Mini book on Diabetes and nutrition management

Diabetes mellitus is the name for a group of serious and chronic (longstanding) disorders affecting the metabolism of carbohydrates. These disorders are characterized by hyperglycemia (abnormally large amounts of glucose in the blood). According to the American Diabetes Association, 23.6 million people in the United States have diabetes. An estimated 17.9 million people have been diagnosed with the disease with 5.7 million going undiagnosed. There are approximately 57 million people with pre-diabetes. There were 1.6 million new cases of diabetes in people 20 years old and older diagnosed in 2007 (American Diabetes Association [ADA]). It is a major cause of death; blindness; heart and kidney disease; amputations of toes, feet, and legs; and infections. Hundreds of years ago, a Greek physician named it diabetes, which means “to flow through,” because of the large amounts of urine generated by victims. Later, the Latin word mellitus, which means “honeyed,” was added because of the amount of glucose in the urine.
Diabetes insipidus is a different disorder. It also generates large amounts of urine, but it is “insipid,” not sweet. This is a rare condition, caused by a damaged pituitary gland. It is not discussed in this chapter. The body needs a constant supply of energy, and glucose is its primary source. Carbohydrates provide most of the glucose, but about 10% of fats and up to nearly 60% of proteins can be converted to glucose if necessary. The distribution of glucose must be carefully managed for the maintenance of good health. Glucose is transported by the blood, and its entry into the cells is controlled by hormones. The primary hormone is insulin. Insulin is secreted by the beta cells of the islets of Langerhans in the pancreas. When there is an inadequate production of insulin or the body is unable to use the insulin it produces, glucose cannot enter the cells and it accumulates in the blood, creating hyperglycemia. This condition can cause serious complications. Another hormone, glucagon, which is secreted by the alpha cells of the islets of Langerhans, helps release energy when needed by converting glycogen to glucose. Somatostatin is a hormone produced by the delta cells of the islets of Langerhans and the hypothalamus. All actions of this hormone are inhibitory. It inhibits the release of insulin and glucagons. The amount of glucose in the blood normally rises after a meal. The pancreas reacts by providing insulin. As the insulin circulates in the blood, it binds to special insulin receptors on cell surfaces. This binding causes the cells to accept the glucose. The resulting reduced amount of glucose in the blood, in turn, signals the pancreas to stop sending insulin.

 ETIOLOGY The etiology (cause) of diabetes is not confirmed. Although it appears that diabetes may be genetic, environmental factors also may contribute to its occurrence. For example, viruses or obesity may precipitate the disease in people who have a genetic predisposition. The World Health Organization indicates that the prevalence of the disease is increasing worldwide, especially in areas showing improvement in living standards.

SYMPTOMS The abnormal concentration of glucose in the blood of diabetic clients draws water from the cells to the blood. When hyperglycemia exceeds the renal threshold, the glucose is excreted in the urine (glycosuria). With the loss of the cellular fluid, the client experiences polyuria (excessive urination), and polydipsia (excessive thirst) typically results. The inability to metabolize glucose causes the body to break down its own tissue for protein and fat. This response causes polyphagia (excessive appetite), but at the same time, a loss of weight, weakness, and fatigue occur. The body’s use of protein from its own tissue causes it to excrete nitrogen. Because the untreated diabetic client cannot use carbohydrates for energy, excessive amounts of fats are broken down, and consequently, the liver produces ketones from the fatty acids. In healthy people, ketones are
subsequently broken down to carbon dioxide and water, yielding energy. In diabetic clients, fats break down faster than the body can handle them. Ketones collect in the blood (ketonemia) and must be excreted in the urine (ketonuria). Ketones are acids that lower blood pH, causing acidosis. Acidosis can lead to diabetic coma, which can result in death if the client is not treated quickly with fluids and insulin. In addition to the symptoms previously mentioned, diabetic clients suffer from diseases of the vascular system. Atherosclerosis (a condition in which there is a heavy buildup of fatty substances inside artery walls, reducing blood flow) is a major cause of death among diabetic clients. Damage to the small blood vessels can cause retinal degeneration. Retinopathy is the leading cause of blindness in the United States. Nerve damage (neuropathy) is not uncommon, and infections, particularly of the urinary tract, are frequent problems.

CLASSIFICATION The types of diabetes are prediabetes, type 1, type 2, and gestational. Prediabetes means that the cells in the body are not using insulin properly. The diagnosis is made by a fasting blood glucose, which is more than 110 but less than 126 mg/dl. One’s lifestyle will determine when prediabetes will advance to type 2. Type 1 diabetes develops when the body’s immune system destroys the pancreatic beta cells. These are the only cells in the body that make the hormone insulin that regulates blood glucose. Type 1 diabetes is usually diagnosed in children and young adults. It can account for 5% to 10% of all cases of newly diagnosed diabetes. Some risk factors include genetics, autoimmune status, and environmental factors. Type 2 diabetes was previously called adult-onset diabetes because it usually occurred in adults over the age of 40. Type 2 is associated with obesity, and obesity has become an epidemic, which has drastically increased the incidence of type 2 diabetes among adolescents and young adults. A family history of diabetes, prior history of gestational diabetes, impaired glucose tolerance, older age, physical inactivity, and race and ethnicity can predispose one to type 2 diabetes. African Americans, Hispanic and Latino Americans, Native Americans, some Asian Americans, and Native Hawaiians and other Pacific Islanders are at particularly high risk for type 2 diabetes. It is not uncommon for the client to have no symptoms of diabetes and to be totally ignorant of his condition until it is discovered accidentally during a routine urine or blood test or after a heart attack or stroke.
In type 2 diabetes, hypertension may be present as part of the metabolic syndrome (i.e., obesity, hyperglycemia, and dyslipidemia) that is accompanied by high rates of cardiovascular disease. The American Diabetes Association recommends that blood pressure be controlled at >130/80 mm Hg for diabetics. Type 2 diabetes can usually be controlled by diet and exercise, or by diet, exercise, and an oral diabetes medication.


