's undone mathematics assignments. There's nothing a gardener can do in August to rescue a crop neglected all summer.

I use the word "dailiness" to describe the quality of achieving results through effort applied regularly and consistently over time. (It's a real word, actually, but I use it with a bit of a spin.) There's just so much stuff that benefits from a little effort daily - not EVERY day, necessarily, but consistently. (I'm much better at being aware of the principle than I am putting it into practice. But, baby steps, baby steps.)

There's a great deal of dailiness in diabetes management. There are the daily routines of testing, taking medications, and seeing to the insulin supply. Good eating habits and exercise both have the best outcomes when applied with consistency. (I think I've read that the regularity of exercise may be more important than its intensity or duration.)

I often tinker with the tools I use to improve my daily practice of important habits. My morning pill sorter is on my living room table, where I'll be sure to see it, my evening pill sorter is in the bathroom (where I end each day), and I have a computer reminder to remind me of afternoon pills, since I'm almost always at one PC or another at that time of day. I've read of people who keep exercise clothes right by the door, serving both as reminder and shortcut. I'm beginning to experiment with checklists, to try to harden some of the things I should be doing into routines that I don't need to think about.

Have you found any tools that help reinforce your daily routines?

Sunday, July 04, 2010

Those Blasted Pills!

"I can't complain but sometimes I still do." - Joe Walsh *

This post is clearly in the category of complaining about something trivial. I think it says something important about my life with a chronic disease, but the highly kvetching-sensitive might want to skip this one.

I had a Twitter exchange with my friend Mike this evening which started when he mentioned having finished his pill sorting for the week. I replied that the weekly pill session is what I might find most irritating about diabetes and its cronies -- not the worst or most worrisome by any stretch, but the most irritating. (OK, office goodie pushers are worse. But still.) Mike responded with the perfectly sensible attitude that he finds it annoying, but that taking all the meds beats the alternative. My feelings about the pill session are stronger than that.

It's long been apparent to me that my mind often settles on something insignificant as a sort of psychological focus for something I feel uncomfortable about. On the rare occasions that I hold a grudge against someone, I'll find myself deeply annoyed by their voice, say, or a hairstyle. My pills are a Good Thing, since I believe I benefit from them, and the sorters are also a Good Thing. (Since I only have to think about my meds once a week, my regularity in taking them is VASTLY improved.) But I think that few minutes once a week carries part of the emotional weight of diabetes. I don't just sit down to sort pills, I sit down to my resentment over needing the pills, annoyance at the cost of the pills, anger that there isn't a cure, and fears about the future.

("Look, Mommy, this blogger is being a weenie again!" "Yes, sweetie, he is, but at least he's almost done for today.")

Man, since they bear all that weight, it's good that the sorters are built of such sturdy plastic!

* Walsh, Joe. "Life's Been Good To Me So Far" But Seriously, Folks... New York: Asylum Records, 1978.
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T Minus Two by Bob Pedersen is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.