Eight Tips for Super Blood Sugar Control

A1C Levels- Below 7%

| May 20, 2011

You're heard the doctors. You've read the articles. You know all about tight control.

Ever since the results from the Diabetes Control and Complications Trial were published in 1993, everyone has known that reducing A1C levels staves off complications and keeps us healthy longer. We know this. And we've listened.

But many type 1s--and even type 2s who aggressively manage their illness--suspect that they could do better. And just a bit of searching around the web or browsing in your local bookstore will prove you right.

For me, it was the work of Dr. Richard Bernstein. "Diabetics are entitled to the same, normal blood sugars that nondiabetics enjoy," Bernstein wrote in the preface to his book Dr. Bernstein's Diabetes Solution. He's stated that viewpoint repeatedly in interviews and articles.

And who could argue with it? Some disagree with Bernstein's advice on how to get that level of control--an extremely low-carb diet figures into his plan--but his basic notion tantalizes. Are normal blood sugars possible? Can people with diabetes transform good blood sugar control into great blood sugar control?

I think we can. And what's more, it's not that complicated. Here are eight suggestions.

Have a goal.

The American Diabetes Association says that people with diabetes should aim for an A1C--a three-month average blood glucose level--below 7%. The American Association of Clinical Endocrinologists advises an A1C of 6.5% or under. Most doctors would be pleased with either number.

But what's your goal? If your A1C is 8% or  9%, hitting 7% is a worthwhile aim. However, if you've managed to achieve an A1C near 7%, perhaps you could try for a lower number. Talk to your doctor and diabetes educator and see if they think you can safely aim for even tighter control.

Whatever you're aiming for, having that target number in mind will help. That's where you want to go. That's what you want to do. And that goal will help motivate you in the days and weeks ahead.

A note of warning: Don't aim for the impossible right away. If your A1C is quite high, don't immediately try for the lowest possible number. Talk to your doctor and set a reasonable goal. Then meet it. Then set another goal.

Check your blood sugar. A lot.

No piece of advice could be more obvious, but it's easily overlooked in the hustle and bustle of daily life. If you don't know what your blood sugar is, you can't hope to keep it at a nondiabetic level.

According to the National Institutes of Health, which funded the Diabetes Control and Complications Trial, it was once standard practice to check blood sugar a single time each day. That landmark study raised the standard to four.

But four checks a day, while better than one, can miss a lot. If you want tighter control, try six or eight checks a day. That's right: Take your blood sugar every two or three hours when you're awake, and definitely check overnight. You might be surprised to learn where your numbers go.

This can be a costly prospect for some people. You can only do what you can afford. But almost everyone can try the extra checks for a few days or a couple of weeks, and that information alone will be helpful. You'll learn how your body reacts to different kinds of food. You'll find out how long it takes your body to absorb insulin.
This is your baseline information. This is the stuff you have to know. The best technology and the most extensive education don't make the slightest bit of difference if you don't know what your blood sugars are most times of the day.

You also might want to consider a continuous glucose monitor. This device gives you a constantly updated blood glucose trend line and can alert you if your numbers rise too high or fall too low.

Carry glucose tablets. Everywhere.

Lows are a real challenge when trying to maintain near-normal blood sugars for any considerable length of time. Think about it this way: A problematic low of 40 is just 50 points away from a great blood sugar of 90. But it's 200 points away from the high blood sugar of 240. If you hate the way low blood sugars make your feel, it might seem more comfortable to stay in the high range. But that high range increases your risk of serious diabetic complications.

Glucose tablets can help solve this vexing problem. Have a low blood sugar? Pop three of four of them, wait a couple of minutes, and be on your way. Have them available at all times, in all the places that you might need them--at home, in the car, and at work.

The government's Centers for Disease Control and Prevention puts it simply: "Always carry some type of carbohydrate sugar food or drink with you." The CDC also advises wearing a medical alert bracelet and carrying a card in your wallet saying that you have diabetes.

For years, I didn't believe in glucose tablets. Why not use candy, I wondered. Or juice? They were both so much tastier than the tablets. But that's the problem. Who eats just three pieces of candy? Who drinks just a few ounces of OJ? It's too easy to over-correct and send your blood sugar sky high.

Stick with glucose tablets. They're tasty enough to be palatable, but bland enough that you won't be tempted to sneak one when your stomach rumbles.

