American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Reference from the Diabetes Experts

CHAPTER 10

Healthy Eating

• Food Groups

• Choosing a Meal Plan

• Carbohydrate Counting

• Food Labels

• Eating In and Eating Out

• Special Considerations

Healthy eating is a challenge for everyone. And it’s no surprise. It can be difficult to change how and what we eat, as these choices are interwoven with our family and work lives, and even our upbringing.

The truth is that healthy eating for a person with diabetes is no different from healthy eating for a person without diabetes. It’s a matter of eating a variety of foods and a balanced amount of carbohydrates, proteins, and fat. It doesn’t mean you have to give up all sugars or special treats. You just have to make sure you account for them in your total meal plan for the day.

However, people with diabetes need to work harder to balance the foods they eat with their blood glucose levels. You’ll need to make sure that your calorie and carbohydrate intake is balanced with your medication and physical activity. A dietitian or diabetes educator can help you come up with a meal plan that fits your goals and includes foods you like. Dietitians and diabetes educators are discussed in more detail in chapter 17 on your health care team.

First, let’s discuss the different types of foods and their effects on your body. Once you know the food groups and some general guidelines, you’ll find out more about developing a meal plan.

Food Groups

The best approach to healthy eating is to eat a wide variety of foods. Your body requires nutrients to repair and replace proteins, tissues, and cells throughout your body and to keep you rolling along. Your body needs three important nutrients to do this: protein, carbohydrate, and fat, as well as vitamins and minerals.

Various combinations of these nutrients are found in different foods. So, by eating a variety of foods, you are sure to get all the nutrients you need. Eating a variety of foods is much better than taking vitamin supplements because nature combines the needed nutrients in food in a way that your body can best use them.


Food Groups Preview

Carbohydrates. These include vegetables, fruits, beans, and whole-grain cereals, grains, pastas, and breads.

Proteins. These include beans, meat, eggs, and dairy products. Choose lower-fat versions.

Fats. These include oils, margarines, butter, cream, and chocolate.


Calories 101

• A calorie is a measurement of the amount of energy in a food.

• Carbohydrates and proteins provide about the same amount of 

energy—4 calories per gram.

• Fats provide more than twice that amount—9 calories per gram.

Any food that your body doesn’t use as energy is stored as fat. So, the trick is to balance the total number of calories you take in with the total number you burn up. Proteins and carbohydrates give you fewer calories per bite than high-fat foods. So, if you’re trying to lose weight, cut down on fats. A diet high in saturated fat can also put you at greater risk for developing heart disease and certain cancers.

Carbohydrates

Carbohydrates supply most of the glucose your body uses for energy. Your blood glucose goes up as carbohydrates are broken down into glucose and absorbed. Blood glucose rises within 15 minutes of eating carbohydrates. Several factors affect the way in which carbohydrates work.


More about Carbohydrates

Digestibility. How easily the carbohydrate is digested will affect how quickly glucose is freed and gets into blood. Cooked food digests faster than raw food. Food that stays in bigger pieces, like corn on the cob, breaks down more slowly than smaller pieces, like the bits in creamed corn.

Quantity and quality of carbohydrates. Your blood glucose increases with the amount of carbohydrates you eat. You can get a feel for how the quantity of carbohydrates affects your blood glucose by measuring it 1–2 hours after the first bite of a meal. You may be more concerned about the quality versus the quantity of carbohydrates you eat.

Combination with other nutrients. Fat slows down the absorption of food. Therefore, adding fat to carbohydrate food during preparation or at the table will slow digestion of the carbohydrate and delay the effect on glucose levels.


Types of Carbohydrates

Carbohydrates include vegetables, fruits, cereals, grains, pastas, breads, and milk. These foods are loaded with nutrition. They provide easily used energy, fiber, vitamins, and minerals. They also tend to be lower in calories than foods in other groups.

Sugar is also a carbohydrate. It has long had a bad reputation, especially among people with diabetes. People used to think that eating sugar would cause blood glucose levels to rise much more rapidly than other types of carbohydrates, such as bread or potatoes. So although bread and potatoes were okay to eat, pure sugar or sugar-laden treats were considered taboo. Well, it turns out that the total amount of carbohydrates and its combination with other nutrients, such as fat, are much more important.

Foods that contain sugar can be part of your diabetes plan. You’ll just need to account for the calories and carbohydrates. Keep in mind, sugar has little nutritional value, so filling up on sugars won’t allow you to eat as much of the nutrient-rich carbohydrates.


Sugar

Your dietitian can help you learn how to count sugar as part of your carbohydrate allotment in your meal plan. For example, if you plan on having a small piece of cake for dessert, you might want to skip the rolls you normally have at dinner. Your dietitian or health care provider can also help you decide whether you need to adjust your medication dose to deal with the extra carbohydrates.


Artificial Sweeteners

• Artificial sweeteners give you the sweet taste of sugar without its calories and without raising your blood glucose levels. Depending on the brand used, one packet will usually give the same sweetness as two teaspoons of table sugar.

