DIABETES AND FOOD | Added: 12, August 2017



MAJOR FOOD COMPONENTS AND DIABETES

What are some targets recommended by the American Diabetes Association in terms of food components?

According to the American Diabetes Association’s nutritional guidelines, targets are suggested for the many food components. The following lists those food components and the amounts that are recommended daily:

Recommended Amounts of Food Components

Component

Daily Recommended Amount

Saturated fat

Less than 7 percent of total daily calories

Trans fat

Very minimal amounts, if any

Cholesterol

Less than 200 milligrams per day

Protein

Around 15 to 20 percent of total daily calories

Fiber

At least 14 grams per 1,000 calories a day

Sodium

No more than 2,300 milligrams per day*

*This amount is highly debated; for more about the controversy surrounding the intake of sodium, see this chapter.

Do some foods fight diabetes?

Yes, some foods-too many to mention in this text-seem to help fight diabetes, although the “help” from these foods is often controversial. Although many health care professionals do not advocate its constant use, vinegar has been shown to improve insulin sensitivity, and it may stop the after-meal spikes in a person’s blood glucose levels, too. In one study, participants with type 1 diabetes drank a vinegar-water solution or plain water five minutes before eating a carbohydrate-heavy meal. Participants who drank the vinegar mixture cut their rise in blood glucose levels by almost 20 percent in comparison with those who drank only water. Even as little as 2 tablespoons of vinegar with a meal helped to stop spikes in blood glucose levels. In addition, lemon juice may have the same effect. It is thought that both vinegar and lemon juice have acid, which slows down a person’s digestion, so the body absorbs sugar in the food more slowly. Another possible food contender to help diabetes is the white button mushroom. Found commonly in most grocery stores, these mushrooms are funguses filled with nutrients (vitamins C, D, B2 [riboflavin], and folate), fiber, and many antioxidants-all of which are thought to help lower blood glucose levels in people with diabetes.

If a little vinegar is consumed before a meal with carbs in it, blood glucose will rise less.

WHAT ARE FOOD EXCHANGES?

What are “food exchanges” in the context of food and diabetes?

Food exchanges put together groups of foods that have a similar combination of carbohydrates, fat, protein, and calories. The “exchange” comes from the idea that a person can exchange one food serving for another, depending on the carbohydrate amount. According to the Diabetes Teaching Center in San Francisco, foods with a similar amount of carbohydrates per serving size are grouped together (remember, serving size is different from portion size; for more, see this chapter). This way, people can manage the amount of carbohydrates they eat in a meal.

How does a person use the exchange list?

To use the exchange list, a person chooses various foods based on their carbohydrate, fat, protein, or calorie content. This is a good way to keep blood glucose levels more stable and make meal planning easier. There are also exchanges for fats and proteins, although most people with diabetes concentrate on counting carbohydrates to manage their condition. For example, one carbohydrate exchange is equal to 12 to 15 grams of carbohydrate. This group is generally broken down into bread/starch, meats and meat substitutes, fruit, milk, fats, and vegetables. When a meal plan reads “2½ carbohydrate 2 exchanges” (equal to 1 bread/starch, 1 fruit, ½ milk), it means a person can have, for instance, a slice of bread, a fresh peach, and a half cup of nonfat yogurt-or the equivalent carbohydrate exchanges if the other food sources (bread/starch, fruit, and milk) are also equivalent to 2½ carbohydrate exchanges. (For a short list of food exchanges, see Appendix A.)

DIABETES AND GLYCEMIC NUMBERS

What is a glycemic index?

The glycemic index (GI) is an important tool for diabetics as it gives a numerical ranking to foods based on the rate of their conversion to glucose in the body. The scale is from one to 100, with pure glucose (sugar) being the standard at 100. The lower numbers represent a low rise in blood sugar after a certain food is consumed; the higher numbers represent a more rapid rise in blood sugar after a certain food is consumed.

Why do some health care professionals not agree with using the glycemic index?

Although the glycemic index (GI) does prove to be a useful tool, it is not a perfect system. One reason is that the GI ranking applies only when you eat something on an empty stomach-and most people eat many foods together at a meal. Another reason is that the GI doesn’t take into consideration how much a person actually consumes. It is based on a serving of food that contains 50 grams of carbohydrates minus the fiber, then measuring the person’s blood glucose levels over two hours. Because of these inherent problems, the glycemic load was developed.

What is a glycemic load?

Not all foods will immediately give you a boost-even if the item has a high glycemic index. What also becomes important to a person with diabetes is the glycemic load, or the body’s response based on the glycemic index and the amount of whatever carbohydrate is consumed. For example, even though a piece of candy has a high glycemic index, if it is small, it will have a relatively small glycemic response. According to the Harvard School of Public Health, where the idea of the glycemic load was developed, the glycemic load is equal to the glycemic index over 100, then multiplied by the net carbohydrates (that is, equal to the total carbohydrates minus the dietary fiber). Thus, people with diabetes eat both low-glycemic-index foods and restrict their carbohydrates in order to control their diabetes. (For information about foods and their glycemic index and load, see Appendix B.)

DIABETES AND CARBOHYDRATES

What are carbohydrates?

Carbohydrates are a major source of energy for cells and activities within the cells, which means they provide energy for the entire body. They are commonly known as sugars and starches and are organic compounds made up of carbon, hydrogen, and oxygen. They are also the major source of energy for cells and cellular activities and for providing energy for a person’s entire system. In terms of foods, some of the best sources of carbohydrates are legumes, grains, potatoes, and many vegetables and fruits.

Why are carbohydrates a major part of the human diet?

All human cells have evolved so that carbohydrates are the body’s primary energy source. In fact, the body’s entire metabolic system begins with glucose. In general, the digestive system changes carbohydrates into glucose, which is then used for energy for cells, tissues, and all the body’s organs.

Which is a better source of energy for the body-carbohydrates or fat?

In general, fats contain nine kilocalories (indirectly, a form of energy) per gram, while carbohydrates average about four kilocalories per gram. Thus, fats are useful for storing energy, but sugars are easier to break down during metabolism. But no one truly agrees which source of energy is “better.” Perhaps the answer lies in individual situations. For example, babies require fat in their diets for both energy and to build a healthy nervous system, whereas many middle-aged adults often consume too much fat for their body’s metabolic requirements-often leading to their becoming overweight.

Foods rich in carbohydrates are a staple of people’s diets because glucose is a main source of energy.

Why is the role of carbohydrates in the human diet so highly debated?

The role of carbohydrates in our diet is a hotly debated subject, and the reason why is clear: Many popular diets, especially a low-carbohydrate diet, propose that the only way to lose weight is to eliminate carbohydrates. Because of such “trend” diets, for many people, the word “carbohydrate” has become inherently bad. But there seems to be more of a case for the other side. Carbohydrates are fuel for the brain, nervous system, muscles, and various organs. In fact, they are more high-quality fuels than fats and proteins, mainly because it takes little for the body to break them down and release their energy. Thus, the body metabolizes these simple carbohydrates (sugar) and starches into glucose (blood sugar), which becomes the body’s primary fuel source-as long as carbohydrates are eaten in moderation.

Is fiber a form of carbohydrate?

Yes, fiber is another form of carbohydrate, one that has many major health benefits. For example, whole grains are important for reducing the risk of colon cancer and keeping the body’s digestive tract in good working order. Many long-term studies have shown that a diet with the most whole grains and cereal fibers-especially nutrient-rich grains and fibers that are less milled or processed-can provide protection from certain cancers, heart disease, and even type 2 diabetes.

How were carbohydrates once classified, and why was the classification changed?

