If you’re looking for a “diabetic diet” full of bland, boring foods and completely devoid of any desserts, indulgences, or the other little taste treats that make life worth living, you are out of luck. The so-called diabetic diet is largely a myth; people with diabetes can and do enjoy a wide variety of foods, the same foods everyone else can eat. The key is moderation, a focus on healthier carb choices, and a keener awareness of how foods affect your blood sugars and body.
A meeting with a registered dietitian is an absolute must for anyone with diabetes. A good RD will explain the mysteries of exchanges and carbohydrate counting to you and will work with you to create a meal plan that works with your lifestyle. Parents cooking for a child with type 1 diabetes will have a whole different set of concerns and dietary issues than, for example, an adult with type 2 who wants to learn how to eat for better control when he’s out on the road. If you don’t have an RD already, talk to your doctor about a referral, or visit the American Dietetic Association’s online referral database at www.eatright.org.
As part of your diabetes care team, your dietitian should be in close contact with your care provider. Make sure she’s on top of any adjustments to your insulin or medication, which go hand in hand with what you’re eating. The dietitian’s office is another of those places where it helps to bring a spouse or companion for another set of ears, particularly your first time there.
Whether you’re using carbohydrate counting or dietary exchanges, your RD will try to spread out your carbohydrate intake more or less evenly throughout the day to promote blood glucose balance. Again, your dietitian will work with you to come up with an appropriate amount of exchanges or carb grams, fat intake, and protein. He may also suggest other dietary guidelines based on your health history (e.g., low sodium if you have hypertension).
The ADA recommends that people with diabetes eat no less than 130 grams of carbs daily, and the American Association of Clinical Endocrinologists (AACE) suggests that total dietary carbohydrates represent 45 to 65 percent of daily calories. However, many people with diabetes find that a lower intake of carbohydrates offers them better control of their blood glucose levels. If you’d like to try a lower-carb meal plan, talk with your RD and your doctor about an approach that’s right for you.
In 2005, the U.S. Department of Agriculture (USDA) retired the old food pyramid and replaced it with an interactive and individualized tool that bases dietary recommendations on weight, height, gender, age, and activity level. The new nutrition tool, called MyPyramid, uses the 2005 Dietary Guidelines for Americans to generate your plan. The guidelines recommend that between 45 and 65 percent of daily calories come from carbohydrates; and that only half of grain servings come from whole-grain, versus refined, sources. While this may be appropriate for some people with diabetes, for others it could pose a significant challenge.
The Healthy Eating Food Pyramid created by the Harvard School of Public Health is perhaps the best model for healthy eating with diabetes (see www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid). Based on the abundance of research that demonstrates the negative impact of refined starches on blood sugar control, this pyramid uses carbohydrate quality as a blueprint, pushing starchy, high-glycemic index carbs up to the top of the pyramid (to use “sparingly”). It also adds heart-healthy oils to the whole grains at the bottom. Here are its recommendations:
Even if you follow your meal plan to the letter, you’re still going to find that certain foods will give you a bigger spike in glucose levels than expected. You may also find that other foods you expected to pump up your readings barely bump the meter. That’s the individual nature of diabetes. For this reason, a food diary is an invaluable tool in figuring out just how different foods affect your blood glucose levels.
Record the type, amount, and timing of foods eaten, along with what effect they had on your blood glucose levels (a reading before eating and a reading two hours postprandial). Many people choose to record the information in their blood glucose logbook. At first it may feel a little obsessive-compulsive to chronicle every bite, but you’ll find it’s worth it when the time comes to figure out a mysterious high or an unexpected low. It’s also a great cure for mindless eating — you won’t be polishing off what the kids left on their dinner plate or munching samples in the supermarket if you’ve trained yourself to write it down.
Most diabetes educators and registered dietitians teach carbohydrate counting as the primary method of maintaining dietary control of diabetes. Carb counting involves calculating the grams of carbohydrates eaten in a given meal. In theory, regulating carb intake means controlling your blood glucose levels.