Get coaching. Now.

Find a diabetes educator or nutritionist. Go to his or her office and learn.

Perhaps you've had diabetes for a long time and think you know everything you need to know. Perhaps you don't want someone in his 20s or 30s telling you how to manage your disease. Perhaps you think you get along just fine on your own.

If you think any of these things, you really do need to see the educator. Because it's easy for veteran patients to lie to themselves--to say that certain high blood sugars "don't count" or that they're not responsible when bad things happen.

An educator sees right through that. He or she won't discipline you, exactly, but you will need to talk openly and honestly about your disease and how it's going. And your educator will then arm you with knowledge and advice.

Boston's Joslin Diabetes Center actually recommends that people with diabetes go through the education process every year or two, making sure they keep up to date with the latest research and their own goals.

You will leave motivated and ready to look at your disease in a different way. And for those looking to take control to the next level, this motivation is invaluable.

For people more recently diagnosed, educators serve a different role. They can help you understand how the disease works and smooth out your ups and downs. Getting good advice at the start can keep you from making mistakes later.

Consider a medical device.

I've already touched on continuous glucose monitors. But it's also important to talk about insulin pumps. Both of these devices can remake your routine for the better. A consistent flow of fast-acting insulin from a pump can more accurately reflect the way a pancreas works. And the constant monitoring available from a CGM gives you nearly real-time feedback.

Neither device works miracles on its own. Nothing about the devices changes the basic nature of diabetes or the challenges of controlling the disease. People on insulin pumps can have poor control. So can people with CGMs.

But the education provided with the devices can be invaluable. And the mere act of closely looking after the disease pays off. It's important to commit to the treatment, learn all you can about it, and give it a chance.

Diabetes educators and medical device companies can be great sources of information if you're considering taking this step. Don't hesitate to ask them for advice and information.

Don't just count carbs. Limit them.

Not all experts will agree with this point, but it's one that has worked for me.

The standard for diabetic treatment these days is counting carbohydrates in food. That is, your insulin shot should cover the amount of sugar in your food (most starches, like those in bread, break down into sugar). What that means is that you can eat most meats, cheeses, and green vegetables without affecting your blood sugar that much.

If you want more consistent blood sugars, it only makes sense that you would not only know how many carbs you ate so you could give yourself insulin to cover them, but that you would also limit those carbs. If you ate fewer of them, you'd need less insulin, and your blood sugar wouldn't seesaw so much.

I won't say how drastically you should limit those carbs. Different people react to these plans differently, and not everyone can handle restricting such a core part of the diet. It's up to you and your doctor or nutritionist.

What I would urge is that you do some reading. Not just the books by folks like Dr. Bernstein or science journalist Gary Taubes (both of whom advocate very low-carb diets), but also books and websites from those touting more moderate approaches (like the South Beach or Mediterranean diets).

You already plan your meals to one extent or another. It only makes sense that you pick an approach that feels right to you.

Take responsibility.

I don't want to write this, and you don't want to hear it. But it's the most important point I can make, and it's the one that any person with diabetes must take to heart.

This is your job. This is your life.

Minnesota's Mayo Clinic puts this item on top of its list of "10 ways to prevent diabetes complications."  You have to take responsibility, the clinic says, and you have to make the long-term commitment that such responsibility requires.

Ultimately, you can blame no one else for your health or your decisions. Diabetes is a disease that depends on the choices that we make, day in and day out. The decisions often seem small and unimportant. But over time, they accumulate and mark the progress of the disease.

Do we stay healthy, monitoring our blood sugars and food intake, consulting with our healthcare professionals? Or do we let these healthy behaviors slide, with the understanding that we'll always have time to fix it later?

We don't have time. We have to address our health now.

That doesn't mean we panic, and it doesn't mean that we can't ever have a chocolate bar again. But it does mean that we must take real responsibility for ourselves.

Ultimately, if you take responsibility for your disease, the other seven tips here should follow naturally. They're all about taking a commonsense approach to a challenging situation and improving it bit by bit and day by day.

You won't be perfect. But you don't have to be. You just have to be better than you were yesterday.

*These tips are not intended to replace your healthcare's professional advice.  Ask them for their opinion, prior to making any changes to your current therapy.