In the past, carbohydrates were classified as being simple or complex. The simple carbohydrates were considered to be those composed of sugar, such as glucose and fructose. They were the carbohydrates that because of their simple structure were easily and quickly used in the body for energy, increasing blood glucose and insulin secretions. They were also known as carbohydrates that could have negative health effects. The complex carbohydrates were those with the more complex chemical structures, with three or more sugars linked together. They were considered to be foods that contained fiber, vitamins, and minerals and took longer to digest, thus causing blood glucose to rise more slowly. Not all the complex carbohydrates were nutritious, either, especially such foods as white bread and potatoes, which contain mostly starch.

The reason for the change in classification was that these two divisions did not account for the effect of carbohydrates on blood glucose levels and chronic diseases. Therefore, more minute divisions of carbohydrates have been developed to indicate how these organic compounds affect the body. The glycemic index, and later the glycemic load, were developed to better represent carbohydrates, foods, and the body.

How are carbohydrates currently classified?

In recent years, carbohydrates have been classified in several different ways. For example, they are classified by their overall length (monosaccharide, disaccharide, and polysaccharide), and often these classifications are broken down into smaller units. Thus, monosaccharides (single-unit sugars) are further grouped by the number of carbon molecules they contain, including triose (three carbon molecules), pentose (five), and hexose (six). Carbohydrates are also classified by function. For example, storage polysaccharides (glycogen and starch), which store energy, and structural polysaccharides (cellulose and chitin) are both categorized based on function.

What are some of the uses of carbohydrates by the body?

Various carbohydrates have different functions in the human body. The following chart identifies some common carbohydrates-some associated with diabetes, others not-and their general functions:

Carbohydrate Name

Type

General Function in the Body

Deoxyribose

monosaccharide

DNA (deoxyribonucleic acid) is a major constituent of hereditary material

Ribose

monosaccharide

Constituent of RNA (ribonucleic acid)

Fructose

monosaccharide

Important in cellular metabolism

Galactose

simple monosaccharide

Found in brain and nerve tissue

Glucose

monosaccharide

Main energy source for the body’s cells

Lactose

simple disaccharide

Milk sugar; helps the absorption of calcium

Sucrose

simple disaccharide

Produces glucose and fructose

Cellulose

polysaccharide

Not digestible but is an important fiber that provides bulk for the proper movement of food through the intestines

Glycogen

polysaccharide

Stored in the liver and muscles until needed as an energy source and is then converted to glucose

Heparin

polysaccharide

Prevents excessive blood clotting

What are some sources of the various carbohydrates and their effect on blood glucose levels?

There are numerous sources for the various carbohydrates, some that raise a person’s blood sugar rapidly and others that do so slowly. The following lists the name of the carbohydrate, type of carbohydrate, how fast it raises blood glucose levels, and which foods contain the carbohydrate (note: two starches in this list have a different response in the body, depending on whether it is a straight- or branched-chain type of starch):

Dairy products such as milks and cheeses contain the sugar lactose, which will raise blood sugar, but it will do it more slowly than maltose or fructose.

Maltose-Maltose, or malt sugar, is a simple disaccharide made up of two glucose units; thus, it raises blood glucose levels extremely fast. It is produced during the breakdown of starches.

Dextrose-Dextrose is a simple disaccharide that raises the blood glucose levels very rapidly; it is found in many candies and in diabetic products, such as those meant to treat hypoglycemic events (also known as glucose tablets).

Sucrose-Sucrose is a simple disaccharide that raises blood glucose levels quickly; it is found in simple table sugar and in fruits, vegetables, and grains.

Starch-Starch is a straight chain and is made up of long chains of glucose; it raises the blood glucose levels swiftly and is found in potatoes, rice, bread, and cereals.

Fructose-Fructose is a simple monosaccharide that raises the blood glucose levels moderately quickly; it is found in such foods as table sugar, fruit, molasses, and honey.

Lactose-Lactose, also called milk sugar, is a simple disaccharide; it raises blood glucose levels slowly. It is found in milk and dairy products.

Galactose-Galactose is a simple monosaccharide that raises blood glucose levels slowly; it is found in milk and dairy products.

Starch-Starch (a different one than listed above) is a branched chain that raises blood glucose levels very slowly; it is found in legumes and pastas.

Fiber-Fiber is a complex polysaccharide that raises blood glucose levels very slowly; it is found in fruits, vegetables, and legumes.

Why are carbohydrates a highly debated subject in the context of type 2 diabetes?

Carbohydrates are definitely a debated subject when it comes to type 2 diabetes. In particular, some researchers suggest that it is actually an overabundance of carbohydrates in the diet that leads to people’s being excessively overweight. They believe that the ups and downs of glucose levels after carbohydrate ingestion eventually cause the pancreas to “wear out,” or stop functioning well, leading to type 2 diabetes. (For more about this controversy, see the chapter “Diabetes and Obesity.”) But overall, recent research has shown that people develop type 2 diabetes for many reasons.

DIABETES, FIBER, AND FATS

What is fiber?

Fiber (also called dietary fiber) is a type of carbohydrate that cannot be broken down by digestive enzymes. Because of this, fiber passes through the digestive tract more quickly, aiding in elimination. There are two basic types of fiber: insoluble and soluble. The insoluble fibers help to move food through the digestive tract, while the soluble fibers help to slow down food in the digestive tract. Because both types of fiber absorb water, in most cases, they help treat and prevent constipation. The soluble fibers dissolve in water and stick together. Fibers include such foods as oatmeal, oat bran, lentils, barley, and even pectin-rich fruits such as apples and strawberries. Insoluble fiber does not dissolve in water; it passes through the digestive system chewed but otherwise unchanged. Insoluble fibers include such foods as the edible skins of many fruits (such as apples, pears, and peaches), wheat bran, brown rice, and whole-wheat products.

What are fibrous carbohydrates?

Fibrous carbohydrates are not like sugar or starch carbohydrates, as the body cannot use them for energy, but they are still important for the body’s overall health. In fact, “fibrous carbohydrate” is merely another name for “fiber.” (For more about carbohydrates, see this chapter.)

What is the difference between a lipid and a fat?

These two terms are often confused. In reality, “fats” are a category of lipids, but everyone uses the terms interchangeably. Lipids are bio-organic molecules that are hydrophobic (they do not mix with or dissolve in water), but they can be dissolved in certain organic solvents such as ether, alcohol, and chloroform. Besides fats, lipids include oils, phospholipids, steroids, and prostaglandins.

Why are fats important to the human body?

Fats are energy-rich molecules that are used as an internal source of energy for the body. They are stored in the form of triacylglycerols, or what are commonly known as triglycerides (for more about triglycerides, see the chapter “How Diabetes Affects the Circulatory System”). Fats also provide the body with insulation, protection, and cushioning (especially of the body’s organs) and help the body absorb certain vitamins, including vitamins A, D, E, and K.

Bacon, eggs, and grease all contain lots of saturated fats, increasing the bad LDL cholesterols in the blood when consumed. This, in turn, can lead to insulin resistance and glucose intolerance.

What is the difference between saturated and unsaturated fats?

Saturated fats are solid at room temperatures (except palm, palm kernel, and some coconut oils) and include most animal fats (meat, poultry, eggs, and dairy, such as beef, butter, and cheeses). Saturated fats are often associated with raising blood cholesterol. This usually occurs because saturated fats interfere with the removal of cholesterol from the blood.

Unsaturated fats (or the polyunsaturated and monounsaturated fats) have been known either to lower or to have no effect on blood cholesterol. But when polyunsaturated fats are hydrogenated, they become them firmer and more like saturated fats. They can then affect the body’s blood cholesterol in the same way that saturated fats do. Monounsaturated fats are liquid at room temperature; they include olive, canola, and peanut oils, along with some nuts, seeds, and avocados. These fats are also considered helpful to human health (when eaten in moderation), as they are often associated with lowering the bad LDL cholesterol levels in the blood.

