Expert Q&A: A Healthy Diet for Type 2 Diabetes

Expert Q&A: A Healthy Diet for Type 2 Diabetes
An interview with Hope Warshaw, MMSc, RD.
By R. Morgan Griffin

FeatureReviewed by Louise Chang, MDHere's some good news: Healthy eating can have a dramatic impact on the symptoms and progression of type 2 diabetes and its frequent precursor, prediabetes. But the problem is that there's a lot of conflicting information out there. Just what does healthy eating with type 2 diabetes really mean? No sweets? Scheduled snacks? Low-fat, low-carb -- or neither?

To help guide you, Let's turned to Hope Warshaw, MMSc, RD, CDE. She's been a dietitian and diabetes educator for almost 30 years, and is the author of numerous books on the subject, including Diabetes Meal Planning Made Easy, published by the American Diabetes Association.

How does a healthy eating plan for someone with type 2 diabetes differ from what everyone else should be eating?
It doesn't. The nutrition recommendations from the American Diabetes Association echo the healthy eating guidelines for the general public. Everyone should be eating more whole grains, fruits, and vegetables and less saturated and trans fat. Remember that the type of fat matters to your heart and blood vessels. We've moved away from recommending a strict low-fat diet and shifted toward an eating plan that allows for a moderate amount of fat, provided you choose healthier fats, like monounsaturated and polyunsaturated fats.

If you have diabetes and are trying to lose weight, don't take the drastic diet approach, like a low-carb diet. It might help you lose weight in the short-term, but there's not good evidence that it will help you keep it off. Here's my point: You're going to have diabetes for the rest of your life. You need to be thinking about minor doable changes in your eating habits that you can really maintain. Even small steps towards healthier eating result in big rewards, like lower blood glucose and improved blood pressure and lipids.

You also don't need a special diet to tell you how to eat healthy. Most people -- especially people reading WebMD -- already know. The big challenge is actually doing it day after day, year after year.

What is the connection between diabetes and heart and blood vessel diseases?
The connection is huge. It is said that diabetes is a cardiovascular disease. But lots of people haven't realized it yet. They worry more about diabetes affecting their eyesight and kidneys. Yes, that can happen. But the fact is that people with diabetes suffer and die much more from heart and blood vessel disease. That's the real issue.

This is the key reason there's been a big change in the focus of diabetes management. It's no longer just about glucose control. It's at least -- if not more -- important for people to focus on controlling blood pressure and blood lipids, particularly LDL cholesterol. By the time someone gets diagnosed with diabetes, he or she may have already been living with serious risk factors for heart and blood vessel disease for years.
What is prediabetes and what should people do if they're diagnosed with it?
Prediabetes is an in-between stage -- blood glucose is higher than normal but not high enough to fit the diagnosis of diabetes. The diagnosis of prediabetes should be a clear message that you're currently on the road to type 2 diabetes. If you don't take action now, you have a greater than 70% chance of developing type 2.

But this doesn't need to happen. Results from several studies, including the Diabetes Prevention Program, suggest that a small amount of weight loss -- 5% to 7% of your body weight combined with 150 minutes a week of physical activity -- can help slow down the progression. If you catch it early and do something, you can really have an impact on either preventing or delaying the onset of type 2.

What is the relationship between being overweight and type 2 diabetes?
It's a pretty direct relationship. About 80% of people with type 2 diabetes are overweight. Excess weight leads to insulin resistance, and insulin resistance leads to elevated blood pressure, abnormal blood lipids and diabetes.

Do people with type 2 diabetes need to eat snacks throughout the day to control their glucose?
No, but there's a lot of confusion about this. Experts used to tell people to eat snacks because the only medications we had to treat high blood glucose levels could cause the side effect of hypoglycemia, or low blood glucose. Regular meals and scheduled snacks were a way of limiting the problem. But now there are several newer medicines that lower blood glucose without that side effect. Plus, people have blood glucose meters and can check their glucose at any time.

If snacking is your natural way of eating, there's nothing wrong with one or two snacks a day. For instance, if a healthy snack in the afternoon -- like an apple and some reduced-fat cheese -- prevents you from being so famished at dinner that you gorge yourself, go ahead.

