Diabetes

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NOTE TO THE READER: This article is for you if you are a vegetarian who has just developed diabetes, or if you are a diabetic who would like to try a vegetarian diet. If you are a diabetic, be certain to work with a registered dietitian when planning your diet,especially if you are a new diabetic.

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DIABETES AND A VEGETARIAN DIET by VIRGINIA MESSINA, M.P.H., R.D.

The earliest diabetes diet was described in Egypt around 1550 B.C.E.and suggested the use of "wheat grains, fresh grits, grapes, honey, berries, and sweet beer," in other words, a high carbohydrate diet. However, by the late 18th century, a British surgeon was recommending "animal food and confinement with an entire abstinence from every kind of vegetable matter." Almost every type of diet that falls between these two extremes has been recommended at one time or another. Our understanding of the best diet for diabetes is ever evolving. We do know, as did our ancestors, that diet is important in the control of this disease.

WHAT IS DIABETES?

Diabetes, or Diabetes Mellitus as it is properly called, is the inability to process food properly. Much of what we eat is digested and converted to glucose, the sugar found in blood. Glucose, carried through the blood to the body organs, is transported into individual cells, where it is used as an energy source. Most of the body's organs require the hormone insulin to get glucose into cells. In diabetes,insulin is either absent, present in insufficient amounts, or ineffective. Therefore, cells cannot get enough glucose. As a result, glucose builds up in the bloodstream. When blood glucose (blood sugar) is high, it is called hyperglycemia.

Short-term effects of hyperglycemia may include thirst, frequent urination, weakness, lack of ability to concentrate, loss of coordination, and blurred vision. With very high levels of blood glucose, loss of consciousness is possible.

COMPLICATIONS OF DIABETES

Diabetes is much more than high blood glucose. The effects of the disease are far-reaching, sometimes unexplained, and potentially devastating. Diabetics often have high levels of blood lipids(cholesterol and triglycerides) and are at increased risk for developing a therosclerosis, or blocked arteries. Untreated diabetes results in increased risk for heart attack, stroke, and vision problems, including blindness. Some experts feel that the long-term complications of diabetes may result from years of high blood glucose.

As ominous as this sounds, there is good news about diabetes. Diabetes can be controlled. A look at the diet recommended for diabetics can help us to see why vegetarians may have the advantage in controlling this disease.

TWO TYPES OF DIABETES

Much confusion about diabetes arises from the fact that it is really two separate diseases. Type I diabetes is also called insulin dependent diabetes mellitus (IDDM) and was formerly referred to as juvenile onset diabetes. Those with type I diabetes produce no or very little insulin. There is no cure for this type of diabetes although proper diet and exercise can decrease insulin needs.

Type II diabetes, or non-insulin dependent diabetes mellitus (NIDDM),used to be called adult-onset diabetes. About 90% of all diabetics fall into this category. Obesity is believed to be a major risk factor for type II diabetes. Some type II diabetics produce insufficient insulin and may benefit from insulin injections. More typically however,these individuals produce sufficient or even excess insulin; but their cells are resistant to the insulin. These diabetics may take medications called "oral hypoglycemic agents" to help lower blood glucose. In many cases weight reduction alone will help to normalize blood glucose levels. Regardless of the type, diet is a critical factor in attaining normal blood glucose levels in diabetes.

There are four goals of the diabetic diet.

1. TO ACHIEVE AND MAINTAIN NORMAL BLOOD GLUCOSE LEVELS. Blood glucose levels are affected by the type and amount of food consumed, and for people taking insulin, by the timing of the meals.

2. TO ACHIEVE AND MAINTAIN ACCEPTABLE BLOOD FAT LEVEL. Since diabetics are at higher risk for atherosclerosis and associated problems, blood levels of cholesterol and triglycerides are important.

3. TO PROVIDE GOOD NUTRITION. The nutritional needs of diabetics are the same as those of all other individuals.

4. TO MAINTAIN AN APPROPRIATE WEIGHT. This is especially important for type II diabetics, many of whom are overweight. Obesity is a significant risk factor for diabetes

Based on these goals, the principles of the diabetic diet are as follows.

1. LOW-FAT, SPECIFICALLY LOW SATURATED FAT. This is the most important principle of the diabetic diet. Foods high in fat are also high in calories, and therefore contribute to obesity. Additionally,high fat, high saturated fat diets are associated with atherosclerosis.

2. HIGH CARBOHYDRATE. Many people are surprised to learn that diabetics can and should eat starches such as potatoes, bread, pasta,and legumes. A high complex carbohydrate diet helps to control blood glucose. The American Diabetic Association recommends that at least 55 - 60% of the calories consumed be from carbohydrate.

3. HIGH FIBER. Fiber seems to be especially effective in normalizing blood glucose levels and lowering blood lipid levels, as we shall see.