Can excessive amounts of saturated fats increase the risk of diabetes?

Many foods can increase the risk of developing type 2 diabetes, including saturated fats, such as those found in high amounts in desserts like cheesecake and ice cream. The saturated fats definitely affect a person’s immune system. The immune cells believe the saturated fats are foreign invaders and start pumping out inflammation-causing compounds, which are linked to diabetes. In fact, in one study, mice that had healthy immune systems and were fed a high-fat diet eventually developed glucose intolerance and insulin resistance, both precursors to type 2 diabetes.

Can a high-fat meal raise blood glucose levels?

Yes, although they are not as “efficient” at raising blood glucose, fats can contribute to a rise in glucose levels. In general, a high-fat meal can cause an increase in what are called free fatty acids (FFAs) in the bloodstream. Higher levels of FFAs in a person’s blood usually indicate more ingestion of high-fat meals, especially including highly saturated fats. Higher FFAs, along with obesity, are often found in people with liver insulin resistance. (For more about the liver and insulin, see the chapter “How Diabetes Affects the Digestive System.”)

Liver insulin resistance caused by higher consumption of FFAs means that a person will need more insulin in his or her system. The insulin can come naturally from the pancreas for a person without diabetes or from insulin injections for a person with type 1 diabetes. (Some research also suggests that FFAs may reduce the amount of insulin that the pancreas’s beta cells produce, but more studies are needed.) In addition, fats can also affect the timing of a person’s blood glucose rise after a meal. This is because fats take a long time to go through the digestive tract-unlike carbohydrates, which are digested quickly-sometimes four to six hours after a meal. Thus, if a person with type 1 is taking insulin, FFAs may change the type of insulin (for example, fast- or slow-acting) and/or times the person injects himself after a high-fat meal.

What should a person with diabetes be aware of after eating a fatty meal?

Even though fatty meals have been associated with changes in insulin, there is no reason for staying away from fats. In fact, an occasional fatty meal is usually fine, as long as it does not have more than 40 grams of fat (especially saturated fats found in meat, butter, etc.). If a person with diabetes eats a fatty meal, he or she should pay more attention to blood glucose levels, especially after the meal. In addition, if a person with type 1 diabetes knows he will be eating such a fatty meal, he may want to adjust the timing, amount, and/or type of insulin. If someone has type 2 diabetes and is taking oral medications, research has shown that doing some type of moderate physical activity (such as walking) after eating a high-fat meal will often help lower blood glucose levels-and some say help with digestion, too.

What are omega-3 and omega-6 fatty acids?

There are two types of polyunsaturated fats-or polyunsaturated fatty acids, or PUFAs-the two essential fatty acids called omega-3 and omega-6. They are considered essential fats. In other words, the body cannot make them, so they must be obtained from the diet. Both are thought to play an important role in brain function, as well as in aiding normal growth and development of the brain and eyes in infants. The omega-3 fats are also thought to help prevent blood clotting, which is often known to trigger strokes or heart attacks. They are also thought to lower triglycerides, thus decreasing the risk of a heart attack (thus, they are often called “heart-healthy” fats). In addition, omega-6s are thought to lower LDL (the “bad” cholesterol) and to improve insulin sensitivity. But they have a “bad” side, too, as they are thought to increase inflammation in the body. Still another study points to a possible connection between the rise in inflammatory diseases-such as those associated with obesity and metabolic syndrome-and the increase in omega-6 fatty-acid consumption. This connection is suspected because omega-6 is called “pro-inflammatory,” whereas omega-3 is considered to be neutral.

Are fat calories the same as protein or carbohydrate calories?

No. Therefore, it is a myth that all calories from food are the same. In fact, the body’s ancestral makeup is to blame-as it protects itself from starvation by using up carbohydrate stores before it dips into the fat reserves. Overall, calories from fat are more fattening than those from proteins or carbohydrates, and the body has a tendency to store more excess calories from fat intake than from excess calories from proteins or carbohydrates. The body not only stores more fat calories, but it also burns them less readily than those from proteins or carbohydrates. And because the stomach takes cues that the person is full based on food volume, not calories, calorie-for-calorie fat is less satisfying.

Are various PUFAs associated with different risks for type 2 diabetes?

Yes, various types of polyunsaturated fatty acids (PUFAs) are associated with an increased and decreased risk of type 2 diabetes. In a study conducted in 2016, researchers measured circulating PUFAs in the blood samples of individuals from eight European countries (this was part of EPIC-Interact, the world’s largest study of onset type 2 diabetes; for more about EPIC-Interact, see the chapter “Resources, Websites, and Apps”). They compared different PUFAs-both omega-3 and omega-6-and adjusted for various factors that contribute to the risk of type 2 diabetes (such as smoking, body mass index, age, and sex). The researchers found that higher amounts of omega-6 linoleic acid (from a variety of foods, such as vegetable oils) were associated with a lower risk of future type 2 diabetes. But higher levels of four other omega-6 fatty acids were associated with a higher risk of developing type 2 diabetes. Overall, the omega-3 fatty acids-most often associated with fish or seafood-were not associated with future type 2 diabetes, and a plant-origin omega-3 fatty acid called alpha linolenic acid was associated with a lower risk of developing type 2 diabetes.

The researchers know that more studies need to be done, as their work was limited by their inability to distinguish dietary and metabolic influence on PUFAs circulating in the blood. But what this study does show is that the emphasis in the research on PUFAs and diabetes should not be just on the entire class of polyunsaturated fats but on the individual types of PUFAs.

What are trans-fatty acids?

Trans-fatty acids, or trans fats, are made when manufacturers add hydrogen to liquid vegetable oil-in a process called hydrogenation-creating solid fats like shortening and hard margarine. Hydrogenation increases the shelf life and flavor stability of foods containing these fats. Diets high in trans fats raise the LDL (low density lipoprotein) or “bad” cholesterol, increasing the risk for coronary heart disease. Cakes, crackers, cookies, snack foods, and other foods made with or fried in partially hydrogenated oils are the largest source (40 percent) of trans fats in the American diet. Animal products and margarine are also major sources of trans fats. Since January 2006, the U.S. government has directed that the amount of trans fat in a product must be included in the “Nutrition Facts” panel on food labels.

Healthy omega-3 fatty acids are found in foods such as fatty fish (salmon, mackerel, sardines), nuts, and avocados.

Can excessive amounts of trans fats (trans-fatty acids) increase the risk of type 2 diabetes?

Yes, most health care professionals agree that excessive amounts of trans fats increase the risk of type 2 diabetes in many people. For example, foods such as french fries contain trans fat, and like saturated fat, trans fats seem to boost the inflammation response in the body. In several studies, the more trans fats people consumed, the more likely they were to develop diabetes.

How do refined grains increase the risk of developing type 2 diabetes?

It is thought that a diet heavy in refined grains-such as white bread-boosts a person’s insulin resistance and causes problems with blood glucose levels. In one study, older adults who ate the most refined grains had the highest fasting blood glucose levels. This is because refined grains are actually carbohydrates that are easily digested and absorbed into the bloodstream. Overall, this means more of a rise-and quicker, too-of insulin in the body after eating, which can cause the insulin-making cells in the pancreas to “burn out” faster. It is also why so many health care professionals advise patients to eat foods that contain 100 percent whole grains, including products with whole wheat, whole rye, oatmeal, barley, wheat berries, or brown rice as the first ingredient.

MANAGING EATING HABITS

Is there one diet for a person with diabetes?

No! Everyone on the planet has different conditions and various needs when it comes to eating, and people with diabetes should also be treated individually when it comes to what to eat. Even though working out the best eating plan for a person with diabetes seems complicated at first, with education and experimentation, a person’s way of eating can be a good diabetes-management tool. This is because what a person eats definitely affects his or her blood glucose levels.

