Chapter 8
Other Notable Nutrients
While carbohydrate is the nutrient of primary focus for people with diabetes because of its direct impact on blood glucose, for general good health it’s important to routinely take a step back and maintain sight of the overall eating picture.
As you learned in Chapter 1, there is no “ideal” eating pattern for people with diabetes, but rather a variety of eating patterns that can benefit blood glucose control and lower cardiovascular risk factors. Whether you choose to eat Mediterranean style, vegetarian or vegan, low fat, low carbohydrate, or follow a DASH approach, the core recommendations for overall healthy eating from the Dietary Guidelines for Americans provide general guidance that’s good for people with diabetes, too.
As you step back and evaluate your overall eating patterns, ask yourself:
Do you avoid eating too much . . .
• Saturated fat?
• Trans fat?
• Cholesterol?
• Sodium?
• Added sugars?
Do you get enough . . .
• Protein?
• Dietary fiber?
• Potassium?
If you’re not sure what “too much” or “enough” means, read on and you’ll quickly learn!
Because maintaining heart health (including blood pressure control) and kidney health is particularly important for people with diabetes, let’s delve a little deeper into the nutrients with a specific impact in those arenas, including:
• Protein
• Fats
• Dietary fiber
• Sodium
• Potassium
Protein
As you recall from Chapter 2, protein is one of the three building blocks of the foods we eat. (Carbohydrate and fat are the other two.) Protein supplies energy and helps ward off hunger. Protein also helps build, repair, and maintain body tissues. Everybody needs protein to power their bodies regardless of whether they have diabetes or not.
Which Foods Have Protein?
Protein is found in many foods. Good protein sources include meat, poultry, and fish; eggs; milk, cheese, and yogurt; soy, beans, and lentils; and nut butters. Vegetables, cereals, and grain products also contain some protein but in much smaller amounts.
An additional consideration with protein foods is that they may contain some fat. And, as you likely know, the amount of fat varies depending on the food. A good rule of thumb is to aim for 5 grams of fat or fewer per ounce of protein. Check out the nutrition information label to learn about the fat content of proteins you eat and to look for “hidden” carbohydrate, which you’ll find in many plant-based proteins sources, such as beans, veggie burgers, or hummus. Think about the protein foods you eat.
How Much Protein Is Enough?
With the popularity of 10-ounce steaks and 3-egg omelets, there is certainly no shortage of protein in the average American diet. Most Americans get plenty of protein, but could benefit from lower-fat, lower-cholesterol, and more varied protein selections to improve nutrient and health benefits. Take this into particular consideration if you choose to embrace a low-carbohydrate (and thus higher-protein) eating pattern.
The amount of protein you need depends primarily on your age, sex, and level of physical activity. While your registered dietitian/registered dietitian nutritionist and diabetes health-care team can help confirm exactly how much protein is best for you, generally 5–6 ounces per day will cover your basic needs. To put that in perspective, the size and thickness of an average woman’s palm is about the size of a 3–4-ounce protein serving, whereas the size of the average man’s palm is closer to 5–6 ounces.
6 Protein Pointers
1. Keep it lean. Choose lean cuts of meat and poultry. They have less saturated fat and cholesterol than higher-fat meats, and thus are more heart healthy. (More information on fats follows later in this chapter.) Aim for 5 grams of fat or less per ounce of protein and trim away any visible fat. Keep it lean by grilling, baking, or broiling proteins and using nonstick skillets with cooking spray for “frying.” Clue words for lean cuts of meat include:
• “90% lean” (or higher)
• “Chuck”
• “Flank”
• “Loin”
• “Round”
• “Tenderloin”
2. Flip for fish at least twice a week. Many types of fish—including halibut, herring, mackerel, salmon, sardines, trout, and tuna—are rich in heart-healthy omega-3 fats (reviewed later in this chapter). The more often you can work in fish, the better. Fried fish doesn’t count, though!
3. Go meatless a couple days a week. Make beans, lentils, or soy products the focus of your meals. While adding variety, this will also save you money because these protein sources cost less than meat, poultry, and fish. Try black bean soup, tempeh vegetable stir-fry, or red beans and rice. Not sure about going meatless? Start with one day each week, or by beginning the week with “Meatless Mondays.”
4. Nibble on nuts, seeds, and nut butters. A small handful of almonds, pistachios, soy nuts, or walnuts provides crunch, protein, and heart-healthy fats. Sprinkle a few pine nuts or sunflower seeds on a salad or a few crushed pecans on oatmeal or yogurt. Lightly spread a slice of whole-wheat toast with peanut butter, almond nut butter, or soy nut butter. Don’t go nuts on portion sizes, though—the calories can add up quickly!