six Types of Oral Diabetes (Glucose-Lowering) Medications
 Meglitinide Repaglinide (Prandin) Nateglinide (Starlix)
Thiazolidinedione Pioglitazone (Actos) Rosiglitazone (Avandia)
Combination drugs Glyburide and metformin (Glucovance)
 Glipizide and metformin (Metaglip)
Nonsulfonylurea Metformin (Glucophage) Melformin and a time-released controlling polymer (Glucophage XR)
Alpha-glucosidase inhibitor Acarbose (Precose) Miglitol (Glycet)
Second-generation sulfonylureas Glyburide (DiaBeta, Micronase, Glynase Prestabs) Glipizide (Glucotrol, Glucotrol XL) Glimepride (Amaryl)

The National Diabetes Education Program of the U.S. Department of Health and Human Services (National Institutes of Health, 2005) is spreading the word that lifestyle changes can be especially effective in preventing type 2 diabetes in adults aged 60 and older. The National Institutes of Health (NIH) reports that about 40% of adults ages 40 to 74 (approximately 41 million people) have prediabetes, a recognized risk for developing type 2 diabetes, heart disease, and stroke. Studies show that although adults over 60 are at increased risk for type 2 diabetes, the combination of losing a small amount of weight and increasing physical activity is especially effective in reducing that risk among this age group. The NIH is committed to getting the word out to middle-aged and older adults that modest lifestyle changes can yield big rewards in preventing or delaying the onset of type 2 diabetes. Steps for older adults include: • Finding out if they are at risk for type 2 diabetes • Learning what actions they can take to prevent the disease • Losing a small amount of weight by following a low-fat, low-calorie meal plan • Getting 30 minutes of physical activity five times per week These lifestyle interventions worked particularly well in people aged 60 and older, reducing the development of diabetes by 71%. (Source: Data compiled from National Diabetes Education Program, 2005.) SPOTLIGHT on Life Cycle -_

HgbA1c a blood test to determine how well blood glucose has been controlled for the last 3 months types of oral glucose-lowering medications in order from newest and most frequently used to oldest and least frequently used. The goals of medical nutrition therapy for clients with type 2 diabetes include maintaining healthy glucose, blood pressure, and lipid levels. Also, because approximately 80% of type 2 clients are overweight, these clients may be placed on weight reduction diets after their blood glucose levels are within acceptable range. Thus, monitoring their weight loss also becomes part of their therapy. Exenatide (Byetta) injection is the first in a new class of drugs for the treatment of type 2 diabetes. The drugs are called incretin mimetics. When food is eaten, incretin hormones are released from cells located in the small intestine. In the pancreas, incretins will act on the beta cells to increase glucose-dependent insulin secretions to ensure an appropriate insulin response after a meal. This medication is used in conjunction with the nonsulfonylurea metformin to help clients lower their HgbA1c to less than 7%. HgbA1c is a blood test to determine how well blood glucose has been controlled for the last 3 months. The American Diabetes Association prefers the outcome be less than 6%. Gestational diabetes can occur between the sixteenth and twenty-eighth week of pregnancy. If it is not responsive to diet and exercise, insulin injection therapy will be used (Figure 17-1). It is recommended that a dietitian or a diabetic educator be consulted to plan an adequate diet that will control blood sugar for mother and baby. Concentrated sugars should be avoided. Weight gain should continue, but not in excessive amounts. Usually, gestational diabetes disappears after the infant is born. However, diabetes can develop 5 to 10 years after the pregnancy (see Chapter 11). Secondary diabetes occurs infrequently and is caused by certain drugs or by a disease of the pancreas. TREATMENT The treatment of diabetes is intended to do the following: 1. Control blood glucose levels 2. Provide optimal nourishment for the client 3. Prevent symptoms and thus delay the complications of the disease Treatment is typically begun when blood tests indicate hyperglycemia or when other previously discussed symptoms occur. Normal blood glucose levels (called fasting blood sugar, FBS) are from about 70 to 100 mg/dl. Treatment can be by diet alone or by a diet combined with insulin or an oral glucose-lowering medication plus regulated exercise and the regular monitoring of the client’s blood glucose levels. The physician and dietitian can provide essential testing, information, and counseling and can help the client delay potential damage. The ultimate responsibility, however, rests with the client. When a person with diabetes uses nicotine, eats carelessly, forgets insulin, ignores symptoms, and neglects appropriate blood tests, he or she increases the risk of developing permanent tissue damage. EXPLORING THE WEB Search the Web for additional information on gestational diabetes. What are the presenting signs and symptoms of gestational diabetes? What are the dangers of gestational diabetes to the mother and to the fetus if left untreated? Are there factors that put certain women at a higher risk for developing gestational diabetes? If yes, what are these risks? -_ SECTION 3 Medical Nutrition Therapy –—320 Figure 17-1 A pregnant woman can develop diabetes during her pregnancy that may need to be managed by insulin