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Categories: A1c Test, American Diabetes Association, Blood Sugar, Centers for Disease and Control, Diabetes, Diabetes, Diabetes Control and Complications Trial, Diabetic, Diets, Food, Health, Low Carb, Medical Alert Bracelet, National Institutes of Health, Type 1 Issues, Type 2 Issues

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Posted by PinePienaarInfo on 20 May 2011

Thank you for posting this insightful article. I have found it full of practical tips and advice that could be implemented in everyday diabetic-life.

Posted by Anonymous on 22 May 2011

This article posts an HgbA1c value of 7.0 at the very top of the page. This is equivalent to an average blood sugar 0f 180mg/dl; more
than double that of non-diabetics. How can you
even mention Dr Bernstein's teachings while suggesting A1c s of 6.5 or 7%? The non-diabetic range clusters at 4.2-4.5%.

Posted by Anonymous on 22 May 2011

"Ultimately, you can blame no one else for your health or your decisions. Diabetes is a disease that depends on the choices that we make, day in and day out. The decisions often seem small and unimportant. But over time, they accumulate and mark the progress of the disease."

This is so true. I've been in denial for several years and I've seen and felt how my body has changed from this disease as well as my bad choices. Get right!

Posted by Anonymous on 24 May 2011

Great article with very useful and practical tips. Well done.

Posted by Anonymous on 24 May 2011

i have had diabetes Type 1 for over 50 years, and just went through the Joslin study for medalists. I have had great difficulty with managing my BGs in the last several years, and I monitor my BG from 6- 14 times/day. I think it is due to hormonal changes that can't be monitored daily. Also the study indicates that there are many people who don't have "normal" BGs who have managed to avoid serious complications because of their genetic inheritance. There are also "fast progressors" and they are probably not at fault for developing complications early. Nothing can make up for not having a pancreas. I'm not saying we shouldn't try our best but as a medical social worker for 35 years I know there are many reasons why people can't achieve "perfect" or near perfect control. I am all for doing your best in away that allows you to live your life in the fullest way possible, and being responsible but not overly responsible or blameworthy for your individual health.

Posted by krosetank on 24 May 2011

I agree with all the tips... but also feel that in order to follow through with them all on a regular basis... you need SUPPORT. I am still always learning and reviewing... but it is not just about knowing WHAT to do... rather more about DOING IT all the time. That is where support comes in be it from family, friends, CDE's, diabetes support groups... and COACHING. After 15 years with type 1, I went back to school in nutrition and now am a health coach who specializes in TEACHING and SUPPORTING people HOW to actually eat low carb and enjoy it... it is challenging living in a world with Dunkin Donuts on every corner and birthday cake, pizza, pasta and bagels part of the American psyche. Learning how to eat foods that are low carb on a regular basis is not easy... and no one understands the challenges better than another person with diabetes! 

Posted by kdommer on 24 May 2011

Great article - I am Type 1 for 37 years and on an insulin pump for 10. It is a daily challenge but owning my health and monitoring my progress has meant no diabetic complications after all this time. Maybe I'm just lucky but I think the attention I've paid to this has made a huge difference.

Posted by Anonymous on 24 May 2011


Posted by Anonymous on 24 May 2011

the 84 type one saved by Dr Bernstein

I forgot that using the Pump has been a blessing. To be able to give yourself mini doses ( one unit or 1/2 unit) , to be able to review what you just did or did not do, to look at your history of boluses (especially when memory is bad) is a God send. in the subway in a movie i can give myself a shot and people think I am Twittering

Posted by Anonymous on 25 May 2011

As a Type 1 for 35 years, I agree with the points made and especially the need for the individual to take responsibility for themselves, ie their actions.

But one aspect missing is the consideration of 'quality of life' for the diabetic, whether it be Type 1 or 2. Do you want to live to 120 and not enjoy some wonderful foods from time-to-time simply because they cause your blood sugar to see-saw for a day or two? Or do you want a meaningful life in which food is a pleasure rather than a form of medicine?

Again, I agree taking responsibility is crucial. But If, like me, you enjoy deep, dark chocolate, for example, then for your own mental health and overall well-being, don't beat yourself up over it. Enjoy it. You can always run an extra mile tomorrow!

