We all eat to live (and, indeed, live to eat), but for someone with diabetes, that adage isn't just academic. It's a matter of
staying well and living longer. Because diabetes is a disorder in how your body processes foods, every choice you make to eat or drink is important. The benefits of eating well are powerful, helping to keep your blood glucose, blood fats and blood-pressure levels under control and helping prevent complications of diabetes. Most of all, eating right helps you feel in control.
But that doesn't mean eating has to be like taking medicine. Eating is one of life's most fundamental pleasures, and it's part of our social fabric. Food plays a central role in family celebrations, holidays and business deals; special foods are part of the traditions that define us. Food shouldn't lose all that importance just because you have diabetes.
For the most part, eating to manage diabetes means eating with your eyes open—knowing what's going into your body and when. That means planning for, and keeping track of, your meals.
Ideally, you'll work with a dietitian or diabetes educator to determine an eating plan that works with your schedule and your needs. You'll likely use one of two methods: Carbohydrate Counting or the Exchange System.
The Exchange System
Used in diabetes management for over 50 years, this method groups together foods that have roughly the same amounts of calories, carbohydrate, fat and protein into "Exchange" groups, so that one may be exchanged for another. One exchange in the "Starch" group, for instance, could be a 6-inch corn tortilla or 1/2 cup of green peas or 1/3 cup of pasta; an exchange in the "Lean Meats" group could be an ounce of tuna or lean pork. If you're following the Exchange System, you'll work with a dietitian to plan out your daily meal pattern: which exchanges to include in each meal and how many.
Carbohydrate Counting
For most people with diabetes, Carbohydrate Counting is a more flexible and simple alternative to the Exchange System. It centers on keeping a count of the carbohydrate you take in at each meal, aiming to stay within a predetermined daily range. Carbohydrate is measured in terms of Carbohydrate Servings (see below), or in grams.
No matter which system you use to plan and track your eating, you'll be staying on top of the amount of carbohydrate you consume, trying to keep it consistent throughout the day, and from one day to the next. That's because of all the nutrients we eat—protein, carbohydrate and fat—carbohydrate affects blood-glucose levels the most.
But that doesn't mean you must avoid carbohydrate altogether. That's nearly impossible—and dangerous. Even with diabetes, some carbohydrate is vital to maintain a steady supply of glucose to cells in the body, particularly to the brain, for fuel. The brain needs about 130 grams of glucose from carbohydrate each day (about 9 Carbohydrate Servings) to function well. And carbohydrate-containing foods are important sources of vitamins, minerals and fiber. Today's nutrition guidelines recognize that people with diabetes need a wide variety of foods to stay healthy, and most recommend that people get about half their daily calories from carbohydrate.
There are two different forms of carbohydrate—sugars and starches—but both are made up of the same building blocks: sugar molecules. What we call "sugars" are simply short chains of sugar molecules, while "starches" are longer chains of sugar molecules. When you eat a carbohydrate-containing food, no matter where it comes from, the process of digestion breaks down those sugar molecules into glucose—the form your body can use.
Carbohydrate is found chiefly in plant-based foods, such as grains, fruits and vegetables, and in sweets, as well as in dairy foods like milk and yogurt. These are the kinds of foods you'll be monitoring closely if you are Carbohydrate Counting.
Basics of Carbohydrate Counting
The goal of Carbohydrate Counting is to make sure you're eating a fairly consistent amount of carbohydrate each day, in a similar pattern. You can do this in either of the following ways:
Count Carbohydrate Grams. You aim for a specific amount of carbohydrate grams at each meal—say, 30 grams at breakfast, 45 grams at lunch and 60 grams at dinner. You track your carbohydrate through the day by keeping a running total.
Count Carbohydrate Servings. You track carbohydrate by thinking of it in terms of portions of foods. One Carbohydrate Serving, sometimes called a "Carbohydrate Choice," is a portion of food that contains 15 grams of carbohydrate—about the amount in a small potato, a slice of bread or a medium apple. You aim for a predetermined amount of Carbohydrate Servings at each meal, typically, 3 to 5 Carbohydrate Servings at main meals and 1 to 2 Carbohydrate Servings for snacks. For most people, the daily total number of Carbohydrate Servings will be about 12 (for a 1,500 calorie/day plan) or 16 (for a 2,000 calorie/day plan).