• There are two classes of artificial sweeteners: noncaloric (non-nutritive) and caloric (nutritive).

• Noncaloric sweeteners, such as aspartame, acesulfame-K, sucralose, and saccharin, do not raise blood glucose.

• Caloric sweeteners, such as sorbitol, mannitol, and xylitol, are sugar alcohols. They have calories and are absorbed into the blood, although more slowly.

• Artificial sweeteners are okay for everyone, except that pregnant or breast-feeding women should not use saccharin and people with phenylketonuria should not use aspartame.

Some carbohydrates are harder to spot in foods. Products such as low-fat and nonfat foods have added carbohydrates that can affect blood glucose. You’ll want to keep in mind that even if a product is labeled as low calorie, low sugar, or sugar free, it may contain other substances that raise blood glucose.

Often, these substances are modified forms of carbohydrate that are used as emulsifiers or bulking agents. For example, maltodextrin and polydextrose can be found in products such as sugar-free, nonfat yogurt or low-fat pudding and ice cream. Maltodextrin is digested like a carbohydrate and provides 4 calories per gram. Polydextrose mostly passes through the body and provides just 1 calorie per gram so it does not have much effect on blood glucose.

Protein

Protein is an essential nutrient in any healthy diet. Proteins are used to repair the body. They are not used for energy unless there are not enough carbohydrates and fats present. However, many Americans eat more protein than they need. People who have kidney problems may be advised to limit the amount of protein they eat.

Meat, poultry, milk products, and eggs are all good sources of high-quality protein, but they also come with bad things such as cholesterol and saturated fat (see next section). Select low-fat milk products, lean cuts of meat and poultry, and seafood.

Vegetables, grains, and legumes have protein. They are also low in fat, have no cholesterol, and have other nutrients as well. Nuts are another source of protein. They have fat, but most do not contain saturated fat. See more about types of fat in the next section.


Seafood

Seafood is a good source of protein, and most kinds of seafood are lower in saturated fat and cholesterol than meat. Seafood also contains heart-healthy omega-3 fats.


Fats and Cholesterol

Everyone needs some fat in their diet to make sure their bodies function properly. Fat is used to rebuild the membranes that protect the cells in your body and to help the cells in your body send signals. Fats are also stored and used as energy reserves.

However, too much saturated fat and trans fats can clog up blood vessels and increase your chance of developing heart disease and stroke. Many Americans eat too much fat. You are better off trying to limit the amount of fat you eat, especially unhealthy fats.

Keep in mind that your body also makes its own cholesterol, which is separate from the cholesterol that you eat in food. Your body’s cholesterol is used to make and repair cell membranes and to make many of the essential steroid hormones, such as estrogen and testosterone. You’ll need to limit the amount of dietary cholesterol and harmful fats you take in from foods in order to keep your cholesterol in check (see more about cholesterol in chapter 14 on heart disease).

Healthy Fats

Healthy fats are better for your heart and blood vessels. They are mostly found in plant foods, such as nuts and oil. They include unsaturated fats—monounsaturated and polyunsaturated—and omega-3 and omega-6 fatty acids. Omega-3 fatty acids, which are found in fish, walnuts, and flaxseed oil, are thought to reduce the risk of heart disease. For this reason, three servings of fish a week are recommended.

Types of Healthy Fats

• Monounsaturated fat is in olive and canola oil, avocados, nuts, and all-natural peanut butter.

• Polyunsaturated fat is in corn, cottonseed, sunflower, safflower, and soybean oils, as well as in margarine and mayonnaise.

• Omega-3 fats are in walnuts, flaxseed oil, and fish such as tuna, bluefish, lake trout, salmon, and sardines. Omega-3 and omega-6 fats are found in fish oil and flaxseed and soybean oils.

Unhealthy Fats

Unhealthy fats can lead to clogged arteries, heart disease, and stroke. They include saturated fats, trans fats, and cholesterol. Saturated fats are mostly found in animal fats, such as red meat and bacon.

Some vegetable products are also high in harmful trans fats. These products are often found in cookies, crackers, cakes, snack chips, and pancake mixes. Be careful when you find cookies marked as “sugar-free” or marketed toward people with diabetes because they may provide more than 60% of their calories from fat.

Types of Unhealthy Fats

• Saturated fats are in bacon, butter, cocoa butter (chocolate), coconut oil, full-fat (regular) cream cheese, lard, meat fat, palm oil, solid shortening, and full-fat (regular) sour cream.

• Trans fats are in margarine sticks; shortening; fast-food French fries; some chips and crackers; some muffins, cookies, and cakes; and any product containing hydrogenated or partially hydrogenated oil.

• Dietary cholesterol is in meat, poultry, egg yolks, and dairy products.

Tips for Reducing Meat Fat in Your Diet

• Choose lean cuts of meat. Look for key words, such as “loin,” “round,” “lean,” “choice,” and “select.”