Posted by Anonymous on 25 May 2011

the second person who posted needs to get their information right. a 7% a1c is NOT more than double that of non-diabetics. that would mean a non-diabetic person could have an a1c of 3.5% or less (equates to an average blood sugar of 54!). even an a1c of 4.2 equated to an average glucose of 74, which, is my opinion is ridiculous. even non-diabetics blood sugar goes up after a meal. so, please get your facts straight before you post and ignorant uneducated comment

Posted by Jerry Smith on 25 May 2011

To the last anonymous poster: You are absolutely 100% correct. An HbA1C of 7.0% is equivalent to an Estimated Average Glucose (eAG) of 154 mg/dl! The so called 'non-diabetic range' referenced by the earlier anonymous poster of 4.2% to 4.5% is equivalent to 74 mg/dl to 82 mg/dl. These eAG levels would be extremely dangerous to many Type I diabetics who are subject to severe hypoglycemia.

As to the extremely low carbohydrate diet promoted by Dr. Bernstein: Where do you get your calories from? Higher levels of protein and fat present potential kidney function problems and more dangerous higher levels of lipids. I would suggest a more moderate approach where 40% of calories come from carbs, 40% from protein, and 20% from mostly non saturated fat.

Where am I wrong? I am a 72 year old Type I of 45 years. My goal is an HbA1c of 7.0% in order to avoid the complications that can result from severe hypoglycemia: seizures, cognitive impairment, coma, or DEATH!

Posted by Anonymous on 25 May 2011

There are a lot of worthwhile points in the article and the comments. After 48 years as a T1, I have decided that it is a disease of negative feedback. My resuts are variable, Too high or too low. My MD is so worried about night time lows that I am advised to half my night time basal rates. Then I wake up with high blook sugars. I test 8-10 times a day, use a pump, count carbs - all that good stuff. But if it is always less than perfect, it can be expremely frustating. I am lucky that I know others in a similar situation, but it is tough. I guess I am a winner 'cuz i have had it so long, and I am still here, but it is hard not to feel like a loser.

Posted by Anonymous on 25 May 2011


Posted by Jerry Smith on 26 May 2011


Dr. Bernstein promotes an extreme low carb diet! If I get 40% of my daily calories from carbs, that would be around 180 grams of carbohydrate based on 1,800 calories per day. Dr. Bernstein advocats less than 25% of that or no more than 45 grams of carbs PER DAY. I would consider that exreme.

The remaining 1600 calories would have to come from protein and fat. I believe that excessive protein and fat are more dangerous than a moderate amount of carbohydrate. There are good carbs and then there are bad carbs that some of us just enjoy occasionally.

If you post again, how about including a first name. I would rather respond to you personally than ANONYMOUS. I think we pretty much agree.

How many calories do you consume per day? Each gram of carbohydrate or protein is equal to four calories. One gram of fat is equal to nine calories.

Is Dr. Bernstein still alive? The last I knew he was well into his eighties and doing very well. However, I still think his low carb diet is extreme and not very practical for most people.

Jerry Smith

Posted by Anonymous on 28 May 2011

Well all this is Blaming Us.. Right? We're at Fault, Right?
Butt, what about :
1. These Test strips & Meters Accuracy?

2. And how about how 'Fast' these Novalog Insulins Don't work? Like take up to 3 full hours to get a High BG down..

3. How about how Many times is your Insulin Pens Clog Up or are they dosing ALL of the Insulin? Even 1 Unit less can spike someone 30 pts

4. And how many times have you Pumpers have had major problems with your Pumps and Pods? Ruining not just 1 2-4 hr timeframe but the Whole Day!

5. And How many Of you have even gotten 50% of the Information and Training you should have had right away? How Aggressive has your Endo Been? Helping you get 6% A1c's or better?

6. And how Accurate have those Nice Fancy and Expensive New CGM's been for you? Another $3,000/yr Toy that doesn't work..and gives false readings all the time..

Test More Often? Sure, and who has the $ to do that? Cost to test 10x day? Try over $300/mo Retail and gots to be $150 mo. Wholesale thru Ins. Companies.. And How many T1's Have Insurance in the 1st place?

Oh, and your supposed to spend upto 33% of your Income on your Disease, right? and go live in some Little trailer?

Nice Life to look forward too isn't it?

Yeah, It's Our Responsibility and All Our Fault.. Right? Right, sure it is..