5. Mix it up with lean, soy-based proteins. Try soy-based meat alternatives, such as soy-based “bacon,” or meatless “beef” or “sausage” crumbles. Snack on soy nuts. Toss tofu or tempeh into soups, casseroles, or stir-fries. Substitute a veggie burger at lunch. Enjoy edamame as a side or snack.
6. Eggs to the rescue. As a budget-friendly alternative to meat, switch in an egg. To help keep dietary cholesterol in check, eat egg yolks and whole eggs in moderation, especially since one egg yolk has as much cholesterol in it as you should eat in an entire day. Egg whites and yolk-free egg substitutes have no dietary cholesterol and little to no fat, so they are a heart-healthy alternative to whole eggs.
Fat
For the purposes of this discussion, we’re talking about dietary fat (the fat that you get from foods and beverages) and the effect that dietary fat ultimately has on your blood fat levels (lipids) and overall health.
Fat is another of the three building blocks that make up the foods you eat. All fats are high in calories, containing more than double the calories of carbohydrate or protein on a per-gram basis. Because fats often get a bad rap (particularly in relation to weight and heart health), you may be surprised to learn that fats have important health functions. Some fat is necessary in your diet, and there are actually healthy fats.
Meet the Fats
Although fat is often referred to in a general sense, there are actually three main categories of fat:
1. Unsaturated fats. These are the “healthy” fats and come primarily from plant sources. (Think avocado, canola oil, corn oil, olives, and peanuts.) The two types of unsaturated fats to get familiar with are:
• Monounsaturated fats
• Polyunsaturated fats
2. Saturated fats. These are the “unhealthy” solid fats that come primarily from animal sources. (Think bacon, butter, cream cheese, and lard.)
3. Trans fats. These are “unhealthy” fats that are created in food processing when liquid vegetable oils are transformed into semi-solid fats. (Think stick margarine and vegetable shortening.) At the time this book was published there were efforts in place to remove the artificial trans fats created in food processing from products on the market.
See Table 8.1 for examples of each of these three types of fat.
What Are Omega-3 Fats?
Omega-3 fat is a notable type of polyunsaturated fat with heart-health benefits. You may be familiar with omega-3 fat as the “fish fat.” Fish (especially fatty fish) are indeed rich in heart-healthy omega-3 fat, so eat fish at least twice a week. (Fried fish does not count!) Omega-3 fat is not just found in fish. Other significant food sources of omega-3 fat include:
• Walnuts
• Flax
• Soy
• Canola oil
Eating more omega-3 fat may help reduce your risk for heart disease by decreasing total cholesterol and triglycerides.
What about Cholesterol in Foods and Beverages?
While dietary cholesterol (cholesterol found in foods and beverages of animal origin) is not really a fat but rather a waxy, fat-like substance, it does raise blood cholesterol levels. The main dietary culprits in raising blood cholesterol, however, are saturated and trans fats.
Any reduction in dietary cholesterol may be beneficial to blood cholesterol levels. Foods and beverages with an animal origin that you might focus on modifying include dairy products, cheeses, and meats.
Blood Fats (Lipids) Explained: Getting to the Heart of the Matter
If you’ve had your blood fat (lipid) levels checked recently, you may want to know what it all means. Table 8.2 provides a quick overview of the types of blood fats and the target levels for each type.
Scientific studies suggest that a diet high in saturated fats, trans fat, and cholesterol increases the risk for unhealthy levels of blood cholesterol and, therefore, heart disease. If your blood lipids are above target, the type of fat that you eat is extremely important. Further review follows later in this section on fat quality.
All Fats Are Not Created Equal
As you’ve seen, different fats have differing effects in your body. Just as choosing high-quality foods is key to healthy eating, so is choosing high-quality fats. High-quality fats are the “better-for-you” unsaturated fats—the plant-based fats—reviewed earlier in this section. The Mediterranean style of eating (discussed in Chapter 1) is rich in these heart-healthy, high-quality plant-based fats and may benefit blood glucose control as well, so it can be recommended as an effective alternative to a lower-fat, high-carbohydrate eating pattern.
10 Simple Switches to High-Quality Fat
• Top your morning whole-grain toast or english muffin with almond butter, cashew butter, or peanut butter rather than butter.
• Try almond milk on your morning cereal, rather than full-fat milk.
• Add avocado to a salad or drizzle avocado slices with a splash of balsamic vinegar and olive oil and a sprinkle of sunflower seeds.
