Friday, November 17, 2017

Diabetes Month Tip of the Day


Question
What about “low carbohydrate diets” like Atkins? Or very low carbohydrate plans like the “ketogenic” diets.
Answer
You might be surprised, but even the American Diabetes Association states that very low and low carbohydrate diets, like the Atkins, are one acceptable plan to follow for people with Type 2 diabetes who are trying to lose weight. (See here:) In short, the plans that limit carbohydrate and make provisions to obtain adequate protein, fat, and vegetables are actually backed up by evidence. Unfortunately there are some problems and/or concerns with the low and very low carbohydrate plans that I have encountered over the years:
1) Some plans (like Atkins) will encourage reliance on a particular company’s products (shakes, bars, special low carb cookies, etc.)   These products are often expensive and usually not very nutritious (and people become bored with the particular products). People who want to follow a plan like Atkins, South Beach, Protein Power, etc. might need encouragement to stick with “regular” food instead of convenience items. That doesn't mean that you can't ever use said items; people who are traveling, who have limited skills/time/facilities for cooking, or who have executive dysfunction problems might need to rely on some of these at first. If you find yourself disliking the taste and/or expense of said products, just remember it's one stepping stone in changing your food journey.   
2) Some people think that on these plans that they can eat whatever they want without paying any attention to portions or calories—and the calories on those “low carb” brownies really add up.  There are many people who have spent years trying to find the perfect diet and the appeal of something "easy" is quite powerful. I noticed this ignoring of the need for a reduction in calories a lot in the early 2000’s, when the South Beach Diet first appeared on the scene and there was a proliferation of low carb stores with low carb pasta, low carb tortillas, etc.  People would spend a lot of money on these products, lose a bunch of weight at first, and then see the weight loss plateau because they forgot that they won’t lose weight if there isn’t some kind of caloric restriction.  If you find a brand of low carb pasta, etc. that you really like, and find that it helps you stay on your plan (and you can afford it) by all means use it.  Just remember the portion will still count. 
3) Some people have other health problems that don’t allow them to follow a very low carb diet. For example, if you have gall bladder disease (or have had it removed) you probably won’t be able to tolerate the amount of fat required for very low carbohydrate plan. Some other people with bowel problems find the lack of fiber and/or resistant starch causes additional problems with constipation and/or and alteration in gut flora that may cause constipation or diarrhea. And of course, if you are a Type 1 diabetic who is not trying to lose weight, you will likely need to eat a  minimum amount of carbohydrate grams each day to keep yourself from forming ketones.
4) Some people also find these type of diets so unlike what they are used to that they can’t keep them up long term.  This problem probably should have been labeled number one on the list. In other words, they might benefit from a plan that emphasizes gradual and consistent reduction of carbohydrate so they can actually stay on their plan. A meal plan, or diet, or whatever you want to call it, is only a good idea IF YOU FIND IT SUSTAINABLE. If you can't keep this up long term you might find yourself discouraged/unmotivated, and faced with health problems that come raging back. (I have also had friends/acquaintances that have used all the forms of low carbohydrate diets as a way of "acting out" their disordered eating. If you think you fit that bill, definitely consult with a mental health professional (if you can) before undertaking a restrictive plan.
Other the other hand, some people do try and find ways to find low carbohydrate eating sustainable. That’s why there are so many blogs, support groups in real life and online, social media groups, etc. for eating for diabetes, eating low carb, eating a ketogenic diet, etc.  Low carbohydrate/carbohydrate controlled plans can be very doable, but not necessarily easy to follow at first, and most of us need a little support and encouragement along the way if we are going to stay with it.  (And if you are in an online support group that is...not so supportive....see if you can find another community before giving up). Keep in mind too that updated versions of books like the Atkin’s diet will give instructions for a more moderate approach  to carbohydrate restriction.  (The newer version of that plan was actually co-authored by a Registered Dietitian).

