Diabetes and diet

The goal of diabetes treatment is to keep your blood sugar level within a normal range, as recommended by your doctor. As you may know, diet plays an essential role in the overall management of diabetes. A healthful diet can help you achieve and maintain a reasonable weight, as well as maintain healthy blood sugar levels.


Myths of the diabetic diet
For years, the diabetic diet was associated with no table sugar. It was thought that table sugar was more quickly digested and absorbed into the bloodstream than other carbohydrates, thus causing a larger rise in blood sugar. However, gram for gram, researchers have learned that table sugar doesn't spike blood sugar any faster or higher than other carbohydrates, such as potatoes.
Today, the notion of a single diabetic diet no longer applies. Instead, the American Diabetes Association (ADA) recommends tailoring your diet to your own metabolic, nutritional and lifestyle requirements. Work with your doctor, registered dietitian or diabetes educator to create a meal plan that works for you.


Understanding carbohydrates, proteins and fats
Carbohydrates
Carbohydrates, or carbs, are your body's main source of energy. Carbs provide energy to do everything from breathing and thinking to running a marathon. Glucose (often called blood sugar because it circulates in the blood) is the main type of carbohydrate used for energy.

Carbohydrates come from sugar and starches, such as pasta, rice, bread, fruits, beans, grains and vegetables such as potatoes. Sugar is naturally found in foods such as fruits and vegetables. It may be added to other foods during processing. Sugar is a simple carbohydrate in a form easy for your body to digest. Starches, on the other hand, are complex carbohydrates. Your body must break complex carbohydrates down into simple sugars before it can use them for energy.

If you eat too many carbs, your body will store them in your liver and muscles to use when your blood sugar gets low. If you consume more calories than you need, extra carbs will be stored as body fat.

Proteins
Proteins come from foods such as meat, poultry, fish, eggs, milk, yogurt, tofu and cheese. Proteins build, repair and maintain all body tissues. If your body is low on carbohydrate or fat stores, it will break down proteins for energy. If you consume more protein than you need, the extra protein will be broken down and stored as body fat.

Fats
Despite its bad reputation, fat is an important part of a healthy diet. Fat serves many vital functions, such as providing energy and allowing your body to absorb certain vitamins.

There are three main types of dietary fat: saturated, polyunsaturated and monounsaturated. Food labels list each type of fat separately.

Saturated fat plays the largest role in increasing the risk of high cholesterol and heart disease. The main sources of saturated fat in the typical American diet include meat, dairy products, high-fat snacks and bakery products. Saturated fats -- such as butter and shortening -- are usually solid at room temperature.

Polyunsaturated fats are typically found in corn, safflower, soybean, sesame and sunflower oils. Seafood also contains fatty acids that are mostly polyunsaturated. Monounsaturated fats are the healthiest for your body. These are found in olive, peanut and canola oils. Polyunsaturated and monounsaturated fats are liquid at room temperature.

It's best to minimize your intake of saturated fat. Also, beware of the terms "hydrogenated" and "partially hydrogenated." This means the unsaturated fat has been processed to make it more solid at room temperature, a common process for products such as stick margarine. This process extends the shelf life of the product, but increases the saturated fat content.


Diabetes food guide pyramid
The diabetes food guide pyramid is a good starting point for planning meals and snacks. It's based on the U.S. Department of Agriculture's food guide pyramid, but adjusted to help people who have diabetes manage carbohydrates and other energy nutrients more easily. As you begin to make lifestyle changes to better manage your diabetes, remember that it's easier to make a few simple changes at a time. You may decide to eat more fruits and vegetables and less sweets and meat. Once you make those changes and stick to them, you can incorporate other simple changes.
Initially, you may want to write down everything you eat. A log of your eating habits can help your doctor, dietitian or diabetes educator tailor a diet to your specific needs. It can also help you understand how certain foods affect your blood sugar, which will help you make the right choices for a healthful diet.