injections. NUTRITIONAL MANAGEMENT The dietitian will need to know the client’s diet history, food likes and dislikes, and lifestyle at the onset. The client’s calorie needs will depend on age, activities, lean muscle mass, size, and REE. It is recommended that carbohydrates provide 50% to 60% of the calories. Approximately 40% to 50% should be from complex carbohydrates (starches). The remaining 10% to 20% of carbohydrates could be from simple sugar. Research provides no evidence that carbohydrates from simple sugars are digested and absorbed more rapidly than are complex carbohydrates, and they do not appear to affect blood sugar control. It is the total amount of carbohydrates eaten that affects blood sugar levels rather than the type. Being able to substitute foods containing sucrose for other carbohydrates increases flexibility in meal planning for the diabetic. Fats should be limited to 30% of total calories, and proteins should provide from 15% to 20% of total calories. Lean prot -_–— CHAPTER 17 Diet and Diabetes Mellitus 321 Regardless of the percentages of energy nutrients prescribed, the foods ultimately eaten should provide sufficient vitamins and minerals as well as energy nutrients. The client with type 1 diabetes needs a nutritional plan that balances calories and nutrient needs with insulin therapy and exercise. It is important that meals and snacks be composed of similar nutrients and calories and eaten at regular times each day. Small meals plus two or three snacks may be more helpful in maintaining steady blood glucose levels for these clients than three large meals each day. The client with type 1 diabetes should anticipate the possibility of missing meals occasionally and carry a few crackers and some cheese or peanut butter to prevent hypoglycemia, which can occur in such a circumstance. The client with type 2 diabetes may be overweight. The nutritional goal for this client is not only to keep blood glucose levels in the normal range but to lose weight as well. Exercise can help attain both goals. Carbohydrate Counting Carbohydrate counting is the newest method for teaching a diabetic client how to control blood sugar with food. The starch and bread category, milk, and fruits have all been put under the heading of “carbohydrates.” This means that these three food groups can be interchanged within one meal. One would still have the same number of servings of carbohydrates, but it would not be the typical number of starches or fruits and milk that one usually eats. For example, one is to have four carbohydrates for breakfast (2 breads, 1 fruit, and 1 milk). If there is no milk available, a bread or fruit must be eaten in place of the milk. The exchange SUPERSIZE USA Diabetes is just one of the many health risks associated with obesity. Where you live geographically may have an impact on your chance of becoming overweight. Does your state rank in the top 12 states for obesity? Obesity was based on the 2008 percentage of adults within the state whose body mass index reading fell within the obese range. Check the following list of states, ranking from highest percentage to lowest percentage of obese adults. Mississippi 31.6% West Virginia 30.6% Alabama 30.1% Louisiana 29.5% Arkansas 29.3% South Carolina 29.2% Tennessee 29.0% Kentucky 28.4% Oklahoma 28.1% Indiana 27.5% Georgia 27.4% Missouri 27.4% (Source: Data from CalorieLab, 2008.) -_ SECTION 3 Medical Nutrition Therapy –—322 Table 17-2 Summary of Exchange Lists The Food Lists The following chart shows the amount of nutrients in 1 serving from each list. FOOD LIST CARBOHYDRATE (grams) PROTEIN ( -_–— CHAPTER 17 Diet and Diabetes Mellitus 323 Table 17-3 Exchange Lists for Meal Planning STARCH EXCHANGE LIST One starch exchange equals 15 g carbohydrate, 3 g protein, 0–1 g fat, and 80 calories STARCH Bread Food Serving Size Bagel, large (about 4 oz) ¼ (1 oz) Biscuit, 2½ inches across 1 Bread reduced-calorie 2 slices (1½ oz) with, whole-grain, pumpernickel, rye, unfrosted raisin 1 slice (1 oz) Chapatti, small, 6 inches across 1 Cornbread, 1¾ inch cube 1 (1½ oz) English muffin ½ Hot dog bun or hamburger bun ½ (1 oz) Naan, 8 inches by 2 inches ¼ Pancake, 4 inches across, ¼ inch thick 1 Pita, 6 inches across ½ Roll, plain, small 1 (1 oz) Stuffing, bread 1 ⁄3 cup Taco shell, 5 inches across 2 Tortilla, corn, 6 inches across 1 Tortilla, flour, 6 inches across 1 Tortilla, flour, 10 inches across 1 ⁄3 tortilla Waffle, 4-inch square or 4 inches across 1 More than 3 grams of dietary fiber per serving. Extra fat, or prepared with added fat. (Count as 1 starch fat.) 480 milligrams or more of sodium per serving. Cereals and Grains Food Serving Size Barley, cooked 1 ⁄3 cup Bran, dry oat ¼ cup wheat ½ cup Bulgur (cooked) ½ cup Cereals bran ½ cup cooked (oats, oatmeal) ½ cup puffed 1½ cups shredded wheat, plain ½ cup sugar-coated ½ cup unsweetened, ready-to-eat ¾ cup (continued) -_ SECTION 3 Medical Nutrition Therapy –—324 Table 17-3 Continued Cereals and Grains continued Food Serving Size Couscous 1 ⁄3 cup Granola low-fat ¼ cup regular ¼ cup Grits, cooked ½ cup Kasha ½ cup Millet, cooked 1 ⁄3 cup Muesli ¼ cup Pasta, cooked 1 ⁄3 cup Polenta, cooked 1 ⁄3 cup Quinoa, cooked 1 ⁄3 cup Rice, white or brown, cooked 1 ⁄3 cup Tabbouleh (tabouli), prepared ½ cup Wheat germ, dry 3 Tbsp Wild rice, cooked ½ cup Tip: An open handful is equal to about 1 cup or 1 to 2 oz of snack food. Crackers and Snacks Food Serving Size Animal crackers 8 Crackers round-butter type 6 saltine-type 6 sandwich-style, cheese or peanut butter