I also remind people that “low carbohydrate” doesn’t really have a definition.  (“Lower than what?” is my usual snarky question).  I prefer the term “carbohydrate controlled” which implies that the person is aware of what their carbohydrate budget is (as in about how many grams a day, or which foods affect you) and is taking steps to stay within a certain amount.

Want to keep reading about the evidence for carbohydrate controlled plans?

Thursday, November 16, 2017

Diabetes Month Tip of the Day


Question
I really, really tried that carbohydrate counting yesterday and I got cranky because all my meals were turned into a math equation.  I know some people have to do this…but isn’t there something easier I could try for now?
Answer
If you know which foods fit the different groups—(mostly carbohydrate, protein, fat, or non-starchy vegetables*), there is an easier way to think about this.  Think of your plate as a divided picnic plate.  Fill half the plate with green vegetables, ¼ with protein, and the remaining ¼ with a healthy carbohydrate.  It will look something like this:


And since I couldn’t get a good picture of food at home, something like this:

https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcQACFOe8B57231YZuF9lIt27peSyH51lTII6QgjmhhV2oWDRJZV

It’s very similar to the Myplate graphic from the USDA, but a little “tighter” on the carbohydrate content.  This is a great way for people to at least start thinking about reducing their portions of carbohydrate (and eat more vegetables) even if they are not willing to or feel able to count actual carbohydrate grams. In addition, this graphic is also a great way remind us that the way people with diabetes are “supposed” to eat is a very healthy way for us all to be eating, and it also helps us estimate portions when eating out too.
Speaking of “portions” there is a lot of information about portion and serving sizes out there—most of it is meaningless with some kind of context about how much carbohydrate you tolerate (or how many calories you need). For more context, please go back to the beginning of this series, staring on November 1rst, and do some figuring out about how much carbohydrate you think might be right for you. Again, some of you might decide that the best thing for you is to not have certain carbohydrate foods readily available; for example, maybe you don’t want to bother with figuring out “just” the right amount of rice to eat (or you don’t want to bother with the small portion) so rice just won’t be on the menu very often.  Other people might find that there are certain readily available favorite foods that they want to work in regularly, and will work very hard to do so. 

*You can find lists of food, as well as a lot more info, at educational websites geared toward diabetes and portion control like http://www.joslin.org/info/diabetes-and-nutrition.html

