NUTRITION AND DIABETES

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�� NUTRITION AND DIABETES

��

�� by Jennifer Layton, RD

��

�� The following was the keynote address at the March 24,

2000, Diabetes Action Network seminar, held at the National

Federation of the Blind of Missouri State Convention, in

Jefferson City, Missouri.� Jennifer is the Clinical

Nutrition Manager at the Capital Region Medical Center, In

Jefferson City.

�� I'm Jennifer Layton, a Registered Dietician at Capital

Region Medical Center.� I'm going to talk about basic

diabetes and nutrition, pointing out the differences between

food guide pyramids, the exchange system, and the new

carbohydrate counting.�� I have some food models to pass

around, to give you a feel for what different portion sizes

should be like.� I've got some bottles with mixtures in

them, to show you the consistency of your blood when blood

sugars are normal, or when they are higher than they should

be.�

�� When we eat food, and it is digested, everything is

broken down into different nutrients: carbohydrate, protein,

or fat.� Those are the three main nutrient groups.

Carbohydrates turn into glucose, and we need glucose in our

cells for energy.� When glucose cannot enter the cells

because we don't have enough insulin, that's when we see the

high blood sugars, which I'm sure you are all familiar with.

�� So when and how much you eat is going to affect your

blood sugar level.� Food is a very important aspect of

controlling diabetes.

�

Reasons for Meal Planning

�� We want to maintain our normal blood glucose levels;

we want to maintain normal blood fat (when I talk about

blood fat, I mean triglycerides and cholesterol).� For some

of us, losing weight can actually improve� our diabetes,

prevent complications such as renal disease, hypertension,

high blood pressure, abnormal lipid levels, including

cholesterol, nerve damage, blindness.� So those are all

complications we want to prevent.

�

�� Controlling diabetes is important.� We want to improve

our overall� health.� We want to get enough nutrients,

vitamins and minerals that our body requires every day.

Some reasons will be more important to you, as an

individual.

The Basic Eating Guidelines

�� We definitely want to eat regularly.� Do not skip

meals.�� I know it's hard to avoid doing that sometimes, but

we need to be getting at least three meals a day.� Some of

us will need snacks in between and at night.� So we want to

carry food for emergencies.� If we know we're getting low

blood sugars, we need to have something on hand to keep from

passing out.

�� Choose a variety of foods, from all food groups, not

just one.� I know there's a diet out there that just focuses

on high protein, and eliminates most carbohydrate foods.

But that's not a good diet, because it's not balanced.

�� Portion sizes are very important.� The first food model

I have is a cup of spaghetti and meatballs.� If you pass

that around, you'll see one cup of spaghetti and meatballs

is actually two servings of spaghetti.� And the next one is

a small to medium‑sized apple.� A lot of the apples we get

in the grocery store are huge, and would be at least two

servings.� My apple is actually about the size of a tennis

ball, which is a serving size.� Now we've got a three‑ounce

portion of pork.� Your meat portions shouldn't be any bigger

than that ‑‑ three ounces of meat ‑‑ the size of a deck of

cards, or of� the palm of your hand.�� Mashed potatoes ‑‑

one half cup of mashed potatoes is one serving.� What we've

got next is a handful of popcorn.� It just about fits in the

palm of your hand.� It's one cup.� That's actually only one‑

third of a serving.� Three cups of plain popcorn (no butter)

counts as one serving.� Then we've got a serving of

vegetables, actually a half‑cup of spinach.� Then we've got

a hamburger, three ounces of beef.� Again, it fits in the

palm of your hand.� It shouldn't be any bigger than that.

And the final one is a tablespoon of peanut butter.� Two

level, not heaping, tablespoons count as one meat exchange.

So that tablespoonful is� half of a meat exchange.� Peanut

butter is high in fat too.

�

�� A lot of our servings are bigger than that, especially

if we go out to eat.� Restaurants are very good about giving

us a lot of food, which isn't so good for some of us.� So

when you go out to eat, try to eat half of what you've got,

and take the other half home to eat the next day, or share

it with somebody you go with.

�� Weighing and measuring foods at home can help you out.

I don't expect anyone to do it for the rest of their lives,

but getting a grasp on portion size would be helpful to you.

