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(4) Diabetes

Diet

There must be many people like me who have diabetes but who are not on insulin. Why have I been told to control my weight?

People who develop diabetes later in life are often overweight. For the first few years after diagnosis, they do not usually need treatment with insulin injections – instead their treatment is by diet alone or by diet and tablets.

If you are overweight, the insulin produced by your pancreas is less effective because of the excess fat in your body. This is known as ‘insulin resistance’, and you overcome it by losing some of the fat. Achieving and maintaining a sensible weight therefore helps you improve control of your diabetes. An additional benefit is that it also reduces all the other health risks associated with being overweight, such as high blood pressure and heart disease.

Treatment without insulin

I’m sure I don’t eat too much. Why do I keep putting on weight?

Your body needs energy from food and drink to fuel your body processes, such as breathing, which go on even when you are sleeping. All forms of physical activity (such as walking, shopping, typing and so on) require additional energy. This energy is measured in calories or joules. Ideally your calorie intake from the food you eat should balance the amount of energy used by your body. When this happens you will neither gain nor lose weight. If the amount of food and drink you consume provides more energy (calories) than you use in your daily activities, then the extra food will be converted into

body fat and you will put on weight. If you are overweight, you need to reduce your daily intake of calories so that you are taking in less energy than your body needs. Your body will make up the difference by using up the fat stored in your body and you will then lose weight.

In the UK usually refer to calories, but some countries refer to joules: 1 calorie is equal to 4.2 joules. Strictly speaking, we should really be talking about kilocalories (often abbreviated to kcal) and kilojoules (abbreviated to kjoules or kJ), and these are the units that you will probably see on the nutritional information labels on food packaging. Most people simply use the shorthand term ‘calorie’ when they mean kilocalories.

I have diabetes controlled by diet alone. Do I have to keep to strict mealtimes?

People on medication for diabetes (tablets or insulin) are usually advised to keep fairly closely to regular mealtimes to avoid getting a low blood sugar level (hypo). As long as you are on diet alone, your risk of a hypo is very low, so you do not need to keep to strict mealtimes. However, it is worth remembering that everyone finds their diabetes easier to control if they have three or more small meals a day rather than one or two large ones.

My husband’s diabetes is controlled by diet alone. Since being diagnosed 2 years ago, he has kept strictly to his food plan. In the past year he has not had a positive urine test and his blood glucose measurements at the clinic have been normal. Does this mean he no longer has diabetes?

Once you have developed diabetes, you always have diabetes. This applies to almost everyone and exceptions to this are extremely rare. Your husband has obviously done very well by keeping to his food plan, and this is the reason his diabetes is so well controlled. If he went back to his old eating habits and started putting on weight, it is very likely that all his old symptoms would return and his blood glucose would be high again.

Do people on diet alone need to eat snacks in between meals?

No, not usually. The reason that people taking insulin injections are sometimes advised to eat a snack between their main meals is to balance the effect of the insulin they take. People on diet alone or diet and tablets do not usually have this problem and so do not usually need to have snacks. Of course snacks are not very helpful if you are trying to lose weight. Remember that not eating snacks is not the same thing as missing meals. Some people on diet alone can go hypo if they go without food.

There seem to be many foods offered in the supermarkets now labeled ‘diabetic foods’. Should I be eating these rather than the ordinary types?

No, and we would recommend that you do not even include them in your food plan. They are no lower in fats or calories than ordinary food and they are also expensive. The main selling point for most of these so-called ‘diabetic foods’ is that they replace ordinary sugar with a substitute. This Treatment without insulin substitute may be another type of sugar called fructose, but is often a sugar alcohol called sorbitol. If taken in excess, this often leads to diarrhoea. Fructose and sorbitol both contain calories. Today the recommended food plan for most people with diabetes allows you to include some sweetened foods, especially if you choose products with a higher fibre and lower fat content. If you are of normal weight or below, you will be able to eat modest amounts of ordinary extras or treats, such as biscuits, cakes or confectionery. These should form part of your food plan and should preferably be eaten at the end of a meal. There is therefore no need for you to buy diabetic foods just to give yourself a treat. The only ‘special’ foods we recommend for people with diabetes are the ones labelled as ‘diet’ or ‘low calorie’, especially soft drinks that are sugar-free, reduced sugar preserves, diet yoghurts and sugar-free jellies.

