Diabetes Discussions

Healthful eating is a cornerstone of diabetes management. In fact, it is so important that your doctor will probably refer you to a registered dietitian (a health professional who is an expert in diet and nutrition) or a diabetes educator (a health professional who is certified to teach people with diabetes how to manage it). The dietitian or diabetes educator will develop a meal plan adapted to your specific needs that also takes into consideration your lifestyle and the kinds of foods you like to eat. He or she will probably also consider your ethnic and cultural background when developing your meal plan.

One of the most important things you will learn is when and how to eat the right kinds of carbohydrates, because carbohydrates have the biggest effect on blood sugar levels. Your meal plan will also focus on controlling calories to help you lose weight if you are overweight. For many people with type 2 diabetes, weight loss and increased physical activity are the most effective ways to bring their glucose down to a healthy level and keep it there.

Your Meal Plan

When you have type 2 diabetes, the type and amount of food you eat and when you eat each affects your blood sugar levels. Blood sugar levels go up after eating. You should try to eat about the same amount of food at about the same time each day to keep your blood glucose near normal levels. If you eat a big dinner one day and a small dinner the next, your blood glucose levels may fluctuate too much. The following general eating guidelines can help you keep your blood glucose at a healthy level:

• Eat about the same amount of food every day.
• Consume your meals and snacks at about the same times each day.
• Don’t skip meals (or snacks if they have been recommended).
• If you take diabetes medication, take it at the same time every day.
• Exercise the same amount at about the same time each day.

There is no single diet that is right for everyone. Your doctor and dietitian or diabetes educator will develop a meal plan that is right for you. Consistent timing of your meals and snacks may not be as important as it is for someone with type 1 diabetes who is taking insulin, but keeping blood sugar levels near normal is just as important.

Carbohydrates are especially important because they have the biggest influence on blood glucose. Eat about the same amount of carbohydraterich foods at about the same time each day. Starches (such as wholegrain bread, cereal, rice, and pasta), fruits, milk, and starchy vegetables such as corn and potatoes are all good sources of carbohydrates. Make sure your starches come from whole grains because they contain fiber and many other nutrients and are digested and absorbed by the body more slowly than refined starches, helping to keep blood glucose steady.

While carbohydrates are an important focus of your meal plan, protein and healthy fats are also important. Your dietitian or diabetes educator will carefully calculate the correct ratio of these nutrients. The typical recommendations are 45 to 65 percent of total calories from carbohydrates, 12 to 20 percent from protein, and less than 30 percent from fat (including healthy fats). Depending on your circumstances, your doctor may recommend slightly different percentages for you.

How much of each type of food you need depends on how many calories you need each day to lose weight or maintain a healthy weight

Avoid high-fat foods and sweets because they provide a lot of calories but few nutrients. To make sure your food servings are the right size, use measuring cups and spoons and a food scale. Keeping track of your calorie intake can help you keep your blood sugar at a steady level and can help you make adjustments for reaching weight goals.

To develop a meal plan that fits your needs, your dietitian or diabetes educator will ask you questions about your lifestyle and your personal food preferences. He or she can help you plan meals that include foods that are not only good for you but that are also familiar foods that you and your family like to eat. The biggest dangers for people with type 2 diabetes are cardiovascular (heart and blood vessel) problems, which can lead to heart attack or stroke.

Circulation problems also cause poor blood flow to the legs and feet. To prevent these problems, your dietitian or diabetes educator will teach you about hearthealthy eating that can help you reduce your risk for or avoid heart and blood vessel disease. Your meal plan will probably include the following recommendations:

• Eat foods that are low in saturated fat and have no trans fats; no more than 7 to 10 percent of your total daily calorie intake should come from saturated fat. Buy prepared foods with less than 1 gram of saturated fat per serving.
• Limit your intake of foods that are high in cholesterol, such as egg yolks. Consume no more than 300 milligrams of cholesterol a day, or 200 milligrams if you have heart disease.
• Don’t eat too much salt; buy reducedsodium or “no salt added”

prepared foods. Look for prepared foods with less than 140 milligrams of sodium per serving or 5 percent of the “daily value” for sodium on the food label.

