Diabetes and depression

This past few days being on diabetes "medication" has been a humbling experience. I did not realize the upkeep involved, and even for someone with a half-decent understanding of nutrition, it was not a walk in the park. I screwed up so badly on Saturday that I wrote the day off to start anew on Sunday. That's the fortunate part of only pretending to have diabetes. People really living with the disease can't just decide to do it tomorrow, it is a burden you live with everyday.

There were a few times I forgot to take my "Metformin", and carbohydrate counting, though I did get better, was a tedious experience. I found myself estimating a couple times, which may have been sloppy, but I was either in a rush or just didn't feel like doing the extra work.

I was actually really surprised that I grew more tired of doing a finger prick, than the insulin shot. Pricking my finger is not fun! While the insulin shot gave me the most angst the first time, it was the finger prick that I truly despised in the end. I was able to give myself the insulin shot relatively quickly and with less mess, while pricking my finger gave me more pain, and a few times I had to repeat it as the glucometer read an error.

All these issues of managing diabetes add up, and this all just in a few days. Living with the condition would reveal even more issues that I'm sure would cause a lot of anxiety and frustration for people.

 Studies have shown that depression is twice as likely to occur in diabetics than non-diabetics. This is related to physical, psychological, and genetic factors. The burden of managing a chronic disease on your own, is thought to be a contributing factor to depression in people with diabetes. This highlights the need for a strong social support network, to ease the burden of the person living with diabetes.

While depression can lead to poor diabetes control. Depression has also been shown to double the risk of developing diabetes, so it is difficult to determine how depression develops. Certainly it is not hard to believe that a diagnosis of diabetes would exacerbate depression. Either way it is a vicious relationship.

Understanding the burden of chronic disease is crucial for the delivery of quality healthcare that respects the client. People may struggle with managing their illness, but it does not necessarily mean they are a lost cause, just that they need care to be tailored differently.

Insulin dream

As part of an exercise to better understand what someone with diabetes has to go through in terms of managing the disease, I was set up this week with an insulin pen, blood sugar meter, and "medications" of someone with diabetes. I was also given a schedule to follow, and a chart to track how many grams of carbs I've eaten.

So my schedule looks like this:

-1 unit of Humalog (fast acting insulin), for every 10g of carbohydrate I eat, at meals.

-20 units of Lantus (long lasting insulin) at bedtime.

-1 "Metformin" (oral medication to increase the body's sensitivity to insulin) 3 times a day.

-Test blood sugar first thing every morning, and two hours after every meal.

So just to clarify I'm not actually taking insulin or any diabetes drugs, I'm injecting air into myself, and taking sugar pills. I must admit though it is a little freaky jabbing yourself in the side with a needle, even if it is only 4mm long. I usually have no problem with needles, I'm all screamed out from childhood. Checking my blood sugars also took some mental strength the first couple times. The first time I bent the needle, which didn't make me feel any better about drawing my own blood.

The most difficult part, however, has been taking my insulin based on what I'm eating. It has forced me to plan my meals, and how much I eat, ahead of time. Usually I don't pay much attention to meal times, and just eat and cook whenever I am hungry. To avoid a "low" blood sugar, I'm forced to eat soon after taking my insulin, this is something I am not used too.

In no way do I now understand what it's like to live with diabetes, I know that I'm going to go back to my usual routine in a couple of days, and I don't have the weight of an actual diagnosis on my shoulders, nothing will happen if I don't take my "insulin".

As a dietitian-to-be I'm struggling with some of the carbohydrate counting and meal planning, and I've had to ask my supervisor many questions; yet these expectations we have of our clients. While I would get better at managing with time, I could only imagine the stress the diagnosis would put on someone.

Also I'm not appreciating the red needle dots on my mid-section.

Traveling up the coast...

This past week I had the opportunity to travel up the coast to visit a couple other communities. Taking the flight up the coast seemed more like taking a train. Even though we were traveling all the way to Peawanuck, the furthest community up the coast, you still have stops at all the other communities. So to get to Peawanuck you’re going up and down 4 times with stops in Fort Albany (20min), Kashechewan (5 min), Attawapiskat (30min), and then 45 minutes to Peawanuck. Apparently the flight between Fort Albany and Kashechewan is the shortest commercial flight in the world, as it is only a 10 minute drive on the ice road.