�� Getting back to the three main nutrients in our diets,

your body requires these nutrients to live.� Protein, fat,

and carbohydrates�� those are the three nutrients.� Protein

builds and repairs muscles, builds and repairs skin and

other cells.� So our body requires protein.� Only half of it

turns into sugar when it is digested and absorbed in our

system, so it doesn't have a great deal of effect on our

blood sugars.� Proteins should make up about 20% of our

total calories, and a gram of protein has four calories.� We

find our protein sources mainly in our meats and milk

products.

� ��Then we've got fats, our second nutrient. Fat supplies

energy, maintains healthy skin, and carries some of the fat‑

soluble vitamins through our body.� It provides flavor to

our foods, so we definitely want fat, we just don't want too

much of it.� Excess fat will cause heart disease and weight

gain.� Very little of the fat we eat is broken down into

sugar, less than 10%.�� As� I said, about 50 percent of your

protein intake turns to sugar, and fat is even less.� Fat

should make up less than 30% of your total calories.� Fat

has nine calories per gram, over twice as many calories as

your protein.� And fat is found mostly in high‑fat meats,

whole milk products, and breads, like biscuits, waffles, and

pancakes.

�� Then we get to carbohydrates.� This nutrient is going

to greatly affect your blood sugars.� One hundred percent of

carbohydrates turns into sugar when it is digested and

absorbed in your body.� It is our main source of energy.� It

also provides some fiber and vitamins, and should make up

about 50%� of our total calories.� Most of our diet should

come from carbohydrates ‑‑.we just need to know how much to

have at what time.� Carbohydrates are just like protein:

four calories per gram.� Most of your carbohydrates are

going to be from bread, fruits, and milk, along with your

sweets.

�� I have two bottles to pass around.� You can hear them

shake.� The first is what your normal blood sugars would be

like.� Now this second bottle I've got, you can't even hear

it shaking because the fluid is so thick (it looks like

syrup), and it takes a long time for any nutrients or any

oxygen to get through your blood when it's that thick.� You

can see the effect� high blood sugars have on your blood,

and on the ability of your nutrients and oxygen to get

through to your cells.

�� I have handouts for you.� The first one is the FOOD

GUIDE PYRAMID.� The food guide pyramid is a chart in the

shape of a pyramid.� At the bottom, the base of the pyramid,

the biggest part is your breads and cereals.� They should

make up 50% of your diet.� The next range up we have fruits

and vegetables.� We need five servings of fruits and

vegetables a day to get adequate amounts of vitamins and

minerals.� Then the next tier up we've got milk, yogurt, and

cheese on one side, and meat on the other.� For both, we

want two to three servings a day.� And at the very top,

we've got fats, oils, and sweets, the very smallest part of

our diet.� The main difference between food guide pyramid

and exchanges is that cheese is included in your milk group

on the food guide pyramid.� Cheese is on your meat group on

the Diabetic Exchange List.� I usually try to cross out

cheese on the food guide pyramid when I'm handing these out,

and move it over to the meat group.� Cheese actually

provides protein like the meats do, and cheese is actually a

high‑fat meat, unless you're choosing your reduced‑fat or

non‑fat cheeses.� The Food Guide Pyramid is one of the most

basic, general guidelines.� It gives you how many servings

you should have a day, and on the back it explains what a

serving size is.

�

�� The EXCHANGES, the other handout I have here, has each

food group boxed off, and has a space where the dietician

can fill in the choices you get each day, starches,

vegetables, meats, milk, fruit, and fats.� These boxes

aren't arranged in the same way the pyramid is.� But again,

emphasizing the similarity between the two is that you want

a variety of foods.� And again, on the food exchanges, your

serving sizes are listed for you in each food group, since

knowing your portion size is a very key part of controlling

your diet.

�

�� Remember, the point of all this planning and counting

is to help keep your blood sugars down, as close to a normal

blood sugar range as possible.� That's what you really need

to shoot for.� And diet, my field, is only one aspect.

�� For a balanced diet, everyone is an individual.� What

one person needs is going to be different from what somebody

else needs.� I see a lot of people on an outpatient basis,

and I work one‑on‑one with them.� It's great to do a group

setting; but when you have a group of people, you've got so

many different personalities and different lifestyles that

you've got to take into consideration.� It's best to be one‑

on‑one, to get a really good start.