Wednesday, November 15, 2017

Diabetes Month Tip of the Day


Question
Ok, so I learned where carbohydrates are, and which ones might be better choices, and I have a rough idea of how much might be a good idea to eat at each meal.  Now, how do I “count” these carbohydrates at each meal?
Answer
Great question, but the answer is going to involve some work. Let’s go step by step.
  1. Decide what kind of carbohydrate food to eat based on price, cooking skills, availability at store, and what everyone in the household likes to eat (Whew!). 
    1. If you are new to carbohydrate counting, start with the carbohydrate foods your family normally eats the most of.
    2. Better yet, choose something that you already have in the house as a staple.  We’re here to learn, not condemn our choices!
  2. Pick-up said food at the store or out of the pantry or fridge (let’s use rice as an example).
  3. Look up the amount of carbohydrate on the label, on your favorite carb counting smartphone app, or on the internet (I like calorieking.com).
  4. Finds out that 1/3 of a cup of rice (cooked) has about 15 grams of carb.
  5. Figures out how much dry rice makes a cooked portion. Sighs because even 2/3 of a cup (30 grams of carb) doesn’t seem very much.
  6. Cooks rice.
  7. Portion out about 30 grams worth for me and 45 grams worth for my husband, then pack up leftovers for lunch.
  8. Add in roasted chicken (protein) and steamed broccoli with olive oil and balsamic vinegar (non-starchy vegetables, healthy fats, non-caloric flavorings).  (You remembered to get that at the store and cook it, right?)
Seem complicated?  If it does, you might have an idea of why many people struggle with meal planning and/or struggle with keeping their carbs under a certain amount. Counting carbohydrates does get easier, but you have to practice—like learning any new skill. Sometimes you even have to practice that skill with a healthy dose of “I don’t want to but I know I’ll be better for this!” thrown in. In a later post I will address some “non-counting” methods of reducing carbohydrate intake since the idea of making all meals into a math exercise is not for everyone. Just for the fun of it though, try counting your carbohydrates today if you are not used to it.
If you have Type 1 diabetes, on the other hand, carbohydrate counting is definitely going to be your friend in keeping the blood glucose from going too high or too low (a dangerous condition called hypoglycemia).  If you are able to become proficient at counting/estimating carbohydrates your endocrinology team will be able to assist you in figuring out how much insulin to give yourself based on how much carbohydrate you eat.  This means that you are more likely to have your insulin regimen actually work more like a functioning pancreas to keep your blood glucose levels right where they need to be—not too high or too low.
Many people will turn to “sample diabetic menus” on the internet and/or from a pamphlet they got from their doctor’s office. On those same sample menus you might have seen the term, “carbohydrate serving” or “carbohydrate choice.” A “carbohydrate serving” is a portion of food that is equal to 15 grams of carbohydrate.  There is a history behind the use of the number fifteen (based on how many units of insulin are required to cover 15 grams of carbohydrate), but suffice to say, one particular group of educators wanted an “easier” way to keep track of carbohydrates. As a result, some wonderful group of people took all of those carbohydrate foods and gave us a list of serving sizes where each one is equal to 15 grams of carbohydrate (glad I didn’t have that job).  Once a person works out how many carbohydrate servings is suitable for them, they can choose from a list of carbohydrate foods and use up their “choices” however they want as long as the portions are within a certain amount.  I have never been fond of this method myself, but some people find this an easier way to conceptualize of their “carbohydrate budget.”
Want to keep reading?

Tuesday, November 14, 2017

Diabetes Month Tip of the Day


Question
Are some carbohydrate foods healthier than others?

Answer
The short answer is yes, but remember you still have to watch the amount of carbohydrate you eat.

Otherwise, the healthiest carbohydrates are those that give you the most nutrition per portion and have very little processing done to them.  In other words, if you aren’t trying to eat as much, you want what you do eat to be nutritious, satisfying, and hopefully taste good.  Winter squash (like butternut), tubers (like sweet potatoes), legumes (like pinto beans), and whole fruits are generally “healthier” carbohydrate choices. Real whole grains (like whole oats or barley) can safely be incorporated in by some people with diabetes, but other people might still notice a sharp increase in the blood glucose levels with grains of any type.  Always use your blood glucose meter to determine both what and how much of these foods are safe for you personally.  Anyway, these “healthier” carbohydrates, for the most part, are considered such because they contain vitamins and minerals, and fiber. So, if your doctor has ever told you to eat brown rice instead of white, etc., your doctor was "probably" trying to get you to include higher fiber carbohydrate selections.
Some of these “healthier carbohydrate foods” are beneficial because they contain something called “resistant starch.” Resistant starch is not digested by the body, meaning that it won’t convert to blood glucose, meaning that you can eat a more satisfying portion while still eating less carbohydrate. Some people even find that if they include a good source of resistant starch at the first meal of the day they can fewer have spikes in blood glucose during the day. (In a later blog post we will discuss meal timing and frequency of meals.)  For more about resistant starch, which foods contain it, and how to incorporate it into your diet, go to this link: (https://www.healthline.com/nutrition/9-foods-high-in-resistant-starch#section1) One of my favorite ways to include resistant starch is cooked and cooled potatoes.  Roast a pan of potatoes the night before (http://allrecipes.com/recipe/18324/roast-potatoes/), cool them in a safe manner, and toss them with scrambled eggs and vegetables the next morning.
Many types of bread, pasta, baked goods, fruit juices, cereals (even the ones labeled “made with whole grain), etc. have had most of the nutrition stripped from them and are not very satisfying in small amounts.  As stated before, there aren’t too many people who really want to eat “just a small amount” of pasta or “a few” tortilla chips.  Most people will feel more satisfied if they have chewier, higher fiber, higher resistant starch forms of carbohydrate. I should also give a warning here that even though you might need more fiber and more resistant starch in your diet, start small and build up gradually. If you don’t, like many of my patients found out the hard way, you might get bloating, gas, hard stools, etc.  Start low, go slow, and drink plenty of non caloric fluids! I also cannot emphasize enough that you need to evaluate all these foods against your own blood glucose meter as much as possible.  Some people will find very little different between brown rice and white rice and/or whole grain bread or white bread, for example. You will also find that it is best to stick with foods that have "naturally" occurring fiber instead of the added type as the added fibers usually have very little impact on blood glucose control.
Speaking of, sweets and soft drinks are traditionally called “empty calories.”  They will raise the blood glucose levels and provide calories but not do anything beneficial for your body.  That’s why letting go of the sweets and soft drinks is the first step for a lot of people in reducing their carb intake (it just shouldn’t be the only step!)
*Please note that I have avoided the use of “complex” and “simple” carbohydrates.  Those terms describe the chemical configuration (i.e. how the molecules are strung together) of a carbohydrate but do not actually say anything about the nutrient density or the impact on the blood glucose levels.  For example, pasta has a more “complex” configuration that table sugar (sucrose), but white flour pasta is not really more nutritious, nor does it have a different impact on the blood glucose levels. I have written about this before here: http://skepticrd.blogspot.com/2013/04/chemistry-is-complex.html