• Cut off all visible fat before or after cooking, and remove skin from chicken and turkey.

• Broil, roast, grill, steam, or poach instead of frying.

• Try quick-cooking methods, such as stir-frying, that use marinades or dressings with lots of seasonings to enhance juiciness and flavor.

• Limit your portions of lean meat, fish, or poultry to 3–5 ounces per meal—about the size of a deck of cards. Half of a skinless, boneless chicken breast is about 3 ounces of meat.

• Chill meat broth and drippings so the fat rises and solidifies. Then it can be skimmed off the top before serving or making gravy. You can also use this method to reduce the fat in canned or homemade broths and soups.

Tips for Reducing Other Fat in Your Diet

• Avoid fried foods.

• Limit the number of egg yolks you eat to four per week.

• Use a nonfat cooking spray on pans and cooking utensils to prevent sticking.

• Select reduced-fat or fat-free dairy products, such as salad dressings, baked goods, luncheon meats, soups, and dairy products.


Margarine

Choose a “light” or reduced-fat tub margarine that includes liquid oil, such as olive oil or soybean oil, as its first ingredient rather than one that includes partially hydrogenated oil or trans fat.


Vitamins and Minerals

People with diabetes have the same requirements for vitamins and minerals as people without diabetes. You are most likely getting all the vitamins and minerals you need if you are eating a diverse diet rich in vegetables, fruits, cereals, and grains. The one exception to this may be calcium (to prevent osteoporosis) or vitamin D (if you live in the north or have a darker complexion), which you may need to get from a supplement, if directed by your health care provider.

If you are thinking about becoming pregnant or you are pregnant, you have slightly different nutritional needs. You may need a prenatal vitamin or multivitamin. Folic acid is generally recommended during pregnancy, so check with your doctor.


Should You Take a Vitamin?

Large doses of vitamins or minerals have not been shown to help diabetes or blood glucose levels. In fact, large doses of some vitamins can be harmful. Check with your dietitian before you take any vitamin or herbal supplement. A few changes in your food choices may correct the nutritional deficiency.


Reducing Salt

Too much dietary salt or sodium can increase blood pressure. People with diabetes, especially type 2 diabetes, may already have high blood pressure, so they may need to reduce their sodium intake.

• Put the saltshaker away, and use less or no salt when cooking.

• Read food labels to assess the sodium content (80% of your sodium intake comes from processed foods).

• If you are using canned vegetables, rinse them to remove the salt or choose no-salt-added or reduced-sodium options.

• Avoid fast foods.

• Use flavorings such as herbs and spices to make your food tastier.

• Cook using fresh foods whenever possible.

Choosing a Meal Plan

You are the most important person to consider when choosing a healthy meal plan. Your plan should reflect your goals, needs, tastes, and lifestyle. Your provider and dietitian may recommend certain goals, but you will be the one who chooses a meaningful and realistic plan.

Keep in mind that a healthy meal plan for you is a healthy meal plan for anyone—with or without diabetes. You don’t have to worry about following some strange diet involving weird foods that no one else in your family will want to touch. You can choose foods that will benefit everyone in your family. Often, family members will not even realize that they are eating a “diabetes meal plan.”

Defining Goals for a Meal Plan

• Do you want to lose or maintain weight?

• What are your blood glucose goals? If you have type 2 diabetes, which foods should you choose to help you manage your blood glucose level? If you have type 1 diabetes, which foods are best to eat when taking insulin or other medication?

• How can you use meal planning to fit in with intensive diabetes management?

After first consulting with your diabetes care provider, you will most likely set up a visit with your dietitian to develop a meal plan. You may feel that you don’t really need a dietitian. Maybe you’ve seen sample meal plans recommended for people with diabetes that look easy enough to use. But remember, your meal plan is not a short-term diet that you can follow for a few weeks. You are developing a new way of eating that will stay with you throughout your life.

Your dietitian can help tailor a meal plan to suit your tastes and schedule. As you reach goals or your lifestyle changes, you can remodel your plan to suit these changes. Products change, your life and health needs change, and you change. As these events occur, your dietary goals will change, and you will probably need a new plan.

Designing a Meal Plan

Your meal plan should make it easier—not harder—to manage your blood glucose.

• Include foods you like and that are important to you.

• Take into account your daily activities and schedule.

• Be flexible.

• A plan should help you keep your blood glucose levels within your target range.

• A plan should help you reach and maintain a healthy weight.

• Choose foods that will help prevent diseases and conditions, such as heart disease, high blood pressure, and cancer.

A dietitian with experience in diabetes care can help you develop new ways to look at food. You might want to get a better sense of matching your carbohydrate intake to your insulin or other medication doses to keep your glucose in balance. Or maybe you’d like to know how to manage your blood glucose using a vegetarian diet. Or perhaps you would like to lose weight.

Topics to Discuss with a Dietitian

• What types of foods and how much you need to eat every day.