• Consume 9 to 13 servings of fruits and vegetables each day; whole fruits and vegetables are more nutritious and less calorie-dense than juices and dried fruit.
• Boost your fiber intake by eating whole grains, dried beans (legumes), fruits, and vegetables.
• Limit added sugars to less than 25 percent of your total daily calories. These sugars, which are added to foods (such as pastries, candy, and other sweets) and beverages (such as soft drinks and fruit drinks) during production, usually provide few nutrients but lots of calories.

 Carbohydrates Are Key

The goal of your meal plan is to keep your blood sugar level as close to normal as possible after and between meals. It is important to be aware of how much carbohydrate you are eating, because carbohydrates have the greatest effect on blood sugar levels. Careful carbohydrate planning to keep blood sugar balanced, combined with eating foods that are low in total, saturated, and trans fats, can help lower your heart disease risk and your risk of complications from diabetes.

Carbohydrates are supplied primarily by grains, starchy foods such corn and potatoes, fruit, and milk. Vegetables also have some carbohydrate content, but protein foods, oils, and fats contain very little carbohydrate. Always try to consume carbohydrates that are high in fiber because they are digested slowly and therefore tend to keep blood sugar levels more stable.

How much carbohydrate should you eat? The amount needed varies from person to person. Also important is the distribution of your carbohydrate intake throughout the day in both meals and snacks. Your doctor, dietitian, or diabetes educator will decide how much carbohydrate you should have at each meal or snack depending on your weight and height, activity level, age, and any medications you are taking. The results of tests for blood sugar and cholesterol and triglycerides will also influence your daily carbohydrate count recommendation.

To keep good control of your blood sugar levels, you will have to learn how to be consistent in the type, amount, and timing of the carbohydrates you eat throughout the day and from day to day. The two methods that people with diabetes use to keep track of their daily intake of carbohydrates and other nutrients are dietary exchanges and carbohydrate counting (see page 114).

 Fiber and Blood Sugar Control

You should definitely consume a lot more highfiber foods. Fiber  is especially beneficial for people with type 2 diabetes because it can help keep blood glucose levels steady. There are two types of fiber in the food you eat: water soluble and water insoluble. Neither type of fiber is digestible, but they both play an important role in your diet. Of the two types, soluble fiber has the strongest effect on blood sugar. Foods rich in soluble fiber are digested gradually, slowing down the absorption of glucose into the blood. The result is smaller increases in blood sugar after eating.

Soluble fiber has another possible health benefit: reducing your risk of heart disease. It lowers total blood cholesterol as well as harmful LDL cholesterol by absorbing cholesterol from the bloodstream and excreting it as waste. Soluble fiber may also reduce the amount of cholesterol your liver produces.

Foods that contain high amounts of soluble fiber include grains such as oat bran, oatmeal, barley, and rye; fruits such as blackberries, oranges, apples, and pears; beans and legumes (including kidney beans, black-eyed peas, lentils, split peas, and soybeans); flaxseed; and psyllium (a grass found in some cereal products and breads, some dietary supplements, and some over-the-counter stool softeners and laxatives).

Doctors recommend that most people-including those without diabetes-get 20 to 40 grams of fiber every day. Up to age 50, the recommendation is up to 40 grams a day for men and 25 grams a day for women. After age 50, men are advised to consume 30 grams and women 20 grams daily (because people usually eat less as they get older). Children should have a daily fiber intake equal to their age plus 5 grams per day; for example, an 8-year-old child should eat 8 plus 5 grams, or 13 grams.

These figures may seem daunting, but you’ll find that it’s not so difficult if you add fiber to your diet gradually. Start by buying some highfiber breakfast cereals that contain whole grains or flaxseed. Prepare more fiber-rich dishes such as bean soups, stews, and casseroles. Toss some chickpeas or other beans into your salads. For a side dish, serve black-eyed peas instead of a starch such as potatoes or rice. And, of course, eat lots of fruits and vegetables.

The same foods that contain soluble fiber also supply insoluble fiber in varying amounts. Insoluble fiber increases stool bulk, speeds up the time it takes stool to travel through the intestines, and improves bowel regularity. At the same time, fiber may also reduce your risk of colon cancer, hemorrhoids, and digestive disorders.