Think about what kind of carbohydrates you are choosing, and tomorrow we will talk about how to count them!

Monday, November 13, 2017

Diabetes Month Tip of the Day

Question
I did what you said and I tried to keep track of the amount of carbohydrates in the foods that l eat.  30-45 grams for one meal doesn’t seem like very much. And for the people who have to eat less than that at one meal....wow, I can see why this might be a huge learning curve. And hard to follow if you have budget restrictions that cause you to rely on staples like pasta and rice.
Answer
You are right, those numbers are much less than many people in the United States are used to eating.  My personal carbohydrate tolerance (based on my what my blood glucose meter says) is only about 30 grams per meal, and even as a Registered Dietitian who is proficient in carbohydrate counting, that can be tough to maintain!
If you eat roughly a cup of pasta you’ve eaten 30 grams of carbohydrate, so you’re done for that meal.  Fortunately you do get to fill in with lean protein, healthy fats, and vegetables to make a complete meal (more about that later), but that’s still a big adjustment for some people.  Now, hopefully you are also be getting an idea why many people who successfully control their blood sugars with diet alone usually give up their sodas (40 or more grams of carbohydrate for one can of Coke), fruit juices (30 grams of carbohydrate for 8 oz. of juice), and/or their morning breakfast cereal (45 grams for 1 cup of cereal), etc. And some people even wind up giving up bread, pasta, or certain fruits because they don’t want to bother with the small portions "required" to keep their blood glucose below a certain amount. (In other words, they know that a little bit of rice will just leave them wanting more, so they don't bother).
Keep in mind it’s not just a lack of motivation/lack of desire to “cut back” or “give up” foods that keeps people from controlling their carbohydrate intake, it can also be a lack of access to food for physical or financial reasons.  Foods like pasta and other refined carbohydrates are cheap and easy to prepare, so some people have to make that decision to either eat the bowl of Ramen or not eat anything at all.  Some people who have trouble chewing, swallowing, or other digestive issues wind up eating a lot of carbohydrate foods because they seem easier to chew, swallow, or digest (mashed potatoes, anyone?). And as I said before, some people have made the conscious decision to not give up/limit certain foods because of how it affects their quality of life.
Meanwhile, if you are trying to reduce your carbohydrate intake here are a few suggestions for reducing carbohydrates without necessarily counting them. Just make sure you still look at the labels as “sugar-free” doesn’t mean “carbohydrate free!”
  1. Trade your favorite cola out for iced tea with your favorite sugar substitute (or drink unsweetened).
  2. Trade out your favorite soft drink for flavored sparkling water.
  3. Trade out your favorite cold cereal for a small portion of whole rolled oats (yes, you can make them in the microwave!)
  4. Trade out your favorite fruit juice for a small piece of fruit.
  5. Trade out favorite fruit juice for flavored sparkling water or a carbohydrate free beverage (like crystal lite).
  6. Use bread for sandwiches only, and avoid eating bread at meal times.
  7. Choose “lite” bread or “thins” instead of “regular” bread. (Check labels and serving size to make sure you are really reducing your carbohydrate intake).
  8. Use large lettuce leaves instead of bread or tortillas to make “wraps.”
  9. If you have potatoes at your meal, avoid having pasta/corn/rice at the same meal (and vice versa).
  10. Switch to corn tortillas instead of flour (just check the label and the quantity!).
  11. Cook more meals at home so you don’t get “hidden” carbohydrates as fillers in processed foods.
  12. Add  more green vegetables to your plate so there is less room for starches.
  13. Use pureed cauliflower instead of mashed potatoes (many recipes can be found on line, and some grocery stores sell finely chopped cauliflower in bags).
  14. Use spiralized vegetables instead of pasta (again, many recipes and techniques for preparation can be found online).
  15. Experiment with non-wheat flours like almond flour or coconut flour.  If you are not used to cooking with these flours though, make sure you follow the recipes as listed first so you reduce your chance of having a gooey mess.
  16. When donating to a food pantry, try to focus on donating protein rich foods so they have more than pasta and rice to give out.