• Mash and spread avocado on a sandwich instead of mayonnaise.
• Add crunch to a salad with almonds, pecans, pistachios, pumpkin seeds, toasted sesame seeds, or sunflower seeds instead of bacon.
• Rather than adding butter or bacon drippings to vegetables, try a drizzle of olive oil.
• Switch out canola oil or corn oil for lard or shortening in cooking.
• Lightly dip crusty bread in olive oil rather than slathering with butter.
• Spread on a plant-stanol-ester “buttery” spread or low-fat, trans fat–free margarine rather than butter.
• Choose olives over cheese for an evening appetizer.
Takeaway: The quality, or type, of fat you eat is more important than the quantity, or total amount, of fat you eat. To improve the quality of fat that you eat, substitute unsaturated plant-based fats for solid saturated and trans fats when possible.
How Much Fat Is Enough?
While there is definite consensus that high-quality fat is the way to go, there is no conclusive “ideal” recommended daily amount of fat. Needs vary from person to person. Think about it—fat equals calories. If you’re a runner, or an otherwise highly active individual, you need more calories than someone who is sedentary. Therefore, you could potentially eat more fat (high-quality fat) than someone trying to lose weight, who may accomplish his/her health goals more effectively with a lower-fat, and thus lower-calorie, eating pattern.
A generally acceptable range for fat intake is 20–35% of total daily calories, according to the Institute of Medicine. So, doing the math, that would mean 45–78 grams of fat per day for an average 2,000 calories. Moderation is really the mantra because all fats are high in calories. And that’s an especially important consideration if you’re trying to lose weight or maintain weight loss.
5 General Tips to Trim Fat and Meet Your Goals:
1. Choose lean cuts of meat and poultry and trim off visible fat. (See “Six Protein Pointers” earlier in this chapter for more protein tips.)
2. Choose low-fat and fat-free dairy products.
3. Choose baked and grilled foods more often and fried foods less often.
4. Order sauces and dressings on the side when dining out so you can control the amount that goes on your food.
5. Practice portion control. The amount of fat that you eat depends not only on what you eat, but also on how much you eat.
Get the Facts on Fat
While you’re now equipped with a number of tips to improve the quality of the fats you eat, keep in mind that many foods have a combination of these different fats. The more often you emphasize the sources that are rich in unsaturated fat over saturated and trans fats, the better.
To learn about the fat content of the foods and beverages you eat and drink, turn first to nutrition information labels to familiarize yourself with the amounts and types of fats and cholesterol. If a label is not available, you can learn about the fat in a food or beverage through reliable, free online databases, Internet searches by brand, or mobile apps. Check out the serving size for the food, too. Remember, if the amount you actually eat is more like double or triple one serving, then you’re eating double or triple the fat and other nutrients, too.
Summary—Fat Guidelines for People with Diabetes
• Keep total fat to 20–35% of your daily total calorie intake.
• Trim saturated fat to <10% of your total calories for heart health.
• Limit trans fat as much as possible. Avoiding it is best.
• Hold cholesterol intake to <300 mg per day.
• Eat two or more servings of fish each week (but not fried fish).
• Include 1.6–3 grams per day of plant stanols or sterols (by eating phytosterol-enriched foods) if you have high blood lipids.
Consult with a registered dietitian/registered dietitian nutritionist and your diabetes health-care team for help understanding these numbers and determining individualized goals for you.
Dietary Fiber
Dietary fiber also deserves mention because it plays an important role in promoting good health. Sometimes referred to as “roughage,” dietary fiber is the indigestible portion of plant foods. Fiber is what gives plants shape. Your body cannot digest or absorb fiber, so instead of being used for energy, fiber just passes through your body. Just as fiber provides shape and bulk to plants, it bulks up the contents of your intestinal tract. While fiber is passing through, it provides a number of positive health benefits:
• Fiber aids digestion.
• Fiber promotes bowel movement regularity and colon health.
• Fiber lowers the risk of some diseases, including heart disease and cancer.
It is for these health benefits that a high-fiber eating pattern is encouraged for people with diabetes (as for the general public). Mediterranean-style, vegetarian and vegan, and DASH eating patterns (all reviewed in Chapter 1) can help you achieve a fiber-rich diet.
More about Whole Grains
Whole grains are foods containing the entire grain kernel—the bran, germ, and endosperm. Familiar examples of whole grains include brown rice, oatmeal, popcorn, and quinoa. (Check out the Mediterranean Quinoa Salad recipe.)