Posted by Anonymous on 28 May 2011

Boston's Joslin Diabetes Center actually recommends that people with diabetes go through the education process every year or two, making sure they keep up to date with the latest research and their own goals"

Oh really? And who is supposed to pay for this .. cost an ave of $250

And why can it not be Modernized and Just Put on a CD or Available Via the INTERNET? Oh I forgot, it would cost jobs.. CDE jobs.. since we wouldn't need as many of them to do this Course, right? Instead of 1 at every Hospital doing it , maybe only 1 in every State? Or how about Just The Same course for the whole country put out by the Association?

Update it every Yr? Charge $50 and be done with it.. I bet it would reach 100,000 or even more T1s

Posted by Anonymous on 28 May 2011

For years, I didn't believe in glucose tablets. Why not use candy, I wondered. Or juice? They were both so much tastier than the tablets. But that's the problem. Who eats just three pieces of candy? Who drinks just a few ounces of OJ? It's too easy to over-correct and send your blood sugar sky high.

Stick with glucose tablets. They're tasty enough to be palatable, but bland enough that you won't be tempted to sneak one when your stomach rumbles."

Yes, that's fine for Normal Hypo's of being in the 70-60's....

Guess you never have been seriously hypo..like 50's to 40's and sweat really bad, can't hardly see with Spots in your eyes and it takes alot of work and frustration to sit there and try to chew away on 3 glucose tabs..

Take Juice, a Reg. Can of Pop.. Just use the 15 carb rule.. Make sure you know the TOTAL Carbs and subtract that 15 c from it and wait 1/2 hr and take a bolus for the excess..

It gets the BG's up faster and you will be fine in a few hours later..

I use a Magic Marker on my Emergency Juice and 1/2 size cans of Pop in the Fridge/Sep Drawer so no-one else touches it.. I write in big #'s the total Carbs in it..-15 and the balance to treat 1/2 hr later..

30 carbs -15 Treat 20 with a B..
If you have a 10-1 ? = Take 2 units.. Hypo's are our bodies way to Remined us Not to do that again..

But when you run Tight Control.and your Active? Expect to get them DAILY! Or the choice is? Don;t be Active..take your choice..

Posted by Anonymous on 28 May 2011

#1- I think those that Got T1 as a Child thru age 18 vs those that got it as "Adult Onset" in their 30-50's are vastly different..

The Juvie T1's are much more Sensitive to Insulin and it takes them 45-50 yrs to develope Problems, but Adult Onset are Not Sensitive, need More Insulin, have a Higher I:CR like 5-1 vs 10-1 both being the same weight..

And the adults get the Complications Faster.. in 10 yrs.. not 40-50 yrs..

I think When you get it as an Adult? You have to Eat alot less Tot Carbs, regardless if you need to loose weight or not, most T1's Don't... and Forget about ever eating about 75% of the Foods.. be they Good or Junk food ever again..

Yes on the Mediteriranian and other Lower Carbs Meals.. or Just Eat a Egg Sandwhich for Bkfst, a 6" sub- 30 carbs for Lunch And Stick to 20-35 carb Healthy Choice Type and Size meals for dinner.. Forget everything else.. It doesn't work ...Unless your An Obsessed person and want to Weight ever bit of your food

And to me? That is not a Quality of Life..That's Living in Hell..

Rather be Dead.. thank you.. and I surely made sure I didn't have any kids.. I couldn't bare if I had a T1 child and gave this Terrible Disease too them.. Knowing the Frustrations and Nightmares they will have to deal with..

Posted by Anonymous on 6 June 2011

I have been a type 1 for almost 30 years and STRESS has major impacts on my ability to control my disease. The simple fact of flying will send my BS into the stratusphere... I can take 15 units of insulin and not even experience a low BS once the trip has ended. In fact, my BS will still remain high and that's typically dosing with the 15 untis with a BS of 110 to 140 preflight. I don't eat while flying so what I have learned is that STRESS is a major issue for me there's not a whole lot you can do to avoid it and I do exercise to try and manage it but my body is extremly sensitive to it.. By the way, my ratio is 10:1.