Peawanuck has a different feel than the other communities. It is more isolated than the others, and people rely more on traditional food systems, such as fishing, trapping, and hunting. Unlike the other communities it seemed as if the community had their dog population under control, if you’ve read my blog post “It’s cold and there are dogs” you understand why this is one of the first things I noticed.

While the community has many positive attributes, delivering health care services to an isolated location still has its challenges. The nursing station has a high staff turnover, with nurses usually staying for only a couple weeks at a time. The current nurse in charge of the station had only been there for a few days, and only found out he was the charge nurse the day he left for Peawanuck. Physician services are few and far between, even though there is supposed to be a doctor in the community every month or so, it is rare when it is that frequent, and for anything beyond basic care people need to be flown south to Moose Factory, Timmins, or Kingston.

I had a chance to visit the grocery store in Peawanuck, which had a produce section slightly better than a 7-11 back home. Alongside the moldy limes and lemons, was a sad head of broccoli for $13, while instant noodles sold for 95 cents. Some people order directly from stores down south, to bypass the retail mark up, but the situation is far from ideal.

  

Another highlight of my trip up the coast was doing home visits in Fort Albany. This also provided me with the unique opportunity to counsel through a translator, as many of the elders speak Cree. At first it was an intimidating experience, but after realizing how unique and limiting the situation was, I started to relax. Using plain language is something you always keep in mind, but it is especially important when communicating through a translator, and you always wonder what has been lost in translation. I also felt pretty useless, offering someone who speaks Cree English language resources. 

What I found the most important was keeping in mind you should speak directly to the client and not with the translator, and secondly to keep a sense a humour about the situation. It is certainly not something I was trained for, but that’s what makes it fun, it forces you to stretch.

Why vitamin water sucks!

There have been a couple situations lately with vitamin water that have really irked me.

The first was from my supervisor who is part of the diabetes program. She mentioned a client had been drinking vitamin water not realizing it contained sugar. Now for most people this would not be a major issue, other than empty calories, but for someone with diabetes this a potentially dangerous situation.

The second was a client who had been feeling tired and ill, and she mentioned she was drinking vitamin water to help her feel better. The client asked about the claim on the bottle suggesting to drink 1 bottle a day for best results. The way vitamin water markets itself is as a health product, which is totally misleading.      

Vitamin water, which is made of  water, sugar, artificial flavour and colour, and fortified with vitamins, markets itself as a health product to great effect. Everything from the label, to the name itself is designed to resemble a prescription.




While vitamin water does contain water and vitamins, as you can see from the label above, it also contains sugar, flavour additives, and some varieties contain artificial colour. Vitamin water is essentially flat coca cola fortified with vitamins, but coke isn't drunk to relieve illness or to be healthier.

The other tricky thing with the vitamin water label is the serving size. For sugar and calories the nutrition information is based on an 8oz serving, where the bottle itself contains 20oz (2.5 "servings"). I think it is fair to say that most people will drink the entire bottle. While a 12oz can of Coke contains 42 grams (~8.5 teaspoons) of added sugar, a bottle of vitamin water contains 32.5g (6.5 teaspoons) of added sugar.

While it may seem obvious to some that vitamin water is not going to make you healthier, it has a subtle affect. Especially in our fast paced lifestyle where it is not uncommon to experience days when you may not eat nutritiously. So why not grab a bottle of liquid vitamins?

But the fact of the matter is you would be better off taking a multivitamin down with tap water. This would save you both money and calories. But really your body will survive one day of poor eating, and you really shouldn't be relying on added vitamins anyway. There is little to no evidence that taking vitamins, most of which have been extracted from corn, will make you any healthier. While there is plenty of research showing a healthy diet will reduce your risk for chronic disease and improve your well being.

My first rant. Feels good!

Community kitchens and the joy of working with kids.

This week I was able to participate in a community cooking class, my first time doing so. The class was geared towards children, with their parents accompanying them to help with anything beyond their skill level.