But people with diabetes should ditch the idea that they need to eat snacks. It can be counterproductive. Some people find all the snacks really inconvenient. Other people sit down for a snack and overeat, or they make unhealthy choices because they don't have anything better around.

Can people with type 2 diabetes eat sweets?
Yes, people with diabetes can enjoy sweets. There's an old idea that sweets are verboten for those with diabetes, but that's no longer correct.

It's true that the carbohydrates in sweets can raise your glucose levels, but an equal amount of starch would have similar effect. I don't think people with diabetes need to run around looking for sugar-free candies or insist that their families bake them sugar-free deserts.

However, you have to be smart about sugary foods and sweets. Sweets pack in a lot of calories and they tend to be high in fat, particularly in unhealthy saturated fat. So anyone with diabetes needs to be careful about how many they eat.
Can people with diabetes drink alcohol?
Yes. Generally, the recommendations for people with diabetes are the same as they are for everyone else. For women it's one drink a day, for men it's two. However, the amount of alcohol you drink -- and whether you drink alcohol at all -- should be affected by how you manage your condition, what medications you're on, and your overall health.

One precaution: some diabetes medications can increase the risk of hypoglycemia when you're drinking alcohol. So if you're at higher risk of hypoglycemia, practice caution.

What impact does physical activity have on type 2 and prediabetes? How much and what types of exercise are recommended?
Physical activity is crucial for people with type 2 diabetes and prediabetes. It helps lower blood pressure and boost levels of good HDL cholesterol, which reduce your risk of heart and blood vessel disease. It lowers blood glucose and decreases insulin resistance. Studies show that while exercise doesn't help much with weight loss, it's critically important for maintaining weight loss.

As for what and how much, start with small steps -- literally! Walking is easy. Find time to walk a few times a week for 20 minutes. Work your way up to 30 minutes five times a week. You need to find physical activities that you enjoy, since you need to incorporate them into your life permanently. Using weights and resistance training can be a good idea too. The higher the percentage of muscle and the lower the percentage of fat in your body, the better your insulin sensitivity.

Do you have any other tips on successful weight loss and control for people with prediabetes and type 2 diabetes?
If you're thinking about losing weight, the first thing you need to do is assess whether you're really ready to make some big, permanent changes. If you are, start by looking at what you're doing now. What are you eating and how much physical activity do you get? Do some self-monitoring. Then once you have a sense, target specific things you want to change. Don't try to fix your whole life at once. You've got to focus on small changes to what you're doing now.

You also need some support. As a dietitian (and person who works hard to manage my weight) I know how hard it is to follow a healthy eating plan and be physically active day after day. So, it's my belief that if people are going to be successful in maintaining weight loss, they need to be connected and supported. For people who are comfortable online, I think the most cost-effective and efficient approach is joining an online program that fits your needs. Today there are a variety of them, from Weight Watchers to Vtrim to the Cardiometabolic Support Network.

In today's environment, I think we all can find it challenging to live a healthy lifestyle. How do you do it?
I'm 4-foot-10 inches and not getting any younger, but I really do put the healthy eating guidelines into practice. Portion control is my 'numero uno' strategy. In fact, my nickname at home with my food-loving husband and daughter is the Portion Control Queen. I enjoy sweets a couple of times a week, but it's either eating a half cup of really good ice cream or splitting a superb dessert from a restaurant or bakery. I don't have the calories to spare on mediocre. When it comes to burning calories, I'm out to exercise nearly every morning Monday through Friday, either for a 2-mile walk or a longer stint at the gym. What really motivates me is both feeling good today and my desire for a healthy future

SOURCE:

Hope Warshaw, MMSc, RD, CDE, dietitian; diabetes educator; author, Diabetes Meal Planning Made Easy, 3rd ed., published by the American Diabetes Association.

Top 10 Everyday Super Foods that Fight Disease

10 Everyday Super Foods

These easy-to-eat foods are packed with multiple nutrients to help you stay healthy.
By Kathleen M. Zelman, MPH

If only there were some kind of potion or pill that had everything you needed for weight loss and good health. Unfortunately, no such pill exists, but there is a solution -- something that not only promotes wellness and weight control but tastes good, too. These multitasking "super foods" provide multiple disease-fighting nutrients, fill you up so you can enjoy plenty of food without excess calories, and are easy to include in everyday meals. After all, what good is a super food that is hard to find, difficult to prepare, and the kids won't eat?

