Diabetes: Maintaining Control with Nutritional Therapy

WebMD Live Events Transcript

Nutritional therapy is a major key to controlling your diabetes. But playing such a big part in your own disease management can be a daunting task! We talked about it with Karmeen Kulkarni, MS, RD, CDE, co-author of The ADA Complete Guide to Carb Counting, on Oct. 7, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Support for this University course was provided by Medical Mutual.

MEMBER QUESTION:
I'm on insulin, 50 units at night, 50 units in the a.m., plus about 20 units of R as needed to help with sugar. No matter what I eat or how strict I am I continue to gain weight (130 pounds in one year) and my sugar levels are never level. I can eat a salad no dressing and within an hour my sugar is over 250. My doctor says to starve myself; that doesn't seem appropriate to me. Help!

KULKARNI:
I agree with you, you shouldn't starve to lose weight. I would recommend several things:

  • See a registered dietician who is also a certified diabetes educator at a diabetes center, and have your food intake evaluated.
  • Make that trip more meaningful by keeping one week's worth of very detailed food records. Include in the records:
    1. The food eaten, the amount of food eaten, and the timing
    2. The insulin dose and when you're taking the insulin
    3. The type -- and timing -- of your physical activity

This data should assist a skilled diabetes educator in finding out what is going on and provide some realistic recommendations.

MODERATOR:
What's the best way for someone to find in their area a dietitian who is also a CDE?

KULKARNI:
They can call, toll free, the American Dietetic Association, 1-800-877-1600, or call the American Association of Diabetes Educators toll free, at 1-800-338-3633.

MEMBER QUESTION:
Is there any herbal medicine good for lowering sugar levels?

KULKARNI:
There are a lot of herbs and herbal supplements that I use for diabetes management. Most of them have not been researched and don't require FDA approval, so it would not be safe for me to make a blanket statement on which or what would help blood glucoses.

"An average rule of thumb is about three to four carb servings for women and four to five carb servings for men at each meal."

MEMBER QUESTION:
Is there a minimum number of carbohydrates a type 2 diabetic has to have during the day to maintain blood sugar levels?

KULKARNI:
This is very individualized, because everyone's height and weight and medication regimen is different. It is very helpful to have a target carbohydrate intake for each meal and a snack or snacks.

Try and stay within those targets. An average rule of thumb is about three to four carb servings for women and four to five carb servings for men at each meal. Again, the emphasis is on the individualization, because of so many differences.

MEMBER QUESTION:
Is milk better to use than orange juice for low blood sugar?

KULKARNI:
Again, this depends on the individual. A rule of thumb would be a 15-gram carbohydrate serving, which translates into either 8 ounces of skim milk or 4 ounces of orange juice. Either would work.

MEMBER QUESTION:
The food labeled with "carb control" -- is it a better option then whole-wheat bread or low-fat yogurt?

KULKARNI:
There currently is no FDA definition of carb control, so food manufacturers use it however and whenever they like. Your best bet is to read the Nutrition Facts panel. Look at the serving size, the calories, total grams of carb. Whole-wheat bread and low-fat yogurt are great healthy choices.

MEMBER QUESTION:
What do you think of using a diet plan such as South Beach, Atkins, or even Weight Watchers?

KULKARNI:
Nutrition goes through fashions. The Atkins diet is not a new concept; it was first made available in the late 1970s, and has come back in style.

When a research group looked at all of the popular diets, be it Atkins, South Beach, Weight Watchers, or traditional calorie-counting programs, they looked at it for a year. They found that the first six months on high protein, low carb (the Atkins-type of diet), people lost weight faster, but after six months all the different programs were about the same in terms of weight loss and keeping it off.

The message there was: Calories matter, regardless of whether they come from protein, carbohydrates, or fat, and physical activity matters for weight loss and keeping it off.

MEMBER QUESTION:
What do you think of the diet drinks made for diabetics such as Glucerna?

KULKARNI:
Glucerna, made by Ross Labs and Choice DM, made by Meade Johnson, are not diet drinks. They are meal replacements or meal supplements to be used instead of a meal or if a person needs to gain weight and must have a supplement.

MEMBER QUESTION:
Are the sugar supplements healthy for diabetics, and is Splenda the best one?

KULKARNI:
There is really no best sweetener; it depends on personal preference and taste. The American Dietetic Association and the American Diabetes Association have position statements on sweeteners. Sweeteners like Splenda and Equal are considered safe.

