At her 80th birthday party, Fran passed up a piece of birthday cake. Once a connoisseur of desserts, Fran swore off sweets on the day she was diagnosed with diabetes at age 58. “After 22 years I’m not about to go back now,” she said.

In the past, doctors routinely warned diabetic patients to avoid sugar and concentrated sweets, and Fran’s unwavering resolve is to be admired. Doctors today, however, would tell Fran there is no reason she should deny herself a piece of birthday cake if it appeals to her.

It’s easy to understand why a person with either type 1 or type 2 diabetes might think of sugar as an enemy to be avoided. Type 1 diabetics can’t produce insulin, a hormone that allows muscle cells to remove sugar from the blood stream and convert it into energy. Type 2 diabetics either don’t produce sufficient quantities of insulin or have an insufficient response to it. In either case, high levels of sugar in the blood are responsible for most of the life-threatening complications of diabetes.

Controlling blood sugar is the key to diabetic treatment, and diet has always played an essential role. The rules are less rigid than they once were, however, and the diabetic diet given to Fran is a relic of the past. New dietary guidelines stress flexibility and the need to tailor food choices to individual preferences and lifestyle.

The goal is not only to control blood sugar but to maintain a desirable weight, reduce blood pressure, improve cholesterol levels, decrease the risk of cardiovascular disease and improve overall health.

These guidelines, for the first time, are evidence-based–grounded firmly in research results.

Starches vs Sugar
Carbohydrates such as whole grain cereals and bread, fruits, vegetables and low-fat dairy products are dietary essentials–for diabetics as for other persons. Generally known as complex carbohydrates, these foods clearly offer more health benefits than the simple carbohydrates found in candy, cakes, cookies and doughnuts. Yet all carbohydrates are converted to glucose in the blood stream.

Previous guidelines, issued in 1994, focused on glycemic index or how rapidly blood glucose rises after eating any particular food. Specific foods clearly vary in their effect on blood sugar levels immediately after a meal, but studies have failed to demonstrate any clear long-term trend beneficial to the treatment of diabetes.

Controlled clinical studies conducted with type 1 and type 2 diabetics eating a variety of sweet and starchy foods found that the amount of carbohydrate consumed was the only significant factor in blood sugar response. As a result, the new guidelines state that a diabetic need not restrict intake of foods containing sucrose, as long as these foods are substituted, calorie for calorie, for other carbohydrates.

Fruits and vegetables, of course, offer far more nutritional value than cookies or doughnuts, which usually come in tandem with substantial portions of fat. An occasional sweet, however, substituted for a comparable amount of carbohydrate, will do no harm and may even be encouraged if it benefits a patient’s mood or state of mind.

What’s important is not that the patient deny herself any food but that she keep track of the calories and carbohydrates she consumes and be aware of their nutritional value.

Protecting the Heart
Because their risk of heart disease is even greater than that of most Americans, diabetics are expected to follow a heart-healthy diet. To keep serum cholesterol at desirable levels, studies have demonstrated the importance of a diet that derives less than 10 percent of total calories from saturated fats and includes less than 300 milligrams daily of cholesterol. These levels are recommended for healthy individuals, and some diabetics might benefit by consuming even lower levels of animal fats.

One study of non-diabetic men found that subjects who got 14 percent of their calories from saturated fat had insulin levels 33 percent higher following a meal compared to subjects who got 8 percent from saturated fats.

As for other fats in the diet, research has demonstrated two effective strategies. Because protein intake should remain fairly stable at 10 to 20 percent of calories, the traditional approach has been to emphasize carbohydrates, limiting total fat to 30 percent. Another strategy, equally effective according to recent studies, is to replace some of those carbohydrates with monounsaturated fats such as those found in olive oil, nuts and nut oils. Mono fats can increase levels of HDL (good) cholesterol, which in turn helps clear LDL from the blood stream.

All fats are, however, relatively high in calories and type 2 diabetics who wish to lower or maintain their weight may be advised rather to follow the traditional low-fat, high-carbohydrate approach.

Maintaining a Healthy Weight
Excess weight is often a factor in the development of type 2 diabetes. At least some weight loss is recommended, and studies indicate that this is best accomplished through a structured program that involves decreasing intake of both calories and dietary fat coupled with regular exercise. Patient education and counseling may also be part of the program.
While exercise may not produce significant weight loss on its own, it’s a proven way of keeping pounds off and it also reduces insulin resistance. Regular exercise is important for persons at risk of diabetes as well as those diagnosed with the disorder.

Although high-protein, low-carbohydrate diets can produce weight loss, there is no evidence of their long-term effectiveness or safety. There is also some concern that they could increase the risk of kidney damage or cardiovascular disease in a person with diabetes.

Controlling blood pressure is a major concern for diabetics, as it is for other persons, and this can be achieved through weight loss, exercise, sodium restriction and a diet high in fruits, vegetables and low-fat dairy products.
In virtually every respect, the dietary guidelines for diabetics reflect what is known about good nutrition for healthy individuals. For diabetics, of course, the stakes are high–both short and long term.

Doctors now know that there are no simple solutions–even denying yourself a piece of birthday cake. Good nutrition is a matter of knowing the facts...and making good choices.

REFERENCES:
“ADA Nutritional Guidelines Stress Carbohydrate Intake over Carb Sources,” Geriatrics, March, 2002.
American Diabetes Association, “Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications,” Clinical Diabetes, Spring, 2002.
“Excerpts from 101 Nutrition Tips for People with Diabetes,” Diabetes Forecast, November, 2000.
Sandra J. Gillespie, Karmeen D. Kulkarni and Anne E. Daley, “Using Carbohydrate Counting in Diabetes Clinical Practice,” Journal of the American Dietetic Association,” August, 1998.
Shauna S. Roberts, “Eating for Good Health,” Diabetes Forecast,” January, 2000.
“Translation of the Diabetes Nutrition Recommendations for Health Care Institutions,” Diabetes Care, January, 2000.
Miriam E. Tucker, “Evidence-Based Dietary Guidelines Target Diabetes,” Family Practice News, March 1, 2002.