Starches (breads, grains and starchy vegetables)
Six to 11 servings per day
One serving:

one slice of bread
half bagel or English muffin
one plain rice cake
six crackers (such as rye crisps or saltines)
6-inch tortilla
3/4 cup dry cereal
1/3 cup rice
1/2 cup pasta or cooked cereal
1/2 cup corn, cooked beans, lentils or peas
one small, plain baked potato
1 cup winter squash
1/2 cup sweet potato or yam
Fruits
Two to four servings per day
One serving:

one small fruit (apple, orange, banana or peach)
one melon wedge
1/2 cup chopped, cooked, frozen or unsweetened canned fruit
2 tablespoons dried fruit
1/2 cup fruit juice
Vegetables
Three to five or more servings per day
One serving:

1/2 cup cooked or chopped raw vegetables
1 cup leafy, raw vegetables
1/2 cup tomato or vegetable juice
Milk and yogurt
Two to three servings per day
One serving:

1 cup low-fat milk
1 cup soy milk
1 cup low-fat, unsweetened yogurt
Protein (meat and meat substitutes)
Two to three servings per day
One serving:

2 to 3 ounces cooked lean meat or poultry or fish
2 ounces cheese
1/2 cup tofu
one egg or equivalent egg substitute
2 tablespoons peanut butter
Fats and oils
Fats and oils supply mostly calories and few nutrients, so use them sparingly. Foods in this group include salad dressing, oil, cream, butter, margarine, gravy and cream cheese. One serving is 1 tablespoon of regular salad dressing, 2 tablespoons of light salad dressing, 1 tablespoon of light mayonnaise, and 1 teaspoon of regular margarine or oil.

Sugary foods
Small amounts of sugary foods can be worked into a meal plan as carbohydrates. As with fats and oils, however, sugary foods are low in nutrients and high in fat. Use them sparingly.


How much to eat
Work with your doctor, registered dietitian or diabetes educator to determine the number of calories you need each day. Here are some guidelines for adults:
1,200 to 1,600 calories

woman with a small frame who exercises regularly
woman with a small or medium frame who wants to lose weight
woman with a medium frame who doesn't exercise much
1,600 to 2,000 calories

woman with a large frame or man with a medium to large frame who wants to lose weight
man with a small frame and healthy weight
man with a medium frame who doesn't exercise much
2,000 to 2,400 calories

man with a medium to large frame who exercises regularly or has a physical job
man with a large frame and healthy weight
woman with a large frame who exercises regularly or has a physical job
Depending on the number of calories you need per day, here are the recommended servings of each food group per day:


Calories Starches Fruits Vegetables Milk Protein
1,200 to 1,600 6 2 3 2 2
1,600 to 2,000 8 3 4 2 2
2,000 to 2,400 11 3 4 2 2


For children, you can estimate the number of calories needed per day with a simple formula -- multiply the child's age (up to 12) by 100 and add 1,000. Ideally, 50 percent of a child's calories should come from carbohydrates, 30 percent from fat and 20 percent from protein. Offer three meals a day and an afternoon and evening snack. Younger children may need a midmorning snack as well.


Exchange lists and carbohydrate counting
Exchange lists or carbohydrate counting help some people keep their blood sugar within an acceptable range. Your doctor, registered dietitian or diabetes educator can help you customize a plan based on your weight, blood glucose levels and medical needs.
The exchange list groups foods in three categories: carbohydrates, meat and meat substitutes, and fats. An exchange is essentially one portion of a food type. Foods within each list can be exchanged for other foods in the same list because they're similar in nutrient content and effect on blood sugar. Based on your individual needs, you'll eat a certain number of servings from each food group each day. The ADA offers a booklet titled "Exchange Lists for Meal Planning" to help you learn how to use exchanges as you plan your daily diet.