Why is it often thought that eating five small meals versus three big meals a day is better for most people?

For a person with diabetes, eating several small meals during the day-along with keeping tabs on blood glucose levels and eating wisely-will help keep blood glucose levels more balanced. According to many dietitians and nutritionists, one of the major problems with eating three big meals a day is that the foods eaten can put stress on the pancreas’s insulin-producing mechanism.

In particular, as sugars from the foods enter the bloodstream, the pancreas secretes a dose of insulin at levels high enough to help get sugar into the muscles’ and other organs’ cells, where it is used for energy. If a large amount of sugar enters the bloodstream-for example, after a bigger meal-then the pancreas releases a great deal of insulin. For some people, this release often creates a problem in the cells, causing them to resist the insulin from the pancreas (called insulin resistance). If this occurs, then the glucose levels don’t drop, and the body secretes even more insulin. This can cause the pancreas to literally wear out, which, in turn, can eventually lead to diabetes. In addition, the excess insulin promotes more fat storage, causing an overweight problem that can also contribute to diabetes.

Why does more research need to be conducted concerning diet and diabetes?

How people eat-whether they have diabetes or not-has always been a difficult subject to research. Dietary guidelines for a long time have recommended eating a variety of foods, but researchers are not truly sure why a varied diet can promote health. Although there has been plenty of research about how various foods relate to nutrition (such as which foods contain certain vitamins and minerals), little is known about whether or not eating a diversity of foods is related to lowering the risk of diseases such as type 2 diabetes. Overall, little research is conducted about whether a diet consisting of the five major food groups reduces the risk of such diseases as diabetes or whether the variety of foods within each of the five food groups is what is important to stave off such diseases. One study suggested that people who ate from all five food groups had a 30 percent lower risk of type 2 diabetes than people who ate only from three food groups. But more studies need to be conducted to truly determine the role of diet and diabetes.

Is it possible to be overweight from producing more insulin as opposed to overeating?

According to some research, producing too much insulin in the body (as per the way in the above question) is why some people who cut down on calories still gain, or cannot lose, weight. They just take in too many carbohydrates for their particular system. Taking in too many carbohydrates causes an excess of insulin. This, in turn, can cause the metabolism to develop cells that begin to resist the insulin (called insulin resistance). The body’s glucose levels don’t drop, and it starts producing more insulin. This can result in two major problems: more insulin can overwork the pancreas, resulting in diabetes, and/or it can promote more fat storage. Thus, in this instance, being overweight may be more from producing more insulin than from overeating.

Why are some herbs and spices usually good for people with diabetes?

Some herbs and spices are usually good for people with diabetes to consume (but as always, people should check with a health care professional if they have any questions about an herb or spice they want to eat). One reason for eating herbs and spices is that they contain antioxidants, which are compounds that inhibit tissue damage and inflammation caused by high blood glucose levels. The main antioxidants found in herbs and spices (mainly fresh herbs and some spices) are called polyphenolic compounds, compounds also derived from coffee and tea. These compounds have anti-inflammatory capabilities that are thought to help reduce not only the risk of some cancers, cardiovascular disease, and osteoporosis, but also of type 2 diabetes.

Also owing to their high polyphenolic concentrations, certain herbs and spices help block formation of what are called AGE compounds, or advanced glycation end products. AGE compounds form during a process caused when blood sugar levels are high and are part of the reason for tissue damage caused by diabetes. According to a study conducted at the University of Georgia, it is thought that some herbs and many spices have a relatively high polyphenolic content. For example, marjoram, garam masala, ground oregano, and cinnamon all seem to inhibit AGE compounds even when ingested in smaller quantities.

What are some spices and herbs that can affect blood glucose levels?

People with diabetes should talk with their health care professional if they consume any of the following herbs (one reason is that according to some research, some of these herbs do affect blood glucose levels, albeit not significantly unless the herb is eaten in large quantities):

True cinnamon and cinnamon extracts-True cinnamon (Cinnamomum burmannii)-native to Sri Lanka-has been around for centuries and was prized by King Solomon, known by Aristotle, and used by the ancient Greeks and Romans to boost appetite and relieve indigestion. Some research indicates that cinnamon not only can help balance cholesterol and relieve bloating and gas after a meal, but it may help control blood glucose levels of people with type 2 diabetes. In particular, in one study done at the Beltsville Human Nutrition Research Center, people with diabetes who took one capsule of cinnamon daily for 40 days saw a marked decrease not only in cholesterol but also in blood sugar just after 20 days. Researchers believe the compounds in cinnamon can make insulin more efficient and especially improve the hormone’s ability to regulate the way glucose enters the cells in the body. And it didn’t matter if the cinnamon was in supplement form-it is thought to be beneficial if it is cooked, baked, put in a liquid, or even steeped as a cinnamon stick in tea or cider.

Coriander-Often used in Indian cooking, coriander (as seeds or ground) may help lower blood glucose levels in people with type 2 diabetes. The extract made from coriander seeds is especially effective. Also for some people with type 2 diabetes, coriander may help the few working beta cells left in the pancreas to produce more insulin.

Cinnamon-real Sri Lankan cinnamon-helps balance cholesterol, as well as having other healthful effects.

What are some of the best fruits to lower the risk of type 2 diabetes?

According to several studies, some fruits are best to consume to lower the risk of developing type 2 diabetes. In particular, those who ate at least three servings per week of apples, blueberries, or grapes were at a lower risk for developing the disease than those who ate less of these fruits per week. Some fruits in studies actually raised the risk for developing type 2 diabetes-especially cantaloupe or fruit juices. More research is definitely needed to understand just what components in these fruits are responsible for helping fight or cause diabetes.

Does grapefruit affect blood glucose?

Yes, some studies show that grapefruit has many attributes, including improving insulin sensitivity and blood glucose tolerance. In addition, eating grapefruit before a meal seems to stimulate weight loss in some people, which can help if a person is trying to lose weight and not develop type 2 diabetes. It also is thought to keep the liver from pumping out very low density (VLDL) cholesterol, thought to be the “bad” cholesterol in the body. The main ingredient responsible for such responses is called naringenin, a nutrient that tells the body to stop storing fat in the liver and to burn it instead. But eating grapefruit in abundance is not the answer, which is why the once popular “grapefruit diet” has been abandoned by most people. In addition, for some people, grapefruit may be harmful, especially if they take medications such as statin drugs-so they should check with their doctor if they want to consume the fruit.

What is juicing of fruits and vegetables?

Juicing-besides being a trend of non-health care-professional celebrities such as Gwyneth Paltrow and Megan Fox-is a way of “drinking” various fresh fruits and vegetables by pressing them through a juicer. This extracts the liquid from the foods (sometimes referred to as nectar) and leaves the pulp, seeds, and skins. Many juicing advocates say the intake of juice from juicing is a good way to get a person’s recommended servings of vegetables and fruits, along with necessary vitamins and minerals. Although juicing is extremely controversial, people who rely on it believe that the body absorbs nutrients from juices better than it does from the foods themselves; they believe it is a way of getting more carotenoids and flavonoids (which fight major diseases such as cancer and heart disease), and they believe that juicing cleans the body of toxins and boosts the immune system. Though juicing is a way of easily ingesting vegetables and fruits, these “scientific” claims have yet to be proven.

What fruit-tree pods may affect a person’s glycogen?

The carob tree has fruit called carob pods. Within the pods are the seeds most people know as carob, which is often used as a uncaffeinated substitute for chocolate. The pods also contain pinitol, a naturally occurring substance thought to act like insulin by making cells more receptive to taking in glycogen. Although sometimes debated, some research claims that pinitol may help people who are insulin resistant by increasing the ability of muscles to use glycogen.

