Chapter 5

Diabetes

     Diabetes is one of the most serious and common diseases in modern society and the incidence of the disorder continues to climb. It can be viewed as two separate diseases. One form (Type I), usually affecting younger people—even young children—is attributable to absolute deficiency of insulin (a hormone produced by the pancreas). The mechanism within the pancreas that normally manufactures insulin becomes badly damaged and can no longer produce the hormone. This type of diabetes, often called juvenile-onset diabetes, is very severe and must be treated with insulin. Juvenile-onset diabetes is rare; and, while diet is a mainstay in its treatment, we cannot prevent its occurrence through dietary modification.

     The second form of diabetes (Type II) is known as maturity-onset or adult-onset diabetes. This type of diabetes is much more common than the first—and, according to the National Institute of Digestive and Kidney Diseases, its prevalence has increased almost 50 percent in the past 12 years. It also results from a deficiency of insulin, but this deficiency is a relative one. The pancreas is perfectly capable of manufacturing the hormone. It often manufactures more insulin than before onset of the disorder; but the body needs more hormones to function properly. Certain changes occur within the tissues, increasing their requirement for insulin. The pancreas responds by making more. First it increases production of insulin. Finally, it works at maximum capacity. If the requirement continues to increase, the pancreas simply cannot manufacture enough insulin. The patient becomes insulin-deficient, and the symptoms of diabetes appear. Sometimes, if this chemical imbalance is not relieved, the overworked pancreas will burn itself out, becoming unable to manufacture insulin. A relative deficiency can then become an absolute deficiency. In certain people, the risk of acquiring the disease may be lowered by dietary modification.

     In this chapter, we shall discuss dietary modifications that can lower our risk for adult-onset diabetes and principles for dietary management of the disease when it is already present. Anyone with either type of diabetes must be under a doctor’s care. The dietary principles outlined here will make it easier to understand why your doctor prescribes a particular type of diet.

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     Juvenile-Onset Diabetes has a very definite genetic component. The genes involved have been identified so that it is possible to predict (with certain specialized tests) which individuals are at risk. However, making this prediction offers little advantage to the person who has the genes that put him at risk for the disease. Only a small number of this population will develop diabetes, and nothing can be done either to identify or to protect them. Presently, we believe that some people with the genetic predisposition are susceptible to what appears to be a viral infection.

     Whatever the case, the insulin-producing cells within the pancreas are selectively destroyed. Before the availability of insulin, all patients with true juvenile-onset diabetes died within a short time. Today, with the availability of insulin, most can live a relatively normal life. However, such patients become susceptible to the same long-term complications of diabetes as those who develop the adult form of the disease. Since the dietary modifications designed to prevent or decrease the severity of these complications are similar, both types of diabetes will be discussed.

     There are no dietary controls to prevent juvenile-onset diabetes. There is no relationship to the number of calories consumed, the amount of carbohydrate, either complex or simple, or the amount of fat in the diet. Disregard any suggestion that you got diabetes because you were too fat (Most juvenile-onset diabetics are thin.) or that you ate too much candy, or ice cream, or sugar. Nothing you did caused juvenile-onset diabetes.

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     Maturity-Onset Diabetes typically begins after the age of fifty, and it too runs in families; but dietary modification may lower the risk. First, we must understand how this relative insulin deficiency develops. Then we can attempt to alter the pattern of development.

     The pancreas lies buried in the abdomen behind the liver and intestines. Insulin producing cells (beta cells) are present in small clumps, or islands, interspersed between the ducts of the pancreas. These islands, called islets of Langerhans (after the man who discovered them), have a characteristic appearance under the microscope. The insulin manufactured in the beta cells is secreted directly into the bloodstream and carried to all the tissues of the body. Protruding from the cells of these tissues are specific appendage-like molecular structures into which the insulin molecules fit and are thereby bound to the cell surface. These appendages, called receptors, are specific for insulin. Usually, there are more receptors than insulin to fill them. As the demand goes up, more insulin is produced. It immediately becomes fixed to a receptor, and is rapidly taken into the cell. If the receptors are not working right, the pancreas will have to produce more insulin for the same amount to get into the cells.

     Once inside the cell, insulin facilitates the passage of glucose, the body’s main energy source, from the blood into the tissues. In the tissues, glucose is either used as fuel or stored as glycogen (a complex carbohydrate similar to starch). Excess calories, beyond the quantity used immediately and that needed to load the tissues with a twenty-four hour or so glycogen reserve, are stored as fat. The body needs more insulin than when caloric intake is lower. Thus, to build up or maintain fat stores, an obese person requires more of the hormone than a lean individual. The beta cells have to work harder as the body’s need for insulin increases. If they can meet that need, the body will function normally. If they cannot, there is an insulin deficiency. The symptoms of diabetes will appear. In some people, the added need for insulin does not stress the beta cells. They simply make more. In others, the cells cannot make it fast enough. Which type of person we are depends on our genetic makeup.

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     Maturity-onset diabetes is a genetic disease that manifests itself when the body requirement for insulin is not satisfied. Under normal circumstances, a person who is at risk for the disease because he or she is carrying “diabetic genes” is likely to develop it at age sixty-five or seventy, or even older. Excessive strain on the pancreatic beta cells may cause symptoms to appear when that person is in the fifties or even younger. People who are genetically prone to the disease will develop it much sooner and much more seriously if they consume excess calories. Calories can come from a variety of sources, and some of these sources are more risky than others.

     The level of blood glucose signals the pancreatic beta cells to make more or less insulin. As the glucose level increases, more insulin is produced. As glucose decreases, less insulin is made. As glucose gets into the cells, the amount in the blood will fall. Thus, another function of insulin is to regulate the level of blood sugar. The level of blood sugar is also sensitive to diet, particularly to the type and the amount of carbohydrate we consume. Complex carbohydrates must be converted to simple forms before they are absorbed from the intestines into the body. Thus, complex carbohydrates release sugar into the blood slowly. Refined sugar (sucrose) is very quickly split by intestinal enzymes into its two simple sugars, glucose and fructose. These sugars are absorbed into the bloodstream very rapidly. Hence, consumption of sucrose will raise blood sugar more quickly than the consumption of complex carbohydrates.

     It has been postulated that a diet high in refined sugar will put an added strain on the beta cells and that, over a long time, such a diet will induce diabetes in susceptible men or women. Several studies have been cited to support this hypothesis. None of these studies were scientifically sound. Yet, there may be an association between high intake of refined sugar and diabetes. People who consume large amounts of sugar also consume excess calories. We have already seen that too many calories can increase a susceptible individual’s risk for diabetes. To the extent that consuming large amounts of sucrose increases our caloric intake, it is a risk for maturity-onset diabetes. Beyond its caloric content, there does not seem to be anything special about sugar that increases the risk.

     The best way to lower our chances of getting maturity-onset diabetes is by reducing our intake of fat. A low-fat diet will necessarily be high in carbohydrate. A low-carbohydrate diet is high in fat. Therefore, it would be very difficult to construct a diet low in both these components. If both calories and the amount of carbohydrate independently increased our risk for diabetes, dietary prevention and treatment would be very complicated. Fortunately, this is not the case. Calories are important; but the portion of the diet consisting of complex carbohydrate is not causative in diabetes.

     A diet high in complex carbohydrate may be especially beneficial in treating diabetes. Large amounts of refined sugar must be avoided because such a diet will provide low bulk and a tantalizing source of excess calories. However, severe restriction of refined sugar is not advocated as a preventive measure for maturity-onset diabetes.