These are not marketed specifically for people with diabetes, but for everyone who wants to keep their weight under control or avoid eating too much sugar. They are usually sweetened with intense sweeteners such as saccharin or aspartame, which are virtually calorie-free. These artificial sweeteners can also be used to replace sugar in your tea or coffee, or you can get them in granular form to sprinkle on your breakfast cereal.

Where or how do I find out about the carbohydrate or calorie content of foods?

The publishers of the many slimming magazines on the market also produce booklets for slimmers listing the calorie contents of foods, and you may find that your local newsagent stocks one of these. You could also look at the labels on the food you buy, as most foods are now labelled with their carbohydrate and calorie content (as well as with other nutritional information). Your dietitian can teach you how to use the information on these labels if you are not quite sure what something means. Some manufacturers label their foods more clearly than others.

I have just started tablets for my diabetes. Does this mean I can relax my diet?

Unfortunately not. You will have been prescribed tablets because treatment with diet alone was not enough to bring your blood glucose level down. If you start taking tablets and then relax your diet, your blood glucose levels may climb even higher. Remember, it’s treatment with diet, exercise and tablets, not just with tablets.

If it has been a while since you have seen a dietitian, it would be a good idea to make an appointment to review your diet now that you are on tablets to see if there are any  changes that you could make.

How does a person with diabetes get an appointment with a dietitian? Will there be one at my doctor’s?

Everyone agrees that food plays a crucial part in the way people look after their diabetes. Soon after diagnosis and at other stages of diabetes, people need expert advice from a dietitian. The availability of dietitians varies considerably across the country, but most diabetes centres have a dietitian as part of the team. Some general practitioners provide

dietitian sessions in their own health centres, but in other places, you will have to wait for an appointment at the local hospital.

I have a number of queries about my diet. Can you tell me how I can get advice about it?

Good advice on diet is essential in the proper care of diabetes and it needs to be tailored to fit every individual person. You can arrange to see a State Registered Dietitian through

your hospital or your doctor. Most hospitals have a State Registered Dietitian attached to the diabetes clinic, and you could arrange to see them at your next clinic visit. Some general practitioners organize their own diabetes clinics, and may arrange for a dietitian to visit this clinic. Many nurses and health visitors who are specially trained in diabetes will also be able to provide good basic dietary advice.

I have many family celebrations in the summer and would like advice on the choice of alcoholic drinks. I have managed to lose weight and my control has improved so much that I have been taken off my tablets. Taken in moderation, alcohol has been shown to be good for people with or without diabetes. You will need to remember that it can become a significant source of calories and can stimulate your appetite but, even on a weight-reducing diet, most people are allowed some alcohol for special occasions. As the control of your diabetes is so good, there will be no problem about enjoying a drink at your family celebrations.

You can choose from all types of wine, red or white, but should probably avoid very sweet wines and sherries on a regular basis because of their high sugar content. Spirits are sugar-free (but not calorie-free) and are best enjoyed with sugar-free (‘diet’ or ‘slimline’) mixers or soda water. If you prefer a pint, you can choose beer, lager or cider. It is best to avoid the ‘strong’ brews, which are often labelled as being low in carbohydrate, as these are higher in alcohol and calories than the ordinary types. Low-alcohol and alcohol-free beers and lagers may contain a lot of sugar, so if you enjoy these you should look for the ones that are also labelled as being low in sugar. Drinking alcohol affects your blood glucose level and you should be aware of this.