It turned out that most of the kids ran off and their parents ended up doing most of the cooking. There were a few kids that participated during the class, but it was difficult to engage children in the cooking process. Short attention spans make even the 10 minutes to cook ground beef feel like an eternity. Other kids disagreed about proper hand sanitizing, and deemed it acceptable to simply wipe their hands on their pants after handling raw meat. Fair enough!

There were moments that made it worthwhile. Watching kids getting involved with cooking, and developing cooking skills, even if at the most basic level, is an incredibly rewarding experience. You can't help but smile when watching a 6 year old peel a carrot for the first time, or watch in a trance his mother cutting up a pepper.

Basic cooking skills are so important to develop, yet are not commonly taught in the school system. I received no cooking or food education during school, and if it weren’t for my parents I would not have any sort of base to work with. Unfortunately not all children are as lucky to have parents that teach them to cook, either for lack of time or lack of cooking skills.

This is part of the reason why processed foods are so popular. Many people are growing up with cooking simply meaning reheating frozen products. That’s why cooking needs to be part of school’s core curriculum.

A recent article, by Thomas & Irwin (2013) in the Canadian journal of dietetic practice and research, looked at what aspects facilitate and act as barriers towards applying skills learned in a cooking class, among high risk youth in Toronto.

Four aspects that promoted the application of cooking skills were identified:

1) Aptitude, which is the possession of knowledge and skills to prepare food at home.

2) Food literacy, which is an understanding and knowledge of food preparation from start to finish, including food selection, purchasing, preparation, and preservation.

3) Local and fresh ingredients, which were identified as important to making healthy and delicious meals.

4) Connectedness, which is related to the youths’ connection to the food and the farmers that grew the food, and also their relationship with health, family, and culture.

Only one barrier was identified, and that was easy access to fast food restaurants, which deterred people away from making home cooked meals.

While the food industry has taken advantage of our desire to have quick meals that meet are busy lifestyle. These products are far from a necessity, and do not benefit our health. It is unlikely that we would starve if these products weren't  available, and more likely that it would force us to incorporate more time to prepare food. Unfortunately we have created a food system that promotes these types of convenience foods.

What we eat is dependant on many factors, including cost, availability etc., but if we want to give kids a chance to eat nutritiously, basic cooking skills are a must. Providing children cooking and nutrition classes from a young age will create a population that is able to choose between eating nutrient poor convenience foods, and cooking nutritious meals at home using fresh local ingredients, when available.

 A choice between health and illness.

JK



   

The Food Industry and You!

The New York Times recently published an article entitled "The extraordinary science of addictive junk food". The article, written by Pulitzer prize winning investigative journalist Michael Moss, paints a frightening picture of how the food industry attempts to hook customers to their products, under the guise of "Giving the customer what they want".

A few passages that really caught my eye I have included below, while the full article can be found here.

The article features a section on Howard Moskowitz, who is a consultant for the food industry, and is hired by companies wishing to create the best possible product. In this case "best product" simply refers to a product that sells.

Ordinary consumers are paid to spend hours sitting in rooms where they touch, feel, sip, smell, swirl and taste whatever product is in question. Their opinions are dumped into a computer, and the data are sifted and sorted through a statistical method called conjoint analysis, which determines what features will be most attractive to consumers.

The mathematical model maps out the ingredients to the sensory perceptions these ingredients create,” Moskowitz said, “so I can just dial a new product. This is the engineering approach.”

Moskowitz describes the ultimate product as having a perfect sensory specific satiety level.

In lay terms, it is the tendency for big, distinct flavors to overwhelm the brain, which responds by depressing your desire to have more. Sensory-specific satiety also became a guiding principle for the processed-food industry. The biggest hits — be they Coca-Cola or Doritos — owe their success to complex formulas that pique the taste buds enough to be alluring but don’t have a distinct, overriding single flavor that tells the brain to stop eating.

An example of this may be a good quality chocolate, which is almost too rich. You can have a little bit, and it is amazing, but it is a hard food to eat in large quantities even though it tastes amazing. In this way cheap snack foods are actually designed to not overwhelm and instead encourage people to eat as much as possible.

Another food industry insider describes the idea of "vanishing caloric density".


