New Dietary Guidelines for Diabetes Management

                            by Mimi Moore, MS, RD


    (This article appeared in the Voice of the Diabetic, Volume 11, No. 1,
Winter 1996, published by the Diabetics Division of the National
Federation of the Blind.)

    Ms. Moore, a Registered Dietitian, gave the following as a keynote
address at the 1995 annual conference of the Diabetics Division of the
National Federation of the Blind.  The conference took place on July 3,
1996 at the annual convention of the National Federation of the Blind in
Chicago. 

    Diet is very important in the maintenance of quality of life. 
Progression in science has guided us in making the very best food choices
in our daily menu planning.  As the saying goes, "you are what you eat." 
Life span increases as we learn to eat more nutritiously. 


What about diet and diabetes?

    Research results have provided us with some new recommendations for
diabetes care and management.  Many of you have heard of the Diabetes
Control and Complications Trial (DCCT).  This was a ten-year project that
involved 1441 participants.  Each volunteer was randomly assigned to one
of two groups, the conventional treatment group or the intensive treatment
group.  After nine years the study was halted and results given: 
Complications of diabetes can be prevented or delayed with intensive
management. 

    One year ago, revised nutrition recommendations for diabetes
management were issued and supported by the American Diabetes Association
(ADA).  The emphasis was placed on individualization of care.  There is
not just one standard plan of mangement for all persons with Type I and
Type II diabetes. 


What is meant by intensive therapy?

    Modified care and management has developed through use of the health
care team (nurse, dietitian, physician, pharmacist, counselor and exercise
physiologist may all be part of the team).  This was one of the main
factors in the success of the DCCT.  Intensive therapy is now advised for
optimal blood glucose control. 

    Intensifying management means improving control, by increased daily
blood glucose checks, multiple injection therapy, and making continuous
adjustments in the coordination of diet, exercise and insulin or
medication. 

    Nutrition therapy is a necessary component in the daily plan for
diabetes management. 

    Long-term dietary goals include:

	Maintenance of near normal blood glucose levels

	Achievement of optimal blood lipid levels

	Providing adequate calories for reasonable weight maintenance,
	normal growth and development, pregnancy and lactation

 	Prevention and treatment of acute and long-term nutrition related
	complications (hypoglycemia, short-term illness, renal disease,
	hypertension, cardiac disease)

 	Improvement of overall health, incorporating guidelines and nutrient
	recommendations for all healthy Americans. 

    These goals are not accomplished by one single method of meal
planning.  Traditionally, the meal plan has been conveyed via the Food
Exchange System, which provides a good basic foundation for understanding
the nutrition principles of diabetes management.  Variation in this method
occurs with food choices made within each Food Exchange Group. 
Individualization depends on the amount and type of food eaten.  In 1986
the ADA dietary guidelines recommended set nutrient proportions for
nutrient composition of the diet:  Up to 60% of daily total calories from
carbohydrate, 12-20% of daily total calories from protein and 30% or less
of daily total calories from fat.
	
    The new 1994 dietary guidelines recommend a shift in nutrient
proportions.  The distribution of carbohydrate and fat is based on the
individual's treatment plan with no mandatory percentages, and 10-20% of
daily total calories from protein.
	
    The American Diabetes Association's position statement (published in
Diabetes Care, May 1994) follows research regarding blood sugar response
to various sources and types of carbohydrate.  The recommendation now
states that the emphasis on carbohydrate intake should be on total amount
versus type of carbohydrate.  The two types of carbohydrate are simple
(sugars) and complex (starches and fiber).  In the past we had all been
advised to avoid foods containing sugar or simple carbohydrate.  Now, with
scientific evidence for support, we have learned that it is acceptable to
have sugar-containing foods, as long as they are worked into the daily
meal plan and not just added.  This liberalization of guidelines has
allowed for much greater flexibility in day to day meal planning. 


How do we carry out these recommendations and implement intensified therapy?


    The changes in carbohydrate and dietary guidelines coincide with
recommendations for intensive therapy.  Continual adjustment is the name
of the game--adjusting food to insulin and insulin to food based on blood
glucose levels.  Greater lifestyle flexibility is an outcome.  You are
able to eat a meal or exercise "off schedule."  Carbohydrate counting has
become a popular method in response to modified therapy. 


What is carbohydrate counting?