Why do some health care professionals caution people with diabetes about juicing?

Most health care professionals see nothing wrong with diabetics’ choosing to juice fresh fruits and vegetables once in a while, but the practice should not be used as a steady, consistent diet. One reason is that our bodies are designed to eat and absorb nutrients from solid foods, such as vegetables and fruits. Another reason is that eating the entire fruit or vegetable is much better at lowering the risk of heart disease and cancer, helping with weight loss, and improving overall health-all things that juicing advocates claim but that remain unproven.

Overall, there are many health and body reasons that eating the entire fruit or vegetable is better than juicing. Too much juicing results in a low amount of protein-and no protein in the diet can lead to muscle-mass loss, even in a few days. In addition, much of the fiber from the food is lost, and lack of fiber can lead to problems with the digestive tract.

What if a person with diabetes still wants to juice fresh fruits and vegetables?

If people with type 1 or type 2 diabetes-or even those who are prediabetic-do want to add fruit and vegetable juicing to their diet, then there are some things they can try, especially under the supervision of a doctor or other health care professional. One is to test how certain juiced foods affect them. For example, juicing cabbage may not spike a person’s blood sugar as much as juicing carrots. While trial and error works for some people with diabetes, overall, doctors and nutritionists usually recommend that a person eat regular, whole, unjuiced foods for the best nutritional value. This is because many foods that are juiced are high in carbohydrates. For example, an 8-ounce glass of fruit juice can contain 30 grams of carbohydrates, a number that can cause blood glucose levels to rise too fast and too much.

Juicing of fruits and vegetables has become a popular trend in cooking these days, but diabetics are warned not to make juices a regular part of their diet. It’s important to eat solid foods, as well.

SUGAR, ARTIFICIAL SWEETENERS, AND DIABETES

Is it all right to consume sugar if a person has diabetes?

There is a misconception that a diabetic should stay away from all refined sugars, such as white or brown sugar, honey, or syrup, no matter what the source (whether in manufactured foods or from the pantry in recipes). No health care professional would advocate that a person with diabetes eat unlimited amounts of these sugars. This is because whether a person has diabetes or not, these sugars provide carbohydrates and calories but don’t offer any fiber, vitamins, or minerals found in other carbohydrate-containing foods such as whole fruits and vegetables. Thus, most people with diabetes can eat refined sugar in moderation.

Should a person with diabetes cut back on fruit because it contains sugar?

Whether to eat fruit should be a decision between the person with diabetes and his or her health care professional. In general, it is a good idea for everyone to limit sugar (see the chapter “Diabetes and Obesity”) because it is often one of the causes of excess weight gain. But eating fruit can be advantageous to everyone, including many people who have diabetes (they should check with their health care professional if there are any doubts). This is because whole fruits have plenty of healthful antioxidants, along with other nutrients, and are high in fiber. Fruits also have sugars, and the body’s digestive enzymes must break down the fruit cells, releasing the sugars slowly into the bloodstream. This is why it is much better to eat the actual whole fruit than to drink fruit juice, in which the crushed fruit juice squeezes the cells, releasing the sugars. This puts the sugar into the bloodstream much faster than when the whole fruit is eaten and may even make a person hungry sooner.

What sweetener is known to be potentially toxic to dogs-especially in terms of affecting their blood glucose levels?

Recently, the U.S. Food and Drug Administration (FDA) issued a stronger warning about a common sweetener and its effect on dogs: xylitol, which tastes similar to sugar and is found in such products as chewing gum, mints, baked goods, cough syrup, children’s chewable vitamins, mouthwash, toothpaste, and other products. The warning is based on the effects of the sweetener on dogs. In particular, if a dog ingests xylitol, then the sweetener is quickly absorbed into its bloodstream, causing a dramatic release of insulin in the pancreas. (Xylitol does not stimulate the release of insulin from the pancreas in humans.) This causes a drop in blood sugar, causing the dog to become hypoglycemic (the reaction can occur within ten minutes to an hour after ingestion). If the ingestion is caught in time, then the dog may recover; others less fortunate can often experience too-low blood sugar, seizures, coma, liver damage, and sometimes death.

A prior warning was issued in 2011 by the FDA’s Center for Veterinary Medicine, mentioning how the sweetener can affect not only dogs but also ferrets. The stronger warning in 2016 came because of an increase in xylitol-related illnesses reported by pet poison control centers, with one report noting that xylitol is estimated to be 100 times as toxic as chocolate to dogs. The biggest concern is how many xylitol-containing products dogs can ingest. The most common source is sugar-free gum. Other sources include specialty nut butters that owners often give their pets as a treat or to administer medications. The FDA reports that ingesting a few pieces of gum can poison even a large dog. So far, the FDA notes that xylitol toxicity in cats has not been well documented. One suggestion is that a cat is less apt to eat sweets left out on a table than is a dog.

What is the difference between fructose and glucose?

Glucose and fructose are both considered sugars, but glucose tends to dampen a person’s appetite, whereas fructose increases the appetite. In addition, a person’s body turns more fructose than glucose into fat-and does it faster. If a person is already overweight or obese, then fructose tends to speed up the sugar’s fattening process. These facts are also why there is so much controversy-and concern-about high-fructose corn syrup found in many foods including fruit juices, ketchup, high-fiber cereals, salad dressings, baked beans, canned goods, regular soda, and salad dressings. (For more about the controversy surrounding high-fructose corn syrup, see below.)

Canned, boxed, and otherwise processed foods often have high-fructose corn syrup added to them. The additive is cheaper than regular sugar, but some people believe high levels of it can promote diabetes.

Why is high-fructose corn syrup so controversial?

High-fructose corn syrup is formed by changing the simple sugar glucose into another simple sugar called fructose. Fructose is cheap to produce and acts as a preservative to extend the shelf life of many sweets and baked goods. Unfortunately, it is high in calories and low in nutrition. And because it is in so many beverages and processed foods, it is linked to obesity. But not everyone agrees. For example, the Mayo Clinic notes that there is “insufficient evidence to say that high-fructose corn syrup is less healthy than any other type of sweetener.” But Mayo does add that any added sugar, not just high-fructose corn syrup, can contribute many unnecessary calories. Those calories are linked to health problems such as weight gain, type 2 diabetes, and metabolic syndrome-all of which increase the risk of heart disease, too.

How can sugar affect the body’s immune system?

Ingesting too much sugar can have a negative effect on the body, especially in terms of suppressing the immune system. In particular, eating or drinking around eight tablespoons (100 grams) of sugar-equivalent to about two and a half 12-ounce cans or bottles of soda-can reduce the ability of white blood cells to kill germs in the body by almost 40 percent. This weakening of the immune system occurs less than 30 minutes after a person ingests the sugar-laden foods or drinks; the effects on the immune system last close to five hours. This is important to a person with diabetes, as he or she already has a compromised immune system from high blood glucose levels.

How much sugar is too much?

Sugar consumption-no matter what the type-is yet another one of those hotly debated subjects when it comes to overall health. One study conducted by the Food and Nutrition Board of the National Academy of Medicine concluded that there is no scientific evidence that any level of sugars increases the risk of dental cavities, changes in behavior, cancer, the risk of obesity, or high cholesterol. This finding was, of course, countered by the World Health Organization and the Food and Agriculture Organization of the United Nations. They stated that sugar leads to obesity-and eventually type 2 diabetes in many people-especially when it replaces other, more nutritious foods in the diet and that sugar definitely does cause dental problems. More recent studies seem to agree. For most people, the intake of sugar affects them on an individual basis. What is a good intake for one person may lead to obesity in another. And thus the debate continues.

What sweetener name should already be removed from ingredient lists?