How many carbohydrates you eat in a given day depends on your unique caloric, medical, and lifestyle needs. An active teenager will have a greater carbohydrate requirement than an inactive adult. Again, the first step in establishing a carb-counting plan is sitting down with a registered dietitian who will discuss your medical history, lifestyle, eating habits, and medication routines, and come up with a plan for how many carbohydrates you should be eating and when they should be consumed.
There are a couple of different variations on the carb-counting theme. Basic carb gram counting is simply calculating the actual grams of carbohydrates consumed and ensuring they don’t exceed a pre-established limit. Another popular method is carb choice.
Since a dietary exchange of starch or fruit carbohydrates is equivalent to 15 grams of carbohydrates, many dietitians use the “15 grams per serving” value as a “rule of thumb” in teaching carb counting, especially to those patients who are already familiar with exchange lists. Each 15-gram serving is called a “carb choice,” and instead of establishing a total number of carbohydrate grams for the day, you will work with your dietitian to determine a total number of carb choices. Here’s how you can translate exchanges into carb choices.
The choice method may not be as exact as calculating carbs strictly by the label, since it involves a certain degree of estimation, but it’s close enough for most people. Talk to your dietitian about the method that works best for you.
Carb counting can also take some practice. In the United States, all food labeling must list carbohydrate content on a per-serving basis, so the carb content in packaged foods is easy to determine. It’s important to remember that FDA-prescribed serving sizes and the portions you are used to may often be two very different things. Make sure you know how many carbs you are consuming in your serving size and that you account for any extra carbs in bigger servings.
A good carb-counting reference book for fresh whole foods is also a must. Even if you don’t cook from scratch, you’ll need to know the carb counts in those fruits and veggies, and a carb guide may also be useful for when you’re eating out and don’t have the benefits of checking labels.
Carbohydrate counting can offer people who use insulin more control and greater flexibility in what they eat. If you use fast-acting insulin like Humalog or NovoLog prior to a meal, you can determine how many units you need to take based on both your blood glucose reading prior to the meal and on the number of carbohydrate grams you plan on eating. This is referred to as “covering” your carbohydrates.
The starting point for this “carbohydrate-to-insulin ratio” is about 1:15 (1 unit of insulin for every 15 grams of carbs on the menu). Along with covering the carbohydrates, an additional unit of insulin should be added for every 50 mg/dl that blood sugar is above the target range. For example, if you had 60 grams of carbs on your lunch menu, and your blood glucose levels were 100 mg/dl over your target goal prior to the meal, you would inject 6 units of insulin (4 for the carbs and 2 for the blood glucose). Your mileage may vary; by logging your glucose levels regularly and tracking reactions to meals and insulin, you and your provider should be able to fine-tune your individual ratios.
While most people are now taught carb counting as the method of choice for managing their diabetes, the dietary exchange system is another alternative. It may be preferred by people just learning meal-planning skills, or by those who have difficulty grasping the computations behind carb counting.
The exchange lists are a team effort by the American Diabetes Association and the American Dietetic Association (the two ADAs), and have been in use for over fifty years. There are three food group types represented in the exchange lists: the carbohydrate group, the meat and meat substitutes group, and the fat group. Each list within each group contains foods with a similar carbohydrate, protein, fat, and calorie content.
When you sit down with your dietitian, she will work with you to specify a certain number of each type of exchanges for your meals based on your caloric requirements and nutritional needs. You can think of exchanges like trading cards. Any food on a particular list can be swapped with another on the same list. So if you have one fruit exchange allotted for a snack and have a taste for fresh fruit instead of the juice you had planned, you could trade your ½ cup of orange juice for 1 cup of raspberries, as both have a roughly equivalent carb, fat, and protein value. Remember that you only trade within lists, not across lists. You can’t trade a fruit exchange for a fat exchange, for example.