filling 3 whole-wheat regular 2–5 (¾ oz) whole-wheat lower fat or crispbreads 2–5 (¾ oz) Graham cracker, 2½-inch square 3 Matzoh ¾ oz Melba toast, about 2-inch by 4-inch piece 4 pieces Oyster crackers 20 Popcorn 3 cups with butter 3 cups no fat added 3 cups lower fat 3 cups Pretzels ¾ oz Rice cakes, 4 inches across 2 Snack chips fat-free or baked (tortilla, potato), baked pita chips 15–20 (¾ oz) regular (tortilla, potato) 9–13 (¾ oz) Note: For other snacks, see the Sweets, Desserts, and Other Carbohydrates list, page 317. -_–— CHAPTER 17 Diet and Diabetes Mellitus 325 Table 17-3 Continued Beans, Peas, and Lentils The choices on this list count as 1 starch 1 lean meat. Food Serving Size Baked beans 1 ⁄3 cup Beans, cooked (black, garbanzo, kidney, lima, navy, pinto, white) ½ cup Lentils, cooked (brown, green, yellow) ½ cup Peas, cooked (black-eyed, split) ½ cup Refried beans, canned ½ cup Starchy Vegetables Food Serving Size Cassava 1 ⁄3 cup Corn ½ cup on cob, large ½ cob (5 oz) Hominy, canned ¾ cup Mixed vegetables with corn, peas, or pasta 1 cup Parsnips ½ cup Peas, green ½ cup Plantain, ripe 1 ⁄3 cup Potato baked with skin ¼ large (3 oz) boiled, all kinds ½ cup or ½ medium (3 oz) mashed, with milk and fat ½ cup French fried (oven-baked) 1 cup (2 oz) Pumpkin, canned, no sugar added 1 cup Spaghetti/pasta sauce ½ cup Squash, winter (acorn, butternut) 1 cup Succotash ½ cup Yam, sweet potato, plain ½ cup FRUITS Fruit The weight listed includes skin, core, seeds, and rind. Food Serving Size Apple, unpeeled, small 1 (4 oz) Apples, dried 4 rings Applesauce, unsweetened ½ cup Apricots canned ½ cup dried 8 halves fresh 4 whole (5½ oz) Banana, extra small 1 (4 oz) Blackberries ¾ cup (continued) -_ SECTION 3 Medical Nutrition Therapy –—326 Table 17-3 Continued Fruit continued Food Serving Size Blueberries ¾ cup Cantaloupe, small 1 ⁄3 melon or 1 cup cubed (11 oz) Cherries sweet, canned ½ cup sweet fresh 12 (3 oz) Dates 3 Dried fruits (blueberries, cherries, cranberries, mixed fruit, raisins) 2 Tbsp Figs dried 1½ fresh 1½ large or 2 medium (3½ oz) Fruit cocktail ½ cup Grapefruit large ½ (11 oz) sections, canned ¾ cup Grapes, small 17(3 oz) Honeydew melon 1 slice or 1 cup cubed (10 oz) Kiwi 1 (3½ oz) Mandarin oranges, canned ¾ cup Mango, small ½ fruit (5½ oz) or ½ cup Nectarine, small 1 (5 oz) Orange, small 1 (6½ oz) Papaya ½ fruit or 1 cup cubed (8 oz) Peaches canned ½ cup fresh, medium 1 (6 oz) Pears canned ½ cup fresh, large ½ (4 oz) Pineapple canned ½ cup fresh ¾ cup Plums canned ½ cup dried (prunes) 3 small 2 (5 oz) Raspberries 1 cup Strawberries 1¼ cup whole berries -_–— CHAPTER 17 Diet and Diabetes Mellitus 327 Table 17-3 Continued Fruit continued Food Serving Size Tangerines, small 2 (8 oz) Watermelon 1 slice or 1¼ cups cubes (13½ oz) More than 3 grams of dietary fiber per serving. Extra fat, or prepared with added fat. 480 milligrams or more of sodium per serving. Fruit Juice Food Serving Size Apple juice/cider ½ cup Fruit juice blends, 100% juice 1 ⁄3 cup Grape juice 1 ⁄3 cup Grapefruit juice ½ cup Orange juice ½ cup Pineapple juice ½ cup Prune juice 1 ⁄3 cup MILK Milk and Yogurts Food Serving Size Count as Fat-free or low-fat (1%) Milk, buttermilk, acidophilus milk, Lactaid 1 cup 1 fat-free milk Evaporated milk ½ cup 1 fat-free milk Yogurt, plain or flavored with an artificial sweetener 2 ⁄3 cup (6 oz) 1 fat-free milk Reduced-fat (2%) Milk, acidophilus milk, kefir, Lactaid 1 cup 1 reduced-fat milk Yogurt, plain 2 ⁄3 cup (6 oz) 1 reduced-fat milk Whole Milk, buttermilk, goat’s milk 1 cup 1 whole milk Evaporated milk ½ cup 1 whole milk Yogurt, plain 8 oz 1 whole milk Balanced Energy: A healthy weight is the result of balancing energy in and energy out of the body. You get energy from the food you eat. Energy is measured in calories. You use energy when you breathe, sit, walk, and move. You stay at the same weight when energy in—the food you eat—is the same as the energy you use. You gain weight when you take in more energy (calories) than your body uses. This extra energy is stored as unwanted weight. You can lose weight by taking in fewer calories than your body needs or burning off more than you take in. Then your body uses stored energy to meet your needs. Ask your RD to estimate how much energy your body needs. When you balance energy from food and energy used for exercise, you can maintain a healthy weight. Dairy-Like Foods Food Serving Size Count as Chocolate milk fat-free 1 cup 1 fat-free milk 1 carbohydrate whole 1 cup 1 whole milk 1 carbohydrate (continued) -_ SECTION 3 Medical Nutrition Therapy –—328 Table 17-3 Continued Dairy-Like Foods continued Food Serving Size Count as Eggnog, whole milk ½ cup 1 carbohydrate 2 fats Rice drink flavored, low-fat 1 cup 2 carbohydrates plain, fat-free 1 cup 1 carbohydrate Smoothies, flavored, regular 10 oz 1 fat-free milk 2½ carbohydrates Soy milk light 1 cup 1 carbohydrate ½ fat regular, plain 1 cup 1 carbohydrate 1 fat Yogurt and juice blends 1 cup 1 fat-free milk 1 carbohydrate low carbohydrate (less than 6 grams 2 ⁄3 cup (6 oz) ½ fat-free milk carbohydrate per choice) with fruit, low-fat 2 ⁄3 cup (6 oz) 1 fat-free milk 1 carbohydrate Note: Coconut milk is on the Fats list, page 325. SWEETS, DESSERTS, AND OTHER CARBOHYDRATES Beverages, Soda, and Energy/Sports Drinks Food Serving Size Count as Cranberry juice cocktail ½ cup 1 carbohydrate Energy drink 1 can (8.3 oz) 2 carbohydrates Fruit drink or lemonade 1 cup (8 oz) 2 carbohydrates Hot chocolate regular 1 envelope added to 8 oz water 1 carbohydrate 1 fat sugar-free