In 2009, the FDA stopped the food industry from using many names on a label’s ingredient list. For example, they asked that the term “evaporated cane juice” be removed from all food labels, as it is a misleading name. After all, it is merely sugar syrup dried into crystals, not something special and “wholesome” as many companies tried to make the public believe. But to date, there are still manufacturers who use the term, and several consumer advocacy groups are bringing lawsuits against these food producers, calling the term deceptive. If a food shopper sees this label, then he or she should understand that evaporated cane juice is just another name for sugar.

Why are artificial sweeteners of concern to many health care professionals-and people with diabetes, too?

Artificial sweeteners are added to many foods and usually give the food a sweet taste without the calories. For most people with diabetes, artificial sweeteners are the answer to eating less or no sugar in their diet. But there are concerns, especially for people who consume large quantities of artificial sweeteners or have allergies or severe reactions after ingesting certain sweeteners. For example, the artificial sweetener aspartame often gives susceptible people a headache about ten to 20 minutes after it is consumed. It also may be a problem for the part of the brain that senses when a person is full, thus causing some people to gain weight. In one study, people who drank artificially sweetened beverages also began to ingest more fat (especially saturated fats) as part of their daily calorie intake. And for people with diabetes who need to keep their weight in check, artificial sweeteners can lead to an inability to control their blood glucose levels.

DIABETES AND SODIUM (SALT)

Does salt affect a person’s blood pressure, especially if he or she has diabetes?

Most health care professionals agree that, for most people, ingesting too much salt can cause the body to develop high blood pressure over time. In fact, when a person eats too much salt, it causes the body to hold extra water in order to eliminate the salt from the system. For some people, this causes extra pressure in the blood, which results in a rise in blood pressure and stress on the blood vessels and heart. Thus, the American Heart Association suggests that people with high blood pressure, or a tendency toward developing it, should eat foods lower in fat, salt, and calories. And in general, for people with diabetes, most research indicates that salt intake should be low since diabetics are more likely to have high blood pressure than people without diabetes. (For more about blood pressure, see the chapter “How Diabetes Affects the Circulatory System.”)

Why is there a controversy over how much salt should be eaten daily?

The average daily intake of salt, in terms of milligrams, has recently become a much-debated subject. For example, the recommendation for daily sodium intake given by the government (Food and Drug Administration, or FDA) for the general population is a maximum of 2,300 milligrams (mg) per day (or about 1 teaspoon of salt). The American Heart Association number is lower; the group recommends a daily sodium intake of no more than 1,500 milligrams for most people. For comparison, the average American diet contains around 4,000 milligrams of sodium a day.

There is good reason for the discrepancies in recommendations. One of the major problems lies in scientific methods. Determining with finality just how much sodium should be consumed daily would require conducting a randomized, controlled trial. In this case, half of a large population would have to consume a high-sodium diet and half a low-sodium diet for a long period. (If some participants ended up with high-sodium diets and were susceptible to sodium in terms of blood pressure, heart problems, and strokes, then few people would want to participate-or even should participate.) In addition, every meal, piece of food, and beverage would have to be measured for sodium content over the entire study period-and for such a study, that would mean following the participants for months or even years. Thus, instead of conducting that somewhat impossible trial, scientists have had to make recommendations based on other “indirect” studies. The majority of them show that an excessive sodium intake is associated with high blood pressure, heart attacks, and strokes, all of which people with diabetes often develop.

Where do most people get their daily intake of sodium?

The most familiar source of sodium is table salt that is added in cooking and/or at the table. But in reality, it is estimated that most people consume around 25 percent of their daily sodium from this source. The other 75 percent commonly comes from processed grocery items and fast foods.

How can a person with diabetes reduce sodium intake?

Instead of adding salt to food, try a mix of other spices to make your dish savory without the sodium.

If a person with diabetes is told to cut back on salt for health reasons, here are some suggestions:

Pack a homemade meal for lunch instead of eating fast-food takeout.

Always taste cooking food before adding any salt, and if it needs salt, add it sparingly.

Use other no-salt-added seasonings in place of salt from the salt shaker, and eliminate (or use less of) those seasonings that contain salt. Look into salt substitutes, or use fresh herbs and spices instead of salt in cooking.

Don’t add salt to cooking water for vegetables, rice, or pasta-it really isn’t necessary.

Buy canned goods with low or no sodium on the label. For example, for canned foods such as tuna, buy water-packed, no-salt-added foods.

Be cautious when buying reduced- or fat-free salad dressings or any pre-packaged sauces as they often are higher in sodium than the regular salad dressings. Also be cautious about other “fat-free”-and even some sugar-free-foods, which often contain excessive amounts of salt.

Read the nutrition label on any food, and pay attention to the suggested daily sodium percent. Since the labels are currently for people taking in 2,000 calories per day, for those who are lowering their calorie intake (or normally do not take in as many daily calories), choose foods that have a lower amount of sodium listed on the label.

Avoid processed foods whenever possible (for more about processed foods and diabetes, see the chapter “Shopping for Food and Eating Out”). Such foods as salted meats or such processed meats as bologna usually have a great deal of salt. Some sauces also contain a great deal of salt. Use them sparingly, or cut down on the amount of salt by adding water to a sauce (it can be thickened with flour or cornstarch, if desired).

DIABETES AND BEVERAGES

Do people with diabetes need to drink more water daily than people without diabetes?

Yes, people with diabetes, if possible, should drink more water daily than people without diabetes. According to a study published in 2016, people with diabetes who drank more than 34 ounces of water a day were less likely to develop hyperglycemia (high blood glucose levels) than those who drank only 16 ounces of water or less. One reason water helps control blood sugar is a hormone known as vasopressin, which is released when a person is too dry. This hormone tells the kidneys to hang on to water and tells the liver to release stored blood sugar, and it also raises the blood pressure. If the person doesn’t drink enough water and there is too much vasopressin in his or her system, then the kidneys don’t make urine, and any extra blood sugar will not pass out of the body-a perfect scenario for developing hyperglycemia.

How much water should a person with diabetes drink per day?

Overall, it often depends on certain conditions. Research varies, and suggestions range from eight to 15 cups per day (the best amount may be somewhere in between). This is because there are water losses for various other reasons during the day, such as physical activity, hot or dry weather, or even high altitudes. Illnesses can also mean more water is needed, including if a person has a fever, high fiber intake, diarrhea, or high blood sugar. And, for a person with diabetes, higher than normal blood glucose means the blood is thicker and stickier, which can cause an increase in insulin resistance (which means glucose has a harder time moving through the small blood vessels to the cells). Drinking more water each day may help with this condition.

Why are some fruit drinks thought to increase the risk of developing type 2 diabetes?

Although not all fruit drinks are in this category, when it comes to fruit drinks, health care professionals and nutritionists advocate reading the bottle’s label. This is because many of these drinks are filled with added fructose, another name for sugar. Studies have shown that large amounts of fructose can lead to insulin resistance, obesity, type 2 diabetes, and even high blood pressure. Fructose is not only found in fruit and soft drinks but also in baked goods, condiments such as ketchup, syrups (even in what is often called “pancake syrup” presented as replacing real maple syrup), and candies. In addition, in the process of making fruit juice, the fruit is squeezed, breaking open the cells and releasing the sugars faster. This means the fructose in the juice goes into a person’s system faster, and he or she is more likely to feel hungry-and thus eat more-not long after drinking the juice.

What are the so-called “energy drinks”?

Energy drinks are beverages that boast of boosting energy levels, improving mental performance, and even aiding weight loss. They are high in caffeine, sugars (the types of sweeteners vary), and herbal compounds (presented as supplements). Because they claim to be dietary supplements, the FDA does not regulate the safety of the ingredients, meaning the manufacturers are responsible, which is often a major controversy involving such beverages.

How do “energy drinks” affect blood glucose levels?