Some people say they find the exchange system limiting because of the finite number of foods on the “official” exchange lists. Take a walk on the wild side and try something exotic. As long as you have the nutritional breakdown of the food, either on the label or through a food guide or database, you can compute the exchanges. You can also look into purchasing software programs that will help you make the calculations.
For those who like to cook, exchanges can also be computed for mixed meals like casseroles, stews, and soups by totaling the carb, protein, fat, and calories for each ingredient and dividing by the number of servings — the result may be translated into exchanges. You will have to use your measuring tools, however; if you are the “pinch of this, dash of that” type, try to reign in your compulsion and use that food scale. There are dozens of excellent diabetes cookbooks on the market that list full nutritional breakdowns with recipes; The Everything® Diabetes Cookbook by Pamela Rice Hahn is a good choice, as is just about anything published by the American Diabetes Association (ADA).
While carbohydrate counting and dietary exchanges are based on the idea that all carbs are created equal and that the total number of carb grams, not the type of carb (i.e., simple or complex, starch or fruit), is the bottom line for blood sugar control, the glycemic index looks at carb quality instead of quantity.
The GI is a measure of how quickly a carbohydrate affects blood glucose levels. High-GI foods cause quick spikes, while low-GI foods provide a slower, steadier release of glucose. In general, unprocessed, fiber-rich foods tend to be the lowest on the GI scale, while processed and starch-heavy carbohydrates are the highest.
To determine the glycemic index of a food, researchers give a test subject some quantity of the food that contains 50 carbs, and then their blood glucose levels are measured at regular intervals to determine how quickly the carbs in the food turn into glucose. That response is then measured against a standard value of how quickly 50 grams of either glucose or white bread (both 100 on the GI scale) cause blood glucose to rise, and is expressed as a percentage between 1 and 140. The results among a group of testers (usually ten) are averaged to come up with the GI.
Some people with diabetes use the GI as a reference guide for choosing slow, low-GI carbs to keep glucose levels under control and avoid blood sugar spikes. High-GI foods also have their place. If you’re about to go for a quick sprint, you’d want to make sure a pre-exercise carb snack provides the quick release of energy you need. And a fast-acting, high-GI carb is preferable over a low one for treating hypoglycemia.
One important caveat to using the GI as your guide: Don’t become so carb-centric that you lose sight of your overall nutrient intake. The lower-GI food may not always be the best choice from a nutritional standpoint; a Snickers bar has a GI of 44 while a bowl of Cheerios has a GI of 74. Although this may be your perfect justification for satisfying your sweet tooth, it’s obvious that the healthier choice here is the cereal. Keep your vitamin, mineral, protein, and fat intake in perspective.
Another anomaly of the GI is that the system doesn’t make adjustments for the quantity of carbs per serving. Some foods with a high index value simply don’t contain enough carbohydrates per serving to make much of an impact on glucose levels. You’d have to eat more than six servings of cooked beets to get the same amount of carbohydrates in one large baked potato, yet both have a relatively high GI (91 and 121, respectively).
Researchers at the Harvard School of Public Health have come up with a way to bridge this quality versus quantity gap — the glycemic load. To compute the glycemic load of a food, convert its GI percentage value into decimal format (i.e., 91 is equivalent to 0.91) and multiply it by the grams of carbohydrates in one serving. At first glance, you might want to pass up beets based on their GI alone, despite the fact that they are an excellent source of folate and potassium. But although the GI of cooked beets is 91, a ½-cup serving only has 8.46 grams of carbs. That makes its glycemic load only 7.69 (0.91 × 8.46). By comparison, a carb-dense large baked potato has 50.96 carbohydrates (with skin), a GI of 121, and a whopping glycemic load of 62.
The GI is a good tool for making smart food choices. However, it does require a motivated patient who isn’t scared of a little math. And because the GI is not something listed on food labels, it requires a small investment in a book of GI listings. Dr. Jennie Brand-Miller and Dr. Thomas Wolever, two leading authorities on the GI, have coauthored what is arguably the best of the bunch — The New Glucose Revolution, 3rd edition. There are also GI databases available online.
