DOCUMENTARY
Insulin Resistance Diet – To Age Or Not To Age –
Diet and Insulin
I have been told that I am going to have to start insulin after many years of diet and tablets. Will my diet need to change?
Possibly, and in any case it would be helpful for you to have the opportunity to discuss your present eating habits with your dietitian before you start on insulin. If you have been trying to avoid going on to insulin by restricting the amount of carbohydrate you eat, you may well be advised to increase your intake.
I am quite a thin person but have been told to watch my ‘diet’. Why?
The word ‘diet’ can often be misleading, as many people think of a diet only in terms of a weight-reducing diet. In fact, the word diet just means a way of eating or a prescribed course of food, and for a person with diabetes it simply means planned eating. It might be better if we all used the terms ‘food plan’ or ‘eating plan’ instead, but most of us just continue to use the word ‘diet’ in our everyday conversation!
The reason everyone with diabetes needs a food plan is to help them balance the amount of food that they eat against the amount of insulin and exercise they take. The simplest plan just encourages you to eat some carbohydrate foods at each meal. Carbohydrate foods are starchy or sugary foods such as bread, biscuits, crackers, crispbreads, pasta, potatoes, pulses, cereals, rice, fruit, and so on.
A more detailed plan would tell you about the amounts of proteins and fats that you should eat. Proteins are an essential part of everyone’s food intake but are only needed in moderate amounts. Foods high in proteins include meat, fish, eggs, cheese, pulses and nuts. Fats are used for energy and are a more concentrated source of calories than either carbohydrate or protein.
However, you should pay attention to the quantity of fat you eat-taken in excess, fat can lead to weight gain and may contribute to heart disease in later life. Examples of fats are butter, cream, margarine, lard and vegetable oils. Fried food, cakes and pastries are also high in fats.
Most people eat roughly the same amount of food each day and so, when you are trying to balance food, insulin and exercise, it makes sense to keep your carbohydrate and calorie intake fairly constant, so that only your insulin and the amount of exercise you take need to be adjusted.
The aim of your food plan is to eat roughly the same amounts of carbohydrates and calories at much the same time every day. The dietitian will firstly assess your previous diet and then advise you on the essential changes you need to make whilst trying to retain as much as possible of your previous eating pattern.
My 16-year-old son has had diabetes since he was. We have managed quite well but since he has been transferred to the diabetes clinic we have seen more of the dietitian. I am confused – she spends time urging us to eat more fibre-rich foods and cut down the fats.
He’s not overweight and has never had a problem with his bowels. Different foods or meals affect blood glucose levels in varying ways even when their carbohydrate content is the same. It’s the total number of calories you eat not just the amount of carbohydrates that affects whether or not you are overweight, and a fibre-rich diet will actually be good for all of you, not just your bowels.
There is now a lot more emphasis on the type and quality of the carbohydrate foods we eat. Carbohydrates that are rich in fibre usually take longer to digest, do not raise the blood glucose quite so much or so quickly, and keep blood glucose at a steady level
for longer, which helps to prevent hypos. They also contain more vitamins and minerals and are believed to prevent the build-up of excess fat in the arteries. The amount of heart disease amongst people with diabetes (and the general population) worries the experts and this is why there is much more emphasis on the whole diet, particularly in eating more of the fibre-rich foods and cutting back on fatty foods.
I gather different forms of carbohydrate have different rates of digestion and that this affects the rise in blood glucose after a meal. I gather there is a ‘glycaemic index’ for each type of carbohydrate. What is this glycaemic index?
Yes, you are quite right. Many carbohydrate foods have been graded according to the extent that they put the blood glucose up after a given amount. Refined carbohydrate (like sugar) and some other foodstuffs (e.g. potatoes) have a high glycaemic index, while some unrefined carbohydrates like rice and pasta have a much lower index.
This means that within your calorie-controlled diet, you can most likely be able to eat more rice and pasta than sugar and potatoes and still maintain the same level of blood glucose control.
Although every person is different, the foodstuffs with a high glycaemic index should be taken sparingly while you will find that you can probably be more liberal with foods with a low glycaemic index without upsetting your glycaemic control. On the other hand you may also be able to improve your control by increasing the proportion of carbohydrates of low glycaemic index in your diet. You need to be aware of the possible need for a reduction in insulin dose under these circumstances.