Energy drinks are known to cause insulin levels to spike, which can often make it difficult to bring blood glucose levels down to normal. In a recent study, the caffeine in energy drinks resulted in a 20 to 30 percent decline in the body’s ability to deal with the high sugar load. In addition, they found that because the caffeine stays in the body for four to six hours after the beverage is drunk, the resulting insulin resistance may eventually lead to problems with glucose metabolism. This can especially affect adolescents who are consuming so many of these drinks. As they grow older, and if they are susceptible, they may be more at risk of developing such problems as heart disease and diabetes.

Energy drinks are filled with caffeine and sweeteners that can affect blood glucose levels.

Is there a connection between drinking coffee and lowering the risk of developing type 2 diabetes?

Several studies have shown a possible connection between drinking coffee and lowering the risk of developing type 2 diabetes. For example, in 2015, a report in the American Chemical Society’s Journal of Natural Products suggested that two compounds may help decrease the risk of type 2 diabetes. Initially, when scientists found that drinking coffee-regular or decaffeinated, up to three to four cups per day-helped to prevent the onset of type 2 diabetes, they believed that the coffee’s caffeine was responsible. Eventually, they showed that caffeine had only a short-term effect on glucose and insulin in the body. Investigators then isolated several bioactive compounds responsible for diabetes prevention, and, using rat cells, tested the effects of different coffee substances on those compounds. Two were found to increase insulin secretion when glucose was added: cafestol and caffeic acid. Cafestol also increased the glucose uptake in muscle cells, an increase that the scientists believe may contribute to the preventive effects on type 2 coffee drinkers. They hope this knowledge will soon help researchers to develop new medications not only to prevent but also to treat the disease.

Another study reported in the Journal of Agricultural and Food Chemistry indicated that coffee drinkers were at a lower risk for developing type 2 diabetes for yet another reason: compounds in the coffee that affect a polypeptide called hIAPP, or human islet amyloid polypeptide, were thought to be one of the causative factors of type 2 diabetes. The researchers believed that certain coffee compounds such as caffeine, caffeic acid, and chlorogenic acid help lower the risk of type 2 diabetes (especially caffeic acid) by suppressing the formation and thus the toxic effects of hIAPP.

Can even one cup of coffee affect the risk of developing type 2 diabetes?

According to a Harvard University study published in 2014 in the Diabetologia journal, researchers followed over 100,000 people for about 20 years, concentrating on a four-year period. They discovered that if a person increased his or her daily intake of coffee by one cup, then the risk of developing type 2 diabetes dropped by 11 percent. People who reduced their daily intake of coffee by one cup actually increased their risk of developing diabetes by 17 percent. As most researchers and doctors agree, this is not a recommendation to drink an overabundance of coffee each day, but it is yet another step toward understanding just why coffee has such an effect on diabetes.

How does the caffeine in coffee affect glucose and insulin in diabetics?

A study in 2004 showed that a dose of caffeine consumed by a person with type 2 diabetes before eating caused a higher blood glucose level and an increase in insulin resistance after eating. This is why the effects of consuming coffee are so confusing: Drinking coffee may help lower the risk of developing type 2 diabetes, but for a person with type 2 diabetes, it may pose an immediate risk after the drink is consumed!

More studies are needed concerning coffee and diabetes. For example, some researchers suggest that other compounds in coffee may have a different effect on insulin and/or glucose levels. In addition, no one knows whether drinking caffeinated coffee over a long period of time (and how much) may change the body’s glucose and insulin sensitivity. And there is always the problem of what a person chooses to put into coffee-especially creamers that contain an overabundance of saturated fats, carbohydrates, and calories. The best suggestion, as always, is for a person with diabetes to discuss coffee intake with the primary-care physician, diabetes educator, and/or nutritionist.

How do other compounds in coffee affect a person with diabetes?

Caffeine is not the only compound found in coffee. For example, a person with diabetes may receive more benefits from drinking decaffeinated coffee. In particular, chlorogenic acid and other antioxidants in the decaffeinated coffee may have beneficial effects, and the magnesium found in coffee may also have a positive effect on insulin sensitivity.

But as with all recent coffee studies, the jury is still out concerning diabetes and coffee compounds. As of this writing, no one has yet discovered how much coffee a person with diabetes can consume, what compounds help or hinder glucose and insulin levels, which types of coffee are most beneficial (compounds in the coffee vary depending on where the beans are grown), or even the effects of how the coffee is prepared.

Should a person with diabetes abstain from drinking alcohol?

Not necessarily, especially if the person has control of his or her blood glucose levels. But there are some caveats. For example, there is the question of healthful versus unhealthful drinking, so no matter whether a person has diabetes or not, he or she should drink responsibly. As for a person with diabetes, keep in mind that too much alcohol can lead to hypoglycemia, or low blood sugar, especially if the individual drinks on an empty stomach. (In addition, according to the American Diabetes Association, people who are on sulfonylureas or insulin should drink alcohol only with meals.) This is because the liver not only processes alcohol, it also stores and releases glucose. Thus, wine, beer, and liquor hinders the liver’s ability to release the necessary glucose, causing hypoglycemia. (Because symptoms of hypoglycemia and inebriation are similar, many law enforcement officials may not be able to tell the difference-which may mean people with diabetes will not get the help they need quickly.) Alcohol provides no nutrition but does contain fat, which can lead to weight gain. And if a person with diabetes is taking any medication, then he or she may want to abstain from drinking any alcohol. If a person with diabetes who is in control of his or her blood glucose levels does want to drink, then some health care professionals suggest having only one drink (or two) a day at the most, eating something to slow the absorption of alcohol into the bloodstream, and nursing a drink over a few hours to lessen the burden on the liver.

The caffeine in coffee can raise glucose levels and increase insulin resistence, while alcohol, if not consumed carefully, can lead to hypoglycemia.

DIABETES AND FASTING

What is fasting?

Most people with diabetes are familiar with the term “fasting” in reference to “fasting blood glucose levels.” This usually means a period after a person fasts (usually while sleeping), with blood glucose levels checked upon awakening. But fasting can also mean not eating for a certain amount of time for various reasons, including for religious, medical, or health reasons, or an unintended fast. For example, certain religions fast for a day or several days, usually in observance of holy days; certain surgeries or medical procedures may include a fast for a day or so; some people fast for a day to “detoxify” the body (although more long-term studies are needed to understand whether there are truly benefits of such practices); and sometimes a person unintentionally misses a meal for various reasons.

How does the body respond to fasting?

Depending on how long a person fasts, changes take place in the body. In most healthy adults, the body usually enters a fasting state about eight hours after the person’s last meal. At first, the body will use stored sources of glucose, such as in the muscles. Later, if the fast is prolonged, then the body breaks down fat stores as an energy source. This has been seen historically, especially in people who used fasting as a means of protest and lost a great deal of weight. But all health care professionals agree that fasting should not be used as means of losing weight in the long term, as it can cause major imbalances in various body systems and reactions-including problems with digestion, blood glucose levels, and dehydration.

How can a person with diabetes cope with fasting for religious purposes?

Depending on the religion, fasting lasts for different periods of time. For example, people who follow Hinduism and Judaism tend to fast only for individual days during religious holidays. Other religious observances, such as the Islamic observance of Ramadan, often include longer periods of fasting. During Ramadan, it is necessary for all healthy Muslims to fast each day between sunrise and sunset for an entire month (the often-heard phrase is “the Islamic month of Ramadan”). In some cases, depending on the religious leader’s ideology and/or the religion or culture, certain groups of people in different circumstances are exempt from fasting. These may include children (under puberty), the elderly, pregnant women (and those who are breastfeeding or menstruating), people who have an illness, those who are traveling, or anyone who would be putting him- or herself at serious health risk by fasting.