• How many grams of carbohydrates to eat each day to keep your blood glucose within your target range—and how to count carbohydrates (see more on carbohydrate counting in the next section).

• How many grams of fat to eat if you want to keep your fat intake low. Generally, this means that the fat in your diet provides no more than 30% of the calories you take in per day. You may also want to discuss how to count fat grams.

• How to adjust your meals for exercise.

• Which foods to have on hand to treat hypoglycemia and sick days.

• New ideas for breakfast, lunch, dinner, and snacks.

• How to reduce your sodium intake—and how to count sodium in milligrams.

• How to read food labels.

• How to meet your nutritional needs when following a specific meal plan such as a vegetarian diet.

Meal Planning and Pregnancy

You will want to pay special attention to the food you eat when you’re pregnant. Eating healthy during pregnancy really isn’t all that different from a healthy meal plan for anyone. However, you will find that you and your growing baby require more nutrients than you did before pregnancy. For example, you will need more protein, calcium, iron, and vitamins while you are pregnant. Your appetite may increase, especially in the last months of pregnancy.

It is important to talk to your provider and dietitian before you decide to become pregnant, because good nutrition starts even before conception. For instance, your provider or dietitian will advise you to take folic acid. Having near-normal blood glucose levels before conceiving is another safeguard against birth defects. If you are overweight, a calorie-restricted diet may be recommended before you conceive.

Once you are pregnant, your dietitian, your diabetes care provider, and your obstetrician can assess your dietary needs and work with you to develop a meal plan that you can use throughout your pregnancy. You will need to take into account your overall health and nutritional status.

Topics to Discuss for Pregnancy and Meals

• How many calories you need to eat each day

• Whether you will need a prenatal vitamin supplement

• How to divide your daily calories and carbohydrates between meals and snacks

• Your goals for your blood glucose readings throughout the day

Your dietitian and other members of your health care team can also help you ease into making lower-fat food choices if controlling weight gain is one of your goals. If you are suffering from nausea, your dietitian can teach you how to incorporate snacks at certain times of the day.

If you are taking insulin, you will also need to learn how to adjust your insulin doses to match the changes in your diet. As your pregnancy proceeds, insulin resistance increases, and you’ll need more insulin.

Ask your dietitian and doctor about the use of caffeine, alcohol, and artificial sweeteners during pregnancy. Unless you have special needs, it is safe to use the artificial sweeteners aspartame and acesulfame-K during pregnancy. You need to avoid saccharin during pregnancy and when breast-feeding. Alcohol is generally not recommended for anyone during pregnancy and can increase the risk of hypoglycemia among women with diabetes.


Small Breakfast

You may be advised to eat a small breakfast because blood glucose is more likely to be high first thing in the morning.


Carbohydrate Counting

Carbohydrate counting, or carb counting, is a specific tool to help you manage your blood glucose. It is based on counting the number of grams of carbohydrates in a meal and the total carbohydrates you eat in a day to balance your blood glucose levels. Carb counting can provide a lot of flexibility in your meal planning because the most important thing is the total number of carbohydrates in meals.

Your dietitian should recommend the number of carbohydrates to eat at meals and snacks. As a general guideline, most women need about 45–60 grams of carbohydrate at each meal and 15 grams per snack. Most men need 60–75 grams of carbohydrate at each meal and 15–30 grams for one or two snacks.

So how do you figure out how many carbohydrates are in foods? The easiest way is to examine the food label. Food labels should contain a line that lists the total carbohydrate grams and percent of daily value. You’ll also want to take into account the serving size. Reading food labels will be discussed in more detail below.

However, many foods like fresh vegetables and fruit don’t have labels. You’ll need to keep in mind some guidelines for these foods when planning your meals. Find out the carbohydrate count of your favorite foods and keep the list with you while you’re learning.

People with type 1 diabetes and people with type 2 diabetes who take insulin can work with their dietitian or diabetes educator to come up with a plan for how much insulin to inject per gram of carbohydrate. You’ll read more about managing your insulin and meals in chapter 13.

You may have heard about the glycemic index of foods. The glycemic index is a tool that may help you fine-tune your blood glucose control while following your current meal planning strategy.

The glycemic index is a tool that may help your current meal plan work a bit better for you. Foods with a high glycemic index raise blood glucose more than foods with a medium or low glycemic index. The total amount of carbohydrate, food composition, and cooking method can affect the glycemic index of foods.

When you eat a carbohydrate food, choose one with a moderate or low glycemic index or eat a small portion of food with a high glycemic index. Your food choice may make it easier for you to meet your post-meal glucose goal. For reliable sources of glycemic index information, visit the official website of the glycemic index, based at the University of Sydney in Australia (www.glycemicindex.com).


Carbohydrate Choices

Some people prefer to think about their carbohydrates as “choices” rather than grams. This method is based on the concept that a carbohydrate choice contains 15 grams per serving. Your dietitian will recommend how many carbohydrate choices you should eat per meal.