    The focus is on the nutrient carbohydrate because it has the greatest
impact on blood glucose levels.  The other two energy yielding nutrients,
protein and fat, do not affect blood glucose levels to the same extent. 
Therefore, attention is placed on the food groups that contain
carbohydrate.  All foods are made up of a combination of six nutrients;
carbohydrate, protein, fat, water, vitamins and minerals.  In turn, all
foods are categorized into one of six groups; starches, meats, vegetables,
fruit, milk and fat.  Because starch, milk, and fruit are the main
carbohydrate containing groups, they become the focus of meal planning. 
One Food Exchange portion from each of these food groups equals one
carbohydrate serving (15 grams carbohydrate = one carbohydrate serving). 
This is where knowledge of the Food Exchange System is helpful.  You can
use the Food Exchange portions for reference.
	
    A specific number of carbohydrate (CHO) servings are assigned to each
meal in creating the meal plan.  For instance, three CHO servings at
breakfast, four CHO servings at lunch and six CHO servings at dinner may
be one person's meal plan.  Individualization is key.  Every individual's
meal plan will be different depending on preferences.
	
    One person may eat two fruit and one starch portion for three CHO
servings.  Another person may eat two starch and one milk portion for
three CHO servings.  Suppose you wanted a slice of cake.  The food label
on your packaged cake says 45 grams carbohydrate per slice.  This would
equal three CHO servings.
	
    Since the focus is on carbohydrate-containing foods, meat and fat are
not counted for CHO servings.  But do not get carried away with portion
amounts on these foods!  Guidelines are given individually for these food
groups.
	
    No restrictions are placed on moderate consumption of vegetables.  If
large amounts of vegetables are eaten, they need to be counted.  Three
vegetable Food Exchange portions equal one CHO serving. 


How does all this fit into the total management routine?

    This is where the health care team is needed.  Insulin doses are set
for the usual carbohydrate serving meal plan.  If more carbohydrate than
the base plan is desired, more insulin is taken.  If less carbohydrate
than the base plan is desired, less insulin is taken.  Each person's
insulin adjustment dose is based on blood glucose values.  It takes weeks
of testing, record keeping and communication with the health care team to
establish the appropriate regimen.
	
    I have gone into detail about carbohydrate counting because it is the
method that now seems best matched to intensive insulin therapy.  The key
is to find a system or routine best suited to your lifestyle and
preferences, making it easy to maintain optimal blood glucose control. 

    As a philosopher once said, "Man should eat to live, not live to eat." 
It's good to know that those times when I want to live to eat, it is OK. 
It just takes a few minor adjustments in my routine. 


    The following were questions the audience asked Ms. Moore at the
completion of her presentation... 


    Q:  When you use the term "intensive insulin therapy," what does it 
mean?  Is there a minimum number of shots per day?

    A:  As per the DCCT, the term means three or more insulin injections
per day, to be counted as "multiple injection therapy".  "Intensifying
insulin therapy" could mean going to two shots per day if you currently
take only one--then you are "intensifying" it.  But when we use the term
"intensive insulin therapy." we are talking about pump therapy (where you
have continuous injection) or three or more shots per day and blood
glucose monitoring four or more times per day. 

                 
    Q:  What about a type II diabetic, on just oral medications?  What
does "intensive therapy" mean for me? 

    A:  As far as the recommendations, these were made for type I
diabetics...But we're assuming that they can also be carried over to type
IIs, because you still need to test frequently to know where your blood
sugars are.  That's important.  You can still adjust your carbohydrate
servings, so that's all a part of it.  As far as working with your
medication, that you need to do with your physician.  However, you can
still carry through many components of the intensive therapy.  It's just
that you don't have any insulin to adjust. 


    Q:  Does the ADA have a "Recommended Renal Diet" or is that something
to be developed individually between me and my doctor? 

    A:  That's a good question.  It's still individualized, but the
recommendation that protein be decreased is not as severe as it was in the
past.  Today we're saying, for a renal diet, the target should be about .8
gram of protein per kilogram of body weight, which is about the American
adult recommended amount. 


    Q:  In many situations, diabetics don't get the kind of dietary advice
they need, probably because they're on some sort of state Medicaid
program.  What do you recommend? 

    A:  As far as being able to obtain diet counseling with Medicaid, it
is difficult.  You could try contacting the ADA, as a start.  Find out
what programs are available in your area.  Which are hospital-based?  As
far as reimbursement issues, that changes constantly, and varies from
state to state as to item and amount reimbursed. 
     
    For the best results, we need a team approach.  We're seeing that
education does help curb costs in the long term.  If you're able to take
care of yourself, you're able to stay out of the hospital.  We need to
have more teams, to provide better health care.  The public health
department usually has access to at least one professional, perhaps a
nurse educator.  There should be a dietitian too.  Check with the public
health department in your city--that would be a good place to start. 