Posted by Anonymous on 6 June 2011

The cost of managing this illness will get to a point where people will begin to cut corners just like some seniors (no offense) have done for years regarding their prescription medications. All of the newer (pump, CGSM) treatements require much, much, much more $. Once we move to a consumer based healthcare system, it will be up to the diabetic to decide what level of treatment they can afford, including saying no to certain bloodwork at each doctor visit. The sad truth is that the cost of 'tight control' will not be feasible for many when it comes to type 1 and no Gov't healthcare system is going to cure that. My pump supplies without insurance would cost $750.00 every three months, add to that $630.00 and add to that the cost of test strips and on and on and on.... Under consumer based, we will be faced with exorbitantly high deductibles befor we even get any co-payment relief... I believe there will be an upswing in complications and poor control because it will become financially unobtainable for many...

Posted by Anonymous on 6 June 2011

In reference to the $630.00 that is for insulin and even that is conservative with it costing about $80.00 per bottle....

Posted by Anonymous on 6 June 2011

It doesn't take a rocket scientist to figure out that tight control can limit complications and their impacts; however, most people live lives far different from previous generations and saying what we all know we should do is far different than simply doing it. Doctor's want more and more blood sugar testing, give us a less invasive method... Doctor's want us to minimize stress and exercise more.. What do I do to minimize my 14 hour workday? Doctor's want us to eat better, then what do we do about all of the readily available garbage to choose from? We all don't have a dietician at home monitoring every food choice... Not to mention, the cost of eating right... Bottom line, we need better, less invasive, less expensive, and more effective treatments, not more of the same legacy treatments... If we live in a society that abuses food and is overweight, all an artificial pancreas will do is increase the waistlines of type-1 because more will be inclined to eat whatever they want when ever they want and more insulin means more weight...

Posted by Anonymous on 6 June 2011

Dr Bernstein, who by the way is now 76, has a methodology which helps diabetics achieve normal blood sugars. The program works, the carbohydrate cravings disappear, the weight falls off and what's more it is doable. Carbs are not essential to life - the body has other mechanisms from which to derive glucose that is required. I have gone from an overweight Type 2 who weighed 200lb with an HbA1C of 7.9% down to weighing 150 lb (still 30 lb to go) and an HbA1C of 5% following Dr Bernstein's program. My neuropathy in my feet has disappeared and I look like I have dropped 10 years in age (not bad for a 59 yr old bird).

We would see a turnaround in the health of diabetics if each and every one of them were given the tools and information in Dr Bernstein's book.

As far as sticking to the program, it does require commitment from oneself, a change in mindset to knowing that it's a program for life (thinking of food as an essential to life rather than a source of emotional gratification) and getting support (which I get from the diabetes-book forum and his teleconference which are free to listen to).

I have learnt so many things from reading his book - that the volume of food influences blood sugars, that small amounts of carb require only small amounts of insulin, how to correct a low blood sugar, how many carb will raise me so many points in my blood sugar levels and that I needed to get my thyroid checked among other things.

It would be fair to say that Dr Bernstein improved my quality of life, improved my diabetes management and in the long term saved my life from what most doctors see as a progressive and debilitating condition.

Don't be a knocker of his methods, they work (which is more than I can say for the local diabetes association recommendations which are in line with the ADA) - read his book and put into practice what he recommends. The fact that he is a diabetic and practices what he preaches speaks for itself as well.

We need to get over the fact that diabetes is a disease you can play around with - just a gluten intolerant person can't eat gluten containing foods, we diabetes are unable to tolerate carbs.

Anyway, that's been my experience and point of view.


Posted by Anonymous on 20 June 2011

"Yes, that's fine for Normal Hypo's of being in the 70-60's...."

Why would you let you blood sugar drop below this, so that you have to drink juice or soda to bring it back up? I thought the point was to avoid spikes and drops. Trying to stabilize huge swings is difficult, and is the point that Dr. Bernstein has been trying to make. If we limit foods that cause the spikes (excessive carbs), then we don't need as much insulin to do the job. My ex-husband developed diabetes and his doctor has advised him to keep his carbs to 60 gms. per meal!! I think this is nuts, and he's not managing the ups and downs well at all. If you loved cats, but were allergic to them, would you go out and get three (just because they're so cute) and take the maximum dose of allergy medicine every day? If your foot hurts because your standing on a nail, the pain killer will work much better if you take the nail out first! And BTW, the fear that has been instilled in diabetics re: fat and protein is really tragic. Yes, get your calories from fat... it has no effect on your blood sugars and is not unhealthful, unless it's trans fat.

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