Tomorrow we will talk about which carbohydrate foods carry a bit more nutrition than others, and we will discuss a bit more about the formation of resistant starch.

Want to keep reading?


Thursday, November 9, 2017

Diabetes Month Tip of the Day


Question
How much carbohydrate can a person with diabetes eat and still keep the blood glucose under control? And still make an attempt to have good quality of life?

Answer
The answer depends on the person’s age, body size, activity level, weight loss goals (if any), what the blood sugar meter says, and how tightly they want their blood glucose controlled by diet.  In other words, the carbohydrate intake needs to be individualized based on those goals, often with the help of a Registered Dietitian and Certified Diabetes Educator.
There are also books and online resources that you can use to help personalize your carbohydrate intake based on what your blood glucose monitoring device says and what your health goals are.  Said online and published resources are not a substitute for seeing an endocrinologist and/or a Certified Diabetes Educator, however, I know that sometimes seeing an educator is cost prohibitive and/or discussing food with a stranger can seem awkward as well.  One of the books that I like to recommend as a way to get started with picking out a blood glucose monitor and setting carbohydrate goal is “Blood Sugar 101: What They Don’t Tell You About Diabetes” (Link).  Despite the rather ominous sounding title, this book outlines a simple plan for understanding what carbohydrates are, target blood glucose goals, and adjusting your carbohydrate intake to include foods you like in the right portions for you. For a more extensive read on diabetes, testing equipment, diet, and a testing plan there is Dr. Bernstein’s Diabetes Solution.
Naturally, when I start to talk about “carbohydrate counting” and “testing” I frequently get a panicked look as many of the people I work with have not had the chance to make testing or math their friend just yet. Or they might be willing to test their blood sugars, but their insurance will only pay for a certain amount of test strips and they don’t feel like they can afford the out of pocket costs for additional strips.  As a result of this, some people will ask for a “ball park” answer.  Said answer, and this is a HUGE ballpark now, people with Type 2 diabetes will usually need to keep their carbohydrate intake about 20-40% of calories.  For the population that I work with, (older, less active) that usually means 100-130 grams per day, or about 30-45 grams at each meal and 15-20 grams per snack (most people eat two or three times that amount).  Again—emphasis on the huge ballpark number.  I have some folks that only eat about 15 grams at meal and some can do the 45, but the portion control is paramount to helping people with diabetes eat a variety of foods while still meeting their blood glucose goals.
For people with Type 1 diabetes, they will usually get better control if their blood sugars if they are able to count carbohydrates and inject meal time insulin based on how much carb they are eating and add a correction factor based on their blood sugar.  (That was a very simple answer to a process that requires a lot more reading about Type 1 diabetes in general; as well as different kinds of insulin and how they work—hard to add in to this particular blog post. Adjusting your insulin based on carbohydrate intake also involves a lot more testing—up to 4 or more times per day, which sounds daunting but becomes easier with time and practice.  Many people also find that making every meal into a mathematical equation is hard at first, and then becomes easier to do with time.