or light 1 envelope added to 8 oz water 1 carbohydrate Soft drink (soda), regular 1 can (12 oz) 2½ carbohydrates Sports drink 1 cup (8 oz) 1 carbohydrate Brownies, Cake, Cookies, Gelatin, Pie, and Pudding Food Serving Size Count as Brownie, small, unfrosted 1¼-inch square, 2 ⁄3 inch high 1 carbohydrate 1 fat (about 1 oz) Cake angel food, unfrosted 1½ of cake (about 2 oz) 2 carbohydrates frosted 2-inch square (about 2 oz) 2 carbohydrates 1 fat unfrosted 2-inch square (about 2 oz) 1 carbohydrate 1 fat Cookies chocolate chip 2 cookies (2¼ inches across) 1 carbohydrate 2 fats gingersnap 3 cookies 1 carbohydrate sandwich, with crème filling 2 small (about 2 ⁄3 oz) 1 carbohydrate 1 fat sugar-free 3 small or 1 large (¾–1 oz) 1 carbohydrate 1–2 fats vanilla wafer 5 cookies 1 carbohydrate 1 fat -_–— CHAPTER 17 Diet and Diabetes Mellitus 329 Table 17-3 Continued Brownies, Cake, Cookies, Gelatin, Pie, and Pudding continued Food Serving Size Count as Cupcake, frosted 1 small (about 1¾ oz) 2 carbohydrates 1–1½ fats Fruit cobbler ½ cup (3½ oz) 3 carbohydrates 1 fat Gelatin, regular ½ cup 1 carbohydrate Pie commercially prepared fruit, 2 crusts 1 ⁄8 of 8-inch pie 3 carbohydrates 2 fats pumpkin or custard 1 ⁄8 of 8-inch pie 1½ carbohydrates 1½ fats Pudding regular (made with reduced-fat milk) ½ cup 2 carbohydrates sugar-free or sugar- and fat-free ½ cup 1 carbohydrate (made with fat-free milk) Candy, Spreads, Sweets, Sweeteners, Syrups, and Toppings Food Serving Size Count as Candy bar, chocolate/peanut 2 “fun size” bars (1 oz) 1½ carbohydrates 1½ fats Candy, hard 3 pieces 1 carbohydrate Chocolate “kisses” 5 pieces 1 carbohydrate 1 fat Coffee creamer dry, flavored 4 tsp ½ carbohydrate ½ fat liquid, flavored 2 Tbsp 1 carbohydrate Fruit snacks, chewy (pureed 1 roll (¾ oz) 1 carbohydrate fruit concentrate) Fruit spreads, 100% fruit 1½ Tbsp 1 carbohydrate Honey 1 Tbsp 1 carbohydrate Jam or jelly, regular 1 Tbsp 1 carbohydrate Sugar 1 Tbsp 1 carbohydrate Syrup chocolate 2 Tbsp 2 carbohydrates light (pancake type) 2 Tbsp 1 carbohydrate regular (pancake type) 1 Tbsp 1 carbohydrate Condiments and Sauces Food Serving Size Count as Barbeque sauce 3 Tbsp 1 carbohydrate Cranberry sauce, jellied ¼ cup 1½ carbohydrates Gravy, canned or bottled ½ cup ½ carbohydrate ½ fat Salad dressing, fat-free, low-fat, 3 Tbsp 1 carbohydrate cream-based Sweet and sour sauce 3 Tbsp 1 carbohydrate Doughnuts, Muffins, Pastries, and Sweet Breads Food Serving Size Count as Banana nut bread 1-inch slice (1 oz) 2 carbohydrates 1 fat Doughnut cake, plain 1 medium (1½ oz) 1½ carbohydrates 2 fats yeast type, glazed 3¾ inches across (2 oz) 2 carbohydrates 2 fats (continued) -_ SECTION 3 Medical Nutrition Therapy –—330 Table 17-3 Continued Doughnuts, Muffins, Pastries, and Sweet Breads continued Food Serving Size Count as Muffin (4 oz) ¼ muffin (1 oz) 1 carbohydrate ½ fat Sweet roll or Danish 1 (2½ oz) 2½ carbohydrates 2 fats 480 milligrams or more of sodium per serving. Note: You can also check the Fats list and Free Foods list for other condiments. Frozen Bars, Frozen Desserts, Frozen Yogurt, and Ice Cream Food Serving Size Count as Frozen pops 1 ½ carbohydrate Fruit, juice bars, frozen, 100% juice 1 bar (3 oz) 1 carbohydrate Ice cream fat-free ½ cup 1½ carbohydrates light ½ cup 1 carbohydrate 1 fat no sugar added ½ cup 1 carbohydrate 1 fat regular ½ cup 1 carbohydrate 2 fats Sherbet, sorbet ½ cup 2 carbohydrates Yogurt, frozen fat-free 1 ⁄3 cup 1 carbohydrate regular ½ cup 1 carbohydrate 0–1 fat Granola Bars, Meal Replacement Bars/Shakes, and Trail Mix Food Serving Size Count as Granola or snack bar, regular or low-fat 1 bar (1 oz) 1½ carbohydrates Meal replacement bar 1 bar (11 ⁄3 oz) 1½ carbohydrates 0–1 fat Meal replacement bar 1 bar (2 oz) 2 carbohydrates 1 fat Meal replacement shake, 1 can (10–11 oz) 1½ carbohydrates 0–1 fat reduced calorie Trail mix candy/nut-based 1 oz 1 carbohydrate 2 fats dried fruit–based 1 oz 1 carbohydrate 1 fat NONSTARCHY VEGETABLES Nonstarchy Vegetables Amaranth or Chinese spinach Artichoke Artichoke hearts Asparagus Baby corn Bamboo shoots Bean sprouts Beans (green, wax, Italian) Beets Borscht Broccoli Brussels sprouts Cabbage (green, bok choy, Chinese) Carrots Cauliflower Celery Chayote Coleslaw, packaged, no dressing Cucumber Eggplant -_–— CHAPTER 17 Diet and Diabetes Mellitus 331 Table 17-3 Continued Nonstarchy Vegetables continued Gourds (bitter, bottle, luffa, bitter melon) Green onions or scallions Greens (collard, kale, mustard, turnip) Hearts of palm Jicama Kohlrabi Leeks Mixed vegetables (without corn, peas, or pasta) Mung bean sprouts Mushrooms, all kinds, fresh Okra Onions Oriental radish or daikon Pea pods Peppers (all varieties) Radishes Rutabaga Sauerkraut Soybean sprouts Spinach Squash (summer, crookneck, zucchini) Sugar pea snaps Swiss chard Tomato Tomato sauce Tomatoes, canned Tomato/vegetable juice Turnips Water chestnuts Yard-long beans More than 3 grams of dietary fiber per serving. 