    Q:  If you check your blood sugar, and find that it's high, is there a
set formula for how much insulin physicians think you should take,
according to the amount your blood sugar is over? 

    A:  There is no standard formula, because it all depends on how you as
an individual respond.  You might come down a given percent per unit
injected, but someone else might need less or more.  It's very
individualized.  You would have to set up a program, establish some kind
of scale, in order to know how much insulin to take when your blood sugar
is past a certain level.  Everybody responds differently, and there is no
set answer.  And if you as an individual are elevated, perhaps 180, not
quite 200, what you may need is exercise or dietary adjustment, eating
less at mealtimes.  This holds true for special occasions, times you wish
to eat more, as well. 


    Q:  What are the "norms" for blood sugar levels?  What are the current
recommendations? 

    A:  For NON-diabetics, the acceptable range is 60 to 110 mg/Dl.  For a
diabetic, we recommend aiming for 70 to 120.  Of course the best range for
you depends on your condition.  You need to be careful of hypoglycemia,
especially if you have cardiac complications.  Depending on the individual
person, what complications they have, and how active they are, the optimum
range may change.  With children and infants it is very hard to detect
hypoglycemia, so the ranges may be a little higher.  Intensive insulin
therapy is not recommended for children with diabetes under under two
years of age. 


    Q:  We diabetics who are on dialysis face two contrary sets of dietary
requirements.  When one says "you can eat this," the other says "you
can't."  It is hard to establish an individualized diet plan.  Can you
explain? 

    A:  The diabetic on dialysis faces the most frustrating of diets,
because there are so many restrictions on it.  You can feel like there's
nothing you're allowed to eat.  There is controversy about what the
standards should be.  Should protein be kept low?  High? No animal
protein?  Plant only?  How many calories?  Until more is known about how
diet directly impacts renal disease, there will continue to be
controversy. 
     
    You look at the "macro nutrients;" carbohydrates, proteins, and fat,
but you're also looking at minerals too.  You've got to go deep into it
and pay close attention to your food types and amounts. 
     
    A higher incidence of hypoglycemia is associated with renal disease,
and you have to figure that into the diet too.  Traditionally, health
professionals have said "treat hypoglycemia with orange juice", but then
somebody comes along and says "no more!" and you have to find something
new.  That's where it helps to work with the same dietitian, who knows you
as an individual, long term.  But do recognize that as renal disease
progresses, you will have to make changes in your diet. 

	
    Q: You've talked about minerals.  Why do food labels never mention
potassium or phosphorous content?  Where can I get that information? 

    A: There is a book you can buy, titled Food Values of Portions
Commonly Used, 16th ed., 1994, by Bowes and Church.  This guide lists all
food products, with their analysis.  If you're on dialysis, you need your
own copy.  But the food labels don't have that information because the
average American doesn't need it. 
     
    Another source for the detailed materials you need is available from
most dietitians working with renal issues.  This is the information
commonly called a "renal packet."  It is a very difficult diet to follow,
because there are so many factors you need to coordinate.  You may feel
like you have to follow it exactly, but really you don't.  Just work
toward some sort of balance each day.  (Editor's Note:  The NFB Materials
Center in Baltimore has the ADA Food Exchange Lists in Braille or
cassette.)

     
    Q:  Can anybody use an insulin pump?  What are its advantages and
disadvantages?  How does one deal with the risk of infection at the
injection site?  For diabetics with cardiovascular problems, is an insulin
pump a possibility? 

    A:  It should be an option, but needs to be evaluated individually. 
In some cases, like pregnancy, the insulin pump is recommended, because it
does a better job of coping with the ups and downs, and will provide
tighter control.  As far as the risk of infection at the pump site, you
minimize that by frequent changing of your tubing, your catheter, perhaps
more often than the recommended time.  Some people are allergic to the
adhesive tape used to attach the tubing, but that's another problem. 
     
    If you are using the pump, you will need to test your blood sugars
four to six times per day minimum.  This is important.  If you want the
pump, you need to commit long term to the testing.  Some people don't like
the feel of the pump at night.  The insulin pump may not be for everybody. 
It is individually evaluated.  It is one of the recommended ways to
institute intensive insulin therapy. 


    Q:  If you are overweight, is there a safe way to lose weight while
controlling both diet and insulin?  Should I just go to my dietitian for
that?  Are there other resources? 

    A:  Start with your dietitian.  The dietitian may connect you with a
counselor who'll help you work on behavior changes, not just food changes. 
Any changes of this type, you'll want to be long term. 