How long before eating should I have my insulin injection?
People who do not have diabetes start to produce insulin at the very beginning of a meal. Since it takes some time for injected insulin to be absorbed, you should ideally aim to have your insulin injection about 30 minutes before your meal, unless you are taking Humalog or NovoRapid, which should be given just before a meal. If your blood glucose level is low at the time of the injection there should be less delay between your insulin andyour food.
I am on two injections a day. Sometimes I find it inconvenient to take my evening injection. Can I skip it and have a meal containing no carbohydrate?
No, you cannot skip your evening injection. When the effect of your morning injection wears out, your blood glucose levels will rise even if you have no carbohydrates to eat. Nowadays you can use an insulin pen, which makes it more convenient to inject insulin.
Do people taking insulin need to eat snacks in between meals?
Sometimes, yes. When your pancreas functions normally, it produces insulin ‘on demand’ when you eat and ‘switches off’ when the food has been used up. Injected insulin does not ‘switch off’ in this way.
As injected insulin has a peak effect at certain times of the day, it is important for you to cover its action by eating a certain amount of carbohydrates, or you will have a hypo. It is worth remembering that the carbohydrates will last longer if they are rich in fibre (with a low glycaemic index), as they are then more slowly absorbed.
If you find it difficult to eat between meals it may be possible to cut down the number of snacks that you need by changing from a short-acting insulin to an intermediate-acting insulin, although some people still need to eat snacks even when taking a longer-acting insulin, particularly if they are very active.
Alternatively, you could try a new very short-acting insulin analogue. There are many ways in which you can adjust your insulin regimen to suit the life you want to lead, and your doctor or diabetes specialist nurse will be able to advise you about these.
As I have to take insulin should I eat a bedtime snack?
Generally speaking, no, unless your blood glucose level is less than 7 mmol/litre at bedtime. If it is lower than this, or if you have hypos during the night (blood glucose tends to fall during the night) then you might need a bedtime snack. Something like a bowl of cereal, a piece of bread or toast, a sandwich, or some wholemeal crispbreads will last you better through the night than a rapidly absorbed milk or fruit juice drink with biscuits. If you are on insulin, you may do better by adjusting your dose.
Should I increase my insulin over Christmas to cope with the extra food I shall be eating?
Yes, you can take extra insulin to cover the extra carbohydrates that you eat on any special occasion, not just Christmas. At Christmas everyone (including people with diabetes) eats more and it is best to accept this – but you also have to accept that extra food will increase your waistline! Extra food does need extra insulin and it is up to you to try to discover by how many units you should increase your dose. You will probably need to work this out by trial and error, but firstly we would suggest that you do not increase the insulin by more than four units at a time, best taken in a quick-acting form shortly before your meal.
Don’t forget the effect of exercise on your blood glucose – the traditional afternoon stroll after Christmas lunch is a good idea. Is it all right for me, as someone who takes insulin, to have a lie-in on Sunday or must I get up and have my injection and breakfast at the normal time?
As with many of the answers in this book, the best advice we can give is try it and see on a couple of occasions. Try the effect of delaying your morning injection and breakfast and measure your blood glucose when you get up 3 or 4 hours later. If it is well below 10 mmol/litre, all well and good, but if your blood glucose is higher than 10 mmol/litre it means that you should not have missed your insulin. You may have to persuade someone else to give your morning injection and bring you breakfast in bed!
I have two injections a day: morning and evening. I keep regular times for breakfast and evening tea but I would like to vary the time that I take lunch. What effect would this have on the control of my diabetes?
Sometimes I suffer from a poor appetite. Is it all right for me to reduce my insulin dose on such occasions?
Yes, that is perfectly acceptable provided that you do not miss out completely on a main meal. You will have to find out for yourself (by measuring your blood glucose) by how much you should reduce your insulin for a particular amount of food. If you are underweight do not reduce your food intake too drastically. On the other hand, if you are overweight, you will need to reduce both your food intake and your insulin.
My daughter has had diabetes for 4 years and has had no problems with her diet. She takes part in most school sports but, since she has taken up running longer distances, she finds that she has a hypo about 2 hours after she has finished running. She has no problems during the run so what should she do to counteract this?
The effect of exercise on the body can last well after the exercise has stopped, as the muscles are restocking their energy stores with glycogen. Your daughter is obviously taking in enough food to last her during her run, but not enough to keep her going through this ‘restocking’ process.