How can a person with diabetes observe religious practices that include fasting?

For a person who has diabetes and is in relatively good health (meaning his or her blood glucose levels are balanced), fasting for religious purposes is often possible-but also can be quite a challenge. According to several diabetes organizations, the first and best thing to do is consult a health care professional to see whether it makes sense for the person to fast. In many cases, the medical recommendation will be not to fast if the person has diabetes, especially with a history of ketoacidosis, is pregnant, or has poor blood glucose control. People who do heavy manual labor or have certain illnesses-and diabetes-probably will also be advised against fasting.

Some religious people practice periods of fasting, which can be problematic for a person with diabetes, but it can still be done safely if precautions are taken.

But if someone with diabetes is in relatively good health and still decides to fast, then it is best to consult a health care professional to help prepare for potential problems. For example, according to organizations such as Diabetes UK, for a person observing a fast such as Ramadan:

People with type 1 or type 2 diabetes should speak to their health care team before fasting, especially to better understand how to control possible blood glucose problems before, during, and after the fast. The goal is to prevent blood glucose levels from dropping too low (hypoglycemia, which is usually defined as a blood glucose level less than 70 mg/dl; possible symptoms include feeling shaky, sweaty, and/or disoriented), especially if the person is taking insulin or other diabetes medication. In addition, for people with type 1 diabetes, there is a danger of blood glucose levels measuring too high (hyperglycemia), resulting in the buildup of ketones, creating ketoacidosis (symptoms include excessive thirst, passing copious amounts of urine, and tiredness). Understand that people taking insulin may need less of it before the start of the fast or more-depending on their condition.

People may need a different type of insulin from their usual type because of fasting during the day.

Before a fast, include more foods in the diet that are absorbed slowly, such as basmati rice, pita bread, and dhal, along with fruits, salads, and vegetables.

Check blood glucose more than usual over the course of the day.

If a person has any sign of hypoglycemia (low blood glucose levels), then it is better to break the fast and immediately start such treatments as taking glucose tablets, or GlucoGel. (For more about treating hypoglycemia, see the chapter “Taking Charge of Diabetes.”)

Know when to break a fast. Both extremely high and low blood glucose levels are dangerous to a person with diabetes. Religious leaders tend to agree that fasts are truly not meant to create life-threatening situations.

After fasting for the day, eat only small amounts of food and avoid eating sweet or fatty foods (or just have very small amounts). Too many sweets and fatty food will cause weight gain.

In the case of such observances as Ramadan, try to eat just before sunrise (before the fast starts), and regulate insulin or diabetes medication to fit.

At the end of fasting, drink plenty of sugar-free and decaffeinated liquids to avoid becoming dehydrated.

What is juice fasting-and is it good for people with diabetes?

Juice fasting means abstaining from solid foods for a couple of days and getting nutrients from juices through juicing. Many people advocate this to allegedly cleanse the body of toxins, such as pesticides, pollution, artificial colors, and preservatives, but cleansing claims have not been proven. And for people with diabetes, especially type 2, juice fasting can aggravate their condition. In particular, ingesting just vegetable and fruit from juicing can cause excessive highs or lows in blood glucose levels. If a person with diabetes does want to try juice fasting, then it is best to be supervised by a health care professional or a dietitian familiar with diabetes and nutrition.

DIABETES, DIETING, AND EATING DISORDERS

Why are some “fad” diets so controversial, including for people with diabetes?

There are plenty of controversial “fad” diets that should be viewed cautiously. Most fad diets are thought to be more harmful than helpful, mainly because they do not provide all the nutrients the body needs to stay healthy. In fact, most studies have shown that many fad diets do not help people really lose weight. For example, because people lose water weight fast, especially at the beginning of many diets, the fad diet can give the illusion of losing weight. Most fad diets do not teach anyone how to eat well and keep the weight off but are just a “quick fix.” And when the dieters go back to their usual eating routine (often because the fad diet becomes boring or too hard to follow), they usually regain any weight lost.

For people with diabetes, eating a lower amount or different types of foods advocated by the fad diet may not be what they need to maintain healthy blood glucose levels. According to the National Institutes of Health, low-calorie diets-such as those based on less than 800 calories a day-can affect the heart and other organs and, indirectly, may even contribute to people’s becoming overweight (as the body thinks it is starving, thus it stores more fat). This type of diet can also increase the risk of diabetes for many people. For those who have diabetes, it may contribute to such problems as hypoglycemia.

What is an eating disorder?

According to the American Diabetes Association, eating disorders are considered an illness with a biological basis that is modified and influenced by emotional and/or cultural factors. The disorders include anorexia (or anorexia nervosa, in which the person has an obsessive fear of gaining weight, so he or she starves or eats very little in order to lose and keep off weight); binge-eating disorder (compulsive overeating, in which a person has periods of uncontrolled, impulsive, or continuous eating despite feeling full); and bulimia (in which a person rapidly consumes a great amount of food, then purges the food).

Binge eating-as well as other disorders such as bulimia and anorexia-can wreak havoc with one’s blood glucose levels.

What is diabulimia?

According to several recent studies, a somewhat new eating disorder-especially for young people with type 1 diabetes-is diabulimia, an alarming way to lose weight. Although it is not a recognized medical condition, diabulimia has recently been showing up in alarming numbers in teens and young adults who have type 1 diabetes. People with type 1 diabetes need to have continuous treatments with the insulin hormone in order to get glucose from their bloodstream into the cells. But people with diabulimia try to manipulate blood glucose levels through what they eat, along with withholding their normal insulin injections or manipulating their insulin pumps. This makes their glucose levels rise, causing the sugars to spill into the urine. And this, in turn, causes rapid weight loss. But diabulima is dangerous. It can lead to hyperglycemia (high blood glucose levels) from insulin deficiency and/or damage small blood vessels, leading to peripheral neuropathy, causing eye problems and trouble in the extremities. If a person is diabulimic for a long time, then it can lead to other more serious health problems, including diabetic ketoacidosis, and the increased risk of kidney disease, nerve damage, amputations, and heart disease.

Are people with diabetes immune to eating disorders?

No, people with diabetes can have eating disorders, and many of the eating problems can compromise the ability to manage blood glucose levels. For example, in many women with type 1 diabetes, bulimia is the most common eating disorder. There is also a relatively new term, diabulimia, meaning when people with type 1 diabetes try to control their glucose levels by reducing or not taking their insulin injections in order to lose weight (see sidebar). In many women with type 2 diabetes, binge eating is the most common eating disorder.

What can happen to a person with diabetes if an eating disorder is not controlled?

If a person with diabetes has an eating disorder, then it can lead to several health problems, with most of the problems precipitated by uncontrolled blood glucose levels. These include a higher risk of developing infections; higher A1c levels (that don’t go down unless the eating disorder ends); more trips to the hospital and emergency room (usually because of hypoglycemic episodes); possible episodes of diabetic ketoacidosis (or DKA, a dangerous kidney problem); and more frequent occurrences of-and more rapidly developing-diabetic complications, such as heart and kidney disease, nerve damage, and eye problems.

What are some ways to recognize an eating disorder in a person with type 1 diabetes?

People with type 1 diabetes are known to develop certain eating disorders. In fact, it is thought that women with type 1 diabetes are more than twice as likely to develop an eating disorder than women of the same age who do not have diabetes. Some researchers suggest that there are signs that a person with diabetes has an eating disorder. They include an unexplained rise in the person’s A1c values; the person’s expressing extreme concerns about his or her weight and body shape; a change in eating habits; unusual patterns of intense exercise (this often occurs with bouts of hypoglycemia; for more about hypoglycemia, see the chapter “Type 1 Diabetes”); and for women, skipping their monthly periods (called amenorrhea).

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