In part because of their relative complexity, the glycemic index and glycemic load have not enjoyed widespread use for diabetes management. But the World Health Organization (WHO) and the European Association for the Study of Diabetes (EASD) have recommended the use of the GI for the nutritional management of diabetes, and the ADA acknowledges that its use “may provide a modest additional benefit over that observed when total carbohydrate is considered alone.” If you’re interested in trying the GI yourself, talk with your dietitian or doctor about how to incorporate it in your meal plan.
You can’t measure every morsel that passes your lips, but it’s a good idea to measure most foods and beverages until you get a feel for portion sizes. It’s a supersized world out there, and most people are surprised to find that their idea of a single serving is actually two or three.
If you’re into bells and whistles, there are food scales that are preprogrammed with nutritional information, as well as scales that will keep a running total of your daily food and nutrient intake for you. The only tools you really need, however, are a simple and inexpensive gram scale, dry and liquid measuring cups, and measuring spoons. Early on, it’s a good idea to run everything that isn’t premeasured through a scale, cup, or spoon first.
Get intimate with your food, or rather, your dishes. Have a favorite mug or bowl? Pay attention to how completely a serving of yogurt or soup fills it up. You’ll soon that find it’s second nature to guesstimate your portion sizes.
There will be times when you can’t use your favorite cup. Pulling out a gram scale at your special restaurant is a little unrealistic. In these cases, it helps to have some rough equivalents for comparison.
Here are some typical serving sizes and some points of reference for estimating portion sizes:
Using your hands to estimate servings is probably the easiest method — you don’t leave home without them. However, make sure you compare your hand amounts against food that has been measured out until you get a sense of how accurately you’re estimating. Of course, if you have particularly large or small hands, you need to adjust for size.
Even for the more experienced portion predictor, it’s a good idea to test your skills at least once a month and measure your guess at a serving size. It’s easy to start overdoing it, and the little bits (and bites) add up. If your control has been off for no apparent reason, one of the first things to check is whether your serving sizes are on target.
Restaurants are notorious for serving up heaping helpings well beyond a single serving size. To keep your intake under control, you can split an entrée, order off the appetizer menu, or simply eat half and take half home. In some restaurants, you may be able to order a child-size portion (but even some children’s menu items may be larger than a single serving).
When planning a meal out, don’t set yourself up for failure. Choose a place that you know offers some food choices that will fit in to your meal plan. Many national restaurant chains, particularly fast-food establishments, will provide nutritional and serving size information on menu items upon request. Ask your server, or look online.
If you must meet at the local greasy spoon — the one that considers lard a food group — fill up on a healthy meal at home first. If you’re on the road or in unfamiliar territory, don’t be afraid to phone first or ask to see a menu at the door before committing to a restaurant choice. Ask questions about ingredients and preparation method. Explain that you’re on a special diet. Some establishments may offer to prepare a dish in an alternate way (e.g., steaming instead of frying it) that isn’t on the regular menu to keep your patronage.
Stay away from the breadbasket, chips and salsa, or other complimentary snacks if you’re fond of munching mindlessly. Look for low-carb appetizers on the menu such as antipasto platters, shrimp remoulade, and smoked salmon. Cut green veggies with a low-carb dip are also a good option.
Because soda is often dispensed from a fountain at restaurants and bars, it isn’t unusual for servers to accidentally substitute regular soda for diet or sugar-free versions. When ordering a diet drink, emphasize the diet. If you’re comfortable with doing so, tell your server you have diabetes — wait staff will usually be more mindful of ensuring your order is right if they know your health is at stake. And if you’re dining with a large group and are concerned about “look alike” orders being confused with yours, ask for a slice of lemon or lime as a garnish to set your drink apart.