480 milligrams or more of sodium per serving. Note: Salad greens (like chicory, endive, escarole, lettuce, romaine, spinach, arugula, radicchio, watercress) are on the Free Foods list, page 326. MEAT AND MEAT SUBSTITUTES CARBOHYDRATE PROTEIN FAT (grams) (grams) (grams) CALORIES Lean meat — 7 0–3 45 Medium-fat meat — 7 4–7 75 High-fat meat — 7 8 100 Plant-based protein varies 7 varies varies Lean Meats and Meat Substitutes Food Amount Beef: Select or Choice grades trimmed of fat: ground 1 oz round, roast (chuck, rib, rump), round, sirloin, steak (cubed, flank, porterhouse, T-bone), tenderloin Beef jerky 1 oz Cheeses with 3 grams of fat or less per oz 1 oz Cottage cheese ¼ cup Egg substitutes, plain ¼ cup Egg whites 2 Fish, fresh or frozen, plain: catfish, cod, flounder, 1 oz haddock, halibut, orange roughy, salmon, tilapia, trout, tuna (continued) -_ SECTION 3 Medical Nutrition Therapy –—332 Table 17-3 Continued Lean Meats and Meat Substitutes continued Food Amount Fish, smoked: herring or salmon (lox) 1 oz Game: buffalo, ostrich, rabbit, venison 1 oz Hot dog with 3 grams of fat or less per oz 1 (8 dogs per 14 oz package) Note: May be high in carbohydrate. Lamb: chop, leg, or roast 1 oz Organ meats: heart, kidney, liver 1 oz Note: May be high in cholesterol. Oysters, fresh or frozen 6 medium Pork, lean Canadian bacon 1 oz rib or loin chop/roast, ham, tenderloin 1 oz Poultry, without skin: Cornish hen, chicken, domestic 1 oz duck or goose (well drained of fat), turkey Processed sandwich meats with 3 grams of fat or less 1 oz per oz: chipped beef, deli thin-sliced meats, turkey ham, turkey kielbasa, turkey pastrami Salmon, canned 1 oz Sardines, canned 2 medium Sausage with 3 grams of fat or less per oz 1 oz Shellfish: clams, crab, imitation shellfish, lobster, 1 oz scallops, shrimp Tuna, canned in water or oil, drained 1 oz Veal, lean chop, roast 1 oz 480 milligrams or more of sodium per serving (based on the sodium content of a typical 3-oz serving of meat, unless 1 or 2 oz is the normal serving size). Portion Sizes: Portion size is an important part of meal planning. The Meat and Meat Substitute list is based on cooked weight (4 oz of raw meat is equal to 3 oz of cooked meat) after bone and fat have been removed. Try using the following comparisons to help estimate portion sizes: • 1 oz cooked meat, poultry, or fish is about the size of a matchbox. • 3 oz cooked meat, poultry, or fish is about the size of a deck of playing cards. • 2 Tbsp peanut butter is about the size of a golf ball. • The palm of a woman’s hand is about 3 to 4 oz of cooked, boneless meat. The palm of a man’s hand is a larger serving. • 1 oz cheese is about the size of 4 dice. Medium-Fat Meat and Meat Substitutes Food Amount Beef: corned beef, ground beef, meatloaf, Prime 1 oz grades trimmed of fat (prime rib), short ribs, tongue Cheeses with 4–7 grams of fat per oz: feta, mozzarella, 1 oz pasteurized processed cheese spread, reduced-fat cheeses, string -_–— CHAPTER 17 Diet and Diabetes Mellitus 333 Table 17-3 Continued Medium-Fat Meat and Meat Substitutes continued Food Amount Egg 1 Note: High in cholesterol, so limit to 3 per week. Fish, any fried product 1 oz Lamb: ground, rib roast 1 oz Pork: cutlet, shoulder roast 1 oz Poultry: chicken with skin; dove, pheasant, wild duck, 1 oz or goose; fried chicken; ground turkey Ricotta cheese 2 oz or ¼ cup Sausage with 4–7 grams of fat per oz 1 oz Veal, cutlet (no breading) 1 oz High-Fat Meat and Meat Substitutes These foods are high in saturated fat, cholesterol, and calories and may raise blood cholesterol levels if eaten on a regular basis. Try to eat 3 or fewer servings from this group per week. Food Amount Bacon pork 2 slices (16 slices per lb or 1 oz each, before cooking) turkey 3 slices (½ oz each before cooking) Cheese, regular: American, bleu, brie, cheddar, hard 1 oz goat, Monterey jack, queso, and Swiss Hot dog: beef, pork, or combination 1 (10 per lb-sized package) Hot dog: turkey or chicken (10 per lb-sized package) 1 Pork: ground, sausage, spareribs 1 oz Processed sandwich meats with 8 grams of fat or 1 oz more per oz: bologna, pastrami, hard salami Sausage with 8 grams fat or more per oz: bratwurst, 1 oz chorizo, Italian, knockwurst, Polish, smoked, summer More than 3 grams of dietary fiber per serving. Extra fat, or prepared with added fat. (Add an additional fat choice to this food.) 480 milligrams or more of sodium per serving (based on the sodium content of a typical 3-oz serving of meat, unless 1 or 2 oz is the normal serving size). Plant-Based Proteins Because carbohydrate content varies among plant-based proteins, you should read the food label. Food Amount Count as “Bacon” strips, soy-based 3 strips 1 medium-fat meat Baked beans 1 ⁄3 cup 1 starch 1 lean meat Beans, cooked: black, garbanzo, kidney, ½ cup 1 starch 1 lean meat lima, navy, pinto, white “Beef” or “sausage” crumbles, soy-based 2 oz ½ carbohydrate 1 lean meat (continued) -_ SECTION 3 Medical Nutrition Therapy –—334 Table 17-3 Continued Plant-Based Proteins continued Food Amount Count as “Chicken” nuggets, soy-based 2 nuggets (1½ oz) ½ carbohydrate 1 medium-fat meat Edamame ½ cup ½ carbohydrate 1 lean meat Falafel (spiced chickpea and wheat patties) 3 patties 1 carbohydrate 1 high-fat meat (about 2 inches across) Hot dog, soy-based 1 (1½ oz) ½ carbohydrate 1 lean meat Hummus 1 ⁄3 cup 1 carbohydrate 1 high-fat meat Lentils, brown, green, or yellow ½ cup 1 carbohydrate 1 lean meat Meatless burger, soy-based 3 oz ½ carbohydrate 2 lean meats Meatless burger, vegetable- and 1 patty (about 2½ oz) 1 carbohydrate 2 lean meats starch-based Nut spreads: almond butter, cashew 1 Tbsp 1 high-fat meat butter, peanut butter, soy nut butter Peas, cooked: black-eyed and split peas ½ cup 1 starch 1 lean meat Because carbohydrate content varies among plant-based proteins, you should read the food label. Food Amount Count as Refried beans, canned ½ cup 1 starch 1 lean meat “Sausage” patties, soy-based 1 (1½ oz) 1 medium-fat meat Soy nuts, unsalted ¾ oz ½ carbohydrate 1 medium-fat meat Tempeh ¼ cup 1 medium-fat meat Tofu 4 oz (½ cup) 1 medium-fat