Eaten regularly, these foods will help you satisfy the recommendations of the U.S. government's 2005 Dietary Guideline, giving you nutrients that are typically missing from American diets. According to the Guidelines, Americans need to eat more fruits, vegetables, whole grains, and low-fat dairy products.

Of course, experts are quick to point out, this list of top 10 super foods by no means includes all the nutritious foods that should be part of a healthy diet.

"What is ultimately the most important to good health is a dietary pattern that includes all these foods, along with a wide variety of other nutritious foods and regular physical activity," says Tufts University researcher Alice Lichtenstein, DSc.

And don't forget that portion size matters, even when it comes to healthy foods. You can take more liberties when eating simply prepared vegetables, but you should take care to eat other super foods in sensible portions.

"Foods like nuts are nutrient rich, but if you overeat them you can pack on the pounds, and that defeats the purpose," says Elisa Zied, MS, RD, author of Feed Your Family Right!

Top 10 Multitasking Super Foods

Low fat or fat-free plain yogurt is higher in calcium than some other dairy products and contains a great package of other nutrients, including protein and potassium. It can also be enhanced with other good-for-you substances. "Yogurt is a vehicle food that can be enriched with probiotics for a healthy balance of bacteria in your gut, and beneficial, heart-healthy plant stanols," says Zied. "And lactose sensitive people may tolerate yogurt better than milk." Look for plain yogurt fortified with vitamin D, and add your own fruit to control sweetness and calories. Versatile yogurt can also be used in entree and bakery recipes, in dips for veggies, etc. Don't like yogurt? Skim milk is another super dairy food that has only 83 calories per cup and is easy to slip into coffee to help you get one of the recommended three servings of dairy each day. "Dairy foods contain practically every nutrient you need for total nutrition -- and in just the right balance," says bone health expert, Robert Heaney, MD. "No other food group in the diet is as complete or as economical."

Eggs make the list because they are nutritious, versatile, economical, and a great way to fill up on quality protein. "Studies show if you eat eggs at breakfast, you may eat fewer calories during the day and lose weight without significantly affecting cholesterol levels," says Elizabeth Ward, MS, RD, author of The Pocket Idiot's Guide to the New Food Pyramids. Eggs also contain 12 vitamins and minerals, including choline, which is good for brain development and memory. Enjoy them at any meal or hard-cooked as a portable snack.

Nuts have gotten a bad rap because of their high fat content. But their protein, heart-healthy fats, high fiber, and antioxidant content earn them a place on the top 10 list. The key to enjoying nuts, experts say, is portion control. "All nuts are healthful in small doses, and studies show they can help lower cholesterol levels and promote weight loss," says Today Show nutritionist Joy Bauer, MS, RD. "I like pistachio nuts because they also contain plant sterols and it takes longer to crack the shell and eat them, making it easier to control the portion. Whether you prefer pistachios, almonds, peanuts, walnuts, or pecans, an ounce a day of nuts help fill you up. Nuts add texture and flavor to salads, side dishes, baked goods, cereals, and entrees. They taste great alone, too. Zied recommends putting together your own "100-calorie packs" of nuts for easy and portable snacks.

Kiwis are among the most nutritionally dense fruits, full of antioxidants, says Ward. "One large kiwi supplies your daily requirement for vitamin C," says Ward. "It is also a good source of potassium, fiber, and a decent source of vitamin A and vitamin E, which is one of the missing nutrients, and kiwi is one of the only fruits that provides it." The sweet taste and colorful appearance of kiwis makes it easy to slice in half, scoop out with a spoon and enjoy alone, or slice it into desserts, salads, or side dishes. Kiwifruit can also have a mild laxative effect due to their high fiber content.