With carbohydrate counting, you'll learn the carbohydrate content of foods as well as the total number of carbs you're allowed per day. You'll split that total between your meals and snacks, trying to keep the amount of carbs per meal and snack consistent each day. Carbohydrates have the greatest effect on blood sugar, so limiting your carbs can help you manage your blood sugar. Carbohydrate counting can be a good method for people who have a healthy weight and take multiple injections of insulin each day or use an insulin pump.


Glycemic index
The glycemic index (GI) was introduced in the early 1980s as a way to rank carbohydrate-rich foods according to their effect on blood sugar. Foods are ranked as high GI or low GI based on the rate at which the carbs they contain are digested. Some research has indicated that a diet containing more low-GI carbohydrates improves overall blood sugar management. Following a low-GI diet can be complicated, however. The ADA stresses the importance of limiting the total amount of carbohydrates in your diet as a top priority, rather than knowing the glycemic index of those foods.

Managing portion size
Accurate portion sizes are essential to help you gauge your overall caloric intake and manage your blood sugar. At first, use measuring cups, measuring spoons and a kitchen scale to help you serve accurate portions. For example, measure a portion of cereal, pasta or rice into a bowl or plate. When you eat that food again, use the same bowl or plate to gauge the correct amount. Fill a juice glass with one serving of juice and mark the glass. Read food labels to learn more about portion sizes.
While you're learning, here are some general guidelines:

One cup of carbohydrates -- including fruit, vegetables, pasta or rice -- is about the size of a small fist.
Three ounces of protein -- such as meat, fish or poultry -- is about the size of a deck of cards or the palm of your hand.
One ounce of cheese is about the size of your thumb.
One cup of milk, yogurt or fresh greens is about the size of a tennis ball.
One teaspoon of butter or peanut butter is about the size of the tip of your thumb.

Artificial sweeteners and sugar alcohols
Artificial sweeteners are considered "free foods" because they have no calories and no impact on blood sugar levels. The U.S. Food and Drug Administration (FDA) and the ADA have approved the following low-calorie artificial sweeteners for people who have diabetes:
Aspartame (NutraSweet and Equal, for example) can be used in small amounts to sweeten foods. High temperatures can decrease the sweetness of aspartame, so it may not be the best choice for certain recipes. Note: People who have the rare disease phenylketonuria (PKU) should avoid aspartame.

Acesulfame potassium (Sunette, for example) and Sucralose (Splenda, for example) can be used in any type of baking or cooking. You may need to add a small amount of sugar to improve the texture of certain foods.

Saccharin is also a safe choice for most people. Although it was found to cause cancer in rats when given in large amounts, research shows the same is not true for humans. Note: Saccharin is strongly discouraged for pregnant women because it can cross the placenta and may remain in fetal tissue.

New sweeteners approved by the FDA in the last few years include tagatose and neotame.
Sugar alcohols, or polyols, are another category of sweetener. They're naturally present in many foods, including many fruits and vegetables. Sugar alcohols can also be added to foods. You may notice sorbitol, mannitol or xylitol on the food label. Sugar alcohols require little or no insulin for metabolism and are absorbed slowly and incompletely. They're a carbohydrate, however, so they provide calories. Your doctor, registered dietitian or diabetes educator can help you plan how to fit these sweeteners into your diet.


Tips for overall management
As you take an active role in controlling your blood sugar, keep these general tips in mind:
Check your blood sugar regularly as recommended by your doctor.

Each day, eat the same amount at about the same time. A big lunch one day and a small lunch the next may cause your blood sugar levels to change too much depending on your insulin or medication regimens. It's also important not to skip meals.

Eat whole grains and foods made from whole grains, such as brown rice and brown bread. These foods have more vitamins, minerals and fiber than white rice and white bread.

Steam your vegetables with a little water or low-fat broth. Season them with herbs and spices or mix in some chopped onion or garlic. If you use a small amount of fat, opt for canola oil, olive oil or soft margarine (the liquid or tub variety).