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     Who is a risk? Anyone with a family history of diabetes is at risk for developing the disease. The stronger the family history, the greater the risk. Also important in determining the influence of the genetic component is the time of life when diabetes appeared in those members of your family who developed it. The earlier the onset of their disease, the more you are at risk. But a family tree totally free of diabetes is not absolute assurance for a lack of genetic risk. Life expectancy has increased dramatically in recent decades, and since diabetes may appear late in life, susceptible members of your family may not have lived long enough to show it, or it may not have been diagnosed. As many as half of those who have the disease are not aware of it.

     If you belong to an ethnic group in which the risk for diabetes is high, you are at risk. Among these high-risk groups are Ashkenazi Jews, African-Americans, and Native Americans. If you fit in to one of these groups, you should examine your family tree very carefully. If information about certain close relatives is unavailable, you should assume yourself at increased risk. The dietary modifications to reduce this risk are simple and safe. They are also useful in protecting against other diseases (atherosclerosis, hypertension, and obesity). It is better to err on the safe side.

     If you are a woman and have children, did you have high blood sugar during pregnancy? If so, you are at risk for diabetes. Pregnancy puts an added strain on the pancreatic beta cells. Because your own growing tissues and those of your developing fetus require increased amounts of energy, and because you must deposit fat in your own body for use during lactation, your body requires more insulin. If the beta cells are not able to keep up with these extra demands, insulin production will be insufficient and blood sugar will rise. If your blood sugar goes too high, you may require treatment during pregnancy. You have what we call gestational diabetes. Even if it disappears after delivery (It usually does.), this is a warning sign that you are at risk for developing maturity-onset diabetes later in life. If you fall into this category, you must be considered at risk.

     If you have ever had a glucose tolerance test, you should know if it was normal. A glucose tolerance test consists of having a person drink a fixed amount of glucose (100 grams) in water, then doing blood-sugar determinations periodically for the next four to six hours. This test indicates the ability of the pancreatic islets to produce insulin. As the blood sugar rises from the initial loading dose, the beta cells respond by releasing insulin. This promptly results in a lowering of the blood sugar, which, in turn, signals the beta cells to cut back insulin production. If a person has a “tendency to diabetes,” the beta cells respond sluggishly and the blood sugar rises initially to levels above normal. In addition, once the blood sugar is lowered by the release of insulin, and returns to normal, the sluggish beta cells continue to release insulin beyond the necessary time. The result is that the blood sugar drops below normal before it returns to its proper range. This high one-hour blood-sugar level followed by a low three- or four-hour blood-sugar level is the characteristic diabetic or pre-diabetic pattern sometimes called “metabolic disorder.”

     While not as definitive as a glucose tolerance test, fasting blood-sugar levels are valuable in detecting pre-diabetes. Fasting blood sugar tests are easily done, inexpensive and require, at most, the discomfort of a pricked finger. Anyone with a moderate risk for diabetes should have this test as part of an annual physical examination. In preparation for the test, you need to go without food for twelve hours before the blood is drawn. Refrain from food (Water is allowed.) after midnight on the day before the test and delay breakfast until after your morning visit to the clinic. A high fasting glucose test will alert your doctor to order more specific tests for a definitive diagnosis.

     Certain medications, the most important of which are the cortisone-like drugs, independently raise blood-sugar levels and thereby invoke an insulin-releasing response in the pancreatic beta cells. A sluggish response by these cells will result in a “diabetic-like” syndrome, often called cortisone-induced diabetes. If you respond in this manner, you are at increased risk for developing maturity-onset diabetes. Any person who takes cortisone or its derivatives, particularly for a chronic illness such as asthma or arthritis, should have a glucose tolerance test, or at least a fasting blood sugar test, while under the influence of the drug. If a diabetic pattern emerges, it is a warning to take whatever steps possible to lower your risk.

     Finally, are you obese? The question of obesity as an independent risk for diabetes has not been settled. There is a strong association between obesity and maturity-onset diabetes. Both diseases have a solid genetic component. Hence, it is possible that people who are genetically prone to diabetes are also genetically prone to obesity. However, some studies suggest that the relationship of diabetes to obesity is more than this type of genetic linking. First, obesity puts a specific strain on the pancreatic islet cells. Second, in some obese patients who develop diabetes, weight reduction alone can control the disease. Third, in populations where diabetes was once rare, the disease has become much more common as that population has become heavier. These data strongly suggest that in people who are at risk for diabetes, obesity will significantly increase that risk. It is much less clear whether obesity per se increases a person’s risk for diabetes. We do know, however, that people without any other known risks for diabetes are more likely to develop the disease if they are obese than if they are lean. While this does not prove that obesity is an independent risk for diabetes, it suggests that we treat it as if it were. Since we already know that obesity should be prevented for many different reasons, we will include it as a risk for diabetes. Until more information is available, this is the most prudent course.

     What about the lean individual with a sweet tooth? The person who consumes large amounts of refined sugar and does not gain weight? We all know and envy people like these. Are they increasing their risk for maturity-onset diabetes? If they have no other risks, they are probably not. If they are already at risk, we are not certain. There are theoretical reasons that consumption of large amounts of refined sugar might increase the stress on an already susceptible pancreas. However, there is no data suggesting that this happens. Thus, we will assume that a person who has an increased risk for diabetes will not increase that risk by consuming moderate amounts of refined sugar. As for the true “sugar-holic,” even though the evidence may not support any belief, we feel that the possibility of additionally increasing our risk is sufficiently strong that we recommend such persons reduce the amount of refined sugar in their diet.

     Since diabetes is genetic in origin, it will be more prevalent in some demographic groups than in others. African-Americans, Native Americans, and Jews of European extraction are among those who have a high incidence of the disease. However, diabetes can and does occur in almost every ethnic group. Therefore, you are not completely safe even if you belong to a low-risk population.

     Your family history is more important. Question your living relatives about their health and that of their ancestors. Spread the branches as far as feasible. If your relatives are not sure, try to piece together as much information as possible. Even if only one close relative is known to have had diabetes, your risk increases. How much depends on how prevalent this disease is in your family health tree.

   If only one or two distant relatives have had diabetes, score 3. If a few close relatives or many more distant relatives are diabetics, score 5. In addition, if you belong to a high-risk ethnic population, add 2.

   If you have had persistently high blood-sugar levels or an abnormal glucose tolerance test during pregnancy, score 5. If your fasting blood sugar was elevated occasionally during pregnancy, score 3. If you have had one or more very large babies (nine pounds or more), score 2. (This is because infants of mothers with diabetes or a tendency toward it are often large.)

   If your glucose tolerance test results in a diabetic-like curve or a higher-than-normal half-hour or one-hour blood sugar (even if the values were not high enough to diagnose diabetes) this significantly increases your risk for developing the disease; so score 5. If your fasting blood sugar was high on several occasions, you should get a glucose tolerance test. If that test is abnormal, score 5. However, even if it is normal, you must still consider yourself at increased risk. If you show repeated high fasting blood-sugar levels, score 3.

   Adrenal steroids are used in the treatment of a large number of chronic diseases and are often taken for long periods of time. As we have seen, these drugs independently raise blood-sugar, and insulin production is stimulated by these high levels. Thus, the beta cells of any patient consuming these drugs will be under constant stress. If you have a tendency toward diabetes, your beta cells may not respond perfectly and your blood sugar may be somewhat elevated. Any patient with steroid-induced high blood sugars should have a glucose tolerance test while on steroids. If a diabetic-like curve appears, score 5. If not, we still cannot be complacent—score 3.

   If you are truly obese, that is, 20 percent or more over your ideal weight, you must consider yourself at high risk for diabetes, even if you have no other risks. Therefore, we are assigning a risk factor of 5 to this condition. If you are overweight but not clearly obese (105 to 120 percent of your ideal weight), score 3. Suppose you are not obese but are at high risk for becoming obese (see the previous chapter), score 2. Being moderately overweight or being at risk for obesity without any other risk does not require dietary modifications. By contrast, a strong family history of gestational diabetes, an abnormal glucose tolerance test, or true obesity all place you in a high-risk category.

