Diet Focus

Diet has been a major component of diabetes treatment plans for years, but today there are many exciting changes occurring in the way we approach diet for diabetes. Diet plans are now far more individualized, flexible and adaptable to each patient's unique lifestyle, calorie requirements and overall personal health. So why plan your life around a diet for diabetes when you can plan the diet around your life?

What Is Diabetes?

Diabetes mellitus is a chronic disease in which the body either cannot produce enough insulin or cannot properly use the insulin it does produce.

Insulin is a hormone produced by the pancreas that is released into the bloodstream when the level of glucose in the blood -- commonly known as blood sugar -- rises, like after a meal. Glucose is a carbohydrate that serves as the body's main fuel; insulin helps take it from the bloodstream into the cells of the body for energy.

If the body does not produce enough insulin (or fails to use insulin properly), and the cells therefore do not get the glucose they need for energy (or are unable to use it if they do get it), the glucose in the blood will remain at high levels. This condition of high blood sugar is called hyperglycemia, and it can have adverse effects on many of the body's systems. Over time, high blood sugar, if left untreated, can result in damage to the heart, arteries, eyes, nerves and kidneys.

There are four major types of diabetes.

• Type I: The pancreas produces little or no insulin. About 10 percent of all people with diabetes have this type. It usually affects younger people, but can occur in adults.
• Type II: The pancreas produces insulin, but there are not enough insulin receptors, or the receptors do not work properly; therefore, the glucose can not get to the cells. As a result, glucose builds up in the blood.
• Gestational Diabetes: This is the term for diabetes that starts during pregnancy.
• Other Specific Types: This includes all other types of diabetes, such as diabetes caused by genetic defect, virus infections or injury to the pancreas.

Diabetes affects millions of people in this country -- and more are affected every day. All one has to do is look at the facts to see that it is a growing problem:

• An estimated 16 million in the United States have diabetes mellitus.
• About 1,700 new cases of diabetes are diagnosed daily in the US.
• Most new cases are Type II diabetes.
• Annually, one out of every seven healthcare dollars is spent annually on diabetes.
• The amount spent on diabetes every year totals about $100 billion.

What You Can Do

Treating diabetes is all about keeping food, body and medication in balance, in order to maintain normal blood sugar levels. The following are specific goals of diabetes treatment:

1. Control the symptoms of high blood sugar.
2. Achieve a state of physical well-being and reduce the risk of complications.
3. Reach and maintain a near-normal blood sugar level, between 70 mg/dl and 150 mg/dl.
4. Achieve a normal long-term blood sugar level as measured by a glycosylated hemoglobin test. This test measures long-term glucose control over 60-120 days; an acceptable measure would be 4-7 percent.
5. Foster patient responsibility for self-monitoring blood sugar levels.
6. Achieve and maintain a desirable weight.
7. Keep up a healthy level of physical activity.

Why so much emphasis on blood sugar in the treatment plan? The Diabetes Control and Complication Trial, a 10-year nationwide study, demonstrated that by keeping blood sugar as close to normal as possible, people with Type I diabetes were able to reduce their risk of serious long-term complications by 50 percent or more.

Although diet does play a critical role in controlling diabetes, it is by no means the only treatment tool available to people with diabetes. A complete diabetes management plan must include all three of the following fundamentals of treatment:

1. Meal Planning
   To help manage blood sugar levels through meal planning:
   • Select the right foods, while taking weight goals and food preferences into account.
   • Eat the right number of calories to reach or maintain a healthy weight.
   • Schedule meals and snacks appropriately.
   • Time meals in relation to medication times, exercise levels and weight goals.
2. Physical Activity
   Exercise does much more than help improve overall health for people with diabetes. It also:
   • helps the body use insulin more effectively
   • plays an important part in reaching weight goals
   • preserves and improves muscle tone and strength
   • improves circulation
   • increases lung capacity
3. Medication
   Treatment of diabetes may include insulin injections or oral medications, depending on the type of diabetes and its severity. For instance:
   • People with Type I diabetes need insulin injections to stay alive.
   • Some people who need injections may be able to use an insulin pump instead.
   • Others with Type II diabetes must take pills to help their body produce more insulin or use insulin more effectively.
   • Still others with Type II diabetes may need insulin injections to control blood sugar levels if they do not produce enough insulin on their own.

Patient self-monitoring of blood sugar levels is an important step in treatment. By using a glucose meter to test blood sugar at specific times of the day, someone with diabetes can tell immediately when to take action to correct a blood sugar level that is too high or too low. Self-monitoring also enables patients to keep thorough, accurate records of blood sugar levels and dietary intake that their doctor and dietitian can use to assess and adjust the treatment plan.

Nutritional Goals for People With Diabetes

Below is a chart with general guidelines for people with diabetes. As always, if you have specific questions or concerns regarding your diet or condition, consult your physician.