I have had diabetes for 22 years and have only recently come back under the care of my local hospital. When I talked about my diet to the dietitian she was keen to make some changes saying that there were quite a lot of new ideas and diet recommendations. What are these and is it worth me changing after all this time?

Advice on diet for people with diabetes has certainly changed since you were first diagnosed. Much more is now known about nutrition, and a diagnosis of diabetes no longer means eating differently from everyone else. In fact, the advice on a healthy diet for people with diabetes is exactly what has been recommended for the population as a whole – eating less fat, in particular saturated or animal fat, and sugar, and more fruit, vegetables and pulses.

It’s an eating plan that your whole family could follow if they want to eat healthily and well. Changing to a diet with more fruit and vegetables and less fat is certainly worthwhile and may reduce your risks of developing heart disease in later life.  We now know much more about carbohydrate, which is found in both sugary and starchy foods. In general, the carbohydrates found in sugary foods are more rapidly absorbed by the body, and make your blood glucose levels rise very quickly, which is not a good thing if you have diabetes. Starchy, high-fibre carbohydrate foods are absorbed more slowly and are more suitable because they make blood glucose levels rise more slowly. However, these days we rank carbohydrate foods in terms of their glycaemic index (GI).

This is just a term to describe how slowly or quickly carbohydrate foods raise blood glucose levels. Foods that have a low glycaemic index like fruits, vegetables, pulses, pasta and rye bread should be combined with meals and snacks to help to control blood glucose levels, more easily. Oat bran, for example, has a low glycaemic index. Low glycaemic index diets make insulin more responsive or ‘sensitive’ and this will help people with diabetes keep their blood sugar under control.

The dietary fibre found in these starchy carbohydrate foods is of two main types: ‘fibrous’ fibres, which are typically found in wholegrain cereals, wholemeal flour or bran; and ‘viscous’ fibres  found in pulses (peas, beans and lentils) and fruit and vegetables. Viscous fibres (especially those found in beans) appear to be of particular benefit because they slow down food absorption and hence the rate at which carbohydrate present in a meal will be absorbed into the bloodstream.

All plant foods, especially those eaten raw or lightly cooked, are digested very slowly because the plant cell walls have to be broken down before their carbohydrate content is released. As well as this slow absorption (which means a slower rise in blood glucose levels), foods rich in fibre have a more prolonged effect on maintaining blood glucose levels. This reduces the risk of unexpected hypos if meals or snacks are delayed. So it is worth updating your diet. Your dietitian will provide individual advice, but the main recommendations are summarized in the box (overleaf). I am gradually losing my desire for sweet foods.

When I do have them I follow my dietitian’s advice and make sure that it is at a time when they are least likely to result in high blood glucose. However, I really do not enjoy my selection of high-fibre breakfast cereals without some sweetener – I was a Sugar Puff fan before! Can I put a little sugar on?

Nowadays most experts accept that your food plan can include some sugar as part of a balanced diet. However, use one of the granulated sprinkle-type sweeteners, which are virtually calorie free. Primarily aimed at slimmers, they are readily available in chemists and supermarkets. Brand names to look for include Canderel, Sweetex granulated, Sweet ‘n’ Low, and Hermesetas Sprinkle. These will not have any effect on your blood glucose.

 Dietary advice for people with diabetes

• Eating too many calories in your diet will have a bad effect on control of your diabetes. Everyone with diabetes therefore requires a food and eating plan, based on their own individual needs, that does not contain surplus food energy. (We have discussed balancing calories taken in and used up in more detail in the questions at the very beginning of this section.)

• To reduce your risk of developing coronary heart disease and arterial disease (and also to help you keep your weight under control) you should reduce the amount of saturated or animal fat in your diet. You can do this easily by substituting semi-skimmed or skimmed milk for whole milk; using less butter or margarine and replacing them with low fat spreads; reducing your intake of cream and cheese; grilling rather than frying foods; choosing fish, including two portions of oily fish per week, lean meat or poultry (skin removed). You should not eat too much protein and people with diabetes should probably avoid high protein/low carbohydrate diets.