With either system, you'll need to know the carbohydrate content of a food first. Your diabetes specialist can provide you with food lists to get you started. As you become more familiar with standard portions, you'll be able to estimate the carbohydrate of more complex foods, like pizza. Recipes with nutrition information, like those in this book, are a good source of carbohydrate amounts. On packaged foods, such information is on the nutrition label: First, check the food's "Serving Size," then look for the "Total Carbohydrate" value in grams. The "Dietary Fiber" listing is also important. The higher the better, as explained below with the Carbohydrate-Servings Calculator.
Carbohydrate Bargains
Since you are following a carbohydrate "budget" of sorts, it makes sense to opt for the best quality you can get. That means the bulk of your carbohydrates should come from so-called "good carbohydrates": fiber-rich and whole-grain foods.
Whole-grain foods are made with all the original parts of the grain: the bran (the fiber-rich, protective outer coating), the endosperm (the starchy center, containing mostly carbohydrate and a little protein) and the germ (the vitamin- and mineral-rich seed core). That means they contain all the original nutrients, including fiber, B vitamins, vitamin E, zinc, iron and other protective phytochemicals. Good examples of whole-grain foods are whole-wheat flour, whole cornmeal, barley, whole-grain oats and brown rice.
But when these grains are processed, such as when wheat is ground and the bran is removed to make white flour, or when brown rice is hulled to make white rice, the result is pure endosperm—basically, just starch. Some of these so-called "refined" grains are enriched to add back some of their nutrients—white flour and white rice are enriched with B vitamins—but some nutrients, notably fiber, are not restored. And the phytochemicals are lost.
Studies show that people who eat more whole grains and fewer refined grains have lower risks of diabetes and heart disease; whole grains may even help people maintain a healthy weight. That's why in the latest edition of the Dietary Guidelines for Americans, the U.S. Department of Agriculture recommends all Americans get at least three daily servings of whole grains—preferably replacing the refined-grain foods they'd normally eat.
Trading Up to Whole Grains
• Seek out whole-grain versions of your favorite foods, such as whole-wheat pasta, whole-wheat bread, brown rice and whole-grain crackers. If you don't like one brand, experiment with another.
• Phase in a whole grain by mixing it half-and-half with a refined one—for example, a blend of whole-wheat and regular pasta, or brown and white rice. Gradually increase the proportions until your palate—and digestive tract—have adjusted.
• Expand your whole-grain pantry—how about bulgur (cracked, steamed and dried wheat kernels), whole-wheat couscous, quinoa or millet? A trip to a natural-foods store will inspire you.
• Start your day with whole-grain breakfast cereal or old-fashioned (not instant) oatmeal.
The Fiber Plus
Fiber is the part of plant foods that the body can't digest, and it's chiefly found in carbohydrate foods: whole grains, vegetables, beans, peas and whole fruits (rather than fruit juice).
Fiber, especially fiber from whole-grain cereals and bread, bran and the skins of fruits and vegetables, helps add bulk to digestive waste and keeps you "regular." Though it doesn't dissolve in water, fiber absorbs water as it moves through the digestive system, helping to push other substances along.
Fiber also has proven cholesterol-lowering benefits. Some fiber, especially fiber from oats, barley, fruits, vegetables, beans, seeds, nuts and brown rice, forms a gel in the digestive tract, which binds with cholesterol particles and removes them from the body unabsorbed.
Focus on getting at least 25 grams of fiber daily. That's about twice as much as most Americans now eat, so you'll probably have to make a conscious decision to include more fiber-rich plant foods, and to get at least half of your grain-based foods each day from whole-grain sources.
Another benefit to put you in the pro-fiber camp: fiber can help you control your weight. Although it contains nary a calorie, fiber adds bulk to foods—so you'll feel fuller after eating. And since fiber-rich foods take longer to digest, they can help you stay satisfied longer.