meat Tofu, light 4 oz (½ cup) 1 lean meat Note • Beans, peas, and lentils are also found on the Starch list, page 314. • Nut butters in smaller amounts are found below in the Fats list. More than 3 grams of dietary fiber per serving. Extra fat, or prepared with added fat. (Add an additional fat choice to this food.) 480 milligrams or more of sodium per serving (based on the sodium content of a typical 3-oz serving of meat, unless 1 or 2 oz is the normal serving size). FATS 1 fat choice equals: • 1 teaspoon of regular margarine, vegetable oil, butter • 1 tablespoon of regular salad dressing Unsaturated Fats—Monounsaturated Fats Food Serving Size Avocado, medium 2 Tbsp (1 oz) Nut butters (trans fat-free): almond butter, cashew 1½ tsp butter, peanut butter (smooth or crunchy) -_–— CHAPTER 17 Diet and Diabetes Mellitus 335 Table 17-3 Continued Unsaturated Fats—Monounsaturated Fats continued Food Serving Size Nuts almonds 6 nuts Brazil 2 nuts cashews 6 nuts filberts (hazelnuts) 5 nuts macadamia 3 nuts mixed (50% peanuts) 6 nuts peanuts 10 nuts pecans 4 halves pistachios 16 nuts Oil: canola, olive, peanut 1 tsp Olives black (ripe) 8 large green, stuffed 10 large Polyunsaturated Fats Food Serving Size Margarine: lower-fat spread (30%–50% vegetable 1 Tbsp oil, trans fat-free) Margarine: stick, tub (trans fat-free), or squeeze 1 tsp (trans fat-free) Mayonnaise reduced-fat 1 Tbsp regular 1 tsp Mayonnaise-style salad dressing reduced-fat 1 Tbsp regular 2 tsp Nuts Pignolia (pine nuts) 1 Tbsp walnuts, English 4 halves Oil: corn, cottonseed, flaxseed, grape seed, safflower, 1 tsp soybean, sunflower Oil: made from soybean and canola oil—Enova 1 tsp Plant stanol esters light 1 Tbsp regular 2 tsp Salad dressing reduced-fat 2 Tbsp Note: May be high in carbohydrate. regular 1 Tbsp (continued) -_ SECTION 3 Medical Nutrition Therapy –—336 Table 17-3 Continued Polyunsaturated Fats continued Food Serving Size Seeds flaxseed, whole 1 Tbsp pumpkin, sunflower 1 Tbsp sesame seeds 1 Tbsp Tahini or sesame paste 2 tsp 480 milligrams or more of sodium per serving. Saturated Fats Food Serving Size Bacon, cooked, regular or turkey 1 slice Butter reduced-fat 1 Tbsp stick 1 tsp whipped 2 tsp Butter blends made with oil reduced-fat or light 1 Tbsp regular 1½ tsp Chitterlings, boiled 2 Tbsp (½ oz) Coconut, sweetened, shredded 2 Tbsp Coconut milk light 1 ⁄3 cup regular 1½ Tbsp Cream half and half 2 Tbsp heavy 1 Tbsp light 1½ Tbsp whipped 2 Tbsp whipped, pressurized ¼ cup Cream cheese reduced-fat 1½ Tbsp (¾ oz) regular 1 Tbsp (½ oz) Lard 1 tsp Oil: coconut, palm, palm kernel 1 tsp Salt pork ¼ oz Shortening, solid 1 tsp Sour cream reduced-fat or light 3 Tbsp regular 2 Tbsp -_–— CHAPTER 17 Diet and Diabetes Mellitus 337 Table 17-3 Continued FREE FOODS Selection Tips • Most foods on this list should be limited to 3 servings (as listed here) per day. • Food and drink choices listed here without a serving size can be eaten whenever you like. Low Carbohydrate Foods Food Serving Size Cabbage, raw ½ cup Candy, hard (regular or sugar-free) 1 piece Carrots, cauliflower, or green beans, cooked ¼ cup Cranberries, sweetened with sugar substitute ½ cup Cucumber, sliced ½ cup Gelatin dessert, sugar-free unflavored Gum Jam or jelly, light or no sugar added 2 tsp Rhubarb, sweetened with sugar substitute ½ cup Salad greens Sugar substitutes (artificial sweeteners) Syrup, sugar-free 2 Tbsp Modified Fat Foods with Carbohydrate Food Serving Size Cream cheese, fat-free 1 Tbsp (½ oz) Creamers nondairy, liquid 1 Tbsp nondairy, powdered 2 tsp Margarine spread fat-free 1 Tbsp reduced-fat 1 tsp Mayonnaise fat-free 1 Tbsp reduced-fat 1 tsp Mayonnaise-style salad dressing fat-free 1 Tbsp reduced-fat 1 tsp Salad dressing fat-free or low-fat 1 Tbsp fat-free, Italian 2 Tbsp Sour cream, fat-free or reduced-fat 1 Tbsp (continued) -_ SECTION 3 Medical Nutrition Therapy –—338 Table 17-3 Continued Modified Fat Foods with Carbohydrate continued Food Serving Size Whipped topping light or fat-free 2 Tbsp regular 1 Tbsp Artificial Sweeteners: Sugar substitutes, alternatives, or replacements that are approved by the Food and Drug Administration (FDA) are safe to use. Common brand names include: • Equal and Nutrasweet (aspartame) • Splenda (sucralose) • Sugar Twin, Sweet-10, Sweet’N Low, and Sprinkle Sweet (saccharin) • Sweet One (acesulfame K) Although each sweetener is tested for safety before it can be marketed and sold, use a variety of sweeteners and in moderate amounts. Condiments Food Serving Size Barbecue sauce 2 tsp Catsup (ketchup) 1 Tbsp Honey mustard 1 Tbsp Horseradish Lemon juice Miso 1½ tsp Mustard Parmesan cheese, freshly grated 1 Tbsp Pickle relish 1 Tbsp Pickles dill 1½ medium sweet, bread and butter 2 slices sweet, gherkin ¾ oz Salsa ¼ cup Soy sauce, light or regular 1 Tbsp Sweet and sour sauce 2 tsp Sweet chili sauce 2 tsp Taco sauce 1 Tbsp Vinegar Yogurt, any type 2 Tbsp 480 milligrams or more of sodium per serving. Drinks/Mixes Any food on this list—without a serving size listed—can be consumed in any moderate amount. • Bouillon, broth, consomme • Bouillon or broth, low-sodium • Carbonated or mineral water • Club soda -_–— CHAPTER 17 Diet and Diabetes Mellitus 339 Seasonings Any food on this list can be consumed in any moderate amount. Be careful with seasonings that contain sodium or are salts, such as garlic salt, celery salt, and lemon pepper. COMBINATION FOODS Entrees Food Serving Size Count as Casserole type (tuna noodle, lasagna, 1 cup (8 oz) 2 carbohydrates 2 medium-fat meats spaghetti with meatballs, chili