    Plan on going "multistep;" one step at a time. set small goals.  Lose
four or five pounds at a time--this amount is advantageous! 

	
    Q:  What if I want some ice cream?  How would I "count" it as a
carbohydrate? 

    A:  Are you talking about regular or "lite" ice cream?  We no longer
have just the conventional, high-fat type out there.  Today there are also
ice milks, frozen yogurts, sorbets, and sherbet.  All have varying degrees
of fat. 
     
    If you really want that premium ice cream, what will you leave out of
your diet to balance all that fat?  You have to exchange!  For one
half-cup you have to exchange one bread but also two or three fat
servings.  Somewhere in your meal plan you can eat less meat, so as to
leave out some of that fat.  If you want more for your dollar, have the
sorbet instead, and leave off just a few pieces of bread.  Sorbet is
nonfat.  And remember:  Just because something is "fat-free" doesn't mean
it is calorie-free, or sugar-free!  Even ice cream made with NutraSweet or
sorbitol can be high in carbohydrates, especially if it has a milk base. 
     
    Still another trap is "no sugar added", or "sugar-free". They contain
carbohydrates, because fruit has been added for sweetening.  Sometimes the
fruit-sweetened product contains more carbohydrate than does the
sugar-sweetened one.  Look at the total carbohydrate content on the label. 


    Q:  When I look at a box of cereal, I see listed:  "Total
carbohydrates, complex sugars, dietary fiber, and other carbohydrates." 
With the new guidelines, what should I be looking at? 

    A:  Cereal is a hard product to work with.  There is so much
variability, and the different cereals have different serving sizes. 
One-half cup of one may contain the same amount of carbohydrate as one
third cup of another.  I would start by looking at the serving size.  If I
want to eat a big bowlful, I'll look for a flake cereal.  Next, I would
look at fiber content.  If I want high fiber, I will choose bran, wheat,
or oats, as the corn flakes or rice krispies don't have a high fiber
content. 
	
    As far as the new recommendations, what we're saying is that the total
amount of carbohydrate is what matters, more than what kind.  If you want
frosted sugar flakes, go have it, but then look at what your total
carbohydrate serving is.  That is more important to focus on than the
sugar.  If there are 36 grams of carbohydrate in a half-cup portion,
that's going to count for two servings of carbohydrate.  Look at the total
amount of carbohydrate per serving.  I would also look at fiber content
and serving size. 


    Q:  How do I know if there's sugar in my food? 

    A:  Dextrose, fructose, lactose, corn syrup, honey...those all are
sugars. If it ends in "---ose," it's a sugar.  All simple sugars have the
same calorie content per gram.  With the old recommendations, when we used
to watch out for different types of sugars, we had so much more to sift
through.  Was it corn syrup or was it fructose?
	
    Now, with the new recommendations, we are saying the type of sugar
doesn't matter--you need to look at the total amount.  There may be corn
syrup in one product, fructose in another, but 15 grams of carbohydrate
will react the same, no matter what form it takes. 


    Q:  How much carbohydrate per day should a person have?  And what
kind?  If too much of the total comes from sugar, won't that burn off
quickly and cause reactions? 

    A:  We used to say that up to 60% of a person's total caloric intake
should come from carbohydrate.  Now, we look at the individual. There are
a lot of "ifs" about total amount. 
     
    When you're looking at carbohydrate intake, it doesn't matter the
source.  If you have 30 grams, as far as its impact on your blood sugar,
it doesn't matter whether it comes from sugar or starch.  If you eat a
mixed, balanced meal, and stay on your program, you are at no greater risk
for reactions than before.  In fact, compared to fats and proteins,
carbohydrates are the fastest to be metabolized. 


    Q:  Can you talk about sodium?  How much should we have per day? 

    A:  As you eat more salt, you crave more salt.  The average American
probably consumes 6000 milligrams per day.  We recommend that a healthy
American consume 2400 to 3000 mg of sodium per day, and 2400 mg, a "low
sodium diet," is what people with diabetes should aim for. 
     
    The more processed foods you eat, the more salt you are consuming. 
Convenience foods, fast foods, anything processed usually has salt or
sugar added.  These alone can probably take you to the 6000-mg mark. 


    Q:  I've been told intensive insulin therapy won't work for me,
because I have "hypoglycemia unawareness."  It that right? 

    A:  You have to do what is appropriate and safe for you.  What we call
"full-blown intensive therapy,"  with its increased risk of hypoglycemic
episodes, may not be appropriate in your case.  Perhaps you can intensify,
improve your control, without going as far.  Keep those blood sugars under
the best possible control.