Beyond Carbohydrate: Other Essentials for Healthy Eating
• Protein is used by the body to build tissues, as well as to repair and replace body cells. Found in both plants and animal-based foods, it's especially high in fish, poultry, meat, dairy products, eggs, beans, soy foods and nuts. Because it's so widely available, getting enough protein is rarely a problem. In fact, most Americans eat at least 50 percent more protein than they need. The recent popularity of high-protein diets for weight loss has made that issue all the more acute.
Does having diabetes mean you need more protein than the rest of the population? On the surface, it might seem to be a helpful ally, since protein produces no rise in glucose levels. Not long ago people with diabetes were encouraged to eat a little protein at every meal and snack with the belief that adding protein would slow the rise in glucose from carbohydrate foods. But when this theory was put to the test, it didn't hold water. Studies showed that blood glucose rises were the same following a meal whether it contained carbohydrate alone or in combination with protein. Furthermore, even if protein does not affect blood-glucose levels, it still stimulates insulin.
More reasons to avoid protein overload: when you eat more protein than you need, your body will store the excess the way it stores any other caloric substance—as fat. And favorite protein sources like meats and cheeses can also be sources of heart-threatening saturated fat.
The protein recommendations for people with diabetes, then, are similar to what's recommended for all Americans: aim to get between five and seven ounces of protein foods each day, or about two to three servings. Be picky about your protein sources, favoring types that are lowest in saturated fat and cholesterol, such as beans and tofu, lean meats, skinless poultry and reduced-fat dairy products.
• fat is our body's storage form of energy, supplying essential fatty acids and fat-soluble vitamins. It's important to the functioning of the immune and nervous systems and in maintaining the integrity of the body's cells. It also makes food more delicious and satisfying—we couldn't live, physically or spiritually, without it.
Like protein, though, getting enough fat isn't a problem in the American diet. It's easy to find, in oils, butter, meats, cheeses and full-fat dairy products, nuts, fried foods and sweet treats. On average, the fat we eat accounts for about a third or more of the calories we consume each day.
While most nutrition experts no longer routinely recommend a low-fat diet for everyone, there's no denying that fat is—well, fattening. At nine calories per gram, it contains more than twice the amount of calories as protein and carbohydrate (both four calories per gram). So if you're trying to lose weight, as are many people with diabetes, keeping your fat intake moderate is a good goal. Just as important, if not more, is to be vigilant about the kinds of fats you eat. There are several different types, and each has different actions in the body.
The Right Fats
Nutrition experts recommend that most of the fat you eat come from the following sources:
• Monounsaturated fats are favored by cardiologists and nutritionists alike. "Mono" fats are found in plant-based oils like olive, canola and high-oleic varieties of safflower and sunflower oil, as well as in nuts and avocados. They tend to raise heart-healthy HDL cholesterol, while lowering "bad" LDL cholesterol—an undeniable win-win combination, especially for people with diabetes who are at increased risk of heart problems. Mono fats play an important role in the cuisines of countries around the Mediterranean Sea, one of the world's healthiest eating patterns.
• Polyunsaturated fats also come from plant sources, including corn oil, soybean oil and other salad oils. These "poly" fats also tend to lower LDLs, but can lower heart-protective HDLs at the same time. The negatives on HDL seem to be modest, though, and mostly outweighed by the heart-healthy positives. In the huge Nurses' Health Study at Boston's Harvard School of Public Health, for example, women who used the most salad dressings (including poly-fat-rich mayonnaise-based types) had half the risk of fatal heart disease as those who rarely used dressings.
Aim for 25 to 35 percent of your daily calories to come from fat, staying on the lower end of the range if you need to lose weight. If your eating plan averages 2,000 calories per day, that's 56 to 78 grams of fat. If your plan averages 1,500 calories per day, that's 42 to 58 grams of fat.
Fats to Limit
The following fats fall squarely into the "eat less" category, whether or not you have diabetes.