FIBER

The hottest area in diabetes in the past decade has been the effect of fiber on blood glucose levels. Fiber is found only in plant foods. Foods derived from animals do not contain any fiber.

Some researchers have been able to show that the total level of complex carbohydrate (starch and fiber) is more important than the level of fiber alone. Indeed, several studies have shown that when the level of carbohydrate is held constant, varying levels of fiber have no effect on blood glucose levels. However, the majority of studies support a role for fiber in regulating blood glucose.

There are two types of dietary fiber. Insoluble fiber has little effect on blood glucose. Soluble fiber, however, has been associated with improved blood glucose control in diabetics and with lowering of blood cholesterol levels. The best sources of soluble fiber are shown in the chart on the next page.

What level of dietary fiber should be used in the diabetic diet? Different amounts have been proposed. The American Diabetes Association recommends 40 grams of dietary fiber per day. For comparison purposes, the average American consumes between 10 and 15 grams of dietary fiber per day. The American Diabetes Association does not make a recommendation for a specific amount of soluble fiber.

The panel of National Institutes of Health Consensus Development Conference on Diet and Exercise in NIDDM (Non-Insulin Dependent Diabetes Mellitus) believes the evidence for increasing fiber in the diabetic diet is inconclusive. However, Dr. James Anderson,whose research helped to establish a role for fiber in control of diabetes, recommends very high intakes of fiber. He states that the"ideal" diabetic diet could include as much as 70 grams of dietary fiber per day. Some health professionals suggest caution in the use of very high fiber diets. In some studies, dietary fiber, when consumed at very high levels, has been shown to bind minerals such as iron and calcium, making them unavailable to the body.

Although there is no consensus on the amount of fiber to be eaten,health professionals agree that many Americans do not eat enough dietary fiber. Vegetarians are more likely to achieve the recommended increase in fiber intake because of their reliance on plant foods. Replacing non-fibrous foods such as meat, cheese, and eggs with grains and legumes is an excellent way to increase dietary fiber. While a high-fiber diet is difficult for many Americans to achieve, it's a way of life for most vegetarians.

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GOOD SOURCES OF SOLUBLE FIBER

dry or cooked oat bran cooked oatmeal black eyed peas kidney beans pinto beans split peas butter beans lentils fresh peas baked potato with skin Brussels sprouts corn zucchini prunes apricots bananas blackberries barley

NOTE: Dr. Anderson from the University of Kentucky has compiled data for the amount of soluble fiber in the above foods. However,since data on soluble and insoluble fiber in foods has not been agreed upon by experts on fiber, we have not included amounts per serving.

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Increasing your intake of soluble fiber is really quite easy. Be sure to include a serving of legumes in your diet daily -- they are the best food source of soluble fiber, and black eyed peas are the best of the beans! Tofu does not count since it does not include the fibrous portion of the soybean. Experiment with oat bran. See BobbieHinman's article in the March, 1989 Vegetarian Journal. Replace 1/4- 1/2 of the flour in baked products with raw oat bran. Your product will be heavier, but delicious. Eat more berries. Experiment with grains and breads. Barley and corn meal both have more soluble fiber than brown rice.

SUGAR

Can diabetics consume sugar? And if so, how much? Historically,the recommendation has been for diabetics to avoid all sugar. This is because sugars have a simple chemical structure; they are digested and absorbed quickly. It was thought that this could cause a dramatic rise in blood glucose levels. Recent evidence shows that foods high in sugar are not as harmful to diabetics as once thought. Several studies have shown that sucrose (common table sugar) when fed as part of a meal does not cause increases in blood glucose levels any more than do most starches.

Does this mean that there are no restrictions on sugar in the diet of diabetics? Well, not necessarily. For one thing, a number of studies have linked sugar consumption by diabetics with an increase in blood triglycerides, a type of fat. Although the actual significance of increased blood triglycerides remains controversial, unlimited use of sugar does not seem prudent.

What is more important is that foods high in sugar are often high in saturated fat and calories and low in nutrients. For this reason,diabetics, like everyone else, would do well to keep their intake of sweets to a minimum.

The National Institutes of Health Consensus Development Conference on Diet and Exercise in NIDDM states that it is acceptable for up to 5% of total calories to come from sugar. This means that for a person on a 1500 calorie diet, with 60% of calories from carbohydrate,approximately 2 and 1/2 teaspoons of sugar are allowable. While this is a fairly small amount of sweetener, the allowance for some desserts on the diabetic diet is a welcome and realistic one.

ALCOHOL

Use of alcohol should be limited on the diabetic diet. Alcoholic beverages are high in calories and contribute little nutritional value to a diet.

Your physician may allow occasional use of alcoholic beverages. If you do drink alcohol, keep the following in mind.