     Add up your scores from all of the above risk factors (maximum 38 points). Any score of 5 or more warrants attention. You should attempt to lower your risk for diabetes.

     Our dietary strategy will pursue two objectives simultaneously—first, to prevent (or at least delay) the onset of diabetes, and—second, to prevent (or at least minimize) its complications if the disease does occur. The first objective is best achieved by controlling calories; the second by controlling fat. Let us explain the reasons behind this approach.

     As we have seen, the one major risk that you can do something about is obesity. Thus, if you are obese, it is important that you lose weight. If you are overweight (but not obese) and your total score is over 5, you should reduce to as close to your ideal weight as possible. If you are at risk for obesity and your total score is over 5, it is important that you do not become obese. You must pay particular attention to your weight.

     In Chapter 4, we outlined the safest and most effective way to lose weight and to keep weight off. The same methods should be employed to lower our risk for diabetes. Since refined sugar is a food of very low nutrient density, large amounts of it should not be consumed on any reducing diet. This is especially true if a major reason for controlling your weight is to lower your risk for diabetes. If you are a true sugar-holic, you may be putting an unnecessary strain on your beta cells, and you are surely consuming calories in an inefficient manner. Thus, while you do not need to avoid all sugar, you should cut back sufficiently to allow the rest of your low-calorie diet to provide all the essential nutrients you require.

     In our society, a major principle of any reducing diet is lowering the consumption of fat. Fat is the most concentrated source of calories. Therefore, we get the maximum caloric benefit per serving if that food we eliminate from our diet is high in fat. In a weight-control program, it is even more important to minimize our risk for diabetes by restricting the amount of fat in our diet.

     One of the major complications of diabetes is atherosclerosis. This disease may lead to heart attack and stroke. A diabetic person is automatically at high risk for atherosclerosis (see Chapter 2). Similarly, someone at high risk for diabetes is potentially at high risk for atherosclerosis. Since many people at risk will develop diabetes, even if they control their weight, it is important to adhere to a low-fat diet as early as possible. If you are destined to become diabetic, the earlier you begin to control your serum lipids, the better. A low-fat diet (particularly a low-saturated-fat diet) is the best way to do this. Chapter 2 outlines such a diet. It is by nature low in calories. Hence, if you are not obese, you may not need to control your caloric intake any further.

     If you are obese, use this approach, combined with the principles outlined above. Avoid empty calories such as alcohol and refined sugar. Consume foods of high nutrient density. Eat plenty of roughage (fiber); and increase your level of exercise. To construct your diet, refer to Chapter 2. If you are at high risk, diabetes is a constant threat. Thus, the program you will embark on is not a short-term reducing diet to drop five or ten pounds quickly. It is a lifelong eating pattern and must be approached as such. Quick results are not important. A sustained reduction in weight and lowering of your serum lipids will give you maximum benefit.

     If you already have diabetes, controlling your diet will be a major part of your treatment. If juvenile-onset diabetes is the problem, you will need insulin. By contrast, maturity-onset diabetes may not require insulin injections. Oral medications may be sufficient. Sometimes, particularly if you are obese and the disease is mild, slight weight reduction may be enough to control the disease. The balanced low-calorie approach remains best for weight reduction and control of diabetes. It is most likely to produce long-term results. Long-term results are essential. It may be more dangerous to lose weight and gain it back several times than to remain obese. Such “seesawing” may put even more stress on the beta cells of your pancreas than being obese. It is imperative that you limit your fat along with your calories.

     If you are already diabetic, you are automatically at risk for atherosclerosis. Therefore, a low-total-fat, low-saturated-fat (with restriction of trans-fatty acids), low-cholesterol diet is necessary. If you have diabetes, regardless of the type, and need treatment with insulin, the foundation of your eating pattern similarly will be the low-calorie, low-fat diet. This diet will almost certainly be high in carbohydrates. Contrary to what you may have heard, a high-carbohydrate diet is preferable for anyone with diabetes. Some interesting statistics highlight this fact.

     Historically, in this country, most people with diabetes were treated with a low-carbohydrate diet (which was high in protein and in fat). In Japan, diabetes was treated with the standard Japanese diet (high-carbohydrate). The mortality rate from the most serious complication of diabetes, atherosclerosis, was much higher in the United States than in Japan. The same disease, the same type of insulin treatment—the only difference was the type of diet used. The high-carbohydrate diet gave the lower mortality rates. Today, we follow the principle that insulin controls the disease. Diet lowers the risk of certain major complications.

     Keeping our blood sugar within a narrow range may have a beneficial effect on some of the other complications of diabetes. Besides atherosclerosis and its accompanying heart disease and stroke, which are known as macro vascular complications (or diseases of the large blood vessels), the most serious are micro vascular complications (diseases of the small blood vessels). These complications are serious because the small blood vessels most often involved are those in the kidney and in the retina of the eye. Severe kidney disease and blindness are dreaded complications of diabetes. Recent evidence suggests that the more stable our dietary control, the lower the incidence of micro vascular complications. A strict diet may lower our risk not only for atherosclerosis, but for kidney and eye disease as well.

     Although the basic program for any diabetic includes a high-carbohydrate, low-fat diet, the nature of the carbohydrate consumed may be very important. If you are on insulin, you will be taking one or more injections during the day. The type of insulin prescribed by your physician may vary. Some are long-acting. Others are short-acting. You may be taking either type, or, more often, a combination of them. The insulin is adjusted to reach a peak concentration in your blood when your blood sugar reaches the highest level. In addition, it is given in a dose designed to bring that blood sugar back to normal without producing hypoglycemia (low blood sugar). Thus, whereas your own beta cells normally react to your blood-sugar level, this does not happen when the cells do not function properly. Your doctor must anticipate your blood sugar level when prescribing insulin for you.

     By following two additional dietary rules, you can make your doctor’s job easier, and hence bring your diabetes under better control. The first is consistency. You must try to consume the same number of calories at the same times each day. This does not mean that every day you must eat the same number of calories at every meal and every snack exactly on schedule. It means that you and your physician will design an eating pattern that is consistent with your needs and your lifestyle. You will tailor the time and dose of your insulin accordingly.

     This pattern may be more difficult to follow on weekends than on weekdays. It may be different when you are on vacation; and it may change on days when you are very active. For example, during the week, you may consume 25 percent of your calories at breakfast, 20 percent at lunch, 30 percent at dinner, and split the remaining 25 percent between two snacks, one in midmorning and one in mid-evening. By contrast, on weekends you may consume 40 percent of your calories at brunch, 40 percent at dinner, and the remaining 20 percent as snacks. The timing of your insulin dose may be different, but either pattern can be dealt with effectively. After a while, with your doctor’s approval, you may be able to alter your anticipated eating and activity schedule. This approach is not as restrictive as it may seem. Most people establish routine patterns in the way they eat. They vary them very little. The standard pattern of breakfast, coffee break, lunch, dinner, and evening snack applies to millions of Americans.

     A second rule concerns the nature of the carbohydrates we consume. Carbohydrates come in two forms, simple sugars, consisting of a single molecule (monosaccharides) or two molecules bonded together (disaccharides); or complex carbohydrates (polysaccharides), consisting of many simple sugars joined as a chain or a series of branches. The simple sugars are rapidly absorbed from the intestines and reach the bloodstream very quickly. Therefore, our blood glucose level will increase sharply when we consume a large quantity of simple sugars.

     Table 13 outlines the nutrient content of the typical American diet, and compares it with the ideal diet for a person with diabetes.