This,” Witherly said, “is one of the most marvelously constructed foods on the planet, in terms of pure pleasure.” He ticked off a dozen attributes of the Cheetos that make the brain say more. But the one he focused on most was the puff’s uncanny ability to melt in the mouth. “It’s called vanishing caloric density,” Witherly said. “If something melts down quickly, your brain thinks that there’s no calories in it . . . you can just keep eating it forever.”

This design, coupled with the flavour design described above, represents a powerful attack on will power.

Food companies shave also been known to target ethnic minorities that traditionally consume more of their product. In the U.S this has often been African-American, and Hispanic populations. This practice has been the subject of much criticism lately, with Beyonce becoming the new face of Pepsi. Some suggest this is a merely a strategy to encourage Pepsi consumption among young African-American girls.

In an effort to control as much market share as possible, Coke extended its aggressive marketing to especially poor or vulnerable areas of the U.S., like New Orleans — where people were drinking twice as much Coke as the national average — or Rome, Ga., where the per capita intake was nearly three Cokes a day.

By targeting the most vulnerable, the for-profit food system is actually increasing food insecurity, by creating addiction to processed food, and encouraging their consumption. It is incredible the lengths companies will go to turn a profit, and then rationalize it by suggesting if it's not them someone else will do it.

As a dietitian it is important to keep in mind the affect the food industry has on what people eat. While we may encourage people to consume less processed food, and provide an understanding as to why, this may not be enough. You can't underestimate the role that advertising, convenience, taste, and even addiction have on what people eat.

This is why policy is so important. Clearly personal responsibility does not work, at least not at the population level. Restrictions on advertising (especially to children), salt, and trans fat are good places to start. Since we've grown up with processed food, seeing it on a regular basis seems normal, but their is nothing normal about processed food. It is designed purely for profit, with only enough quality to makes us crave more.

JK

Barriers to care

Since working in Moose Factory, one thing that has really stood out has been the high no show rates. I am doing considerably more outpatient counselling here than in Nova Scotia, but the 50% show rate for appointments has been surprising. As a practitioner it is frustrating because you feel that people could benefit by seeing you, and it tends to be the most complicated cases that do not show. I was interested in exploring this further, as it occurs not just in dietetics but also in other outpatient services. There must be some barriers that overwhelm people’s desire or ability to attend.

Barriers to accessing health care differ from one person or population group to another, and what we may think of as routine, may in fact be an insurmountable barrier for another. It tends to be the most vulnerable populations that face these barriers, as health care services are not designed to meet their needs.

The SOGC journal, has an excellent policy statement on recognizing barriers to care in Aboriginal communities. They list potential categories of barriers including: attitudinal, values and beliefs, socioeconomic, and language and communication.

Attitudinal barriers include racism and prejudice, which can be subtle yet incredibly damaging. Differences in values or beliefs can cause people to feel alienated in an unfamiliar environment; First Nation governance was traditionally based on non-interference, this stands in stark contrast to Western medicine featuring an “expert” practitioner who makes a diagnosis and controls the care process. Socioeconomic barriers may include poverty, inadequate housing, low education, and substance abuse; all of which are correlated and contribute as barriers to access. Finally language and communication can become a barrier, not just because of the need for direct translation, but also for interpretation of content to be culturally appropriate.

As Ensor & Cooper (2004) suggest the usual strategy to increase accessibility to health care services has been to supply more health care professionals or increase the quality of care to vulnerable populations, but this may not be the best strategy. More attention needs to be made to the barriers that affect people’s desire to seek care, these include the cultural barriers that hinder the relationship between the community and health care services/practitioners.

Providing traditional native healing in health care institutions is one way to overcome some of these barriers, this is a service that does exist at the hospital here in Moose Factory. However, as my supervisor has mentioned, some people within the community are strongly opposed to this type of care, which puts a whole new spin on cultural appropriateness. Other barriers include the high turnover of health care professionals. In the 6 weeks I have been here I think I have met at least a dozen people that are moving to jobs elsewhere, this lack of continuity does little to improve the community’s relationship with the health care system.

 While many issues exist to increase accessibility, there are no simple solutions. The most important thing is to create open channels of communication between the community and health care services. Culturally appropriate care will need to balance traditional and modern health care, while allowing input from community members.