Think about how much carbohydrate you eat every day, and next week we’ll talk about some basic ways to help people reduce it. (These tips are corresponding to my work week.  Happy Veterans Day tomorrow!)

Want to keep reading about how to individualize carbohydrate counting?


Wednesday, November 8, 2017

Diabetes Month Tip of the Day


Question
What are carbohydrate foods and why are people with diabetes told to limit them?


Answer
Simply put (in non-chemistry terms), a carbohydrate food is a food that contains mostly starch and/or mostly sugar.  From a practical sense carbohydrate foods include the “grain” group, starchy vegetables like potatoes and corn, fruits like apples and oranges, milk and yogurt, and all “sweets” and sweetened drinks.  Many of the people I have worked with do a pretty good job (or have very good intentions, rather) of cutting out the “added carbohydrate” or “concentrated carbohydrate” by avoiding sweets and “regular” soft drinks, but if they haven’t gone beyond the basics they are often surprised to find out that fruit, cereal, and milk could be affecting their blood sugar as well.


Now that you’ve finished that paragraph—go back and read it again and familiarize yourself with which foods groups contain carbohydrate.  Why? Because for many of us, once they have figured out the “sweets” part, our brains now only want to associate carbohydrate with grains and starches.  So if you have cut your bread but you are still consuming large amounts of fruit, you might still be having trouble with your blood glucose. Getting to know your carbohydrates will definitely take some getting used to and a lot of reading, but it does get a little easier with practice.  I also find that having a smart phone app, like this one done in conjunction with Joslin Diabetes center (https://itunes.apple.com/us/app/healthediabetes/id757759280?mt=8) is invaluable.
Learning about your carbohydrate intake, and how to adjust it if desired, with help with blood glucose control because carbohydrate foods change to blood glucose faster than protein foods, fats, and/or non-starchy vegetables do.  People with diabetes have to limit how much they eat of ANY carbohydrate foods (even the ones they thought were healthy) as a first line defense in controlling their blood glucose levels.  For many people this requires a pretty drastic reduction in amounts that they were eating, and some people wind up giving up certain foods because it’s hard for some of us to eat “just a bit” of certain foods.   For example, have you ever tried to eat “just a few” chips or “just one cookie” and succeeded? Okay, so my Type 1 Spouse can, but I don’t find that particularly easy.  And it is definitely not easy for most of the people I work with after having years of not paying attention to food content in general, let alone carbohydrate content.

Speaking of people with Type 1 diabetes, especially those who are not trying to lose weight and are trying to gain muscle mass, they will usually need to make sure they get a minimum amount of carbohydrate every day.  This is often difficult to understand in a world where most people with diabetes have Type 2 and are told to "avoid" carbohydrates (although, as stated above, it's not a matter of avoiding, it is a matter of counting).  If a person with Type 1 diabetes does not get a minimum amount of carbohydrate daily they can start breaking down fat for energy and then the body produces ketones.  If there are too many ketones in the blood stream, combined with less that optimal amounts of insulin (and higher than should-be blood glucose) this can cause a dangerous condition called ketoacidosis. If this condition is left untreated it can lead to severe dehydration and death.
We’ll talk more tomorrow about how much carbohydrate is recommended, but for now if you want to keep reading click on the link below: