Hope Warshaw, RD, is a nationally recognized diabetes nutrition expert with 25 years' experience. She communicates practical solutions to individuals through counseling, and to millions through media channels and her best-selling books, including Diabetes Meal Planning Made Easy.
Q: Do I need to pay attention to the sugars on the nutrition facts label?
A: No. Pay attention to the total carbohydrates. The sugars content includes the amount of added and natural sugar in a serving. The amount of sugars are included within the total carbohydrate count, which is the key piece of information you need for planning meals and snacks. It's also important to pay attention to the serving size. Today's serving sizes are standardized by food-labeling regulations.
Q: What should my blood glucose, blood lipid, and blood pressure numbers be? And what should I do if my numbers aren't within the target ranges?
A: People with diabetes should learn and stay aware of their diabetes ABCs.
- A is for A1C. A1C is an indicator of average blood glucose control over the preceding six to eight weeks. A1C considers all the ups and downs of blood glucose levels during this time. The American Diabetes Association [ADA] recommends that your A1C be less than 7%. The ADA also recommends that fasting or premeal blood glucose should be between 70 and 130 mg/dL, while one to two hours after the start of a meal it should be no more than 180 mg/dL.
- B is for blood pressure, which should be at or below 130/80. If your blood pressure is higher than this, you should discuss ways to reduce it with your health-care provider.
- C is for blood cholesterol and LDL, lousy cholesterol, an important number for heart health. LDL should be at or lower than 100 mg/dL. HDL, healthy cholesterol, should be above 40 mg/dL for men and more than 50 mg/dL for women, and triglycerides should be less than 150 mg/dL for both men and women.
If any of your numbers don't meet these target guidelines, talk to your health-care provider about lifestyle changes you can make to improve them. He or she may also suggest that you take medications to help control your blood glucose levels, reduce your blood pressure, or improve your blood lipid levels.
Q: How should I get started making changes in my eating habits to start losing weight and eating more healthfully?
A: Start slowly. Don't think of these changes as a temporary "diet"; instead, think about how you can improve your eating and activity habits for the rest of your life. Give yourself plenty of pats on the back when things go well, and be easy on yourself when they don't. Start with specific, measurable goals and short time frames. Two examples: Two days a week, for the next two months, I will eat a healthy breakfast such as a whole-wheat English muffin with low-sugar jelly and a small banana, or half a whole-wheat bagel with low- or no-fat cream cheese and an orange or half a grapefruit. At least three days a week, I will take a 20-minute walk after lunch.
Set one to three goals at a time. Work on these. If you achieve them, set a few more; if you don't, see if you can make the goals easier or find others that will be simpler for you to achieve. Once you accomplish a goal, make it a permanent part of your lifestyle. Keep in mind that success breeds success.
Q: Is the timing of meals important for everyone with diabetes?
A: People with diabetes should aim to spread the carbohydrates they consume in meals and snacks—if you want or need them—as evenly as possible throughout the day. However, if you take a blood-glucose-lowering medication like rapid-acting insulin, you can adjust your doses based on the amount of carbohydrates you eat. Eating similar amounts of carbohydrates throughout the day helps your body keep your blood glucose levels more even and can keep you from being too hungry between meals.
Q: I've just learned I have prediabetes. What changes do I need to make in my lifestyle?
A: By eating healthy, being active, and losing a few pounds, you may be able to prevent the progression to type 2 diabetes, or at least delay this progression. The Diabetes Prevention Program (DPP), a three-year National Institutes of Health study including more than 3,000 people with prediabetes, found that people in the intensive lifestyle group who were counseled and received regular support in their efforts reduced their likelihood of developing type 2 diabetes by nearly 60%. Lifestyle changes involved eating fewer calories, less fat, and smaller portions, and exercising (such as walking) moderately for at least 30 minutes a day five times a week.
Weight loss doesn't have to be dramatic to have an effect; the goal for DPP participants was to lose 7% of their body weight. At the close of the 24-week intensive lifestyle intervention, participants had lost an average of about 12 pounds, and they managed to keep most of it off; average weight loss in the group about three years afterward was nearly nine pounds. All DPP participants are being followed in an ongoing study to determine if continued weight control, exercise, and support can help them continue to prevent and/or delay type 2 diabetes.