Table 13. Composition of the Diabetic Diet

                           Typical                                               Recommended

                           American Diet                                    Diabetic Diet

                     Carbohydrate     40%                                55%-60%

                           (high in simple                                              (high in complex

                           sugars)                                                         carbohydrates;

                                                                                                 e.g., starches and

                                                                                                 vegetables)

                      Fat                      40%                               20%-30%

                           (high in saturated                                          (1:1:1 ratio of

                           fat)                                                                 polyunsaturated

                                                                                                 to monounsaturated

                                                                                                 to saturated fat)

                      Protein                20%                               12%

                      Fiber                   low                                 high

     Let us summarize the most important nutritional guidelines for a person with diabetes:

  •    Calories should be aimed at achieving ideal weight. (In the juvenile diabetic, this often means gaining weight; in the maturity-onset diabetic, this usually means losing weight.)

  •    Fat should be limited to 20 to 30 percent of the total calories consumed.

  •    Saturated fat may supply 10 percent of the total calories; and vegetable fat (polyunsaturated and monounsaturated) can provide another 10 to 20 percent.

  

  •    Protein should contribute 12 to 15 percent of all calories.

  

  •    Simple sugars should be restricted to 10 to 15 percent of all calories consumed, and only a small amount should come from refined sugars.

  

  •    The remainder of the calories (about 40 to 50 percent) should come from complex carbohydrates (starch).

  

  •     Dietary fiber should be increased by ingesting raw vegetables and whole-grain and bran cereals (or bread).

     Our last recommendation is based on several studies that showed that adding 20 grams of crude fiber to the diets of diabetic patients reduced their blood-sugar levels and the amount of insulin necessary to maintain good control of the disease. There are several possible explanations for these results. The one with the most support is that fiber delays the absorption of simple sugars from the gastrointestinal tract. For example, dietary fiber might delay emptying of the stomach, thereby slowing entrance of the meal into the small intestine, where absorption takes place. Alternatively, dietary fiber may affect the cells that are responsible for breaking down and absorbing simple sugars, and might help slow glucose absorption.

     Whatever the exact mechanism, the result of a high fiber meal is a slower and more sustained release of glucose from the gastrointestinal tract into the bloodstream. This is very desirable because it will prevent the wide swings in blood sugar that occur when simple sugars are ingested without any fiber. In addition, it often reduces the amount of insulin necessary to control blood sugar.

     From a practical standpoint, a person with diabetes should consume sugars in a form as close to the natural state as possible. For example, an apple is better than applesauce or apple juice. Furthermore, a diabetic person should increase the fiber content of his or her regular diet. We can add fiber in the form of bran or raw vegetables. Another form of fiber often overlooked is pectin, a soluble fiber from apples and citrus fruits. A powdered form is available in the canning section of your grocery store for making jellies and jams. A tablespoonful of it added to iced tea, for example, gives a fruity flavor; and it will significantly increase your fiber intake.

     Although the importance of fiber in the diet of the diabetic patient has become more and more firmly established, the issue of the rate of release of simple sugars from foods is not settled. There were some surprising results when we compared the speeds with which different foods raise the blood-sugar levels. With a system that lists foods in their “glucose equivalents,” glucose is assigned the number 100 and other foods are compared with it. Foods can then be related to each other as a percentage of the rate of absorption of glucose. This number is called the glycemic index. The more rapid the absorption, the higher the glycemic index. The lower the number, the more slowly the food raises the blood sugar. Table 13 shows the glycemic indexes for some common foods. Notice that certain foods previously thought to affect the blood sugar very slowly have a higher glycemic index than refined sugar (sucrose). Carrots, potatoes, and certain breads and cereals fall into this category. We seldom eat these foods in isolation (except as snacks), but as part of a meal in which they are mixed with fats, protein and fiber.

Table 14. Glycemic Indexes of Common Carbohydrate Foods

                                            (%)                                                     (%)

         Grain, Cereal                              Potato (instant                   80

             Products:                                Potato (new)                     70

         Bread (white)             69             Potato (sweet)                  48

         Bread (whole grain)   72             Rutabaga*                         72

         Buckwheat                 51             Yams                                 51

         Millet                           71             Dried and Canned

         Pastry                        59               Legumes:

         Rice (brown)             66            Beans (canned, baked)      40

         Rice (white)               72           Beans (butter)                     36

         Spaghetti (whole                         Beans (green)                  31

               wheat)                    42           Beans (kidney)                 29

        Spaghetti (white)           50           Beans (soya)                   15

        Spaghetti (white)           50           Beans (canned soya)      14

        Sponge cake                 46           Peas (blackeye)              33

        Sweet com                    59           Peas (chick)                    36

        Breakfast Cereals:                       Peas (green)                   47

         All Bran                         51           Lentils                              29

         Corn flakes                   80       

         Granola                         66          Fruits:

         Oatmeal                        49          Apples (golden del.)         39

         Shredded Wheat          67           Bananas                          62

         Cookies, Crackers:                     Orange juice                   46

         Digestive                       59           Oranges                         40

         Oatmeal                        54           Raisins                           64

         Water                            63       

                                               (%)                                                 (%)

                                                            Sugars:

        Fresh Legumes:                           Fructose                         20

         Broad beans*                79          Glucose                         100

         Frozen peas                 51           Maltose                          105

                                                             Sucrose                          59

        Root Vegetables:

         Beets*                           64        Dairy Products:

         Carrots*                        92            Ice cream                      36

         Parsnips*                      97            Milk (skim)                     32

                                                               Milk (whole)                   34

                                                               Yogurt                            36

        Miscellaneous:

         Sausages                    28             Mars bar                        68  

         Fish sticks                   38             Tomato soup                 38

         Peanuts*                     13              Honey                            87

         Potato chips                51

                *Only 25 g carbohydrate portion given

     These components will attenuate the rate of absorption of the carbohydrates. When consumed alone, as in snacks, the glycemic index may be significant in how fast the sugars get into your bloodstream.

     Finally, besides the composition of the diet, the frequency of meals is very important, particularly in the juvenile-onset diabetic and in-patients with the most severe symptoms of maturity-onset diabetes. As we have seen, wide swings in the level of blood sugar should be avoided. Your physician will probably prescribe a combination of long acting and short acting insulin. Spacing your meals will help by producing a lower, but more sustained, elevation of blood sugar throughout the day. The person with juvenile-onset diabetes or severe insulin-dependent maturity-onset diabetes should consume five or even six meals per day. A good routine would be: breakfast, a midmorning snack, lunch, a late-afternoon snack, dinner, and an evening snack shortly before retiring.

     The diet to lower our risk for diabetes depends on whether we are overweight. For anyone who is obese, the diet discussed in Chapter 4 should be followed. There is no difference between weight-reduction diets for a person at risk for diabetes and for a person who is not. However, the urgency for starting weight reduction may be considerably greater if you are obese and also at high risk for diabetes. If you are obese, do not procrastinate!

     If you are at risk for diabetes (whether you are overweight or not), you should use the Prudent Diet (low-total-fat, low-saturated-fat, low-trans-fatty acids, low-cholesterol) outlined in Chapter 2. It is a low-cost insurance policy that should be instigated by anyone at risk for diabetes. In addition, if one of your risk factors is obesity or a tendency toward it, you should adhere to necessary calorie control as outlined in Chapter 4. The diabetic individual should lower the amount of refined sugar in his or her diet, introduce day-to-day consistency, and utilize proper meal spacing. All these can be accomplished with plenty of variety in our food choices.