* Be certain to always eat some solid foods when drinking.

* Insulin reactions can be difficult to recognize when you have been drinking.

* If you use an exchange list diet, count alcohol using the following guidelines:

12 oz. regular beer 1 bread plus 2 fats

12 oz. light beer 2 fats

1-1/2 oz. distilled spirits 2 fats

3-1/2 oz. dry wine 1 1/2 fats

EXERCISE

Exercise is especially important for Type II diabetics. Research shows that regular exercise can help to increase the body cells' sensitivity to insulin. Remember that one problem in Type II diabetes is that cells are not sensitive to insulin. So exercising diabetics may be better able to regulate blood glucose. This effect is seen only when diabetics exercise on a regular basis. Exercise has the added benefits of improving cardiovascular fitness and aiding in weight reduction. Both are of concern to the diabetic.

Diabetics who take insulin injections can certainly exercise also. However, precautions need to be taken. Rigorous exercise must be accompanied by an increase in food intake, or hypoglycemia (low blood glucose) may result. A dietitian can help you plan appropriate snacks for exercise. All diabetics should consult their physicians before beginning an exercise program.

DIABETES IN PREGNANCY

There are two types of diabetic pregnancies.

GESTATIONAL DIABETES is diabetes that develops for the first time during pregnancy. It usually disappears after the baby is delivered. Women who develop gestational diabetes are at greater risk for developing Type II diabetes later in life.

WOMEN WHO ALREADY HAVE DIABETES WHEN THEY BECOME PREGNANT will experience some changes in blood glucose control. If they are using insulin, they typically will experience a decrease in insulin needs during the first half of pregnancy, followed by an increase in insulin needs during the latter part of pregnancy.

Each diabetic pregnancy is treated individually. Pregnant diabetics need to be certain to consume adequate calories, eat frequent small meals, check their blood glucose frequently, and follow their doctor's advice. Well-planned vegetarian diets are appropriate for pregnant diabetics.

DIABETES IN CHILDREN

Diabetes that occurs in childhood is almost always insulin dependent diabetes (Type I). It is controlled with insulin injections. Diabetic diets for children must contain adequate calories, fat, and nutrients to ensure adequate growth, in addition to controlling blood glucose.

Diet planning with the help of a dietitian is especially important for these children. A plant-based diet for diabetic children should meet all of the above described needs while being acceptable to the child.

THE GLYCEMIC INDEX

The glycemic index is a measure of the blood glucose response to a particular food. Consumption of a food with a high glycemic index value produces a significant rise in blood glucose levels. The theory is that consuming foods with lower glycemic index values will help to maintain a normal blood glucose level.

As interesting as the glycemic index is, most nutritionists consider it to be of little use. For one thing, equal amounts of foods were compared rather than normal serving sizes. Secondly, when foods are served as part of a meal, along with other foods, this index changes dramatically. Thus, a dinner of carrots alone might cause a surge in blood sugar; but a meal of brown rice, lentils, and carrots will have a very different response.

------------------------------------------------------------ --- NOTE FROM THE EDITORS: Since there is such conflicting evidence concerning the glycemic index, our dietitians questioned whether to include this section. However, we left it in, since the glycemic index is mentioned in some of the popular literature. We decided not to include glycemic index values, since they are considered more theory than fact at this time. ------------------------------------------------------------ ---

IN CONCLUSION, recommendations for control of diabetes include a diet low in fat, particularly animal fat, to control blood lipid levels and weight, and high in carbohydrate and fiber to control blood glucose levels. By replacing 6 ounces of meat with 1 1/2 cups of beans, an individual can reduce dietary fat by over 10% and add 10 -25 gramsof dietary fiber! She or he might save up to 200 calories per day.

While few researchers actually recommend a vegetarian diet per se for diabetes, it is clear that the vegetarian pattern is closer to the recommendations than is the typical American diet. Research and nutrition educators are concerned that individuals will not be able to make the diet changes necessary to achieve a high-carbohydrate,high-fiber diet. For most vegetarians, this type of diet is a way of life. A strict or lacto-ovo vegetarian diet is not only allowable for diabetes,it may be the preferred diet pattern.

RECIPES

Diabetics do not need special recipes. The key is to choose vegetarian dishes that are low in fat and high in fiber. Most vegan recipes fit the bill, but be careful with lacto-ovo recipes. Eggs, whole milk, and cheese add lots of saturated fat and have no fiber.

Since the diabetic diet is one which is low in saturated fat and cholesterol, look for cookbooks that emphasize low-fat cooking. Here are a few recommendations to get you started.

Eat Smart for a Healthy Heart Cookbook, Copley and Moore, Barrons,Woodbury, N.Y., 1987. Hardcover, $18.95

Dr. Anderson's HCF Diet: The New High-Fiber Low-Cholesterol Way to Keep Slim and Healthy, Anderson, J. Available from HCF Diabetes Foundation, Box 22124, Lexington, KY 40522. Softcover,$5.00.