Q: I have type 2 diabetes. Should I get a referral to a diabetes nutrition educator or a diabetes education program? If so, why?
A: Yes. You should seek out diabetes education from a diabetes educator when you're first diagnosed with diabetes and on an ongoing basis over the years. Certified diabetes educators (CDE) are nurses, dietitians, pharmacists, and other health-care professionals who can provide you with the education and support you need to make important and challenging lifestyle changes. Research has shown that support is a critical element in helping people achieve their diabetes and health goals. Working with diabetes educators or participating in a diabetes education program can also help you make sense of new diabetes research and how to apply the findings to you.
You can find diabetes education programs that have been recognized for their quality through the American Diabetes Association. Find diabetes educators through the American Association of Diabetes Educators. Find dietitians with expertise in diabetes through the American Dietetic Association.
Q: Will I be able to control my blood glucose levels through weight loss and physical activity, or will I likely need to take one or more blood-glucose-lowering medications?
A: When many people are diagnosed with type 2 diabetes, they have generally had elevated blood glucose levels for many years (estimated at an average of seven to 10 years). If type 2 is detected and treated early, some people can control their blood glucose levels for a time with a healthy eating plan and physical activity. However, most people will need one or more blood-glucose-lowering medications when they are diagnosed or over time. The way to stay healthy with type 2 diabetes is to keep your blood glucose, blood lipids, and blood pressure in healthy ranges. If your health-care provider suggests you take one or more blood-glucose-lowering medications, don't resist. You likely need it to control your blood glucose levels. But it's still important to keep active and eat healthy even if you do begin taking blood-glucose-lowering medications, because the medications are most effective in conjunction with lifestyle changes.
Q: Are nutrition recommendations different for people who have just been diagnosed with type 2 diabetes than they are for those who've had diabetes for years and take insulin injections?
A: No, the Dietary Guidelines for Americans, which are supported by the American Diabetes Association, are appropriate for pretty much everyone, including most people with type 1 and type 2 diabetes: Eat more whole grains, low-fat and fat-free dairy foods, fruits, and vegetables; limit consumption of high sodium processed foods and saturated and trans fats; get more of your protein from seafood and poultry and nonmeat sources, like beans (legumes); and eat all sources of protein in portions no larger than three ounces cooked. The Dietary Guidelines for Americans also recommend getting 45% to 65% of your calories from carbohydrates (with less than 25% of your total carbohydrates from added sugar); 20% to 35% from fat; and 10% to 35% from protein.
Q: I've heard there are healthy and unhealthy carbohydrates. What should I eat more of, and what do I need to limit?
A: Foods that contain carbohydrates are starches, grains, fruit, vegetables, and dairy foods. The healthiest sources of carbohydrates provide plenty of vitamins and minerals per caloriethey are nutrient-dense. Everyone should eat more fiber-rich carbohydrates, such as whole grains, fruits, vegetables, and beans (legumes). You should try to eat at least three servings or half your servings of starches as whole grains each day. Less healthy carbohydrates like candy, sweetened beverages, and ice cream pack little nutritional punch but contain plenty of calories; keep them to a minimum.
Q: What are the most important factors I need to consider about the types and amounts of fats I eat?
A: You should consume no less than 25%, and no more than 35%, of your calories from fat. For example, if you eat 1,600 calories daily, this translates to 400 to 560 calories from fat. Each gram of fat contains nine calories, so you should aim for 44 to 62 grams of fat daily.
Focus on getting most of your fat in polyunsaturated or unsaturated form. Some of these healthier fats help bring down your total and LDL (lousy) cholesterol levels, while boosting HDL (healthy) cholesterol. Polyunsaturated fats include omega-3 fats, found in fish, canola oil, walnuts, flax seeds, and flax seed oil; and omega-6 fats, contained in corn oil, sunflower oil, and other liquid vegetable oils. Nuts, olive oil, canola oil, and avocados are good monounsaturated fat sources.