Diet Goals
Calories	Caloric intake should be enough to achieve and maintain ideal body weight. Use the following guidelines to get an idea of your caloric needs: Calories to Lose Weight = Body Weight (lbs.) x 10 Calories to Maintain Weight= Body Weight (lbs.) x 15 Calories to Gain Weight = Body Weight (lbs.) x 20
Carbohydrates	55-60 percent of calories should come from carbohydrates. Carbohydrates should come mainly from unrefined starches and breads high in fiber.
Cholesterol	Dietary cholesterol should be no more than 300 milligrams per day.
Fat	Less than 30 percent of calories should come from fat (for anyone, not just people with diabetes). Less than 10 percent of the calories that come from fat should come from saturated fats.
Fiber	The recommended daily amount of fiber is 25-30 grams. Fiber slows digestion, which causes blood sugar to rise more slowly when you eat carbohydrates. (This characteristic is defined by the Glycemic Index of foods.)
Protein	10-20 percent of calories should come from protein. Lean animal proteins and complete vegetable protein (soy protein) are preferred. The Recommended Dietary Allowance (RDA) for protein for adults is 0.8 grams per kilogram of body weight. (To figure out your weight in kilograms, divide your weight in pounds by 2.2.)
Sodium	People with diabetes should have no more than the recommended amount for anyone: 2,400 milligrams a day.
Sugar	A modest amount of sugar may be all right, depending on how well you are controlling your blood sugar and body weight. When sugar replaces some carbohydrates in the diet, blood sugar levels do not change.
Non-nutritive Substances	Alcohol tends to lower blood sugar; if you drink, you must adjust your diet and medication accordingly; always check with your doctor about drinking alcohol. Artificial sweeteners are generally fine.

Planning Your Meals

The Exchange System is a widely used food grouping system used by the American Diabetes Association and the American Dietetic Association. It has the following characteristics and advantages:

• The plan is based on the use of six exchange lists which group like foods together.
• Every food on each list has about the same amount of carbohydrate, protein, fat and calories.
• In the amounts listed, all the choices on one list are equal.
• Any food can be exchanged for any other food on the same list.
• This is a good choice for people who need a fixed number of calories for weight control and prefer a fairly regimented eating style.
• The plan requires very little knowledge of food composition.

Here is a quick rundown on the types of food and serving sizes for each of the six lists:

1. Starches/Bread
   • Typical serving: 1 slice of bread or 1/2 cup of cereal, grains or pasta
   • Also includes rice, crackers, biscuits, muffins, pretzels, popcorn
   • Also refers to legumes and starchy vegetables like potatoes, peas, corn, sweet potatoes
   • Most starchy low-fat snacks also can be worked into this group in 80-calorie units.
2. Meat
   • Serving size: 1 oz. of cooked meat
   • Lean meats: lean cuts of beef, veal and pork
   • Other foods in the Lean category: fish, skinless poultry, low-fat cheese, cottage cheese, egg whites, seafood
   • Medium-fat meats: lean ground beef, egg, lamb and cuts of poultry, beef, veal and pork that are not very lean
   • High-fat meats: sausage, hot dogs, fried fish, mixed luncheon meats, peanut butter
   • With so many low-fat products available, you can find a favorite meat and fit it into the appropriate group based on its fat content.
3. Vegetable
   • One serving = 1/2 cup cooked or 1 cup raw vegetables
   • Category of food refers to green leafy and bright yellow vegetables (except corn and peas, which are categorized as starches)
4. Fruit
   • Serving size for most fruits: 4 oz. (1/2 cup) fresh fruit or fruit juice or 1/4 cup dried fruit
   • Bananas are higher in calories than most other fruits, so half of a banana is considered one serving.
5. Milk
   • Standard serving size: 8 oz. (1 cup)
6. Fat
   • Each exchange in this group contains 5 grams of fat or 45 calories.
   • A unit = a teaspoon of oil, margarine, mayonnaise or butter
   • The equivalent of a unit for salad dressings, diet margarine and other products will vary; to determine what amount of any of these amounts to one fat exchange, just compare the fat in the product to the fat exchange of 5 grams

Before you start a diet based on the Exchange System, it is best to meet with a dietitian who can take a careful diet history and use the information to design a diet plan for you. You will need to learn how many servings from each food group you should have in a day, and how to develop a variety of meals with the plan. Always remember that timing is very important in an Exchange System plan. You need to distribute carbohydrates and calories throughout the day, especially when you take insulin or oral medications for diabetes. The purpose of your medication is to reduce your blood sugar after you have eaten, so it is very important to time your meals and snacks carefully.