Low-Fat Cooking, Foley, L. (ed), Meredith Corporation, Des Moines,IA. Hardcover, $6.95.

The Quick and Delicious Low-Fat, Low-Salt Cookbook, J. Williams and G. Silverman, Perigee Books, N.Y.C., N.Y. Softcover, $8.95.

The American Heart Association Cookbook, R. Eshleman, M.Winston, Ballantine Books, N.Y.C., N.Y.

The Oats, Peas, Beans and Barley Cookbook, E. Cottrell, Woodbridge Press, Santa Barbara, CA.

Jane Brody's Good Food Book, J. Brody, Bantam Books, softcover$12.95.

REFERENCES

Anderson, et al. Professional Guide to HCF Diets, HCF Diabetes Research Foundation, Inc., Lexington, KY., 1981.

Bantle, John. "The Dietary Treatment of Diabetes Mellitus," Medical Clinics of North America, Vol. 72, No. 6, Nov. 1988, pp. 1285 -1299.

Anderson, James, et al. "Dietary Fiber and Diabetics: A Comprehensive Review and Application," Journal of the American Dietetic Association, Vol. 87, No. 9, September 1987, pp. 1189 -1197.

Wheeler, Madelyn. "Diet and Exercise in Noninsulin Dependent Diabetes Mellitus: Implication for Dietitians from the NIH Consensus Development Conference," Journal of the American Dietetic Association, Vol. 87, No. 4, April, 1987, pp. 480 - 485.

Snowdon, David and Phillips Roland. "Does a Vegetarian Diet Reduce the Occurrence of Diabetes?" American Journal of Public Health, May, 1984, Vol. 75, No. 5, pp. 507 - 512.

The Surgeon General's Report on Nutrition and Health, 1988. U.S.Department of Health and Human Services

A FEW WORDS ABOUT EXCHANGE LISTS

If you or someone you know is diabetic, you probably have heard about the Exchange Lists for meal planning. This is a diet planning tool used by many Type I diabetics to achieve a consistent daily meal pattern. For a person who takes insulin, a consistent calorie and carbohydrate intake at each meal is important.

The Exchange Lists contain six food groups (starch, meat (or protein),vegetable, fruit, milk, and fat). Individuals are allowed a particular number of servings in each group at each meal.

A quick look at the Exchange Lists reveals that while they are usable by lacto-ovo vegetarians, their use by vegans is more complicated. This represents a shortcoming of the Exchange Lists -- not the vegan diet. The Lists are based on the habits of the average omnivore and are not the only means of achieving diabetic control. Vegan diabetics can use the list with some modifications and should insist on guidance from their health care provider in doing so.

VEGAN DIABETICS: Vegan diabetics may substitute soy milk for 2% cow's milk in the milk exchanges. However, if you do not use soy milk, you may eliminate the milk exchanges from your meal planning and use only the remaining five lists. Be certain to include plenty of tofu (with a calcium coagulant) and leafy green vegetables in your diet to ensure adequate calcium intake.

EXCHANGES FOR SPECIAL VEGETARIAN FOODS

FOOD SERVING SIZE EXCHANGES brewer's yeast 3 TB 1 bread carob flour 1/8 Cup 1 bread kefir 1 Cup 1 milk plus 1 fat Loma Linda Veggie Links 1 oz. 1 high-fat meat Morningstar Farms Grillers 1 oz. 1 high-fat meat miso 3 TB 1 bread plus 1/2 lean meat seaweeds, cooked 1/2 Cup 1 vegetable soy flour 1/4 Cup 1 lean meat plus 1/2 bread soy grits, raw 1/8 Cup 1 lean meat soy milk 1 Cup 1 milk plus 1 fat tahini 1 teaspoon 1 fat tempeh 4 oz. 1 bread plus two protein wheat germ 1 TB 1/2 bread (If you use large amounts, may need to add a fat exchange. Speak to your dietitian.)

Remember that most diabetics are non-insulin dependent, and most do not need to depend on exchange lists, though some may. While we are including information about exchange lists, note that for most people, Non-Insulin Dependent Diabetes can be controlled through a low-fat, high-carbohydrate meal plan with calorie control -- and these diabetics do not need to follow a rigid diet pattern using the exchanges. Consult your health care provider for more information on your situation, and for exchange lists if you need them.

NOTE TO DIETITIANS: In my practice as a dietitian, I treat legumes differently than the American Diabetes Association Exchanges do. I always count 1/2 Cup of legumes as 1/2 protein and one bread exchange, while ADA just counts them as a bread. For a vegetarian,this needs to be modified.