     There is evidence that some individuals with latent diabetes are low in “glucose tolerance factor,” an organic complex which includes chromium (much like vitamin B-12 contains cobalt and hemoglobin contains iron) and assists insulin in getting sugar into the cells. These individuals may be helped temporarily with organic complexes containing chromium. The form of the element in most nutritional supplements, chromium picolinate, is relatively non-toxic; but high doses could be harmful. The best way to get trace minerals (in the right form) is by consuming plenty of fruits and vegetables. Chromium deficiency is not widespread. The metal is found in water (However, some of the metal in water may be toxic due to contamination from industrial waste. Chromium is poisonous in the chemical form used in chromium plating of automobile parts, for example.), beverages, and practically everything we eat. There is no scientific proof that chromium supplements will help us lose weight, build muscle, or lower our cholesterol levels. However, there is evidence that chromium supplements (or, preferably, foods and beverages rich in chromium) may improve glucose tolerance in persons who have Type II diabetes or are borderline diabetics.

     To start calculating Your Diabetic Diet, find your ideal body weight in the table on page 51. Because most food calculations use the metric system, convert your ideal body weight from pounds to kilograms by dividing the number by 2.2. Now, use the chart below (or the chart on page 62 of Chapter 4) to calculate your energy need per day for each kilogram of ideal body weight, depending on your body weight and your level of physical activity.

Table 15. Calorie Expenditure for Wt. and Activity

      (Calories per kilogram)

                                             Sedentary        Moderately      Extremely

                                                                       active               active

                      Overweight         20-25               30                    35

                      Normal               30                    35                    40

                      Underweight       35                    40                  45-50  

     Let us assume your ideal weight is 160 pounds. Dividing this figure by 2.2 gives about 73 kilograms. If you are obese and lead a sedentary life, multiply your ideal weight (73 kilograms) by 20; 1,460 calories per day is what you should consume. If you are overweight but not obese multiply your ideal weight (73 kilograms) by 25; you are allowed 1,765 calories per day.

     By contrast, if you are a very active person whose ideal weight is 73 kilograms and who is not overweight, multiply 73 by 40. You should consume almost 3,000 calories per day. As a final example, let us take a tall, somewhat underweight young juvenile diabetic who should weigh 160 pounds (73 kilograms) and who takes part in competitive athletics. Such an individual might require 73 times 50, or 3,650 calories per day.

     Having determined the number of calories you require, you are now ready to allocate those calories between protein, carbohydrates, and fat.

     Proteins—Proteins (plural because there are more than one) are the most complex substances known to man. One scientist has called them “the noblest pieces of architecture invented by nature.” Proteins, which can be likened to words and sentences, are made up of twenty amino acids, many used more than once, comparable to the twenty-six letters of varying combinations of our alphabet. And from these twenty amino acids, millions of different proteins can be manufactured.

     Each type of cell in every animal, vegetable and microbe contains its own particular kind of proteins; thousands of them. Indeed, proteins are the primary, basic components of life (hence their name, which comes from a Greek word meaning “of first rank”). Some proteins, such as the protein in bones, are part of the carpentry that keeps us erect. Some glue our cells together. Some (enzymes) act as chemical engineers whose job is to help put other substances together or take them apart, while others (antibodies) protect us from disease as part of our immune mechanism.

     Little by little, we have discovered the structure of proteins, the arrangement of those building stones called amino acids. Some of these (the “essential” amino acids) have to be provided in the diet because the body cannot make them, while others (the “nonessential” amino acids) under the right conditions can be synthesized in the body. For a century we’ve known that all proteins are not equivalent. For example, gelatin is a source of proteins, but you couldn’t live on it as your only source because the proteins in it are incomplete. Incomplete proteins are somewhat, or completely, lacking in certain essential amino acids. In general, animal proteins (eggs, milk, meat and fish) are complete proteins, while vegetable proteins are often incomplete. This means animal proteins contain the twenty amino acids that make up protein in about the same proportions we need to make body protein. Vegetable proteins have amino acids in less favorable proportions.

     A mixture of animal and vegetable proteins adds up to better nutrition than do vegetable proteins alone. In fact, a mixture of vegetable proteins—say rice and peas—together with a relatively small amount of animal protein (as in a Chinese meal) may be as good as animal protein, considerably less expensive, and lower in fat than a huge steak!

     In one sense, protein builds muscles. Protein is second only to water as a main constituent of body structures, particularly muscles but also tendons, skin, and other tissues. We need protein to develop muscles and keep them healthy. But muscle “building” or firming and strengthening doesn’t come from eating an unusually large amount of protein. Muscle building takes exercise. And exercise does not significantly increase the need for protein over and above what your body requires if you lead a sedentary life.

     Proteins from the foods we consume are broken into fragments by stomach acids and enzymes, and they are broken down even further (into single amino acids) in the intestine. After absorption from the intestines into the bloodstream, they’re reassembled into human proteins. The body can even make some of its own amino acids out of other amino acids. These are the “nonessential” amino acids—so called not because they aren’t essential to life, but because it isn’t essential to eat these specific amino acids to get them. So long as you eat enough protein generally your body can manufacture them. Eight of the amino acids are essential; they must come from food because the body can’t make them from other substances.

     We need some kinds of protein more than others. We can still use our analogy with printing: In the English language the most frequently used letter is e; the next is t. So you need more of these letters to write something in English than you need g’s or x’s. Thus, proteins that contain the right proportion of amino acids necessary for life and health have greater “biological value.”

     The value of breast milk is high—close to a perfect 100. Whole-egg protein is a close second—about 94—while cow’s milk ranks 85 and meat and fish are fourth on the list, ranging from 76 to 86. Rice (surprisingly) ranks a fairly good 80. Lesser values are found in potatoes, soybeans, grains, peas and beans.

     You already know that meat ranks a little lower than some other proteins in value. But there’s more to it than that. For one thing, about 60 percent of the calories in untrimmed meat come from fat; hence you may have to eat a lot of calories and a lot of saturated fats to get the proteins from beef. Not only that, a mixture of proteins is often better than a single one—or several single ones—taken one at a time. Wheat, for example, is low in the amino acid lysine. But milk does contain it more liberally. So—believe it or not—ordinary white bread made of wheat and skim-milk powder is a fairly good source of protein with good biological value. Chinese meals show how well proteins supplement each other. Rice is low in four essential amino acids, but beans supply two of these, and the other two are in beef, pork, poultry or fish, the usual components of Chinese dinners.

     Convincing studies have shown that an ounce a day of pure protein of good quality is minimally sufficient for the average adult woman. A man, being bigger, needs somewhat more. Children, adolescents and pregnant and nursing women need considerably more. A number of experiments have shown that habitual strenuous exercise does not increase protein requirements, in spite of almost universal belief to the contrary among coaches, athletes and the public.

     We don’t know the advantages, if any, of going far above the minimum protein necessary for life or optimal growth. In the adult, we have seen that an ounce or so of a good protein daily will maintain the average man or woman in good health. To ensure a safety margin, the usual recommendation is about two ounces. Actually, many American men eat between three and four ounces of protein every day, three to four times as much as is required, and almost twice the recommended intake, which already has a margin of safety.

     While both low-protein and high-protein diets have had their proponents, the evidence in favor of or against either position are scant. The long-term differences between high- and low-protein diets are especially hard to evaluate. High-protein diets are usually based on meat and are high in saturated fats (beef, unless it is very lean, may have up to three times as many calories from fat as from protein). Very low protein diets are often poor from other viewpoints; for instance, they are low in certain vitamins and minerals.

     The legumes (dry beans, lima beans, peas, and peanuts) are relatively high in protein of fairly high biological value. Cereal proteins have low biological values, but when they are combined with milk or cheese, their biological values increase. The essential factors missing in cereal proteins are abundant in milk proteins.

     Most vegetarians include dairy products and eggs (high quality, “complete” animal proteins) in their diets. So they are not vegetarians in a strict sense, but “ovo-lacto” vegetarians. When no animal protein is consumed, there is danger of vitamin B-12 deficiency. Much caution is needed when there are growing children in your family. They need lots of complete (high biological value) protein to build enzymes and hormones, muscles, and other tissues for growth.