You should be aware, however, that dietary fiber can influence the effect of some common medications. For example, a high fiber intake can lower the body’s absorption of cholesterol reducing medications called HMG-CoA reductase inhibitors, the heart medication digoxin, and lithium (prescribed for bipolar disorder). If you take any of these prescription medications, talk to your doctor before increasing your fiber intake.

 Dietary Exchanges

The dietary exchange system was developed by the American Diabetes Association and the American Dietetic Association to help people with diabetes plan their meals to gain better control over their blood glucose levels. The system divides food into three main groups: carbohydrates, meat and meat substitutes, and fats. Each group contains a subgroup of foods that are similar in calorie, carbohydrate, protein, and fat content to make the same foods in a list virtually interchangeable. For example, under carbohydrates, you’ll find that one fruit exchange supplies 15 grams of carbohydrates and about 60 calories. Fruits corresponding to one fruit exchange include 1 cup of blueberries, 1 small apple, or 1 medium peach. Under the meat exchanges category, one very lean meat exchange equals 7 grams of protein, 0 to 3 grams of fat, and 35 calories. For the very lean meat exchange, you can choose 1 ounce of chicken or turkey white meat with no skin, 1 cup of low-fat cottage cheese, or 2 egg whites.

A dietitian or diabetes educator develops a meal plan that contains a certain number of exchanges for each day depending on a person’s weight, height, age, medical history, and whether weight loss is part of the plan. Forty-five to 65 percent of total calorie intake each day should come from carbohydrates, your body’s main source of fuel.

Following is a chart showing the dietary exchanges that you can use to help you follow your meal plan and manage your diabetes. As you can see, choosing fat-free milk or very lean poultry instead of whole-fat milk and beef or pork cuts a lot of calories that you can save up for another meal or apply toward your weight-loss plan.

Carbohydrate Counting

An alternative to the food exchanges method for managing food intake to regulate blood sugar is known as carbohydrate counting, which computes the grams of carbohydrates you consume throughout the day. The logic behind carb counting is that all carbohydrates-whether they’re nutritious foods such as whole grains and fruit or nonnutritious foods such as sugary soft drinks and candy-have a similar effect on blood sugar levels. For this reason, the total amount of carbohydrates is the most important factor, not the particular food.

With carb counting, you don’t have to figure out how each food corresponds to the traditional exchange meal plan; you just need to know how much carbohydrate it contains. Purchase a good pocket reference book or pamphlet that shows how many carbohydrates are in a serving of fresh or unpackaged foods such as produce. Using a food scale and measuring cups and spoons to measure food servings can help you learn to eyeball serving sizes (see page 119).

Counting carbohydrates can help make your carbohydrate intake more precise, leading to greater control of your blood glucose.

Counting the grams of carbohydrates you need each day makes it easy to plan meals because all you have to do is look at the nutrition label on a packaged food or the nutrient analysis box on a recipe to see how many grams of carbohydrates it contains. (Watch serving sizes so you don’t inadvertently consume more than one serving and miscalculate your carb count.) To simplify the task even more, many people count the carbohydrate content of one serving of starch, fruit, or milk as 15 grams.

Three servings of nonstarchy vegetables are also counted as 15 grams, and you don’t need to count one or two servings of nonstarchy vegetablesthey’re considered free carbs. Each meal or snack should supply a certain number of carbohydrate grams, according to your meal plan. Let’s say your meal-plan breakfast is supposed to have four servings of carbohydrates, which translates into 60 total grams of carbohydrates for that meal. Looking at your box of shredded wheat, you see that one serving contains 30 grams of carbohydrates (make sure you don’t exceed one serving).

One cup of milk adds another 15 grams, bringing your carb count to 45 grams. A small apple or pear adds another 15 grams, for a total of 60 grams. If you also eat a 2-ounce serving of cheese at breakfast, it will not add to your carbohydrate count because cheese contains little carbohydrate.

 Glycemic Index

Another school of thought says that all carbohydrates are not created equal and that some that break down quickly in the intestine raise blood sugar too fast.

This ranking of carbohydrates is called the glycemic index, a system that rates carbohydrate foods by their effects on blood sugar. Carbohydrates that break down rapidly in the bloodstream have a high glycemic index; those that break down more slowly have a lower glycemic index. Eating lower-glycemic-index foods can result in a smaller rise in blood sugar after meals, the theory goes.