Quinoa is now readily available in many supermarkets and is one of the best whole grains you can eat, according to Zied. "It is an ancient grain, easy to make, interesting, high in protein (8 grams in 1 cup cooked), fiber (5 grams per cup) and a naturally good source of iron," she says. Quinoa (pronounced keen-wa) also has plenty of zinc, vitamin E, and selenium to help control your weight and lower your risk for heart disease and diabetes, she says. Quinoa is as easy to prepare as rice and can be eaten alone or mixed with vegetables, nuts, or lean protein for a whole-grain medley. Try to make at least half your daily grain servings whole grains. In addition to quinoa, try barley, oats, buckwheat, whole wheat, wild rice, and millet.

Beans, beans, good for your heart -- really! Beans are loaded with insoluble fiber, which helps lower cholesterol, as well as soluble fiber, which fills you up and helps rid your body of waste. They're also a good, low-fat source of protein, carbohydrates, magnesium, and potassium. Bauer favors edamame (whole soybeans) because they also contain heart-healthy omega-3 fatty acids. Beans can easily substitute for meat or poultry as the centerpiece of a meal, says Bauer, but they also work as a side dish, or tossed into soups, stews, or egg dishes. The U.S. Dietary Guidelines recommend 3 cups weekly.

Salmon is a super food because of its omega-3 fatty acid content. Studies show that omega-3 fatty acids help protect heart health. That's why the American Heart Association recommends eating fatty fish like salmon twice weekly. Salmon is low in calories (200 for 3 ounces) has lots of protein, is a good source of iron, and is very low in saturated fat. You can simply grill or bake it, top it with salsas or other low-fat sauces, or serve it on top of salad greens. If you don't like salmon, Lichtenstein recommends eating other kinds of fish, like canned tuna. And what about the mercury content? (Mercury is known to accumulate in fish.) "The benefits of eating salmon or other fatty fish twice weekly far outweigh any risks, but if you are concerned, check with your doctor," says Zied.

Broccoli is one of America's favorite vegetables because it tastes good and is available all year long. It's a rich source of vitamin A, vitamin C, and bone-building vitamin K, and has plenty of fiber to fill you up and help control your weight. "Some people think beta-carotene (vitamin A) is only found in orange and yellow vegetables, but broccoli is an excellent source," says Ward. You can eat broccoli raw, lightly steamed, stir-fried, roasted, or grilled. Eat it as a side dish, or toss into grains, egg dishes, soups, and salads.

Sweet potatoes are a delicious member of the dark orange vegetable family, which lead the pack in vitamin A content. Substitute a baked sweet potato (also loaded with vitamin C, calcium, and potassium) for a baked white potato. And before you add butter or sugar, taste the sweetness that develops when a sweet potato is cooked -- and think of all the calories you can save over that loaded baked potato. "If we eat more foods like sweet potatoes that are rich sources of potassium, and fewer high-sodium foods, we can blunt the effect of sodium on blood pressure and reduce bone loss," says Zied. Other dark orange vegetable standouts include pumpkin, carrots, butternut squash, and orange bell peppers.

Berries pack an incredible amount of nutritional goodness into a small package. They're loaded with antioxidants, phytonutrients, low in calories, and high in water and fiber to help control blood sugar and keep you full longer. And their flavors satisfy sweets cravings for a fraction of the calories in baked goods. Blueberries lead the pack because they are among the best source of antioxidants and are widely available. Cranberries are also widely available fresh, frozen, or dried. All can add flavor and nutrition to numerous dishes, from salads and cereals to baked goods and yogurt.

SOURCES: Robert P. Heaney, MD, John A. Creighton University Professor, Creighton University. Joy Bauer, MS, RD, author, Joy Bauer's Food Cures; nutritionist, the Today Show. Elizabeth Ward, MS, RD, author, The Pocket Idiot's Guide to the New Food Pyramid. Elisa Zied, MS, RD, spokeswoman, American Dietetic Association; author, Feed Your Family Right! U.S. Department of Agriculture's 2005 U.S. Dietary Guidelines. Alice Lichtenstein, DSc, Stanley N. Gershoff Professor of Nutrition Science and Policy, Friedman School of Nutrition Science, Tufts University. Asia Pacific Journal of Clinical Nutrition, June 2002; vol 11, issue 2: pp164-168.

Reviewed on December 04, 2008

Four Tricks to Cut the Salt

Low-Sodium Recipe and Cooking Tips

According to the U.S. government, Americans are supposed to eat no more than 2,300 milligrams -- about 1 teaspoon -- of salt a day. People with high blood pressure are told to limit salt even more, to just 1,500 milligrams. That's about a half teaspoon of salt daily.