     Making a rough estimate of your protein intake is fairly simple. An ounce (28.4 grams) of relatively lean meat or an ounce of fish, poultry or cheese contains, on the average, 7 grams of protein, as does one egg. Fattier meats, of course, provide less. An 8-ounce glass of milk provides 8 grams. A serving from the bread and cereal group contains about 2 grams, and a cup of dried peas or beans is about 14 grams or about twice the amount in an ounce of meat.

     So, if you eat 6 ounces of meat-group foods (which adds up to 42 grams of protein), 2 cups of milk (16 grams) and 4 servings from the bread-and-cereal group (8 grams), you have easily met your protein requirement for the day. Cereal proteins, which are not as complete as others, are enhanced by combining them with animal proteins. Eating dry cereal with milk is a classic example of how cereal protein is improved in a natural combination of foods. Protein is one of the nutrients listed in grams per serving right on the label under the guidelines for nutritional labeling of foods.

     A more generous allowance for an adult, and the most frequently quoted rule of thumb, is 1.0 gram per kilogram of your ideal weight, no matter what you weigh. Thus, all the people described above would have the same protein requirement—73 grams (for the person whose ideal weight is 160 pounds). This represents roughly 300 calories. The obese, sedentary individual will therefore be taking in 20 percent of his calories as protein. This amount is somewhat high, but is acceptable in the absence of kidney or liver disease. Other individuals should have no problems with this amount of protein. Three hundred calories represents about 18 percent of 1,800 calories, 10 percent of 3,000 calories and about 8 percent of 3,600 calories. Use the 12 percent rule for the latter two. (12 percent of 3,000 is 360, and 12 percent of 3,650 is 438).

     Carbohydrates—are made of carbon and of hydrogen and oxygen in the proportion seen in water, hence their name. They are major sources of energy for most of the world’s people. They are assembled in green plants by the light from the sun working on carbon dioxide and water. They come to us as starches and sugars for nourishment and as cellulose for roughage (“fiber”). The starches figure prominently in such foods as potatoes, cereals and breads. Ordinary table sugar, white or brown, is sucrose, which is made of fructose and glucose, two “simple” sugars. Glucose (known also as dextrose or blood sugar) deserves emphasis. It can be synthesized by the body from other carbohydrates and also from protein. Glucose is the only true “brain food.” It is overwhelmingly the main fuel for the brain (perhaps the only one under normal circumstances). Under resting conditions (sleeping), the brain uses 50 percent of the total energy consumed by the body. When blood glucose is very low, the brain can use ketones (from breakdown of amino acids) for energy. The level of our blood glucose must be neither too low (hypoglycemic) or too high (hyperglycemic).

     The body stores some glucose in the liver and the muscles as glycogen, a complex carbohydrate similar to starch; enough for quick energy needed in the next twelve to twenty-four hours. The remainder of that not needed for immediate energy production is converted to fat.

     Carbohydrates should account for 55 to 60 percent of total calories—at least 825 calories for the obese and sedentary person (ideal weight 73 kg), 990 calories for the overweight sedentary person, 1,650 calories for the active, not obese person, and 1,980 calories for the young, active underweight diabetic. Remember that 10 percent, or less, of total calories should come from simple sugar and only a small amount of this should be refined sugar. Thus, the first person is allowed 150 calories from these carbohydrates, the second 180 calories, the third 300 calories, and the fourth 365 calories. More specifically, the obese sedentary person can consume 625 calories as complex carbohydrate and 150 calories as simple sugar (total 825). The overweight sedentary person can consume 810 calories as complex carbohydrate and 180 as simple sugar (total 990). The normal-weight, very active person can consume 1,350 calories as complex carbohydrate and 300 as simple sugar (total 1,650); and the underweight diabetic athlete can take in 1,615 calories as complex carbohydrate and 365 as simple sugar (total 1,980).

     Fats—The rest of your calories will come from fat. See Chapter 2 (Atherosclerosis) for a discussion of fats. In the case of the first person discussed above, 1,500 (total) minus 300 (protein) and 825 (carbohydrate), or 375 calories will come from fat. One-hundred-fifty calories (10 percent of total energy) of this can be saturated fat. The second person could take in slightly more fat calories, 510; the third, about 990 calories; and the fourth, about 1,182 calories. (Remember that protein and carbohydrate yield 4 calories per gram, whereas fat yields 9 calories per gram.) Thus, even the young underweight athlete will be consuming only about 130 grams (about 4.7 ounces) of fat. To construct your own diet, you need to know the composition of all the foods you consume. However, it is not practical for a diabetic to calculate his or her allowances from scratch. Therefore, “exchange lists,” which group foods of similar composition, have been devised. By knowing the number of calories you require and employing these lists, you can arrange a diet that meets all the criteria outlined above.

     Using the exchange lists in Table 16, you can convert your diet requirements into food servings, and distribute these among meals and snacks without going through all the calculations. The foods in the exchange lists are grouped according to their nutrient similarities: vegetables; fruits and juices; and starchy foods (breads, cereals, and beans) are together as are meat, fish, and poultry; milk products; and fats. Within each list, foods are shown in specific quantities or units. An “exchange” means a serving of a food within a list can be exchanged for another one within the same list. On the fruit list, you can exchange ten cherries for one-half cup of orange juice. On the meat list, you can substitute one ounce of lean beef for one ounce of fish or skinned poultry, or for two teaspoons of peanut butter. Or you can make two or more exchanges. For example, ten cherries and one-half cup of orange juice equal one large apple (each equals one-half apple, or one small apple). Three meat exchanges would equal three ounces of lean meat, or three small lobster tails, or three-fourths of a cup of tuna fish or salmon, or two eggs and one-half ounce of hard cheese. To accommodate individual preferences, the possible combinations allow many choices.

Table 16.  Exchange Lists   

List 1. Free Foods

Bouillon                         Mustard                       Endive

Clear broth                    Pickle, sour                 Escarole

Coffee                           Pickle, dill—                Lettuce (all

Sparkling water                                                unsweetened    kinds)     

Tea                               Parsley                       Radishes

Gelatin,                          Chicory                       Vinegar

   (unsweetened)           Chinese                      Watercress

Lemon, lime                    cabbage                    Watercress

 

List 2. Vegetable Exchanges

     One exchange (½ cup cooked or 1 cup raw) of vegetables contains about 5 grams of carbohydrate, 2 grams of protein, and 25 kcal.

All leafy greens                          Cauliflower                    Sauerkraut

Asparagus                                  Celery                          Summer squash

Bean sprouts                              Cucumbers                 Tomatoes—1 cup

Beans (green or wax)                Eggplant  (raw or ½ cup)

Broccoli                                     Mushrooms                  Tomato or vegetable

Beets                                          Okra                               juice—6 oz.

Brussels sprouts                         Onions                       Catsup (2 tbs.)  

Cabbage (all kinds)                    Peppers (red or green)               

Carrots                                       Rutabaga                     

List 3. Fruit Exchanges

One exchange of fruit contains 15 grams of carbohydrate and 60 kcal.

FRUITS:

Apple—1 small                          Blueberries—3/4 cup

Applesauce—½ cup                   Cantaloupe—1/3 med. (5”

Apricots, fresh—4                        diam.)

Apricots, dried—7 halves                       Cherries—12  large

Bananas—½ (9” fruit)                Dates—2 ½ med.

Fruit cocktail, canned—¾ cup    Papaya—½ med.

Figs, dried—2 small                   Peach—1 med.

Grapefruit—½ med.                   Pear—1 small

Grapes—15                                Pineapple—3/4 cup

Honeydew—1/3 med.                  Prunes, dried—3

Mango—½ med.                         Raisins—2 tbs.