The following are examples of foods that are high on the glycemic index and, therefore, are thought to raise blood sugar levels quickly: • White rice

• White bread
• White potatoes
• Saltine crackers
• Orange juice
• Pastas made from white flour

Examples of low-glycemic-index foods include:

• Wholegrain breads and cereals
• Oatmeal (not instant)
• Sweet potatoes
• Cooked dried beans, peas, and lentils
• Fresh fruit

Many doctors don’t consider the glycemic index an essential tool for helping people regulate their blood sugar because the body’s response to eating is much more complicated than the glycemic index suggests. For example, different people digest food at different rates, so a given food can make one person’s blood sugar level go up faster than that of another person. Also, your body’s blood sugar response to eating a food depends on such factors as the type of food, how much you consumed, how it was cooked or processed, and whether you ate fat or protein with it. Age and activity level also influence how a certain food can affect blood sugar.

 Dietary Guidelines for Americans

Much chronic illness in the United States, including type 2 diabetes, is linked to a poor diet and a sedentary lifestyle. The Dietary Guidelines for Americans, published jointly by the US Department of Health and Human Services and the US Department of Agriculture, are designed to provide common-sense recommendations to promote good health and reduce the risk of disease through a balanced, varied diet and regular physical activity.

A basic premise of the Dietary Guidelines is that nutrients should be consumed primarily through food. Healthful foods contain a variety of nutrients that have beneficial effects on health. Fortified foods and dietary supplements may be useful in providing nutrients that might otherwise be consumed in insufficient amounts, but dietary supplements can never replace a healthy diet.

The Dietary Guidelines advise taking action to improve your health by following these nine recommendations:

1. Get adequate nutrients within your calorie needs. Choose a variety of high-nutrient foods and beverages. Limit your intake of foods containing saturated and trans fats, cholesterol, added sugar, salt, and alcohol.
2. Manage your weight. To keep your weight within a healthy range, don’t regularly consume more calories than you expend each day. To prevent gradual weight gain as you age, increase your level of physical activity.
3. Get 30 to 90 minutes of physical activity each day. Perform 30 minutes of exercise to lower your risk of chronic disease, 60 minutes to prevent weight gain in adulthood, and 90 minutes to lose weight.

Include aerobic exercise to strengthen your heart, stretching exercises to increase flexibility, and resistance exercises for muscle strength.

4. Boost your intake of certain food groups. Each day, consume the equivalent of 2 cups of fruit and 2’/2 cups of vegetables for a 2,000calorie diet. Include plant foods from the dark green, orange, starch, and legume groups each week. At least half of your grain foods should come from whole grains. Consume 3 cups of fat-free or low-fat milk or other dairy products a day.
5. Know your fats.

• Maintain your saturated fat intake below 10 percent of total calories, and consume less than 300 mg of cholesterol each day. Keep trans fat consumption as low as possible.
• Your total fat intake should range between 20 and 35 percent of calories, with most fats coming from the polyunsaturated and monounsaturated varieties.
• Select lean meats and poultry and fat-free dairy products.

6. Be smart about carbohydrates. Boost your intake of fiber from whole grains, fruits, and vegetables. Don’t add sugar to foods and beverages. Consume sugar-containing foods and beverages infrequently.
7. Restrict sodium intake and get sufficient potassium. Limit your intake of salt to 1 teaspoon (2,300 mg) per day; 1,500 mg if you are middle aged or older, have high blood pressure, or are African American. Increase your consumption of potassium-rich fruits and vegetables (such as bananas, oranges, greens, peas, and tomatoes).
   8. Drink alcohol in moderation, if at all. Limit alcohol consumption to two drinks a day for men and one drink a day for women. Don’t drink alcohol at all if you are alcoholic, pregnant, trying to become pregnant, breastfeeding, or a minor, or if you take medications that can interact with alcohol or you have certain medical conditions, such as liver disease.
   9. Prepare and store food safely.
   • Wash your hands before and after preparing food. Wash all fruits and vegetables before preparing.
   • Keep raw foods separate from other foods while shopping for, preparing, or storing them.
   • Cook food thoroughly to kill dangerous microorganisms.
   • Avoid unpasteurized milk and juices; raw eggs; undercooked meat, poultry, fish, and shellfish; and raw sprouts.