Limit saturated and trans fats, which increase both total and LDL cholesterol. Saturated fats are found in meats and dairy foods, as well as the coconut oil, palm oils, and palm kernel oils often used to make store-bought cookies, snacks, and other processed foods. Trans fats have no nutritional value and should be limited as much as possible. Partially hydrogenated oils used to make some baked goods, prepared snacks, and deep-fried fast foods are the main source of trans fats in the U.S. food supply. Nutrition Facts labels generally include information on a food's saturated and trans fat content.
Q: Is it OK for me to consume alcohol in moderation? What caveats should I follow, and are some types of alcohol better than others?
A: Moderate alcohol consumptionone drink a day for women, two a day for menis fine for everyone, including people with diabetes. Drinking lightly can actually have health benefits, for example, reducing the risk of heart and blood vessel disease. But don't start drinking to get these benefits if you don't already. Sip alcoholic beverages slowly, and consume them with meals. Be aware that alcohol can cause blood glucose to go too low for people who take insulin or certain diabetes pills (ones that can cause low blood glucose or hypoglycemia), while alcohol can also cause hyperglycemia due to its carbohydrate content. The health benefits for all types of alcohol are the same. If you choose to drink, you can keep the amount of carbohydrates in drinks down by avoiding drinks mixed with juice or soda and using low-calorie mixers like club soda and tomato juice.
Q: Should people with diabetes eat snacks?
A: Years ago, health-care providers would advise people with diabetes to eat three meals a day and three snacks to keep their blood glucose levels up. But today, there are several blood-glucose-lowering medications that don't cause hypoglycemia and types of insulin (long-acting and rapid-acting) that cause fewer problems with low blood glucose. Some people may not initially need to take any blood-glucose-lowering medication. So the recommendation to eat several snacks a day is considered old-school. Today's advice is: Include snacks in your eating plan if you want them, if your blood glucose still tends to drop below normal even after you've worked with your health-care provider to adjust your medications, or if you need snacks to get the calories or nutrients you require.
As with all the foods you eat, choose foods for snacks that contain healthy sources of carbohydrates and trim fat content. A few healthy and portable snacks are: fresh or dried fruit; individual containers of fruit packed without added sugar; a handful of nuts; low-fat, high-fiber crackers with peanut butter, reduced-fat cheese, or part-skim cheese; raw vegetables; or reduced sugar yogurt.
Q: Which sugar substitutes are best for a person with diabetes?
A: Aspartame (NutraSweet) and sucralose (Splenda), the sugar substitutes most commonly used in the U.S., are virtually carbohydrate free and will not increase your blood glucose levels. Three other no-calorie sweeteners that won't affect blood glucose have been approved as food additives by the FDA: acesulfame potassium (Sunette and other brands), neotame (which currently isn't in a tabletop sweetener or in many foods), and saccharin (Sweet n' Low and other brands). According to the American Diabetes Association and the FDA, these are all safe for people with diabetes and the general public to use. Extracts of stevia, a South American plant with very sweet leaves, have not been approved by the FDA as a food additive, although stevia is available as a dietary supplement.
Q: Are "low-sugar" or "sugar-free" foods beneficial to people with diabetes?
A: Foods labeled as low-sugar or sugar-free may or may not contain carbohydrates and therefore may or may not be advantageous to use. Some sugar-free foods are sweetened with a sugar substitute or two and contain no calories, such as diet soda; some sugar-free foods are sweetened with lower calorie sweeteners or bulking ingredients in known as polyols. These include sorbitol and xylitol, and they contain about half the calories of other carbohydrates, on average, because the body doesn't digest them completely. Eating large amounts can cause gas, cramps, and diarrhea in some people. Foods sweetened with polyols usually contain calories and carbohydrates that can raise blood glucose. This is true for sugar-free ice cream, cookies, candy, and more. Read the nutrition label and ingredients. This will help you choose sugar-free foods that make sense for you to use.
Q: Is it OK for people with prediabetes and diabetes to eat some sugar and sweets?