�

�� I was asked about special diets, and I would absolutely

not recommend the Atkins Diet, if you have diabetes.� This

diet is okay short term, but� I would never do it for a long

term diet.� It's not something that's healthy for you long

term.� It was originally developed for patients who were

going to undergo heart surgery and needed to lose weight

quickly, and they weren't meant to be on it for a long time.

�� The Atkins diet will give you about 15 grams of

carbohydrates a day, which is one serving of a carbohydrate.

You need� carbohydrates, even if you have diabetes and the

high blood sugars that comes with carbohydrates.� That's

what gets confusing, I think.� You need a constant source of

carbohydrates.� Fifty percent of your diet should be

carbohydrates.� And from the Atkins diet, you're definitely

not getting that.� A high‑protein diet can cause

dehydration,� can cause heart problems,� and can overtax

your kidneys, which is risky if you're dealing with kidney

complications from diabetes.� So if you're eating high‑

protein, you're putting your kidneys at risk.� If you don't

get the carbohydrates, you're missing out on a� lot of fiber

in your diet, plus some of the vitamins and minerals they

provide.� A low‑carbohydrate diet deprives the brain of

energy it needs to function properly, and when there is a

deficiency of glucose, the body produces ketones.� Excess

ketones result in ketosis, a lowering of the blood's pH.

This is potentially toxic.

��

�� Getting on to carbohydrate counting.� On an 1800‑

calorie diet, you can have about 225 grams of carbohydrate

per day, about � your total food budget.� That's about 15

choices.� Since 100% of carbohydrates is converted into

sugar, we need to control how much carbohydrate we take in.

Each serving is 15 grams of carbohydrates, though calories

vary.� One serving of starch would be about 80 calories.

One serving of milk, skim milk, would be about 80 calories.

Your fruits would be a little less, at about 60 calories.

When you're counting carbohydrates, what you're doing

basically is lumping your starches, fruits, and milk

together.� So normally on an exchange diet, if I say you can

have two starches, a fruit, and a milk in the morning,

switching over to carbohydrate counting, I would say you

could have four carbohydrates. �Then you choose how many

starches you want.� You choose how many fruits and how many

milks, as long as they all total up to four.� Each of those

servings has approximately 15 grams, and we want a total of

60, or four servings per meal.

�

�� Reading food labels gets kind of tricky when you're

trying to� decipher the sodium, sugar, and calories.� You've

got so many things to consider.� When you're doing

carbohydrate counting, pay attention to the total

carbohydrates on your food labels.� Even if there is sugar

listed on the labels, the total carbohydrates number

includes that sugar�� sugar is a carbohydrate.� When you're

looking at the label, every 15 grams, you count that as one

carbohydrate exchange.� So one fruit, one starch, one milk,

equals the same thing as one carbohydrate exchange.

�� Carbohydrate counting is good because it gives you more

control, and more variety in your meal planning, because I

wouldn't tell you how many starches, fruits, and milks to

have.� That's up to you.� But the problem is that you don't

always get as much variety in your diet.� Maybe you're

someone who doesn't like fruits.� Then you might say, "I can

get away with not getting my fruits today.� I'll just eat

them all as starches,"� which essentially you can do,

because your body reacts to those food groups the same, but

you're not getting the vitamins and minerals from those

fruits.� Often with carbohydrate counting, as well, you see

weight gain, because you're focusing in on your

carbohydrates so much that you lose sight of controlling

portion sizes of meat and fat, because you're just looking

at fats.� So I caution you against that.� I think

carbohydrate counting is a wonderful thing, and I've used it

for the past three years I've been at the hospital, and have

had some pretty good results with the patients� I've seen.

I've had many physicians very excited.� They love the way

that it's being taught.� They see the effects more than I

do, since often I don't see people for the follow‑up; but

they often tell me to keep doing what I'm doing, because

it's working.� So carbohydrate counting, if you don't know

it or aren't using it yet, continue to seek information.

�� Vitamin supplements are fine.� If you don't get a good,

balanced variety of foods, I would recommend taking vitamin

supplements.� Although we often want to buy the more generic

brands of vitamins, our bodies often don't utilize them as

well as the name brands.� I would recommend at least a

multivitamin.

�� Editor's Note: Your diet is an important part of

diabetes management�� and its in your hands.� Your dietitian

will help you design a diet that is appropriate for you.

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