Foods with 15 Grams of Carbohydrate

Small piece of fresh fruit

1/2 cup starchy vegetable or black beans

1/4 large baked potato

1/3 cup pasta or rice

One slice of bread

One-half banana

4 ounces or 1/2 cup juice


Sports Drinks and Juice

Don’t forget to consider the calories and carbohydrates in sports drinks 

and juices as part of your daily intake. Sometimes people forget that beverages can have significant calories too.


Food Labels

The U.S. Department of Agriculture and the Food and Drug Administration regulate food labels. Most manufacturers are required to display food labels, except distributors of fresh vegetables, fruits, and seafood. You’re probably quite familiar with the black and white “Nutrition Facts” labels on foods. The Nutrition Facts label is an essential tool for eating healthfully. Here is the valuable information contained on a food label.

NutritionFacts.jpg

Nutrition Facts Labels

• Serving Size.

• Servings per Container. Keep in mind that there may be many servings per container in a frozen pizza or bag of chips.

• Amount per Serving: Calories and Calories from Fat.

• Daily Values: Total Fat (Saturated and Trans Fat), Cholesterol, Sodium, Total Carbohydrate (Dietary Fiber and Sugars), and Protein.

• Ingredients are listed in descending order by weight. Look for foods with healthier ingredients, such as whole-wheat flour, listed first.


How Foods Measure Up Against Each Other

Nutrient amounts are shown in grams (g) or in milligrams (mg). A gram is a very small amount, and a milligram is one-thousandth of that. For example, a nickel weighs about 5 grams. So does a teaspoonful of margarine. Use the label to compare labels of similar foods. For example, choose the product with a smaller amount of saturated fat, cholesterol, and sodium and try to select foods with more fiber.


Percent Daily Values

The percent daily value tells you how much of the total daily intake you use up when you eat one serving of a food. These numbers assume that you are eating 2,000 calories each day. For many people, the true percentages may be higher or lower depending on how many calories you need, which you can learn from a registered dietitian.


Health Claims

Sometimes you’ll see a food label with a health claim such as “calcium helps prevent osteoporosis.” Food manufacturers can only make health claims that are supported by scientific research. These claims can suggest a relationship between a potentially helpful or harmful ingredient and a disease.

Examples of Health Claims

Here are a few of the ingredients and linked conditions or diseases that are allowed on food packaging in the United States.

• Calcium and osteoporosis

• Fiber-containing grain products and cancer

• Fruits and vegetables and cancer

• Fruits, vegetables, and grain products that contain fiber—particularly soluble fiber—and the risk of coronary heart disease

• Fat and cancer

• Saturated fat and cholesterol and coronary artery disease

• Sodium and hypertension

• Folic acid and neural tube defects

• Olive oil and coronary heart disease

Nutrient Content Claims

Manufacturers also make claims about the nutritional value of their products. Sometimes these claims can be a little confusing. What’s the difference between low-calorie or “lite”? What is “natural”? Below are some details on what these claims mean.

Calories

• Calorie free means that the product has fewer than 5 calories per serving or another designated amount (make sure to note the size of the serving).

• Low calorie means 40 calories or less per serving.

• Light or lite means that the food has one-third less calories, 50% less fat, or 50% less sodium than the food with which it is being compared, usually the full-calorie version of the same food.

• Less and reduced (as in fat or sugar) mean that the food is at least 25% lower in calories or other ingredients compared with the full-calorie or regular version. When these words are used on a label, the actual percentages must also be included, for example, “50% less salt” or “fat reduced by 25%.”

Cholesterol

• Cholesterol free means that the food must contain fewer than 2 milligrams of cholesterol and 2 grams or less of saturated fat per serving. For example, although vegetable oils contain no cholesterol, they are 100% fat. Vegetable oils are still preferable to butter or lard because they have less saturated fat. But a tablespoon of vegetable oil still has about 14 grams of fat and the same 126 calories found in a tablespoon of butter or cream.

• Low cholesterol indicates that a given serving contains 20 milligrams or less of cholesterol and 2 grams or less of saturated fat per serving.

Fat

• Low fat means that a food must have 3 grams or less of fat per serving.

• Fat free means that a food has less than 0.5 grams of fat per serving.

• Low saturated fat means that a food has 1 gram or less of saturated fat per serving and not more than 15% of its calories come from saturated fat.

Sodium

• Low-sodium foods contain 140 milligrams or less of sodium per serving and per 100 grams of food. Ordinary table salt (sodium chloride) is not the only source of sodium. It is also found in monosodium glutamate (MSG), sodium bicarbonate (baking soda), and sodium nitrate and occurs naturally in some foods.

• Very low sodium means that a food contains 35 milligrams or less of sodium per serving and per 100 grams of food.

• Sodium free or salt free items have less than 5 milligrams of sodium per serving.

• Light in salt means that the food has 50% less sodium than the regular version.

Other

• Sugar free means that the item has less than 0.5 grams of sugar per serving.