Nectarine—1 med.                     Strawberries—1¼ cup

Orange—1 med.                         Tangerine—1 large

                                                    Watermelon—1¼ cup,

                                                                          cubed

JUICES:                             

Apple, pineapple—½ cup

Grapefruit, orange—½ cup

Grape, prune—1/3 cup

List 4. Starch/Bread Exchanges (cooked servings).

            One exchange of starch contains 15 grams of carbohydrate, 3 grams of protein, and 80 kcal.

BREADS:                                  

Any loaf—1 slice                        Bun, hamburger or

Bagel—½                                     hot dog—½

Dinner roll—1 (2” diam.)            Cornbread (1½”)—1 cube

English muffin—½                     Tortilla (6 “diam.)—1

VEGETABLES:

Beans or peas                           Potatoes, White—1 small or

   (plain), cooked—½  cup                ½ cup

Corn—1/3 cup or ½ med. ear    Potatoes, sweet or

Parsnips—2/3 cup                          yams—¼ cup

Pumpkin—3/4 cup                      Winter squash—½ cup

DESSERTS:

Fat free sherbet—4 oz.             Angel cake (1½” square)—1

CRACKERS:

Graham (2½” square)—2          Pretzels—8 rings

Matzoh (4” x 6”)                          RyKrisp—3

Melba toast—4                           Saltines—5

Oyster (½ cup) 20

CEREALS:

Bran—5 tbs.                               Pasta—½ cup

Dry flakes—2/3 cup                    Rice—½ cup

Dry puffed—1½ cups                Wheat germ—2 tbs.

Hot cereal—½ cup

List 5. Meat Exchanges (cooked weight)

One exchange of meat contains 7 grams of protein, 5 grams of fat, and 75 kcal. (Based on med. fat meat—For higher fat content of meat, count one fat exchange (list 7) for each 5 grams of additional fat.

Beef, dried,                        Beef, lamb, pork,                 Cottage cheese,

  chipped—1 oz.                    veal (lean)—1 oz.                uncreamed—¼ cup

Poultry without                  Tuna, packed in                   Egg—1 med.

  skin—1 oz.                         water—¼ cup                  Hard cheese—½  oz.

Fish—1 oz.                        Salmon, pink,                      Peanut butter—2 tsp.

Lobster Tail—1                     canned—¼ cup               Oysters, clams,

  (small)                                                                                shrimp—5 med.

List 6. Milk Exchanges

One exchange of milk contains 12 grams of carbohydrate, 8 grams of protein, and 90 kcal.

Buttermilk, fat free—1 cup        Skim milk—1 cup        1% fat milk—7 oz.         Yogurt, plain, made with                                                                                                                            nonfat milk—3/4 cup

List 7. Fat Exchanges

One exchange of fat contains 5 grams of fat and 45 kcal.

Avocado (4” diam.) —1/8                       French dressing—1 tbs.           Olives—5 small                          Bacon, crisp—1 slice              Roquefort dressing—2 tsp       Peanuts—10

Butter, margarine—1 tsp                        Thousand Island          Oil—1 tsp.                                 dressing—2 tsp

Walnuts—6 small                                   Mayonnaise—1 tsp                             

     The same exchange lists are used regardless of how many calories you will be consuming. Table 16 lists the number of items from each exchange list permitted daily for persons taking in 1,000, 1,200, 1,500, and 1,800 calories (most adult-onset diabetics). If you need more calories, simply double the items in the appropriate column. For example, if you require 2,000 calories, double the 1,000-calorie list; if 3,000, double the 1,500-calorie list, and so forth. When Table 17 is used, the protein intake at all calorie levels will be adequate. Vitamin and mineral supplementation should not be necessary if selections are made from a variety of foods, except that iron should be given to women on 1,000 or 1,200 calories. Let us now construct a daily menu for a person on a 1,500-calorie diet. By using similar menus that fit the overall number of exchanges listed in Table 16, you can devise an endless variety and remain within the limitations set forth in this chapter. This system takes into account your individual food preferences, and when spaced according to your doctor’s orders, it will allow the use of the minimum amount of insulin necessary to control your diabetes. As a practical matter, some of your meals (such as soups, stews, and pizzas) you may include prepared foods composed of combinations of the exchange groups. We have included a list of commercial meals, frozen entrees, snacks, etc. in Appendix A (page 199). Alcoholic beverages (Alcohol is counted as fat.) are listed in Appendix B (page 213).

     These lists are included for your perusal to evaluate your personal food choices, not to recommend any commercial products; and, because manufacturers occasionally change the composition and packaging of their products, the values presented here may not exactly represent products currently on the market.

Table 17. Number of Exchange Portions Allowed Daily

                      for Various Calorie Levels

Food Exchange Group                1000    1200  1500  1800

List 1 Free Foods                       …Unlimited…

List 2 Vegetable Portions              2          2         3        3

List 3 Fruit Portions                       3          4         5        5

List 4 Starch Portions                   3          4         6         9

List 5 Protein Portions                  4          4         4          5

List 6 Milk Portions                       2          2         2          2

List 7 Fat Portions                        1          2         4          4

     Since diabetes is often accompanied by other medical problems that require special diets, the basic diet may have to be further modified. Salt restriction may be necessary if you have heart or kidney disease. Some people with kidney or liver problems may need to lower their protein intake. For most diabetic people, however, the basic diet offers calorie control, low fat, high complex carbohydrate, and low simple sugar. If used wisely, it can provide ample amounts of fiber and plenty of variety.

     It may be difficult at first to use these lists, but in the long run, it will be worth your patience to stick with it. While this plan may be somewhat more restrictive than some, it can be used not only for the person who already has diabetes but also by anyone who wishes to lose weight or lower his or her risk for atherosclerosis. A sample seven-day menu is presented in table 18. You can easily revise it for your own taste by exchanging your choice for each item from the appropriate food list. It offers a viable alternative to people at risk for obesity or atherosclerosis. It is not very different from the plans used in the chapters that discuss those diseases. It does not control your salt intake. If you are at risk for high blood pressure, it must be adjusted in the same way as any other diet (see Chapter 3). A person who has a combined high risk for diabetes and high blood pressure can modify this diet to lower its salt content and still get all the necessary nutrients.

Table 18. A Sample Basic Menu Schedule

Day 1

Morning

List 4 = 1 starch              ½ cup cooked oatmeal

List 4 = 1 starch              1 slice raisin toast sprinkled with cinnamon-sugar

List 3 = 1 fruit                ½ cup orange juice

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Noon

List 5 = 2 protein             ¼ recipe tuna and pasta salad:

List 4 = 2 starch              1 can tuna in spring water, 4 cups cooked shell pasta

List 2 = 2 vegetable        2 cups tender-crisp chunks of carrots and zucchini, chopped scallions

List 7 = 2 fat                    2 tablespoons reduced-calorie mayonnaise

List 3 = 2 fruit                  2 medium tangerines

List 1  — free —             1 glass ice tea

Evening

List 4 = 2 starch              2 10-inch thin-crust cheese pizza

List 5 = 2 protein             Lettuce salad with 1 cup tomato

List 2 = 1 vegetable               wedges, cucumber slices, mushrooms and scallions

List 7 = 1 fat                    2 tbs. red-wine vinegar/Canola oil dressing

List 6 = 1 milk                 1 cup 2% milk

List 7 = 1 fat

Snack

List 3 = 2 fruit                1 cup cubed cantaloupe with squeeze of lemon

Day 2

Morning

                                       Egg and muffin sandwich:

List 5 = 1 protein                        1 poached egg and sliced tomato on

List 4 = 2 starch              1 English muffin

List 3 = 1 fruit                ½ cup orange juice

List 1 — free —                         1 cup coffee

Noon

List 2 = 1 vegetable        1 cup cream of broccoli soup (made

List 4 = 2 starch                            with 2% milk)