She would probably find it helpful to eat an extra carbohydrate snack, such as a fruit juice and a sandwich, after her run has finished. It might also be a good idea for her to reduce her morning dose of insulin on the days she is running.
My son has been putting on weight since being diagnosed as having diabetes 3 months ago. What are the reasons for this?
Most people lose weight before their diabetes is diagnosed and treated. In uncontrolled diabetes body fat is broken down and many calories are lost as glucose in the urine. As soon as the diabetes is brought under control, the body fat stops being broken down, the calories are no longer lost and the weight loss stops.
Many people, like your son, begin to put weight back on again. If your son starts to put on too much weight, he should discuss this with his diabetes specialist nurse and his dietitian. They will advise him about his diet and, if he is on insulin, about reducing his food intake and his insulin simultaneously.
I have been taking insulin for 8 years and over this time I have put on a lot of weight. My doctor says that insulin does not make you fat, but if that is so, then why have I put on so much weight?
People tend to lose weight if their diabetes is badly controlled, mainly because they are losing a lot of calories as glucose in their urine. Once the diabetes is controlled, the calories are no longer lost in this way, the weight loss stops, and there will be a tendency for a person starting treatment to put on weight.
Insulin in the right dose does not make you fat, but if you are having too much insulin you will have to eat more to prevent hypos, and these extra calories will increase your weight.
When you are on insulin and become overweight, then losing the extra weight can be a slow business. You cannot afford the luxury of sudden, drastic dieting (not that this is recommended for anyone – it is not the best way to lose weight) but can lose weight only by careful reduction of both food and insulin.
This can be a delicate balance but many people do manage it successfully. There is a particular risk of weight gain when children stop growing. Children need enormous amounts of food when they are actually growing taller, but once fully grown they need to make a conscious effort to reduce their total food intake. Girls usually stop growing a year or two after their first period and unless they eat a lot less at that stage they will almost certainly become overweight – and will find that it is much easier to put on weight than to take it off.
Since I went onto multiple injections to improve my control and fit them in with my hectic work schedule I have put on quite a lot of weight. I am really pleased with my control but I know in part it is because I take my insulin now whereas I often didn’t before because of the fear of hypos. Why do I keep on getting fatter?
The new system is helping you control your diabetes in your hectic lifestyle but it is important to realize that now you are taking your insulin at the right time all the food you eat is going to be used, and the excess is going to be stored as fat!
To control your weight you need to balance the food you eat with the amount of energy you use up. You should aim for a weight loss of between 0.5–1 kg (1–2 lb) a week. Start by looking at the amounts of fat and alcohol in your diet, as these are both very concentrated sources of calories.
Try to cut back on fatty foods, perhaps by having low fat products instead of full fat, and having fruit or a diet yoghurt instead of crisps or biscuits, as snacks. Always choose lean rather than fatty meat or replacing it with fish or poultry with the skin removed. If your weight loss slows up or stops, then be prepared to consider reducing also your intake of starchy foods.
Before you start to notice a drop in weight your control might well improve further, so do be prepared to monitor your blood glucose and reduce your insulin as necessary. Regular exercise will help burn off some of the fat and stop the problem developing in the future. If your weight continues to be a problem, record all your meals and snacks for 3 or 4 days and then ask the dietitian to go over them with you to see where further changes can be made.
My 18-year-old daughter has diabetes and is trying to lose weight. She eats a low-carbohydrate diet and sticks to this rigidly. I cannot understand why she does not lose any weight.
Just reducing the amount of carbohydrate in her diet will not necessarily result in her losing weight. When you are trying to lose weight it is important to reduce the total number of calories in your diet, and this involves reducing the amounts of fat, protein, and alcohol you consume – particularly fat as it is such a concentrated form of calories. Your daughter should avoid fried foods, sugary foods and alcohol, cut down her cheese intake, substitute skimmed milk for ordinary full-fat milk and allow only a scraping of butter or margarine on her bread.
She will find a diet that contains plenty of high-fibre carbohydrates will be more satisfying and cause less fluctuation in her blood glucose and, as a result, it will be easier for her to follow. Ask your daughter to seek help from her doctor, dietitian and diabetes specialist nurse so that they can work together to prevent hypoglycaemia.