Drink juice only in small amounts. Small pieces of fruit, which are more filling than juice, are often a better choice.

Limit your intake of fried foods and high-fat starches, such as fried tortilla chips, french fries and doughnuts. Try pretzels, fat-free popcorn, baked tortilla or potato chips, or low-fat muffins instead.

Broil, grill, stew, stir-fry, roast or steam your foods, rather than frying them.

Choose lean cuts of meat, and remove any visible fat before cooking. Remove the skin from chicken and turkey.

When cooking, use vegetable oil spray rather than oil, shortening, butter or margarine. Choose canola oil or olive oil instead of butter or margarine.

Reduce the amount of sugar in recipes by one-third to one-half. Use extra vanilla and spices to improve sweetness.

Replace half the meat in casseroles with beans, lentils or grated carrots.

Use only half the suggested butter or margarine when preparing pasta, stuffing and sauces from packaged mixes.

Choose the reduced- or low-fat version of various products, such as salad dressing, margarine, mayonnaise, milk, sour cream, cheese, cottage cheese and yogurt. You can also substitute low-fat plain yogurt for sour cream.

Choose soft tub margarine over the stick variety or butter. Use mustard instead of mayonnaise on a sandwich.

Use lemon juice, salsa, ketchup, soy or teriyaki sauce, barbecue sauce, herbs and spices to add more flavor to foods. Read labels carefully -- some sauces may be high in fat. If you're on a low-sodium diet, be aware that some sauces may be high in sodium.

To satisfy your sweet tooth, choose sugar-free frozen fruit bars, diet soda, sugar-free hot chocolate, fat-free and sugar-free ice cream, or fat-free frozen yogurt.
Snacks to raise your blood sugar
If you have symptoms of low blood sugar, it's important to eat a snack. As a general rule, eat or drink 15 grams of carbohydrates for blood glucose readings below 70 mg/dL. For example:

1/2 cup (4 ounces) fruit juice
1/2 cup (4 ounces) nondiet soda
1 cup (8 ounces) milk
five to six pieces of hard candy
1 to 2 teaspoons sugar or honey
glucose tablets (Read the package label to find out how many tablets contain 15 grams of carbs.)
If you don't plan to eat a meal for at least another hour, incorporate both a carb and a protein in your snack to maintain your blood sugar. Good choices include:

cheese or peanut butter and crackers
half of a turkey or ham sandwich
1 cup milk and crackers or cereal
Eating out
With a little planning, you can follow your meal plan and eat healthfully at a restaurant. If you anticipate a wait, keep a snack handy. Here are some other tips to keep in mind:

If you'd like an appetizer, order a fruit cup. For your entree, try a salad and a low-fat item from the appetizer section of the menu.

Ask for fish or meat broiled with no extra butter. Don't order breaded or fried foods. If the food comes breaded, peel off the coating.

Order baked potatoes plain and add your own toppings, such as a teaspoon of margarine, low-fat sour cream or a handful of vegetables from the salad bar.

Ask for low-fat items, such as salad dressing -- even if it's not on the menu. Vinegar and a dash of oil is a healthier choice than high-fat dressing.

Ask for sauces, gravy and salad dressings on the side. Dip your fork in the salad dressing before spearing the lettuce, or add just one teaspoon to your salad. Do the same with sauces and gravy.

Opt for marinara sauces for pasta and tomato-based broth or soups. Cream sauces and cream-based soups are high in fat.

Ask for substitutes, particularly for breaded or fried foods. Instead of french fries, for example, request a double order of vegetables. Or, ask that the french fries be left off your plate.

Eat the same portion sizes you would at home. If you receive a large serving, share with someone or bring the extra home.

Eat slowly.

Discuss alcohol consumption with your doctor ahead of time. As a general rule, don't drink when your blood sugar is low or your stomach is empty.
Eating when you're ill
Blood sugar levels can climb when you're ill -- the hormones your body releases to fight disease may raise your blood sugar level and interfere with insulin's ability to lower your blood sugar.