A: Yes. People with diabetes can enjoy sugary foods and sweets in moderation. However, the amount of sweets you eat should be balanced with your diabetes nutrition goals, such as weight loss, blood glucose, and blood lipid control. Be aware that some desserts and sweets, for example ice cream and cheesecake, are also high in fat and the fat may be the unhealthy saturated type. Keep portions small, and check your blood glucose an hour or two after you indulge; this can help to guide you toward sweets that you can continue to eat on occasion and to learn which ones you should avoid. Knowing your blood glucose number may also help you, if you are able, to adjust your blood-glucose-lowering medication to compensate for sweets.
Q: How many carbohydrates should an adult man or woman who is trying to lose weight eat each day?
A: Aim to get roughly half of your calories from carbohydrates. For example, a sedentary woman who wants to lose weight should limit her calories to 1,400 to 1,600 a day, so she should consume 700 to 800 calories from carbohydrates daily. At four calories per gram of carbohydrate, this translates to 175 to 200 grams of carbohydrates. Following is a sample meal plan that would meet this guideline, along with examples of serving sizes.
- Seven starch servings (one serving is a slice of whole wheat bread, or half a medium baked potato)
- Two servings of milk and yogurt (one serving is eight ounces of fat-free milk, 2/3 cup of fat-free yogurt)
- Four servings of vegetables (one serving is one cup of salad or a half-cup of cauliflower or carrots)
- Five ounces of meat (cooked)
- Three servings of fruit (one serving is a cup of cantaloupe, 2 small tangerines, a small banana, or a small apple)
- Six servings of fat (one serving is a teaspoon of olive oil, two tablespoons of avocado, four pecan halves, or a tablespoon of reduced-fat mayonnaise)
Q: I have high blood pressure. I've been told to limit my intake of sodium. What are a few suggestions?
A: About three-quarters of the sodium that people eat comes from processed foods. Therefore, decreasing the amount of processed foods you eat is a good way to reduce sodium. Check the sodium count of a food on the nutrition facts label. Processed and ready-to-eat foods may be high in sodium, so limit your consumption of them and choose fresh fruits, vegetables, and meats instead. Make your own salad dressing from scratch, because commercial dressings are frequently high in sodium. Don't use added salt in cooking, and use lemon juice, mustard, vinegars, and other lower-sodium condiments to add flavor to food. And be sure you're getting enough potassium, which is found in fruits, vegetables, and dairy foods. Increasing potassium intake can blunt the effect of too much sodium on blood pressure.
Q: As a person with diabetes, should I be taking dietary supplements? If so, which ones?
A: According to the American Diabetes Association, if you're eating a variety of nutritious foods, consuming at least 1,200 calories a day, and are able to keep your blood glucose under control, you don't need extra vitamins, minerals, or other dietary supplements. You can take a supplement with 100% of the daily values of vitamins and minerals if you're concerned about getting enough nutrients from food. Your health-care provider may recommend that you take certain vitamin or mineral supplements if you're a vegetarian, are cutting calories to 1,200 daily or less to lose weight, are pregnant or breast-feeding, or have certain illnesses.
Q: What's the difference between glycemic index and glycemic load?
A: The glycemic index (GI) of a food measures how much blood glucose rises within the two hours after you eat it, while the glycemic load (GL) additionally accounts for a food's typical serving size. Low GI foods, such as whole grains, vegetables, and some fruits, can be healthy, but aren't always. Considering the GI and GL of foods can be helpful, according to the American Diabetes Association, as long as it's done in conjunction with and after you are already carefully monitoring carbohydrate intake and eating healthy.
Q: Since I have diabetes, do I need to prepare my food separately from my family?
A: No. The foods that are healthy choices for you will also be healthy choices for your family members who don't have diabetes. The easier you make it for everyone to eat healthy together, the more likely it will be that you'll be able to continue practicing the important lifestyle changes over the years and the more likely you will raise your children and grandchildren with healthy eating habits. Keep in mind that if you have diabetes, they are at greater risk of diabetes too.