To give you a better idea about how the Exchange System works, here is an example menu for a 1500 calorie diet:

• Breakfast
  • 1/2 banana (1 fruit)
  • 4 oz. (1/2 cup) orange juice (1 fruit)
  • 3/4 cup Total flakes (1 starch)
  • 8 oz. (1 cup) skim milk (1 milk)
• Lunch
  • 2 slices whole wheat bread (2 starch)
  • 1/2 cup water-packed tuna (2 meat)
  • 1 Tbsp. reduced-calorie mayonnaise (1 fruit)
  • lettuce and tomato (free)
  • 1 cup carrot sticks (1 vegetable)
  • 1 cup cantaloupe (1 fruit)
  • glass of diet soda
• Snack
  • 8 oz. (1 cup) sugar-free yogurt (1 milk), combined with
  • 3 Tbsp. Grape nuts (1 starch)
• Dinner
  • 1 1/2 cups cooked spaghetti (3 starch)
  • 3 one-oz. meatballs (3 meat and 1 fruit)
  • 4 oz. (1/2 cup) spaghetti sauce (1 vegetable)
  • tossed salad (1 vegetable)
  • 1 Tbsp. salad dressing (2 fats)
  • diet Jell-O
• Evening Snack
  • 4 oz. (1/2 cup) apple juice (1 fruit)
  • 3 square graham crackers (1 starch)

Flexible Exchanges is a method based on the Exchange System, but it provides more choice and flexibility. For instance:

• Foods from the starch/bread, fruit, and milk lists are interchangeable in this method.
• The carbohydrate content in each of these three groups is similar (12-15 grams of carbohydrate per serving), so their effects on blood sugar tend to be similar, too.

This program works well for those who enjoy a more flexible approach, do not need strict glucose control, and can understand how to use the Exchange System.

The Total Average Glucose (TAG) diet system method is based on adjusting insulin to the total amount of glucose derived from foods. It is more complex, but does an excellent job of controlling glucose intake. Here are some facts about the TAG system:

• The amount of glucose derived is equal to the sum of the glucose available from 100 percent of carbohydrate, 58 percent of protein and 10 percent of fat.
• "Points" are calculated from each meal according to its content of fat, protein and carbohydrate.
• People likely to do well with this system must be able to understand this advanced method well.
• This approach is a good choice for very motivated people who need tight glucose control.
• The diet requires that you weigh your food regularly.

Carbohydrate Counting focuses on the grams of carbohydrate eaten at meals and snacks, since carbohydrate has the greatest effect on blood sugar.

• Carbohydrate Counting is more precise, yet simpler to apply, than the Exchange System;
• Like the Exchange System, Carbohydrate Counting requires referring to a list of food.
• Among those who do well with this approach are people who need something simpler than the Exchange System.
• This is also a good plan for people who are very carbohydrate-sensitive and need tight glucose control.

The Importance of Timing

Regardless of which diet plan works best for you, it is extremely important to time your meals and snacks appropriately. If you are using insulin, you need to know the onset, or the period of time insulin takes to begin working, and the duration, or the length of time it is active and when it tapers off. For instance, an often used insulin called NPH is intermediate-acting. It begins to work within 1-3 hours of injection, reaches a peak in 6-12 hours, and then tapers for up to 18 more hours.

Facts About Artificial Sweeteners

One of the principles of an Exchange System diet is that you can exchange equal amounts of sweet foods for starches -- gram of carbohydrate for gram of carbohydrate -- and still keep your blood sugar in control. But this does not mean that sugar and sweets should be a regular part of your diet. To enjoy a sweet taste without the excess sugar, you may want to try the wide range of "substitute sugars" available today.

Keep these facts about substitute sugars in mind:

• There are two types of sweeteners, those with calories and those without. The ones that do have calories - fructose, sorbitol, and mannitol -- can cause cramping and diarrhea if used in large amounts.
• Corn syrup, honey, molasses and sucrose are natural sweeteners which are similar in calories to sugar.
• There are three major non-nutritive sweeteners on the market -- aspartame, saccharin and acesulfame K.

How Exercise Affects Blood Sugar

When you exercise, your muscles use two fuels -- glucose and fatty acids -- to burn fuel; insulin is important in exercise because it enables your body to use blood sugar for energy.

Always keep these exercise tips in mind:

• If your blood sugar is above 240 mg/dl and your urine has ketones, you should not exercise.
• Choose the best time to exercise. Since exercise helps lower blood sugar, it is best to exercise when your blood sugar is at its highest, which is usually about an hour after a meal.
• If your medication is at peak activity, it is better not to exercise, because this could lower blood sugar.
• Blood sugar is usually lowest before a meal, so that is not the best time to exercise, either; however, it might be all right if you have a light snack before you exercise, to prevent low blood sugar.
• Low blood sugar can occur 12-24 hours after vigorous exercise. This lag is due to the decreased reserves of glycogen being replenished by the sugar in your blood, resulting in a lower blood sugar level than you might otherwise expect.

Putting It All To Work

Having the right kind of diet can make living with diabetes easy. Of course, with all of the details to remember and the limitations to abide by, it might seem like having "real food" might be a thing of the past. But that’s just not true. To help give you an idea about what kinds of foods can be enjoyed by diabetics, check out these great-tasting recipes. You’ll be surprised by what diabetics can eat – why, it’s real food!!!

More Resources

For more information about diabetes and what you can do to reduce your symptoms, consult your physician and visit any of the following web sites:

• American Diabetes Association
• Diabetes.com
• My Diabetes
• Diabetic Gourmet Magazine