List 6 = ½ milk                          

List 7 = 2 fat                   1 ounce reduced-fat cheddar cheese

List 4 = ½ starch             2 bread sticks

List 2 = 1 vegetable        6 cherry tomatoes

List 3 = 1 fruit                1 small pear

List 6 = ½ milk               ½ cup 2% milk

List 7 = ½ fat

Evening

List 5 = 3 protein                        3 ounce broiled halibut steak  marinated in juice of 2 lemon and 2      

List 7 = 1 fat                  lime, chopped garlic, and shallots

List 4 = 1 starch              ½ cup packaged rice mix (made without margarine)

List 2 = 1 vegetable        ½ cup steamed beets sprinkled with fresh chives

List 4 = 1 starch              1 slice crusty whole wheat bread

List 3 = 1 fruit                ½ cup fresh fruit salad

List 6 = 1milk                 1 cup 2% milk

List 7 = 1 fat

Snack

List 4 = 1 starch              3 cups microwave popcorn (light)

List 7 = 1 fat                              

List 3 = 2 fruit                1 large apple 

List 1  — free —             Sparkling water

Day 3

Morning

List 4 = 2 starch              2 frozen blueberry waffles

List 7 = 1 fat

List 1  — free —            1 tablespoon reduced-calorie syrup

List 3 = 1 fruit                1 kiwi

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Noon

List 5 = 2 protein                2 ounces lean roast beef,

List 2 = 1 vegetable          Dijon mustard, sweet onion,

List 4 = 2 starch                   lettuce and tomato on onion roll

List 3 = 2 fruit                    1 banana

List 1  — free —                Sparkling water

Evening

List 5 = 3 protein              3 oz. ginger-chicken (stir-fried with    

List 7 = 1 fat                         chopped garlic and ginger root in 1 teaspoon sesame oil

List 2 = 2 vegetable        1 cup snow peas, fresh mushrooms

                                              and red peppers                         

 List 4 = 1 starch             ½ cup brown rice

List 3 = 1 fruit                  ½ cup mandarin oranges

List 6 = 1milk                   1 cup 2% milk

List 7 = 1 fat

 Snack

 List 4 = 1 starch             5 oyster crackers (1 oz.)

 List 3 = 1 fruit               4 oz. orange juice

Day 4

Morning

List 4 = 2 starch              1 bagel

List 7 = 1 fat                   1 tablespoon cream cheese

List 3 = 2 fruit                1¼ cup low-calorie cranberry juice cocktail

Noon

List 4 = 1 starch              ½ cup cooked spaghetti topped with

List 2 = 2 vegetable        ¼ cup meatless spaghetti sauce

List 5 = 2 protein                        2 tablespoons Parmesan cheese

List 4 = 1 starch              1 piece garlic bread

List 7 = 1 fat                   1 teaspoon margarine

List 3 = 2 fruit                1 cup fruit cocktail

Evening

List 5 = 2 protein                        2 ounces lean ham

List 4 = 1 starch              ½ cup packaged au gratin potato mix (made with skim milk)

List 2 = 2 vegetable        Spinach salad with 1 cup shredded

List 1  — free —                          carrots, tomato wedges, sweet

List 7 = 1 fat                     onion and white wine-wine

                                               vinegar with tarragon/canola

List 3 = 1 fruit                1 small pear

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Snack

List 4 = 1 starch              2 graham crackers

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Day 5

Morning

List 4 = 1 starch              ½ cup bran flakes cereal

List 4 = 1 starch              1 slice whole-wheat toast

List 1  — free —              1 teaspoon low-sugar spread able fruit

List 6 = 1 milk                 1 cup 2% milk

List 7 = 1 fat      

Noon

List 2 = 1 vegetable        1 cup vegetable soup

List 4 = 2 starch              2 slices crisp bread

List 5 = 2 protein             2 ounces reduced-fat Swiss cheese

List 3 = 2 fruit                1 large apple

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Evening

List 5 = 2 protein           1 cup Broccoli Seafood Linguine

List 4 = 1 starch           

List 2 = 1 vegetable        Cucumber salad with herb-flavored

List 7 = 2 fat                       vinegar/canola oil dressing

List 3 = 1 fruit                 2 plums

List 1  — free —           1 glass ice tea

Snack

List 4 = 1 starch             5 gingersnaps

List 3 = 2 fruit                1 cup orange juice

List 7 = 1 fat

Day 6

Morning

List 6 = 1 milk                1 cup plain non-fat yogurt mixed

List 3 = 1 fruit                  with ½-cup chunky applesauce

List 4 = 1 starch              1 English muffin

List 1  — free —             1 teaspoon low-sugar spreadable fruit

List 3 = 1 fruit                ½ cup orange juice

Noon

List 5 = 1 protein            1 ounce sliced turkey breast

                                       1 tablespoon reduced calorie              

List 7 = 1 fat                  mayonnaise, sliced tomato and alfalfa sprouts on

List 4 = 2 starch              2 slices dark rye bread

List 3 = 1 fruit                2 tablespoons whole cranberry sauce

List 2 = 1 vegetable        ½ cup green pepper sticks

List 1  — free —                        1 glass iced tea

Evening

List 5 = 3 protein                        3 ounces broiled top round steak

List 7 = 2 fat                                       with fresh mushrooms sautéed in

                                                               Worcestershire sauce and 1 tablespoon olive oil

List 2 = 1 vegetable        1 4-inch frozen corn on-the-cob

List 2 = 1 vegetable        ½ cup baby carrots

List 4 = 2 starch              2 slices French bread (toasted)

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Snack

List 4 = 1 starch              12 pretzel sticks

List 3 = 2 fruit                1 large apple

List 1  — free —                        Sparkling water

Day 7

Morning

List 3 = 1 fruit                   small grapefruit     

List 5 = 1 protein            1 large poached egg               

List 4 = 1 starch              1 slice whole wheat bread 

List 6 = 1 milk                1 cup 2% milk

List 7 = 1 fat

Noon

List 5 = 1 protein              2 slices fat-free cheese, lettuce,

List 1  — free —                        pickles, lemon juice, vinegar

List 4 = 2 starch                          2 slices bread

List 7 = 2 fat                   2 tsp. mayonnaise         

List 2 = 1 vegetable        3 slices tomato

List 3 = 1 fruit                 ½ cup diced pineapple   

List 6 = 1 milk                            1 cup 2% milk

List 7 = 1 fat

Snack

List 3 = 2 fruit                1 large apple

Evening

List 5 = 2  protein           2 oz. chicken (no skin), lettuce, radishes, soy sauce, vinegar

List 2 = 2 vegetable        ½ cup string beans      

                                        ½ cup cauliflower    

List 4 = 1 starch              1 slice bread               

List 3 = 1 fruit                   1 medium orange

List 1  — free —                 Sparkling water

Snack

List 4 = 1 starch              ½ cup low-fat ice cream

List 7 = 2 fat              

List 4 = 1 starch                          1½ in. square sponge cake

     *This basic menu has 1,500 calories—about 55 percent from carbohydrate, 20 to 25 percent from protein and less than 30 percent from fat. If you need more than 1,500 calories, use this guide:

1,600 calories—add servings: 1 starch (list 4)

1,700 calories—add servings: 2 starch, 1 protein (List 5)

1,800 calories—add servings: 3 starch, 1 protein,

1,900 calories—add servings: 3 starch, 1 protein, 1 fruit (list 3),1 vegetable (List 2),1 fat (List 7)

2,000 calories—add servings: 3 starch, 2 protein,

                          1 fat, 2 fruit, 1 vegetable.

     Once you have diabetes, you will have it for the rest of your life. Therefore, it is important to have a regimen that will offer you the most options. Develop your own plan (with whatever professional help you need)—and stick with it! You will reap many benefits.                                                                                                                  

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