• Saturated fats are easy to spot because they're solid at room temperature—like the marbling in a steak, or a pat of butter. Saturated fats come mostly from animal sources, like meats, poultry skin and dairy products, such as cheese, butter and whole milk, as well as from palm and coconut oils. Saturated fats hinder LDLs, or "bad" cholesterol particles, from getting into cells where they belong. As a result, cholesterol stays in the blood longer, and can become a part of the blood-vessel plaques that build up and cause heart disease. So decreasing saturated fat intake is the most important dietary step you can take to lower your blood cholesterol. Because of an increased heart-disease risk, people with diabetes need to be vigilant about limiting saturated fats. Limit saturated fat to 7 to 10 percent of your daily calories, staying on the low end of that range or below if you have high blood cholesterol. If you get about 2,000 calories per day, that means no more than 15 to 22 grams of saturated fat daily—about the amount in two to three (3 1/2-ounce) hamburgers. If you eat about 1,500 calories per day, that means no more than 12 to 17 grams of saturated fat daily. That's two to three (1-inch) Cheddar cheese cubes.
• Trans fatty acids are a product of modern technology that, like Frankenstein, haven't quite turned out as hoped. Trans fats are formed by a chemical process called hydrogenation that enables unsaturated fats (usually vegetable oils) to resemble saturated ones, giving them a solid texture and a longer shelf life. From your heart's point of view, trans fats are even worse than saturated fats. Not only do they raise harmful LDLs, they reduce heart-protective HDLs.
Solid vegetable shortenings and margarines are our main sources of trans fats, especially the crackers, chips, cookies, cake mixes, bakery goods and other foods made with them. Federal regulations were recently updated to require food manufacturers to list trans fats on their nutrition labels. To detect trans fats on older labels, look for the words "partially hydrogenated" or "hydrogenated." There is currently no "safe" daily amount of trans fats, so avoid them as much as possible. Thankfully trans fats are becoming scarcer as many manufacturers are reformulating their products to be "trans-fat-free." Seek out those choices.
• Cholesterol is a fatlike substance that's an essential component in the walls of all our cells; we also need it to make hormones and bile acids. Technically, there's no need to get any cholesterol in the foods we eat, because our bodies manufacture all the cholesterol we need. But we take in cholesterol every time we eat foods from other animals that make their own cholesterol too: meat and poultry, eggs and full-fat dairy products.
Compared with saturated fat and trans fat, dietary cholesterol isn't as powerful an influence on our blood-cholesterol levels. Usually, our bodies compensate for the cholesterol we eat by manufacturing less. But it's still important to limit—possibly more so with diabetes. Keep your intake of cholesterol to 300 milligrams (mg) per day—under 200 mg if you have an LDL cholesterol reading of over 100. For comparison, a large egg yolk contains 218 mg cholesterol. Compared with the general public, people with diabetes appear to be more sensitive to dietary cholesterol. Not to mention the fact that the foods that supply cholesterol frequently deliver a hefty dose of saturated fat too.
What About Sodium?
Since many people with diabetes have high blood pressure, chances are you've been asked by your health-care team to limit your sodium (the main ingredient in table salt). Studies show that, on average, as sodium intake rises, so does the incidence of high blood pressure—and, when people make a conscious effort to reduce their salt intake, their blood pressure tends to drop.
The Institute of Medicine of the National Academies (IOM) recently revised its guidelines for sodium, recommending that adults get no more than 2,300 milligrams (mg) of sodium daily—and that people with diabetes try to stay under that amount. That's slightly less than the amount in a teaspoon of salt (2,400 mg). Since most Americans regularly take in much more sodium than current recommendations, you'll probably have to make a concerted effort to cut salt intake if that's your goal.
Most of the sodium in our daily eating— approximately 77 percent, according to the IOM report—comes from prepared or processed foods. So one of the best ways to limit sodium is to cook and eat more meals made "from scratch."
What About Supplements?
Some nutrients your body needs only in trace amounts. These micronutrients include vitamins and minerals, some of which are involved in the process of blood-glucose control. Does that mean you need to take special supplements? You might be hearing from well-meaning friends or on the Internet that taking chromium picolinate or magnesium is advised. But scientific studies have not really supported their efficacy. Unless there's a proven deficiency, say experts, there's little evidence that taking specific micronutrient supplements can help. But a daily multivitamin/multimineral supplement is a good dietary "insurance policy." Choose one with no more than 100 percent of the daily value (DV) of the listed nutrients.