DIABETIC DIET & WEIGHT MANAGEMENT

Here are the 5 most important points to remember about a good diabetic diet: 1) Diabetics should eat a well-balanced diet with adequate amounts of proteins, fats and carbohydrates so as to attain and maintain an appropriate body weight. 2) A diabetic diet should include at least 3 meals and a bedtime snack daily. 3) Those meals should be consistent from one day to the next, in terms of when the meals are eaten, the number of calories eaten at each meal, and the amount of carbohydrate eaten at each meal. 4) Diabetics should avoid simple sugars, candies, etc. between meals as these concentrated sweets cause rapid swings in blood sugar levels (causing poor control). 5) The diet should be low in fat (<30% fat), particularly saturated fat (<10%). If you just follow these 5 principles, you will achieve 90% of the important goals of a diabetic diet. If you are already doing all these things, you really don’t need to go any further. Skip the rest of this section!

Skipping meals or bedtime snacks will impair your ability to optimally control your blood sugar levels, and could lead to a serious low sugar (hypoglycemic) reaction. Eating your meals at different times on different days will increase fluctuations in you blood sugar levels (Try to eat your meals within an hour of the same time every day). Varying your calorie intake from one day to the next will cause variations in your blood sugar too. If one day you have 3 meat, 1 milk, 2 vegetable and 2 bread exchanges for dinner, then every day for dinner you should have 3 meat, 1 milk, 2 vegetable and 2 bread exchanges. This will help to keep your calorie intake and your carbohydrate intake constant from lunch to lunch and dinner to dinner, and improve your ability to control your blood sugar.

This paragraph is a brief review of diet composition (carbohydrates, fats and proteins). If you are already familiar with these concepts, skip it and read on. All foods are made up of 3 different components: carbohydrates, fats and proteins. Carbohydrates are molecules that exist as either sugars or polysaccharides. Polysaccharides are strings of sugars that are connected together one after another. Starch is the name we give to polysaccharides produced by plants. Glycogen is the name we give to polysaccharides produced by animals. Fats are molecules existing as either fatty acids or glycerides. Glycerides are glycerol molecules that can attach to 1 fatty acid chain (monoglycerides), 2 fatty acid chains (diglycerides), or 3 fatty acid chains (triglycerides) simultaneously. Lipids are the molecules in the bloodstream that contain fat and cholesterol. Cholesterol is a waxy substance that is a fundamental building block of animal cell membranes and many body hormones and compounds. Cholesterol is not soluble in water but is soluble in fats and therefore is transported around the body in lipid molecules. Proteins are molecules that are composed of amino acids. Amino acids are organic compounds that contain an amino group and a carboxyl group. Protein is one of the three types of nutrients used as an energy sources by the body, the other two being carbohydrates and fats. Proteins and carbohydrates each provide 4 calories of energy per gram, while fats provide 9 calories per gram. So gram for gram, fats contain more than twice the calories of the other 2 nutrients. To calculate the calories contained in a meal, look up the number of grams of protein, carbohydrate and fat in the foods, multiply by the appropriate number of calories of energy per gram of protein, carbohydrate and fat, and add up the calories.

An exchange refers to a particular food portion (developed in the 1950s by the American Dietetic Association, the American Diabetes Association, and the U.S. Public Health Service as a standardized amount) that may be interchanged with any other food item on the same list. An exchange can be explained as a substitution, choice, or serving. Each list is a group of measured or weighed foods of approximately the same nutritional value. Within each food list, one exchange is approximately equal to another in calories, carbohydrate, protein, and fat. We can therefore talk about carbohydrate exchanges, protein exchanges and fat exchanges. To use the exchange lists, an individual needs an individualized meal plan that outlines the number of exchanges for each meal and for snacks. These exchange lists are commonly available in pamphlets or booklets at most grocery stores and bookstores, or through your doctor.  A full exchange list is available on this website in the Diabetes Education Program Section.