It's important to develop a meal plan with your doctor or diabetes educator ahead of time to manage your diabetes when you're ill. Until the plan is in place, keep these points in mind:

Call your doctor if you:

are sick or have a fever for two days or more and don't seem to be getting better
vomit more than once or have diarrhea for more than six hours
have a moderate to large amount of ketones in your urine
take insulin and your blood sugar level is higher than 240 even though you've taken extra insulin
take oral medication for diabetes and your blood sugar is higher than 240 before meals and stays there for 24 hours or longer
have symptoms that signal a serious condition such as ketoacidosis or dehydration, including pain in your chest, trouble breathing, breath that smells fruity, or extremely dry lips or tongue

Track your blood sugar and urine ketone levels more often than normal -- up to every four hours if you have type 1 diabetes. Be prepared to tell your doctor what medications you take, how long you've been sick, whether you can keep any food down, and if you've lost weight or have a fever.

Continue taking your medications when you're ill. If you're vomiting and can't keep your medication down or wonder if you need extra insulin, consult your doctor.

Keep eating. Stick to your normal meal plan if you can, and be sure to add at least one cup of water or other caffeine-free liquid every hour while you're awake. If you can't eat your normal diet or certain foods are hard to eat, try to consume the same amount of calories by eating bland foods such as crackers, soup, applesauce or gelatin. Drink liquids that contain carbohydrates, such as juice, broth or nondiet soda. Try to consume 50 grams of carbs every three to four hours. You could also try creamed soup, frozen nondiet juice bars or nondiet sherbet, pudding or fruit-flavored yogurt.

Be aware of other medications you take. Some over-the-counter medications, such as cough medicine, contain sugar. Ask your pharmacist about sugar-free alternatives. Decongestants can raise blood sugar, and other medications -- such as large doses of aspirin -- can lower blood sugar. Some antibiotics lower blood sugar in people who have type 2 diabetes and take oral diabetes medication. Your blood sugar can also be affected by medication you take for other health problems.

Considerations
Again, a carefully planned diet plays an important role in the overall management of diabetes. Blood sugar rises in response to the foods you eat. The more you eat, the higher your blood sugar rises. Over time, high blood sugar may lead to complications such as kidney disease, amputation, blindness and diseases related to hardening of the arteries, including heart attack and stroke.
If you're overweight and have type 2 diabetes, weight loss alone may be enough to control your blood sugar or reduce the amount of medication you need. Losing weight lowers insulin resistance, which allows your natural insulin to do a better job of lowering your blood sugar.

To help prevent illness, ask your doctor about a yearly flu vaccination. A one-time pneumonia vaccine is also recommended. If you're age 65 or older and it's been more than five years since your last pneumonia vaccine, you'll need a second shot.


Pregnancy-specific information
There are no universal dietary standards for pregnant women who have diabetes. Remember, however, that using saccharin during pregnancy is strongly discouraged because it can cross the placenta and may remain in fetal tissue.
The number of calories you consume each day may need to be adjusted during various points in your pregnancy. For example, you may need fewer calories during the first 12 weeks. Your doctor will help you plan a diet that takes both your pregnancy and diabetes into account.

If you develop gestational diabetes during pregnancy, it's important to control your blood sugar to prevent complications for you and your baby. Learn what to eat and how foods affect your blood sugar. For most women who develop gestational diabetes, blood sugar levels return to normal after delivery. There's an increased risk of developing type 2 diabetes in the future, however.


Senior-specific information
Type 2 diabetes is common in elderly adults. In fact, slightly more than 20 percent of adults age 65 and older are estimated to have diabetes. It may be difficult to make dietary adjustments later in life. The key is to make gradual changes and stick with them before making any other changes. Again, if you're age 65 and it's been more than five years since your last pneumonia vaccine, you'll need a second shot.