MEMBER QUESTION:
Have the ADA and AHA worked together to form a heart and diabetic healthy plan and if so how can I get this information?

KULKARNI:
The American Heart Association, the American Cancer Society and the American Diabetes Society, have a three-way partnership for a public health message that includes:

  • Healthy food
  • Low fat
  • High fiber
  • Maintaining body weight

This is a general message that is very, very important. To get a personalized meal plan I encourage you to contact a registered dietician.

MEMBER QUESTION:
How can I find a true list of glycemic values for the foods I eat, like my bad bagel?

KULKARNI:
There is a term: glycemic index of foods, and this categorizes foods that have a low, medium, or high glycemic index. However, this index does not take into account portion sizes and grams of carbs eaten, so it has limitations.

Your bagel is not the villain that shoots up your blood sugar; it is the size of the bagel. A 2-ounce bagel will cause a lower blood glucose rise as compared with an 8-ounce bagel.

MEMBER QUESTION:
Can you recommend a book that simplifies diabetic diets and carb counting?

KULKARNI:
I recently revised The Complete Guide to Carb Counting for people with diabetes published by the American Diabetes Association. It is a how-to guide, and I hope you find it useful.

"Your bagel is not the villain that shoots up your blood sugar; it is the size of the bagel."

MEMBER QUESTION:
My AC1 is 7.4. I have cut down my carbohydrates and increased my exercise to three times weekly. Is there anything else I can do to lower the amount insulin I use daily?

KULKARNI:
I don't know what your weight is, but if there's room for weight management you might want to look at portion sizes and calories. However, insulin does help in management of diabetes and the goal overall should not be just lowering your total daily dose.

MEMBER QUESTION:
I find that I crave sweets terribly and I'm wondering what can help me with these cravings.

KULKARNI:
That is definitely a challenge if you have cravings. There are foods with sweeteners and reduced amounts of sugar. That may help with substitutions. Also cookbooks from the American Diabetes Association, with recipes which could be worked into your daily meal plan, would help.

MEMBER COMMENT:
I find fresh fruit helps me with sweet cravings.

KULKARNI:
That's a great idea. Fruit is healthy, provides fiber, minerals, and definitely would be my first choice.

MEMBER QUESTION:
My type 2 long-term control is good (A1C of 6.7) but I get most of my "control" from exercise and I "cheat" occasionally with high-sugar desserts (eating more than I know I should). How much damage to my body am I doing by "cheating?"

KULKARNI:
First, congratulations on the exercise. I would never use the word cheating. If you did want a high-calorie dessert, I would substitute it for another carbohydrate in your meal and possibly step up the exercise. So basically you've worked it in and you haven't cheated.

MEMBER QUESTION:
What are good foods to take with me for a quick breakfast or lunch on the run?

KULKARNI:
There are many options:

  • Yogurt (gives you a balance of protein, carb, and low fat)
  • String cheese (also gives you a balance of protein, carb, and low fat)
  • For lunches, take a pre-made sandwich, piece of fruit, baby carrots, cherry tomatoes

For more options go through the list of ADA cookbooks.

MEMBER QUESTION:
I am a 56, type 2, going through menopause. When I was diagnosed a year ago I was put on oral medication. At that same time my ob-gyn put me on Premphase. I lost 24 pounds. After a year I went off Premphase and now I'm gaining weight. I walk 6 miles a day, eat healthy, and keep track of calories and carbs. Why is this happening?

KULKARNI:
I think it's probably a metabolic shift and something to do with the menopause and hormones. I'm not an expert in that area, so I would encourage you to go back to your ob-gyn and discuss this in more detail.

MEMBER QUESTION:
Which fruits should we avoid because of their high glycemic index?

KULKARNI:
There are no fruits that I would encourage you to avoid. It's the size of the fruit. Rather than buying the largest fruit in the store, buy the smallest, and plan for one fruit at each meal.

MEMBER QUESTION:
I was told only to eat fruit with meals, not as a snack, is that correct?

KULKARNI:
You could have it as a snack. It depends on your blood glucose control and how much you're planning to eat.

"There are no fruits that I would encourage you to avoid."

MEMBER QUESTION:
I am taking Starlix before each meal and Glucophage XR at dinner. I sometimes forget the before meal pill and take it after. Is this a real bad thing?

KULKARNI:
It's not a question of a bad thing, but the reason the Starlix is meant to be taken before the meal is because after you eat, the blood glucose goes up and the Starlix is in your system to help bring it down.