Research has concluded that eating whole grains is not associated with improved blood glucose control in type 2 diabetes; however, it does provide other health benefits, including reducing cardiovascular disease risk. So go for more whole grains!
How Much Dietary Fiber Do You Need?
Because of the general health benefits of fiber and whole grains, people with or at high risk for type 2 diabetes should make at least half of their grains whole grains, as is recommended for the general population. Most Americans fall short on the amount of fiber and whole grains in their eating patterns. The average American gets around 15 grams of fiber per day, whereas the recommended healthy amount is 14 grams for every 1,000 calories consumed, which means about 25 grams daily for adult women and 38 grams daily for adult men.
The good news is that you don’t have to eat huge portions of plant foods to get the daily 25–38 grams of fiber! Replacing a morning granola bar with a tasty high-fiber cereal bar (such as Fiber One bars) easily meets up to one-third of your daily fiber goal. Focus on fiber from food sources rather than supplements, and consult with your health-care team about how much fiber is right for you.
As you’ve seen, eating patterns rich in fiber have many health benefits. However, to recognize improvement in blood glucose, you would have to eat >50 grams of fiber per day, which isn’t realistic for most people. Achieving and maintaining a fiber intake of 50 grams per day can be a challenge since fiber isn’t always palatable; it’s hard to consume that amount consistently on a daily basis, and eating large amounts of fiber can bring some uncomfortable side effects (including gas, bloating, and diarrhea).
Soluble or Insoluble?
Although focusing on total daily fiber consumption is the goal for most people, the two different types of fiber deserve mention. They are soluble fiber and insoluble fiber.
Soluble fiber is a type of fiber that dissolves in water and is found in foods such as legumes, barley, oats, and nuts. Research shows that certain soluble fibers (such as those in oat bran cereal, black beans, and pinto beans) lower blood cholesterol levels and may slightly slow glucose absorption. However, most people consume so little soluble fiber that its effect on blood glucose control is fairly insignificant.
Insoluble fiber does not dissolve in water and is found in many plant foods including whole wheat, whole grains, seeds, nuts, brown rice, fruits, vegetables, and root-vegetable skins (such as potato skins). Insoluble fiber absorbs water, bulks up the stool, and sweeps matter through the colon. You may hear insoluble fiber referred to as “nature’s broom.” Insoluble fiber may help prevent and treat constipation, but it has no effect on blood lipids.
Your best bet is to try to get a combination of both types of fiber.
Sodium
Why the Concern about Sodium?
Too much sodium can lead to significant health problems aside from bloating and swelling. One big concern is high blood pressure, which is common among many people with type 2 diabetes. High blood pressure, in turn, may increase your risk for heart disease, stroke, and kidney disease. There is wide agreement in the health-care world that the average American’s sodium intake of 3,400 mg/day (excluding sodium added from table salt) is excessive and should be reduced. For people with diabetes, as for the general public, the goal is to scale sodium down and hold your overall daily sodium intake to 2,300 mg or less. To put that in perspective, 1 teaspoon of salt contains about 2,300 mg of sodium. However, one too many shakes from the saltshaker is not the main source of sodium in Americans’ diets.
You’ve probably picked up on the fact that the terms “sodium” and “salt” are often used interchangeably, though here’s an important distinction between the two: Sodium is a natural mineral that is also a component of salt (salt = sodium + chloride). Sodium may be naturally present in foods, or sodium may make its way into foods under the guise of “salt.” Any way you look at it, less sodium and less salt is the way to go.
Finding Sodium
Review nutrition information labels to find out the sodium content of foods; this will guide you in making lower-sodium choices. Although labels may grab your attention with a claim that a food is “low sodium” or “reduced sodium,” check the exact sodium content on the nutrition information panel to see how it measures up against your sodium goals. Single servings of a food with >400 mg of sodium and entrées with >800 mg of sodium are too high in sodium.
Sodium Claims on Labels—Breaking it Down
• Salt/Sodium-Free: <5 mg of sodium per serving
• Very Low Sodium: 35 mg of sodium or less per serving
• Low Sodium: 140 mg of sodium or less per serving
• Reduced Sodium: At least 25% less sodium than in the original product
• Light in Sodium or Lightly Salted: At least 50% less sodium than the regular product
• No Salt Added or Unsalted: No salt is added during processing, but the product is not necessarily sodium-free
Do You Savor the Flavor of Salt?