Request that all condiments are served on the side so your food isn’t swimming in sauce, and don’t be afraid to request reasonable substitutions. If you have a taste for the steak dinner but the stuffed baked potato will be carb overload, ask to swap it for a double serving of the salad or veggies instead.
When you drink, your liver decides to shut down its regular glycogen storage and glucose production operation, opting instead to concentrate on clearing the alcohol from your body. The result can be hypoglycemia, either while you’re drinking or hours afterward while your liver continues to clear alcohol from the bloodstream. For this reason, you should always eat when you drink, and be on the lookout for symptoms of a low.
If you choose to drink alcohol, it is absolutely essential that you have a nondrinking friend with you who knows how to recognize the symptoms of hypoglycemia and treat them appropriately. Because alcohol can so easily impair judgment, this should be someone you can trust not to drink.
Always eat something when you drink to keep glucose levels up, and be sure to assess any mixed drinks for “hidden” calories and sugar from fruit juices or mixes (and work them into your overall meal plan). A snack before bed is also important if you’ve indulged to ward off overnight lows. And when you’ve been drinking, it’s always a good idea to set your alarm to awaken you for a middle-of-the-night blood test for the same reason.
Even if you choose to abstain or have only one drink, but attend a function where the alcohol is flowing freely, it’s important to have a designated nondrinking buddy who knows what to look out for. Some of the symptoms of a low — confusion, mood swings, and incoherence — can easily be mistaken for intoxication by others (especially if they’ve had a few themselves) and not treated appropriately.
You’ve had a delicious, yet healthy meal and are feeling pleased with yourself for turning down the bacon double-cheeseburger that had been calling your name for broiled fish and steamed veggies. And then — the torture device rolls into view, a dessert cart laden with trays of cheesecake, hot fudge cake, and apple-caramel pie. You can feel your blood sugar rising just looking at it.
You can say “to hell with it!” and order the richest slab of carbs on the cart; grin and bear it while your dining companion savors his slice of pie à la mode; or use the situation as an opportunity to practice moderation. You will not be struck by lightning if you indulge occasionally, provided your splurges are factored in to your overall meal plan. Split a small dessert with a friend, or ask for half now and half in a takeout bag. If the offerings are truly too rich for your blood, promise yourself a favorite low-carb treat on your way home. Don’t deny yourself — it’s not an all-or-nothing game. In fact, the stress of doing so constantly may raise your blood glucose levels higher than the occasional brownie.
Social occasions centered around eating, such as a birthday party, a holiday gathering, or a family reunion barbeque, offer a whole new set of challenges. Well-meaning friends and relatives frequently feel the need to be the food police, asking with every pass of the plate, “Should you be eating that?” The best answer is simple: “Most people with diabetes can eat just about anything you can, in moderation. I have a few books you can borrow that explain more if you’re interested.” With any luck, they’ll take you up on your offer and learn a thing or two. If they don’t, you’ve probably stopped them from pestering you, at least until Thanksgiving.
Even though you can indulge occasionally, if you’ve made a regular habit of junk food, it’s one you’ll have to kick. Still, having many small meals, or minisnacks between meals, can be beneficial to keeping blood glucose on an even keel, and your RD will work these in to your meal plan.
Cut out the fatty fried snacks, sugary drinks and sodas, and sugar-crusted snack pies, and try some of these healthier snack choices instead, all with around 15 grams of carbs (one carb choice) or fewer:
If you haven’t already, at one point in your life you will probably end up with an “Oh, wow!” reading after splurging on something you shouldn’t have. Ask yourself if there was a specific trigger for the slip-up, such as a particularly stressful day at work or going to a party hungry. If you can pinpoint a cause, think about how you can prevent it from happening next time, whether by adjusting your eating schedule or learning some stress management techniques.
It is not the end of the world if you screw up. If you’re too busy kicking yourself, you’ll miss any lesson you might gain from your mistake. Diabetes is a disease of highs and lows, both physically and emotionally. Strive to achieve balance in the emotional area as well as the physical one.