When you take it after the meal, it's basically after the fact. It's not going to work effectively. It's sort of a waste of the pill. So try and come up with a system to help you remember. Maybe try putting stickies on your refrigerator.

MEMBER QUESTION:
I've lowered my blood sugar from 140 in the morning to the mid-120s. To do this I usually need some type of snack at bedtime. Popcorn seems to work the best. Are there better options?

KULKARNI:
Congratulations on reducing your blood glucose so effectively. If the popcorn is working, I'd stay with it, or you can try other high-fiber carbohydrate foods like whole-grain breads and cereals.

MEMBER QUESTION:
Do soy products, like soy milk, cheese, and tofu help to control blood sugar?

KULKARNI:
It depends on the person, and how much you eat or drink. The best way to check is to do a pre-soy blood glucose and a two-hour, post-soy blood glucose.

MEMBER QUESTION:
I noticed that my numbers are lower when I combine carbohydrates with protein. How much protein can we eat daily?

KULKARNI:
That depends on your health profile. If your kidneys are healthy and you're not spilling any protein in your urine, it's about 0.8 grams of protein per kilogram body weight (a kilogram is 2.2 pounds). So if you weigh 150 pounds, divide that by 2.2 and your body weight would be 68 kilograms.

Then multiply that 68 kilograms by 0.8. The answer is 54 grams of protein for the day, which I divide by 4 calories, which is about 13 ounces per day. That would be on the high end.

MEMBER QUESTION:
With type 2, can I have one glass of red wine a night to reduce the risk of high blood pressure?

KULKARNI:
Well, the jury changes their verdict on alcohol and eggs every year. One year they're healthy and the next year they're not. So it really is not necessary, unless you really want it.

MEMBER QUESTION:
What about an apple for snack at bedtime? Helps to lower cholesterol too, right?

KULKARNI:
There's not one particular food that helps lower cholesterol. If you want an apple as a bedtime snack, a small one should be fine.

MEMBER QUESTION:
What is best to eat first thing in the morning when you have type 2 diabetes?

KULKARNI:
There's no best thing to eat. Again, it depends on:

  • Your weight
  • Your medication (whether you're on insulin or oral medication)
  • Your fasting blood glucose

All of that needs to be taken into consideration.

MEMBER QUESTION:
My husband has type 2 and I was wondering what bearing pepperoni would have on his sugar level. I made whole-wheat pizza with low-fat cheese and I put pepperoni on it. The next morning his sugar was above 200.

KULKARNI:
I don't think we can blame the pepperoni. It depends on how many slices he ate. You can try the same pizza and have him eat less and then check the blood glucose.

"I would encourage vegetables at lunch and dinner, particularly from the non starchy group."

MEMBER QUESTION:
Which vegetables should be avoided or eaten in moderation for type 2 diabetics?

KULKARNI:
I would encourage vegetables at lunch and dinner, particularly from the non starchy group, which is a long list. Let me share the short list of starchy vegetables:

  • Peas
  • Potato
  • Corn
  • Winter squash
  • Lima bean
  • Sweet potato
  • Yams

Those also can be eaten but trade them for your starch or carb choices.

MEMBER QUESTION:
Is there a big problem eating lots of frozen dinners such as Smart Ones and Healthy Choice?

KULKARNI:
Those are fine as choices. I would also encourage you to check Month of Meals, a series of cookbooks with quick, easy prep recipes, published by the American Diabetes Association.

MEMBER QUESTION:
How do walnuts and sunflower seeds affect blood sugar levels?

KULKARNI:
Nuts and seeds are high in the good kind of fat -- monounsaturated fat.
They probably will not elevate the blood glucose level very high. However, since there's no free lunch, they are high in calories and if weight management is an issue, you need to pay attention to the amount you eat.

MEMBER QUESTION:
Can I safely use sugar-free Metamucil to add a large percentage of fiber to my diet?

KULKARNI:
Check the label on Metamucil as to the number of grams of carbohydrates, if any, then you can work it in. Otherwise, it's a source of fiber for you.

MEMBER QUESTION:
What five actions will most help me to optimize my health as a type 2 diabetic?

KULKARNI:
Five actions that I would recommend:

  • Healthy food choices
  • Daily physical activity
  • Select low-fat foods
  • Be conscious of portion sizes
  • Do blood glucose checks every day

I hope that helps.

MODERATOR:
Thanks to Karmeen Kulkarni, MS, RD, CDE for sharing her expertise with us today. For more information, please read her book The ADA Complete Guide to Carb Counting.



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