One of the biggest hurdles that people must overcome to follow ANY diet is implementing portion control. Most of us have portioned food out all of our lives based upon what we WANT to eat, not based upon what we SHOULD eat. Portion control requires a NEW approach to plating out meals and snacks. The first thing to do is to buy a food scale and measuring utensils (like small metal cups that measure out 1 cup at a time, ½ cup at a time, etc.) It’s also a good idea to have some exchange lists of common foods available from which to compare your measurements. The second step is to begin to measure EVERYTHING that you eat or drink that has any calories. You should do this for a MINIMUM of 2 weeks. This includes whether you’re at home, or at work, or eating out. How do you do it when you’re eating out? One option is to carry your measures with you (e.g. the average sized person’s closed fist will be approximately 1 cup – you can measure yours at home. Put a saucepan in the sink and fill it to the brim with water. Measure it with a measuring cup. Fill it up again. Put your closed fist in it just to your closed fingers. Take it out of the water and now measure what’s left in the saucepan. The difference between the two measurements is the volume of your closed fist.) Or you read the labels on packages, or you eat at home for this period of time. What you’re really doing is training yourself to recognize smaller and standardized food portions as NORMAL serving amounts. Next you’ll want to keep a food diary of what you’re eating on a day-to-day basis. You should pay particular attention to the amount of carbohydrates you are eating at each meal. You can do this by adding up grams of carbohydrates or exchanges of carbohydrates. The number of carbohydrate servings at each breakfast should be the same. The number of carbohydrate servings at each lunch should be the same. The number of carbohydrate servings at each dinner should be the same. The number of carbohydrate servings at each bedtime snack should be the same. NOW you’ve established consistency and portion control at your mealtimes. What do you do with this information? You set up an eating schedule with limits. You count the total numbers of calories/exchanges per day. You stick to your calorie consumption plan. If you are looking to lose weight, and after 3 weeks you have NOT lost any weight or have lost less than ¼ to ½ pound per week, reduce the total calorie intake per day by another 400 calories! Go through the entire process again. Continue to make these small corrections until you find the calorie/exchange intake that meets your needs for weight loss or weight maintenance, and then enforce the diet. Your goal is to learn to make it YOUR diet.

Carbohydrate counting has been popularized in the last 10 years as regular insulin bolusing with meals has caught on as a means of controlling post-prandial blood sugars. The ideas behind carbohydrate counting are that you should 1) focus on counting carbohydrate intake at mealtime and 2) use a formula (based upon your own blood sugar levels and the physician’s expertise) to calculate a particular amount of insulin to take with that meal. For instance, if you are going to eat 60 grams of carbohydrates (4 exchanges) with dinner, then a particular formula might say take 1 U of Humalog insulin for each 10 grams of carbohydrates, so in that instance you would take 6 U of Humalog insulin at that dinner. I believe the idea of counting the carbohydrate calories is sound. What is not sound is how people use carbohydrate counting to skirt around what they really should be doing. The problem with carbohydrate counting as a means of controlling blood sugars is two fold. First, it relies fully on the assumption that a given amount of carbohydrate at a meal is the one and only factor that determines what is going to happen to blood sugar levels after the meal. It relies on this assumption, unchanged, day after day, through all the variables of life, totally blinded to other factors: activity level, what else is eaten in the diet and at that meal, state of health, use of other medications, issues of digestion, etc. That assumption is a gross simplification that AVERAGES what happens to blood sugar levels over many days or weeks of time, and simply DOESN’T predict what is going to happen in any ONE instance. A “system” that uses such assumptions may work fairly well one time, or two times, but it is NOT going to work ALL of the time, and probably not work well even MOST of the time. Secondly, the notion that you have a “system” to work out how much insulin to give yourself to accommodate any meal or change in carbohydrate intake, either large or small, creates a FALSE sense of security and misleads people into thinking that they can stray off their diet at any time (or all the time for that matter) and simply use the “system” to “fix” their situation and keep their blood sugar levels normal. Time and again I have seen this kind of misunderstanding lead to worse diabetic control than the person had BEFORE they adopted the new “system.” However, I DO THINK carbohydrate counting can be useful in some situations. When your diet really does get out of control or when your sugars are already out of control having some feeling for how your body generally responds to changes in carbohydrate intake and insulin intake is VERY helpful in understanding how to change your medication intake by the right amount in certain situations. In general, though, my advice to patients is, WORK FOR CONSISTENCY IN CARBOHYDRATE INTAKE FROM ONE BREAKFAST TO THE NEXT TO THE NEXT, ONE LUNCH TO THE NEXT TO THE NEXT, ONE DINNER TO THE NEXT TO THE NEXT, ONE SNACK TO THE NEXT TO THE NEXT, etc. By doing that you are not limiting your food choices, but you are controlling portion sizes and carbohydrate intake. Your are also eliminating one more variable in a complex set of factors that affect blood sugar levels throughout the day and night, and in doing so, you are much more likely to achieve a better level of diabetic control in the short and the long term. You can then better adjust your insulin every few days to address trends in blood sugar readings that occur in predictable patterns.

Diet fads seem to come and go faster than clothing styles. There is a tabular review of some of the more popular diets, with their pros and cons, elsewhere on this web site (look under Frequently Asked Questions). Diet fads are just that. They become popular for a while, but as time goes by, and they fail the test of time, they lose their shine. It does seem to be true that high protein diets suppress the appetite somewhat more than high fat or high carbohydrate diets. Truly high carbohydrate diets probably do increase blood triglyceride levels and worsen overall diabetic control. There is good experimental data to show that going on and off diets, losing weight and then regaining it back again, DOES appear to be worse for your health than not dieting at all. The greatest failure of ALL diets of ALL time is that they are temporary. When people leave the diet, they go back to what they were doing before, and 95% of people regain the weight that they lost, to the detriment of their health. The solution to all of this nonsense is not to “diet” at all. Find the “diet” that accomplishes your health (and weight) goals, and modify your eating habits to create the lifestyle (“diet”) that you can live with and be on and maintain for the REST OF YOUR LIFE. Don’t try to take any shortcuts here. They’re all dead ends.

The next hurdle is to understand what is happening to your intake when dining out. The most obvious problem is achieving portion control. Many fast food restaurants have increased their portion sizes in the last 10 years to attract more (and, literally bigger) customers. A “regular” serving of French fries may in fact be 2 or 3 or more portions based upon exchange lists. The “Big Mac” or the “Whopper” are good examples of single hamburgers that provide the calorie equivalents of a full meal (550-725 cal). Add to those French fries and a 20 oz “regular” Coke and you are at 1200-1500 calories. That's a full day's energy intake!  The next problem is recognizing that many restaurant foods hide extra sugars and/or fats that you might not normally expect to find in food preparations. For instance, mashed potatoes can also contain unusually large amounts of butter, oil, cream, cheese or other fats to enhance their flavor. Meats may be marinated in sugar solutions and/or dipped in oil prior to frying or grilling. Sauces may contain extra fats or oils. Breaded items may contain fats, oils or eggs that you might otherwise not expect. When you get a deli sandwich, do they use just 1 tablespoon of mayonnaise? Is the cheese low fat? Are they also now putting on oil and vinegar? Above and beyond those issues, our culture encourages us to “eat heartily,” and many people are brought up, “not to waste food.” These are cultural landmines that can undo some of the best-planned diets if they are not fully anticipated and resolved in advance.

We do know a diet high in animal fat (saturated fat) increases the risk of atherosclerosis (hardening of the arteries). Studies suggest that regular table sugar may not be harmful to diabetic control as long as it is eaten in the context of a balanced meal (one that contains fat and protein so that it is absorbed through the stomach and intestine more slowly in order to delay any rapid swings in the blood sugar level.) Again, obviously, the key here is moderation and a balanced diet. A prudent diet is one that is low in cholesterol and large quantities of saturated fats. Excessive intake of these foods predisposes to atherosclerosis (hardening of the arteries). All diabetic patients should have a good general understanding of diets--what proportions of nutrients (proteins, fats, carbohydrates) various foods contain, how to use exchange diets, how to select proper foods when eating out, what foods to avoid, etc. A reasonable diet for diabetics contains about 12% to 20% protein, 50% to 55% carbohydrate, and 25% to 30% fat. These percentages are somewhat flexible. The carbohydrate should be in a complex form such as starch or that found in less than fully cooked vegetables. Whole grain products are preferred because they have a higher fiber content that is beneficial. The use of vitamins is optional. Generally, anyone in the United States eating a balanced diet and consuming 1000 calories or more a day will get enough vitamins and minerals in the foods that they eat that a supplement is not necessary. A good diet is a way to achieve Ideal Body Weight and minimize rapid or wide swings in the blood sugar levels. When exercise and a reasonable diet alone cannot control blood sugar, then medication is needed.

If you are overweight, you should work on losing weight down towards Ideal Body Weight. We have tables that will tell us your Ideal Body Weight. Even a 15 or 20 pound weight loss can make a marked difference for many people. Diet pills do not have proven long term safety. The effective ones are related to amphetamines, which are stimulants with strong addiction potential. They tend to increase blood pressure and increase the workload of the heart. Several drugs had to be taken off the market in the late 1990s because of very serious potential long-term complications. When diet pills are used to help people lose weight, they must be taken forever. There is no safety data that indicates they are safe to use for such long periods. But we know when people stop such medications, they gain the weight they’ve lost right back. We do not recommend fad diets. Diets such as all protein diets, liquid diets, or all fruit diets, are not balanced in terms of nutrients, may not have adequate vitamins so that a supplement will be necessary, and are not sustainable over the long term. Once a person loses some weight on one of these diets, what happens when they go back to their normal diet? What has changed so that the weight will stay off? Studies have shown that seesawing body weight by losing weight and then gaining it back is more unhealthy for people that not losing weight at all! Only by changing your normal everyday diet – FOR LIFE – will you be able to change your body weight on the long term. That’s what a prudent diabetic diet is meant to accomplish.

Americans are changing their eating habits. This trend is based upon the public's interest in maintaining good health and on our increasing knowledge of the effects of diet on physical well-being. Basic diabetic diet principles are nearly identical to the "good nutrition" concepts we see advertised to the American public at large by the United States Department of Agriculture.  These are often referred to as the Dietary Guidelines for Americans as published by the U.S.D.A. The newest revision of these guidelines was published in January 2005. The guidelines are meant to encourage people to eat fewer calories, be more physically active and make wiser food choices. The recommendations include:

EAT A VARIETY OF FOODS
Eating a wide variety of foods will increase the probability of obtaining the proper balance of the 40 or more essential human nutrients as well as reducing the exposure to excessive contaminants and questionable food additives found in any one food.

Food selections should include fresh fruits and vegetables; whole grain and enriched breads, cereals and grain products; nonfat and low fat milk products; lean meats, poultry, fish and eggs; nuts and legumes (dried peas and beans).

It is important to include fresh foods as frequently as possible to avoid the salt, fat, sugar, food additives and low fiber content of processed foods. One should also choose foods that limit the intake of saturated fats, cholesterol and alcohol.  There is no place for trans fats in your diet.

MAINTAIN DESIRABLE WEIGHT
Eating too many calories leads to obesity which will worsen diabetes and increase the risk of high blood pressure and heart disease. A safe weight loss of 1/2 to 1 pound per week can best be achieved by a combination of a reduced calorie intake and increased exercise. Increasing your activity level by walking, swimming or just taking the stairs rather than the elevator will enhance your weight loss efforts and help improve your overall diabetic management. If you are over 40, check with your physician before beginning a more rigorous training program. As you get older, to prevent gradual weight gain, make small decreases in food and beverage portions/calories and increase your physical activity.

STAY PHYSICALLY ACTIVE
Engage in regular physical activity and reduce sedentary activities by doing at least 30 minutes of moderate-intensity physical activity, above and beyond your usual activity, on most days of the week. Consider doing more physical activity if you need to lose weight or you need to sustain a weight loss. Your physical activity program should include cardiovascular conditioning, stretching for flexibility and resistance exercises.

INCREASE THE INTAKE OF CERTAIN FOOD GROUPS
Work towards increasing the intake of fruits and vegetables while staying within your energy needs. For a 2000-calorie diet/day, this would mean 2 cups of fruit and 2 ½ cups of vegetables. Choose a variety of fruits and vegetables. Select all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times each week. Consume at least ½ your intake of grains as whole-grain foods. Consume 3 cups of fat-free or low-fat milk or milk products daily.

AVOID TOO MUCH FAT, SATURATED FAT, AND CHOLESTEROL
There is a strong correlation between total fat in the diet and the incidence of breast cancer, colon cancer, obesity and heart disease. Using the following guidelines can lower dietary fat intake. Choose fish and poultry instead of red meats and cheese. Use plant sources of protein such as legumes, lentils, dried beans and split peas. Remove visible fat from meat and skin from poultry before cooking or eating it. Limit the use and amount of butter, margarine, salad dressings and oils. Roast meat on a rack, bake it, broil it, or stew it rather than fry foods. Discard all fat drippings from meats. Choose low-fat milk and dairy products. Be aware of hidden fats in foods such as French fries, chips, cheese, nuts, avocados, luncheon meats, whole milk, chocolate, ice cream, pastries and croissants. Consume less than 10% of calories from saturated fats and less than 300 mg/day of cholesterol. Keep trans fatty acid consumption as low as possible, or avoid it altogether. Keep total fat intake between 25 to 30% of calories, with most fats either polyunsaturated or monounsaturated (e.g. nuts, fish, vegetable oils).  If you do need to "fall off the wagon" and have that extra snack, look for foods prepared with non-absorbable fats such as chips fried in olestra oil.

Blood cholesterol levels influence the amount of fat and cholesterol that deposits on the inner walls of arteries causing them to be inflexible and narrowed which in turn can obstruct the flow of blood. This may lead to a heart attack or stroke. Both saturated fat and cholesterol in the diet may lead to increased blood cholesterol levels.

Cholesterol is found only in animal products and is particularly high in eggs and organ meats. The fat in red meats, milk products, coconut and palm oils, hydrogenated vegetable shortenings and chocolate are primarily saturated fats and in general should be reduced or avoided.

EAT THE RIGHT CARBOHYDRATES
Complex carbohydrates (starches and fiber) are found in fresh vegetables, legumes (dried peas and beans), nuts and whole grains (whole wheat, brown rice, barley, bulgar, oats, rye, millet and cornmeal). Foods containing these complex carbohydrates are excellent sources of fiber as well as vitamins and minerals.

A long-term low fiber intake may be a causative factor in cancer of the colon, constipation and other intestinal disorders. Choose and prepare foods and beverages with little added sugar or sweeteners.

All people, including those with diabetes, should limit their intake of sugar. The harmful effects of sugar are manifested in dental disease (rampant cavity formation in children and gum disease in adults), diabetes, vitamin and mineral deficiencies and obesity. Nutrient deficiencies can occur when high sugar content foods which contain calories and few other nutrients are eaten in place of foods higher in nutritional value. Foods high in sugar include table sugar, honey, syrup, pies, cakes, cookies, pastries, and sugar coated breakfast cereals. There are 9 teaspoons of sugar in a can of regular soda pop!

Limiting your intake of simple sugars does not mean eliminating your intake of simple sugars. In the context of a meal, adding simple sugar, such as a teaspoon of sugar on cereal may be perfectly fine. It’s the can of Coke on an empty stomach in the middle of the day that creates a problem. Many people use artificial sweeteners as much as possible in place of sugar all the time. This is acceptable, but may not be necessary. You can tell by checking your sugars frequently throughout the day and seeing what happens when you eat certain foods or combinations of foods. Beware that large amounts of some artificial sweeteners can have side effects. For instance, sugar alcohols (sorbitol, xylitol) found in diabetic candies and ice cream when consumed in excess will cause bloating, gas and diarrhea.

AVOID TOO MUCH SODIUM (SALT)
Excessive sodium consumption may cause or aggravate high blood pressure. Even though sodium is an essential nutrient, more than adequate amounts can be obtained from fresh, unsalted foods.

The primary source of sodium in the American diet is table salt (sodium chloride); although it is also found in MSG, antacids, baking soda, baking powder and some food additives. It is important to look for the word sodium on food labels. Consume less than 2300 mg (approximately 1 teaspoon of salt) of sodium per day.

In order to reduce sodium intake, it is necessary to decrease the salt added during cooking and at the table and to use sparingly highly salted foods such as cured, canned and processed meats; canned vegetables; canned and dried soups; condiments such as catsup, mustard, soy sauce and steak sauce; pickles; olives; and salty snacks.

ALCOHOL CONSUMPTION
Alcohol, like fat and sugar, is a dense source of calories. Excessive alcohol consumption may lower the appetite for foods that contain essential nutrients. Vitamin and mineral deficiencies may occur because of poor food intake as well as alcohol's ability to alter the absorption and utilization of nutrients.

Those who choose to drink alcoholic beverages should do so in moderation – defined as up to one drink per day for women and up to 2 drinks per day for men.

Heavy drinking by pregnant women has been linked to birth defects and mental retardation of children. A safe level of alcohol consumption for pregnant women has not yet been established, but total abstinence from alcohol is the only completely safe decision a pregnant woman can make.

Cancers of the head and neck are much more common among people who drink and smoke than among those who do not.

FOOD SAFETY
To avoid food borne illness, clean hands, food contact surfaces, fruits and vegetables. Meat and poultry does not need to be washed or rinsed. Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing foods. Cook foods to safe temperatures to kill microorganisms. Refrigerate perishable food promptly and defrost foods properly. Avoid unpasteurized milk products, raw or partially cooked eggs or foods containing them, raw or undercooked meat or poultry, unpasteurized juices and raw sprouts unless you are sure of credentials of the food purveyor.

Food Exchange Lists for Meal Planning are available in bookstores and many supermarkets, as well as in the Diabetic Education Program section of this web site.  They all use standard measures and portions. Good eating habits based on moderation and variety will help improve and maintain optimal diabetic control.

Revised 8/08

 

©Ted A. Tobey, M.D., Inc. ~ All Rights Reserved