    

    Special Recommendations for Older Adults

   Because older adults tend to eat less than younger people, many do not get sufficient amounts of some key vitamins, especially vitamin D (which maintains bone strength) and vitamin B12 (which maintains nerve function and oxygencarrying red blood cells). Some signs of vitamin 1312 deficiency include fatigue, weakness, loss of appetite, and weight loss, and neurological changes such as numbness and tingling in the hands and feet, difficulty maintaining balance, depression, confusion, dementia, and poor memory. To prevent these problems and maintain bone strength, which tends to decrease with age, the FDA recommends that older people do the following:

   • Consume extra vitamin D from fortified foods (such as milk) or supplements.
   • Get enough vitamin B12 from fortified foods (such as breakfast cereals) or supplements.
   • Get regular exercise to reduce the decline in function that can come with age.

    

    Special Recommendations for Pregnant Women

   
   Pregnancy puts extra nutritional demands on a woman because her body is providing nutrients for the developing fetus. The following recommendations can help you stay healthy during your pregnancy and help ensure that your baby is born healthy:

   • Consume enough folic acid (a B vitamin) to prevent birth defects.
   • Get 30 minutes of moderate physical activity but avoid activities with a high risk for falls or abdominal injury.
   • Make sure you gain enough weight, as recommended by your doctor.

    Special Recommendations for Children

   Because lifestyle factors contribute to common chronic disorders, including type 2 diabetes and heart disease, the FDA is recommending that parents help children adopt healthy habits with the following recommendations. The focus is on helping children avoid becoming overweight, the most important step in preventing type 2 diabetes.

   • Get at least 1 hour of physical activity every day.
   • Avoid weight-loss diets (unless recommended by a doctor).

Instead, increase physical activity and limit highcalorie foods.

• Don’t limit fat consumption until 2 years of age. Keep fat consumption between 30 and 35 percent for children between ages 2 and 3.
• Give children ages 2 to 8 two cups per day of fat-free milk or dairy products; children over the age of 9 years should consume 3 cups.

Because carbohydrates, both simple and complex, have the biggest influence on blood sugar levels, it is important to keep track of the grams of carbohydrates you eat each day. But the type of carbohydrate you eat matters for a different reason. You should try to eat primarily nutrient-dense (“lowglycemic”) carbohydrates such as whole grains, fruits, vegetables, and fat-free dairy products. Limit refined and processed (“high-glycemic”) carbohydratecontaining foods such as white bread, white rice, pasta made with white flour, and cookies and other sweets primarily because they pack a lot of calories but provide few other nutrients.

 How Many Calories Do You Need?

It may be hard to figure out exactly how much you need to eat each day to maintain a healthy weight or to lose weight. The number of calories you need each day depends on your gender, your body frame, how much you weigh, and how physically active you are. Your doctor, dietitian, or diabetes educator will tell you how many calories you need to consume each day, but as a general rule the following guidelines can be helpful.

 Controlling Portion Sizes

Weighing and measuring foods with a food scale, measuring cups, and measuring spoons will help you eat just the right amount at each meal. The following tips can teach you how to eyeball serving sizes once you become familiar with a typical meal-plan serving:

• Measure a serving of cooked pasta or rice or dry cereal into a bowl or plate. The next time you eat the same food, use the same bowl or plate and fill it to the same level.
• Measure one serving of milk into a glass and see how high it fills the glass. Always drink milk out of the same size glass, filled to the same level.
• One 3-ounce serving of meat or other protein is about the size of a deck of cards.
• One ounce of meat or cheese is equivalent to the size of your thumb.
• One teaspoon is about the size of the tip of your thumb.
• One serving of starch is 1 slice of bread, 1 small potato, ‘/2 cup cooked breakfast cereal or 3/4 cup dry cereal, or 1 small (6-inch) tortilla.

 The DASH Eating Plan

Developed by scientists from the National Heart, Lung, and Blood Institute, the Dietary Approaches to Stop Hypertension (DASH) eating plan is a sensible and proven way to lower blood pressure. Yes, you can actually reduce your blood pressure by following this diet, which is low in total fat, saturated fat, trans fats, and cholesterol; low in salt; and rich in fruits, vegetables, and fat-free dairy products.