The taste for salt is an acquired taste. Just as you can become acclimated to the taste of salty foods, you can “unlearn” that taste preference just as easily—in as little as a week—as we see in many of our patients. So, over time, the less salt and sodium-rich foods you eat, the lower your salt threshold or preference will become. You’ll be able to taste the salt at lower amounts. For instance, a regular salted-top cracker may taste too salty once you acclimate to lightly salted crackers.
Resetting Your Salt Preference
While working toward “resetting” your salt preference or threshold, focus on adding in other flavorful ingredients and begin to appreciate the natural flavor of your food. We’ll never forget hearing a patient proclaim, “Wow, I never realized how flavorful green beans are. Now that I’ve gotten used to less salt, I am appreciating their natural flavor.”
Considering a salt substitute? If you are considering using a salt substitute, such as “lite” salt, check with your doctor first. Salt substitutes generally contain potassium chloride, which can be a problem for people with certain heart conditions, kidney problems, or who take certain medications.
Potassium
Research shows that eating foods high in potassium can lower blood pressure by reducing the adverse effects of sodium on blood pressure. Examples of foods rich in potassium include:
• Apricots
• Bananas
• Beans
• Greens
• Lentils
• Nuts
• Milk
• Orange juice
• Potatoes
• Prune juice
• Soybeans
• Spinach
• Sweet potatoes
• Tomatoes, tomato products, and tomato juice
• White beans
• Yogurt
Unless your doctor has advised you to limit potassium because of another health condition, include potassium-rich foods more often.
Next Steps
• Keep a record for 3–4 days of everything that you eat and drink. Take inventory of whether you could switch out some foods to improve your fat quality, trim sodium, and boost your fiber.
• Check the portion sizes of your meat servings. Are they the size of your palm?
What Do I Eat for Dinner?
For 45–60 Grams of Carbohydrate*
Recipe: Hoppin’ John (1 serving)
3 ounces diced cooked chicken breast added to recipe
2 cups green salad
1 tablespoon oil and vinegar dressing
For 60–75 Grams of Carbohydrate*
Recipe: Hoppin’ John (1 serving)
3 ounces diced cooked chicken breast added to recipe
2 cups green salad
1 tablespoon oil and vinegar dressing
1 1/2 cups mixed berries
1 tablespoon light whipped topping or vanilla greek yogurt
*For most women, 45–60 grams of carbohydrate at a meal is a good starting point; for most men, 60–75 grams of carbohydrate per meal is appropriate. Check with your diabetes health-care team to find the amount of carbohydrate that’s right for you.
Swift, Simple Tips
• Use bagged salad greens.
• Try frozen (thawed) mixed berries with no sugar added if fresh berries are not in season.
Hoppin’ John
Serves: 5 / Serving Size: 1 3/4 cups (or 10 ounces)
Preparation Time: 15 minutes / Cooking Time: 15 minutes
Ingredients
2 (15-ounce) cans no-salt-added black-eyed peas (or rinse and drain peas, if a no-salt-added version is unavailable)
1 (14.5-ounce) can diced tomatoes seasoned with basil, garlic, and oregano, drained
1 bag boil-in-bag brown rice
3/4 cup finely shredded part-skim mozzarella (finely shredded provides more ample coverage than a regular shred)
1 1/4 cups coarsely chopped red onion
1 1/4 cups coarsely chopped green bell pepper
1/4 cup fat-free sour cream
1. Combine black-eyed peas and drained tomatoes in a pan, stirring gently to combine. Warm over low heat, gently stirring periodically.
2. Meanwhile, cook rice according to package directions, omitting any salt. Drain well.
3. In an 8 × 12-inch serving dish, or platter of equal size, layer the rice and evenly top with pea and tomato mixture. Sprinkle evenly with cheese, onion, and bell pepper. Top with small dollops of sour cream.
Choices/Exchanges
2 1/2 Starch, 2 Vegetable, 1 Lean Protein
Calories 290
Calories from Fat 40
Total Fat 4.5g
Saturated Fat 2.1g
Trans Fat 0.0g
Cholesterol 10mg
Sodium 360mg
Potassium 590mg
Total Carbohydrate 48g
Dietary Fiber 8g
Sugars 7g
Protein 16g
Phosphorus 290mg
Food for Thought
• Monitor protein portions and keep them close to the size of your palm.
• Choose lean proteins and keep them that way by using low-fat cooking methods.
• Choose heart-healthy monounsaturated and polyunsaturated fats more often and minimize food sources of saturated fat, trans fat, and cholesterol.
• Eat fish more often (at least twice a week).
• Aim to eat 25–38 grams of fiber each day.
• Keep your daily sodium intake at 2,300 mg or less.
• Moderation is the bottom line!