Considering that salt is an ingredient in just about every type of processed food or restaurant meal, it's no wonder most Americans are getting double -- or triple -- the amount of sodium they need each day. Just 8 ounces of tomato soup can have 1,200 milligrams of sodium. Three ounces of ham can have more than 1,000 milligrams. And 1 ounce of pretzels or 2 tablespoons of salad dressing can pack upwards of 500 milligrams of sodium.

Salt may add flavor to your food, but getting too much of it can also cut years from your life. Studies have linked a high-salt diet to increased risk of high blood pressure, which increases the risk of stroke and heart disease. Research also has shown that reducing the salt in your diet may help lower those risks.

Low-Sodium Meals: How to Cut the Salt in Your Cooking
It is possible to limit the salt in your meals without sacrificing the flavor of your food. Here are three low-sodium cooking tips to help you make healthy, delicious meals that are good for your heart:

Keep it real. Processed foods are often loaded with extra salt. That's because salt acts as a preservative. Cooking your own meals from scratch is the best way to control how much sodium goes into your food. Cookbooks and the Internet are full of easy low-sodium recipes that take all of the guesswork out of cooking. Opt for fresh fruits or vegetables instead of canned. Choose fresh poultry, fish, and meat instead of processed or smoked varieties. For side dishes, make brown rice or whole baked potatoes instead of instant or flavored rice or mashed potatoes. If you have to use canned foods, such as tuna, rinse the contents beforehand to wash away some of the sodium.

Become a label reader. Scour every food label for sodium content. Look for products labeled "sodium-free" (less than 5 milligrams of sodium per serving), "very low sodium" (35 milligrams or less per serving), or "no salt added." Watch out for broths, dressings, soy sauce, bouillon cubes, meat tenderizers, seasoned salts, and condiments (mustard, ketchup, barbecue sauce), which are notoriously high in salt. Watch for additives such as monosodium glutamate (MSG), baking soda, baking powder, and sodium benzoate, which are all sodium compounds.
Don't follow directions. When a recipe calls for even a pinch of salt, replace it with another herb or spice. You can try rosemary, marjoram, thyme, tarragon, onion or garlic powder, curry powder, pepper, nutmeg, cumin, ginger, cilantro, bay leaf, oregano, dry mustard, or dill.

Spicing Up Your Low-Sodium Menu
Salt-free doesn't have to mean taste-free. You can substitute dozens of different seasonings and ingredients to spice up to your low-sodium meals. Here are just a few ideas:

Marinate chicken breasts or pork chops in lemon juice, orange juice, or red wine
Roll fish in sesame seeds before baking
Spice up beef with a mixture of onion, peppers, sage, and thyme
Toss in a few fruits and vegetables, such as dried apricots, raisins, red pepper, or yellow pepper for extra flavor
Simmer carrots in cinnamon and nutmeg
Sprinkle some dill and parsley onto potatoes before roasting
Add a dash of chili powder to corn
Toss your pasta with fresh chopped garlic
Replace salted butter with unsalted butter
When cooking with cheese, opt for fresh mozzarella or cheeses labeled "low-sodium"
Try a commercial salt-free seasoning blend (such as Mrs. Dash), or make your own mix with this recipe from the American Heart Association:
1/2 teaspoon cayenne pepper 1 teaspoon mace, ground

1 teaspoon basil, ground 1 teaspoon onion powder

1 tablespoon garlic powder 1 teaspoon black pepper, ground

1 teaspoon thyme, ground 1 teaspoon sage, ground

1 teaspoon parsley, dry flakes 1 teaspoon marjoram

1 teaspoon savory, ground

SOURCES:

USDA: "Dietary Guidelines for Americans -- 2005."

U.S. Department of Health and Human Services: "Your Guide to Lowering Your Blood Pressure with DASH."

Cook, N. BMJ, published online April 20, 2007.

Oklahoma Department of Human Services: "Tips for Managing Your Congestive Heart Failure."

National Heart, Lung, and Blood Institute: "Your Guide to Lowering High Blood Pressure."