• Dietetic has no standard meaning. It indicates only that something has been changed or replaced. It could contain less sugar, less salt, less fat, or less cholesterol than the regular version of the same product. For example, if you look at a package of “dietetic” cookies, you might find that they are low in sodium but are not as low in calories or sugar as you might be led to believe.

• Natural has no specific meaning except for meat and poultry products. For meat and poultry products, it means that no chemical preservatives, hormones, or similar substances have been added. On other food labels, natural is not restricted to any particular meaning by government regulation.

• Fresh can only be used to describe raw food that has not been frozen, heat processed, or preserved in some other way.

Eating In and Eating Out

Once you have a new meal plan in hand, you’ll want to start using it whenever you eat in or eat out. Your meal plan is personal, so you will do a fair amount of troubleshooting on your own to figure out how to shop, cook, and dine out. However, there are some guidelines to shoot for as you think about making healthy choices.

Shopping

Cooking and eating at home can be one of life’s great pleasures. Dinner is a wonderful opportunity to sit around the table with your family or friends.

Eating in with your meal plan may take some planning and improvisation as you learn to shop for and cook with new foods. It may all seem new and overwhelming. Keep in mind—a meal plan is a chance to discover new foods and rediscover cooking. If you aren’t comfortable in the kitchen, your dietitian can adjust your plan to fit your skill level and eating preferences.

Tips for Shopping

Vegetables and Fruits

• Vegetables. Fresh and frozen vegetables are the most nutritious per bite. Drain and rinse canned vegetables to reduce sodium content.

• Fruit and fruit juice. Choose fresh, frozen, or dried fruit, preferably without sugar added. Look for 100% pure fruit juice. Check labels of brands that say “made with 100% fruit juice.” These drinks may list other ingredients first. Look for “no sugar added,” but know that the natural sugar in juice will still raise your blood glucose. Check the Nutrition Facts label.

Grains

• Bread. Look for products that contain whole grains. Look at the ingredient list for items such as whole wheat, whole grain, or whole corn.

• Cereal. Choose brands that list whole grains first on the label and contain (per serving) 3 or more grams of dietary fiber, 1 gram or less of fat, 5 grams or less of sugar.

• Whole grains, rice, and pasta. Choose brown or wild rice of any type. Look for fresh or dried pasta made with whole-grain flours. Try to avoid pastas that contain eggs and fat.

• Crackers and snack foods. Look for whole grains listed first on the label and 2 grams or less of fat per serving. Consider pretzels or plain popcorn (air popped, with no cheese or butter, 2 grams of fat or less per serving) as low-fat snacks. Check sodium content and try to stay under 400 milligrams per serving.

Dairy

• Milk. Choose fat-free or 1% milk, buttermilk made from low-fat milk, and low-fat or fat-free yogurt (artificially sweetened or unsweetened).

• Cheese. Look for fat-free and reduced-fat cheeses with 6 grams of fat per ounce or less.

• Sour cream and cream cheese. Try fat-free or light sour cream or cream cheese. As an alternative to sour cream, consider using fat-free or low-fat yogurt, either plain or flavored with chives, herbs, and spices.

Meat and Seafood

• Red meat. Meat is graded based on its fat content. Choose lower-fat cuts such as Choice or Select rather than higher-fat Prime. Ask the butcher to cut 4-ounce servings of raw meat (on cooking, they will shrink to a 3-ounce serving).

• Luncheon meat. Look for lean or 95% fat-free meats (by weight) with 30–55 calories per ounce and 3 grams of fat or less per ounce.

• Poultry. Breast meat is the leanest of all. Removing the skin before cooking lowers the fat content by 50–75% and cholesterol by 12%. Look for ground turkey that is less than 7–8% fat by weight (often the fatty skin is ground in, giving it a higher fat content). When turkey or chicken is used to make salami, bologna, hot dogs, and bacon, these products can be high in fat. Look for ones that are 30% fat or less.

• Seafood. Supermarkets offer a wide variety of seafood. Buy fresh fish or shellfish. Look for clear eyes, red gills, shiny skin, and no “fishy” smell. Shrimp is usually shipped frozen to preserve freshness. Choose canned fish packed in water or with the oil rinsed off. Look for low-sodium products.

Other Foods

• Frozen desserts. Choose varieties that contain 3 grams or less of fat per 4-ounce serving (1/2 cup). Look for low-fat frozen yogurt or low- or fat-free ice cream. Try frozen fruit juice bars with fewer than 70 calories per bar. Avoid desserts made with cream of coconut, coconut milk, or coconut or palm oil, which are high in saturated fat or contain trans fats.

• Margarine and oil. Choose olive, canola, soybean, safflower, sesame, sunflower, or corn oils. Choose brands with liquid oil listed first on the label and that contain no trans fats. Try using nonstick vegetable cooking spray for cooking and cut back on oil.

• Salad dressings. Try reduced-calorie and fat-free types. Include the carbohydrates in your meal plan.

