A diabetic balancing act

A new handbook from America's leading center dedicated to diabetes shows patients how to manage the disease while enjoying life.

cakes 298.88 (photo credit: Jonathan Bloom)
cakes 298.88
(photo credit: Jonathan Bloom)
When patients are first diagnosed with diabetes, their doctors usually spend time discussing medications, blood sugar monitoring, blood pressure, cholesterol levels, weight loss and exercise. Few have time to go into the details of what they should eat and avoid eating, even though diet has a paramount effect on maintaining proper blood glucose levels and preventing complications of the disease. Some patients are referred to clinical dietitians for advice, but not all have such professionals at their disposal. Now a new softcover book from the Joslin Diabetes Center (www.joslin.org) in Boston - the world's first and most respected diabetes care facility - has been published with this need in mind. Part of the Staying Healthy With Diabetes series and called Nutrition & Meal Planning, the 131-page volume was written by clinical dietitian Amy Campbell and colleagues. Full of nutritional charts, tables and menus, it offers advice that will certainly be helpful to patients - but relevant also to anyone who wants a healthful diet. The advice is suitable to those who inject insulin as well as those who manage their condition with medications. Of course, diabetics should consult their doctors when following its advice because each case is different. Although there are non-kosher entries such as pork and shellfish, the book is nevertheless very useful to observant Jews. Food products mentioned are largely available in Israel, even though not all are common here and Israelis tend to eat at home much more than Americans. The English-language book is available for $12.95 plus shipping and handling through Joslin Diabetes Center's online store at https://store.joslin.org. FOUNDED IN 1898, Joslin is an independent non-profit institution affiliated with Harvard Medical School and Beth Israel Deaconess Medical Center. It employs a team of more than 300 people dedicated to preventing and curing diabetes. Now 114 years old, the center is still the only institution focused exclusively on improving the lives of people with all forms of diabetes and its complications. Its patients range from children to the elderly, from the newly diagnosed to those who have received "Joslin Medals" for living with diabetes for 50 years. In fact, recipients of this medal have been invited by Joslin to participate in a special study examining long-term outcomes. The study is aimed at understanding what contributes to the longevity of such individuals, and some 300 have completed an extensive questionnaire. CALLED "the epidemic of the 21st century," diabetes affects some 150 million people around the globe, according to the World Health Organization, with the number projected to double by 2025. In the US alone, diabetes affects about 21 million children and adults, or 7% of the population. An estimated 14.6 million Americans have been diagnosed, leaving 6.2 million unaware that they have it. In addition, 41 million Americans are thought to have pre-diabetes - elevated blood glucose levels that put them at risk for developing type 2 diabetes. There are some 400,000 Israeli diabetics, the vast majority with Type II, which usually results from lifestyle (overweight and lack of exercise) rather than from an autoimmune attack on insulin-producing pancreatic cells that occurs in Type I. If untreated or poorly treated, diabetes can lead to blindness, heart and kidney disease, stroke, nerve damage and circulation problems requiring limb amputations. CONFLICTING headlines in the media about what foods are good for diabetics can be confusing. The volume, which supplies a "road map" to help guide diabetics and their families to healthy food choices, demystifies nutrition and meal planning. Patients have to know not only the impact on blood glucose levels of everything they put in their mouths, but also the beneficial influence of fiber, and understand the role of fat and simple/complex carbohydrates. Another important topic is how to judge foods according to their glycemic index - a system of ranking food containing equal amounts of carbohydrates according to how much they raise glucose levels. The book explains that 100% stone-ground whole wheat bread has a low glycemic index (GI) that will raise blood sugar levels by significantly less than processed white bread, even though both contain 15 grams of carbohydrates. Even though they are sweet, green grapes have a much lower GI than watermelon, for example. Glycemic load is also an important concept to understand because it relates GI to portion size by combining the GI value and the carbohydrate content of an average meal or a day's worth of food. A food's glycemic load (GL) is calculated by multiplying the GI number of the food (86 for a slice of pizza, 102 for a cup of white rice, 75 for a glass of orange juice, 102 for a serving of white potatoes and 131 for half a cup of carrots) by the number of grams of carbohydrate in a single serving, and then dividing by 100. That gives these foods a GL of 68, 46, 15, 38 and 10 respectively. A GL of 10 or less is low, while 20 or more is high. Thus, calculated by GL, carrots need not be avoided. But the author notes that neither the GI nor the GL should be used as the main method of meal planning (the process of choosing foods to help manage the disease) for diabetics. The focus should be on the total amount of carbohydrates one eats, while choosing food with a low GI and GL to improve blood glucose levels. "No foods are forbidden for people with diabetes," says Campbell, a certified diabetes educator with 20 years of experience and co-author of several books, including The Joslin Guide to Diabetes: A Program for Managing Your Treatment and 16 Myths of a Diabetic Diet,. "You can have a piece of cake on your birthday or go out to dinner. You just need to know how to count carbohydrates and sometimes limit certain foods." A meal plan, Campbell continues, is especially useful if one's goal is to lose weight. Sugar, she notes, can be eaten in modest amounts, as "what is important is the total amount of carbohydrate, rather than its source... Once you know how to count carbohydrates, you'll be able to fit any food, including sugar, into your meal plan. High-sugar foods of course have higher concentrations of carbohydrates, so for a given amount, the portion size is smaller." Campbell also points out that artificial sweeteners are not all the same; the terms "sugarless," "sugar free" and "no sugar added" cannot be taken at face value. There are "nutritive" or "caloric" sweeteners - such as sugar alcohols - that add calories and affect blood glucose. Then there are "non-nutritive" or "non-caloric" sweeteners such as aspartame, sucralose, saccharine and acesulfame-K, which, after extensive testing, are regarded as safe for the general public, including diabetics and pregnant or lactating women. Still, you can't totally substitute non-caloric sweeteners for sugar in baking, as sugar provides bulk as well as sweetness. But in some recipes, vanilla, almond extract, nutmeg or cinnamon can enhance the taste provided by artificial sweeteners, she writes. THE AUTHOR also includes Joslin's Food Lists - 32 pages with serving sizes for carbohydrates (breads, cereals, vegetables, cookies, crackers, fruit, favorite breakfast items and desserts); proteins (meats, cheeses, eggs); fats; "free" foods such as most vegetables and herbs, combination foods; "fast food" and vegetarian meals. Tips for increasing soluble fiber in your diet, reducing salt intake and cutting cholesterol are also given. Dining out, which is not just eating but also a social experience and entertainment, is not forbidden to diabetics. "Even though you are away from your own kitchen, you can and should still control what you eat. By adapting guidelines you've learned for managing your diabetes at home, you can develop a strategy for eating out." Among the hints are to plan ahead what you'll order, avoid "all-you-can-eat" restaurants and "supersize" items, and to eat a snack before you go out. Consumption of alcoholic beverages is also discussed in detail, with the best advice being to avoid large intakes of them but, when drinking, to do so along with food. The message running through this helpful book is that diabetics should not regard themselves as "sick" but as people who have the ability to counter the effects of the metabolic disease by what they eat and how they live. This is just as true for non-diabetics.