At first, doctors could see that the DASH eating plan worked, but they did not understand how. Then researchers found that the diet appears to have the same effect on the body as diuretic medications (water pills) that help remove excess water the body retains. Diuretics are routinely prescribed for treating high blood pressure. Because sodium (salt) in foods tends to make the body retain water, the lowsodium component of the DASH diet may be a key factor in lowering blood pressure.

Blood pressure reductions often begin to appear two weeks after starting the DASH eating plan. Even people with normal blood pressure can reduce their blood pressure further under the plan.

The DASH diet is based on a 2,000calorie-a-day eating plan, so it is not strictly a weight-loss diet. But to reduce your calorie intake you can easily substitute lower-calorie foods for some that are recommended on the DASH diet.

This tactic, combined with a boost in your physical activity, can be enough to help you shed some of those unwanted pounds over time. For example, eating a medium apple instead of four shortbread cookies for dessert will augment your fruit intake while significantly reducing your calorie intake. The chart below shows the daily recommendations for a typical 2,000calorie DASH diet plan.

Adjust your servings per day according to your calorie intake.

The DASH diet provides evidence for the strong influence that dietary sodium can have on blood pressure. Most of the salt in your diet comes not from the salt shaker but from the sodium that food manufacturers add during processing. Most packaged and processed foods are laden with sodium. One cup of packaged rice pilaf or macaroni and cheese, for example, can contain about 600 milligrams of sodium, which is 25 percent of the 2,300-milligram recommended daily allowance. One tablespoon of reducedsodium soy sauce contains about 550 milligrams of sodium, or 23 percent of the daily allowance, while the same amount of regular soy sauce with twice the amount of sodium (1,100 milligrams) provides 46 percent of the daily sodium allowance.

Following are some processed foods that contain high amounts of sodium: • Canned vegetables

• Frozen vegetables with sauce
• Tomato juice
• Soy sauce and other condiments, such as ketchup and mustard • Processed cheese
• Canned beans (rinsing the beans removes a lot of the salt) • Canned soups and broths
• Ham and other smoked meats
• Bologna and other sandwich meats
• Canned fish
• Frozen dinners
• Frozen pizza
• Some breakfast cereals
• Bread

 Reading Food Labels: A Healthy Habit

Reading food labels can help you choose foods that are better for you.

Labels on packaged food contain a section titled “Nutrition Facts,” which lists important information, such as:

• Serving size
• Calorie content
• Fat and cholesterol content
• Sodium (salt) content
• Total carbohydrate content and the amounts of fiber and sugar • Protein content
• Some vitamins and minerals

The serving size and the number of servings in the package are the keys to the nutrient breakdown for that food. The size of the serving determines the number of calories and the content of all the other nutrients on the label. In other words, if the label says a food has 12 grams of total fat, it means 12 grams in one serving. If the package contains three servings and you consume them all in one sitting, you will have eaten 3 x 12 grams, or 36 grams of fat.

It’s especially important to check the fat, cholesterol, sugar, and sodium content. These are the nutrients that people often consume in excess. Make sure that foods you are thinking about buying contain minimal amounts of these nutrients. If the label says that the food contains trans fats, don’t buy it. Trans fats have been found to be the most harmful kind of dietary fat.

Now look at the fiber (which is part of the “total carbohydrate” count) and vitamin and mineral contents. These are nutrients you need to eat more of. On the right side of the label, you will see a column called “% Daily Value.” This column tells you whether a food is high or low in a particular nutrient so you can tell which nutrients contribute a lot or a little to your daily recommended allowance. For example, if you look at the label on a carton of milk, you will see that one serving supplies 30 percent of your daily recommended intake of calcium. Keep in mind that the percent daily values are based on recommendations for a 2,000calorie diet, so if your calorie allotment is higher or lower, you will need to adjust the percentage the given nutrient represents in your diet. For more about how to read food labels, see page 66.

Instead of always relying on convenience foods, buy fresh foods whenever you can, or buy reducedsodium or “no salt added” canned and processed foods.

Cook foods without adding salt. Instead, use herbs and spices to add flavor to the dishes you serve. You can find out exactly how much salt is contained in packaged foods by learning to read food labels. Look for foods with less than 140 milligrams per serving, or 5 percent of the “daily value” for sodium.