• Although you should not add sugar to drinks, you can include foods containing sugar in your diet. You should base meals on starchy carbohydrates, like bread, pasta, rice, cereals and potatoes. Eat plenty of foods such as fruit, vegetables, pulses and beans. Breakfast cereals such as Weetabix, Shredded Wheat, Bran Flakes, All-Bran or porridge are all a good source of fibre.

• If you need to lose weight, you should not follow a diet low in carbohydrate: you should include some bread or potatoes, or pasta or rice, or breakfast cereal at each meal. A high carbohydrate/low fat diet is particularly suitable if you want to lose weight as it contains plenty of bulk and so you are less likely to feel hungry.

• Special ‘diabetic foods’ are not worth including in your food plan because they are expensive and are usually high in calories. Low calorie ‘diet foods’ and drinks that are sugar-free can be usefully included in your diet, especially if you need to lose weight. (We have talked about diabetic and diet foods in more detail in an earlier question.)

• You can drink a moderate amount of alcohol provided that you take its energy contribution (the number of calories it contains) into account. The recommended limit is 2 units per day for women and 3 units per day for men. One unit is the same as a glass of wine or sherry, a measure of spirits or 1⁄2 pint of beer, lager or cider. Beers and lagers specially brewed to be low in carbohydrate have a high alcohol and calorie content and are not recommended.

As a single parent I really find it hard to make ends meet. I know that very often I do not buy the foods that I should to help control my diabetes. Is there any way I can eat healthily but cheaply?

You are far from alone in wanting to eat well but cheaply nowadays. The sort of food plan advised for most people with diabetes should not cost more than the foods most people are eating before diagnosis, but there is no doubt that, when people are on very limited incomes, the amount they have to spend on food is often less than is required to buy a healthy diet. The following tips may help, and you could also ask your dietitian for some more ideas – it is a problem that will have often been met before.

For breakfast, have porridge, which is very cheap and an excellent breakfast cereal from the point of view of your diabetes control. When it’s too hot for porridge, try home-made muesli, which you make by mixing some rolled oats (the type that you use to make porridge) with some fruit (perhaps a chopped apple) and some cold skimmed milk.

You need enough milk to make the mixture about the same consistency as porridge, and you can also add some plain unsweetened low-fat yoghurt if you like. Leave it to stand overnight and it will be ready to eat in the morning. A sandwich lunch can be very healthy, especially if you can use wholemeal bread. Tinned fish such as sardines, mackerel, or pilchards are excellent choices for sandwich fillings and can work out very inexpensive.

You do not really need large helpings of meat at your main meals, and you can often extend it with extra tinned, frozen or fresh vegetables. Diet yoghurts make excellent desserts and are good value for money. You can cut costs further by buying a large pot of plain natural yoghurt (usually cheaper than the fruit varieties) and adding chopped or puréed fresh or tinned fruit in natural juice with a little extra intense sweetener if needed.

Another quick and healthy home-made dessert is a sugar-free jelly (available from most supermarkets) made up with milk or yoghurt.

The dietitian says that my high blood glucose levels during the morning may be caused by the pure fruit juice that I drink at breakfast. It is unsweetened juice, so how can this happen?

Pure unsweetened fruit juice will put up your blood glucose levels, whether it comes from a bottle or a carton or fresh fruit that you have squeezed yourself. All fruit contains natural sugar. If you eat it as the whole fruit then it takes time to be digested and the effect on blood glucose is quite slow. If you take away all the flesh (which contains the dietary fibre) and just drink the juice,  the sugar will pass rapidly into your bloodstream.

You can have fruit juice but limit the amount you drink to a small glass. You can also dilute your fruit juice with mineral water or diet lemonade.

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