• Soup. Choose low-sodium, reduced-fat varieties. In preparing soup, use fat-free or low-fat milk or water.

• Cookies and cakes. Choose brands that contain 3 grams or less of fat per 100 calories. Angel food cake is made without fat and has no cholesterol. Other cakes can be made without cholesterol (by using egg substitutes) but usually not without fat. Some versions substitute applesauce or nonfat yogurt for oil. Some cake mixes include directions for low-fat and low-cholesterol variations. Some fat-free cookies have more calories than the original recipe because of added sugar. Avoid palm, coconut, and hydrogenated oils.

Restaurants

Eating out is a big part of today’s lifestyle—and there is no reason why you should avoid restaurants because you have diabetes. However, it is important to know what you’re eating and to make healthy choices from the menu.

Tips for Eating Out

• Don’t be afraid to ask about ingredients or the serving size of dishes.

• Try to eat the same portion size you would eat at home. Don’t feel you need to clean your plate just to get your money’s worth.

• Ask your server if you can order a smaller portion at a reduced price, share a plate with your companion, or put extra food in a “doggy bag” to take home.

• Ask if no or less butter can be used in preparing your meal.

• Ask that sauces, gravy, salad dressings, sour cream, and butter be served on the side or left off altogether.

• Choose broiled, baked, poached, or grilled meats and fish rather than fried.

• Try asking for substitutions, such as low-fat cottage cheese, baked potato, or even extra vegetables, instead of French fries.

• If you take insulin, ask your health care team for guidelines on adjusting your dose when you eat out.

Special Considerations

Without a doubt, special considerations are likely to come up from time to time. Disruptions in your schedule, holidays, and parties are inevitable. Here are some tips to deal with these situations.

Alcohol

A common myth is that people with diabetes can’t drink alcohol. This is just not true. If your blood glucose levels are on target, it is unlikely that an occasional alcoholic drink at mealtime will harm you. In fact, some studies have shown that light to moderate alcohol intake is associated with reduced risk of death from coronary heart disease for people with type 2 diabetes.

The key is to drink moderately. Moderate drinking is defined as no more than one drink a day for women and two drinks a day for men. One drink is 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits (liquor). If you do not tolerate alcohol well or have had problems with it in the past, however, you should avoid drinking.

Tips for Drinking Alcohol

• Alcohol contains calories, almost as many per gram as fat. If weight loss is one of your goals, then you need to think about the extra calories from alcohol. Generally, alcohol is substituted for fat calories, with one drink equal to 2 fat exchanges (about 90 calories).

• Alcohol can affect your blood glucose, most often causing very low blood glucose when consumed on an empty stomach. If you use certain medications or insulin, drink alcohol with food to prevent hypoglycemia.

• The signs of hypoglycemia (no matter what the cause) are very similar to the signs of inebriation. There is the risk that people will think you are intoxicated if they see your behavior suddenly change. They may not consider the possibility that you have low blood glucose and need help quickly.

• Some people have hypoglycemia unawareness, a lack of symptoms of low blood glucose. Drinking alcohol increases their risk for hypoglycemia.

• Some medications, including some diabetes medications, require limits on alcohol use.

• If you have health problems, such as pancreatitis, high triglyceride levels, gastric problems, neuropathy (nerve damage), kidney disease, or certain types of heart disease, you may be advised to abstain from alcohol.

• Not drinking and driving is sound advice for everyone. But because of the added risk for hypoglycemia from alcohol, it is especially true for people with diabetes.

• Alcohol can affect your thought processes and inhibitions. It’s easy to overeat when you are drinking. In addition, you need to be able to think clearly enough to monitor your blood glucose levels and to know what to do should they drop too low. If you are drinking, make sure to tell a friend what to do in the event of low blood glucose. Your friend should be prepared to take action, even if you are not able to cooperate.

Eating Later than Usual

You may need a snack if your meal is later than usual. Just make sure to account for it in your overall daily nutrition. Always carry snacks with you. You never know when you might get stuck in traffic or delayed at work and start to go low.

If you plan to go out for brunch, eat an early-morning snack. Then, use your lunchtime meal plan and what is left of your usual breakfast plan. If dinner is going to be very late, have your bedtime snack at your normal dinnertime.

If you take insulin and can’t change the timing of your insulin dose, eat a piece of fruit or a starchy low-fat snack. You may need to adjust your insulin later to account for these changes, so ask your health care team how to do this.

Eating More Often than Usual

At holidays, it may seem like you’re around food all day long. Try dividing your total food for the day into snack-size meals. Then you can spread the food out a little more than usual without going over your usual amounts.

Eating More Food than Usual

Sometimes going to parties, having friends visit, or just dining out may tempt you to overeat. You are bound to eat a little more than you planned on occasion. Don’t let an occasional moment of overeating make you feel guilty or like you are “cheating.” Remember, eating healthy is all about making choices. Maybe you can plan some more activity to help with extra food intake if you are working toward losing weight. For people on insulin, covering the extra food with more insulin is a choice too.

Plan ahead what you want to do. If you decide to eat more than usual, think about using your other blood glucose management tools. Do a little more exercise either before or after the event. Regardless of what you decide, think afterward about how your plan worked. Would you try something different the next time?


Eating Until You Are No Longer Hungry

Instead of eating until you are full, eat until you are no longer hungry.


Eating Disorders

Eating disorders occur among people with diabetes just as they do in the general population. Some researchers believe that individuals with diabetes may have an increased risk for eating disorders because they have to pay more attention to what they eat. Unfortunately, in our society, the self-worth of many people comes from having a “perfect” body. Some people resort to extreme measures to get or stay thin.

There are two main eating disorders: anorexia nervosa and bulimia. Each has a distinct set of warning signs. Both disorders stress the body and deny it the necessary nutrients.

People with diabetes and eating disorders are likely to have more episodes of diabetic ketoacidosis (type 1 diabetes) and hypoglycemia, and their A1C levels tend to be higher. They are also at higher risk for diabetes complications because their blood glucose is high.

If you have an eating disorder or are omitting insulin for weight control, professional help is available. Eating disorders are serious and can lead to serious complications and even death. Please talk to someone with whom you feel comfortable discussing your feelings.

Ask your provider to recommend a mental health counselor who can work with the other members of your health care team. Your entire team will work with you and your family to help you understand your disorder and how to treat it. It may help you to join a support group. Talking to others who have similar problems can help you feel understood.


Diabulemia

An eating disorder called diabulemia has been found in people with diabetes who use insulin. They intentionally reduce or omit insulin doses in an attempt to lose glucose and calories in the urine. As in other eating disorders, people who omit insulin for weight loss have more episodes of diabetic ketoacidosis and have problems managing their glucose levels.


Weight Loss

The best approach to weight management is a combination of physical activity and healthy eating. No one plan works for everyone. Some people find it easier to take in fewer calories. Some find it easier to work out more. Whatever your approach, a cornerstone will be to develop a lifetime plan of healthy eating and regular exercise.

If you are beginning to use a healthy eating plan, you are probably already on your way to losing weight. Talk to your dietitian about your weight loss goals and set up a realistic plan for achieving those goals. But don’t try to lose too much weight too quickly. A steady loss of 1–2 pounds per week is a safe and effective means to reach your goal.

Strategies for Losing Weight

• Follow a nutritionally sound, calorie-restricted meal plan designed to achieve gradual weight loss over several months.

• Decrease portion sizes or eliminate certain foods.

• Set behavioral goals.

• The most important thing you can do to lose weight is to choose weekly or monthly goals and short-term strategies to reach those goals. You will be more likely to succeed if you take it one day at a time.

If you use medications to manage your diabetes, you need to monitor your blood glucose levels as you lose weight. You may be able to reduce the dose of your medication as weight loss lowers your glucose levels.

If you have episodes of hypoglycemia, you will need to treat them with food, and this adds calories and can slow down your weight loss. Call a member of your health care team if you start to have more frequent low blood glucose reactions, so they can advise you on decreasing your medication dose.


Are You Obese?

You definitely need to lose weight if you are obese. More than 75% of all people with type 2 diabetes either are or were obese at one time or another. But what is obesity? In medical terms, obesity refers to people with a body mass index (BMI) of 30 or above. Your doctor can help you determine your body mass index and a healthy weight for you. Or you can use the chart on p. 147 to figure out what your BMI is.


A Healthy Weight-Loss Plan

Creating a healthy weight-loss plan is not much different than creating a healthy eating plan for someone who doesn’t need to lose weight. You will need to eat fewer calories than you are used to. You will still want to eat a variety of foods that includes fruits, vegetables, and grains.

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Portion Control: Another Step toward Weight Loss

• Invest in a set of measuring cups and spoons and a food scale that weighs food in ounces or grams.

• Serve yourself your usual portion. Now measure it. Is it more or less than you expected?

• Weigh a piece of bread or a bagel. One serving of bread is 1 ounce. How does yours compare?

• Try dividing and weighing portions of different meats and seafood before cooking. One serving of meat is 4 ounces raw (3 ounces after cooking).

• Practicing portion control at home will help you estimate how much of your meal to set aside for a doggy bag when eating out.

As you plan your weight loss program, think ahead about how to maintain your new weight. Many people are successful in losing weight but have a hard time keeping it off. What are the strategies used by people who get it off and keep it off?

Weight Loss and Physical Activity Together

Remember that weight loss and physical activity go hand in hand. Studies show that exercise is an important part of both taking the pounds off and keeping them off. People who keep lost weight off say that daily exercise is an essential part of their lifestyle. They also report eating more fruits and vegetables than before, a healthy habit they hung on to even after they went off their “diet.” In the next chapter, you’ll learn about how to safely pursue physical activity with diabetes—and have fun, too.



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