with beans, macaroni and cheese) Stews (beef/other meats and vegetables) 1 cup (8 oz) 1 carbohydrate 1 medium-fat meat 0–3 fats Tuna salad or chicken salad ½ cup (3½ oz) ½ carbohydrate 2 lean meats 1 fat Frozen Meals/Entrees Food Serving Size Count as Burrito (beef and bean) 1 (5 oz) 3 carbohydrates 1 lean meat 2 fats Dinner-type meal generally 14–17 oz 3 carbohydrates 3 medium-fat meats 3 fats Entree or meal with less than 340 calories about 8–11 oz 2–3 carbohydrates 1–2 lean meats Pizza cheese/vegetarian, thin crust ¼ of a 12 inch 2 carbohydrates 2 medium-fat meats (4½–5 oz) meat topping, thin crust ¼ of a 12 inch 2 carbohydrates 2 medium-fat meats (5 oz) 1½ fats Pocket sandwich 1 (4½ oz) 3 carbohydrates 1 lean meat 1–2 fats Pot pie 1 (7 oz) 2½ carbohydrates 1 medium-fat meat 3 fats Salads (Deli-Style) Food Serving Size Count as Coleslaw ½ cup 1 carbohydrate 1½ fats Macaroni/pasta salad ½ cup 2 carbohydrates 3 fats Potato salad ½ cup 1½–2 carbohydrates 1–2 fats • Cocoa powder, unsweetened (1 Tbsp) • Coffee, unsweetened or with sugar substitute • Diet soft drinks, sugar-free • Drink mixes, sugar-free • Tea, unsweetened or with sugar substitute • Tonic water, diet • Water • Water, flavored, carbohydrate-free • Flavoring extracts (for example, vanilla, almond, peppermint) • Garlic • Herbs, fresh or dried • Nonstick cooking spray • Pimento • Spices • Hot pepper sauce • Wine, used in cooking • Worcestershire sauce Table 17-3 Continued Drinks/Mixes continued (continued) -_ SECTION 3 Medical Nutrition Therapy –—340 Table 17-3 Continued Drinks/Mixes continued More than 3 grams of dietary fiber per serving. Extra fat, or prepared with added fat. 600 milligrams or more of sodium per serving (for fast food main dishes/meals). Soups Food Serving Size Count as Bean, lentil, or split pea 1 cup 1 carbohydrate 1 lean meat Chowder (made with milk) 1 cup (8 oz) 1 carbohydrate 1 lean meat 1½ fats Cream (made with water) 1 cup (8 oz) 1 carbohydrate 1 fat Instant 6 oz prepared 1 carbohydrate with beans or lentils 8 oz prepared 2½ carbohydrates 1 lean meat Miso soup 1 cup ½ carbohydrate 1 fat Oriental noodle 1 cup 2 carbohydrates 2 fats Rice (congee) 1 cup 1 carbohydrate Tomato (made with water) 1 cup (8 oz) 1 carbohydrate Vegetable beef, chicken noodle, or 1 cup (8 oz) 1 carbohydrate other broth type FAST FOODS The choices in the Fast Foods list are not specific fast-food meals or items, but are estimates based on popular foods. You can get specific nutrition information for almost every fast-food or restaurant chain. Ask the restaurant or check its website for nutrition information about your favorite fast foods. Breakfast Sandwiches Food Serving Size Count as Egg, cheese, meat, English muffin 1 sandwich 2 carbohydrates 2 medium-fat meats Sausage biscuit sandwich 1 sandwich 2 carbohydrates 2 high-fat meats 3½ fats Main Dishes/Entrees Food Serving Size Count as Burrito (beef and beans) 1 (about 8 oz) 3 carbohydrates 3 medium-fat meats 3 fats Chicken breast, breaded and fried 1 (about 5 oz) 1 carbohydrate 4 medium-fat meats Chicken drumstick, breaded and fried 1 (about 2 oz) 2 medium-fat meats Chicken nuggets 6 (about 3½ oz) 1 carbohydrate 2 medium-fat meats 1 fat Chicken thigh, breaded and fried 1 (about 4 oz) ½ carbohydrate 3 medium-fat meats 1½ fats Chicken wings, hot 6 (5 oz) 5 medium-fat meats 1½ fats Oriental Food Serving Size Count as Beef/chicken/shrimp with vegetables 1 cup (about 5 oz) 1 carbohydrate 1 lean meat 1 fat in sauce Egg roll, meat 1 (about 3 oz) 1 carbohydrate 1 lean meat 1 fat Fried rice, meatless ½ cup 1½ carbohydrates 1½ fats Meat and sweet sauce (orange chicken) 1 cup 3 carbohydrates 3 medium-fat meats 2 fats Noodles and vegetables in sauce 1 cup 2 carbohydrates 1 fat (chow mein, lo mein) -_–— CHAPTER 17 Diet and Diabetes Mellitus 341 Table 17-3 Continued Pizza Food Serving Size Count as Pizza cheese, pepperoni, regular crust ½ of a 14 inch 2½ carbohydrates 1 medium-fat meat (about 4 oz) 1½ fats cheese/vegetarian, thin crust ¼ of a 12 inch 2½ carbohydrates 2 medium-fat (about 6 oz) meats 1½ fats Sandwiches Food Serving Size Count as Chicken sandwich, grilled 1 3 carbohydrates 4 lean meats Chicken sandwich, crispy 1 3½ carbohydrates 3 medium-fat meats 1 fat Fish sandwich with tartar sauce 1 2½ carbohydrates 2 medium-fat meats 2 fats Hamburger large with cheese 1 2½ carbohydrates 4 medium-fat meats 1 fat regular 1 2 carbohydrates 1 medium-fat meat 1 fat Hot dog with bun 1 1 carbohydrate 1 high-fat meat 1 fat Submarine sandwich less than 6 grams fat 6-inch sub 3 carbohydrates 2 lean meats regular 6-inch sub 3½ carbohydrates 2 medium-fat meats 1 fat Taco, hard or soft shell 1 small 1 carbohydrate 1 medium-fat meat 1½ fats (meat and cheese) Salads Food Serving Size Count as Salad, main dish (grilled chicken Salad 1 carbohydrate 4 lean meats type, no dressing or croutons) Salad, side, no dressing or cheese Small (about 5 oz) 1 vegetable Sides/Appetizers Food Serving Size Count as French fries, restaurant style small 3 carbohydrates 3 fats medium 4 carbohydrates 4 fats large 5 carbohydrates 6 fats Nachos with cheese small 2½ carbohydrates 4 fats (about 4½ oz) Onion rings 1 serving 2½ carbohydrates 3 fats (about 3 oz) Desserts Food Serving Size Count as Milkshake, any flavor 12 oz 6 carbohydrates 2 fats Soft-serve ice cream cone 1 small 2½ carbohydrates 1 fat Note: See the Starch list and Sweets, Desserts, and Other Carbohydrates list for foods such as bagels and muffins. Extra fat, or prepared with added fat. 600 milligrams or more of sodium per serving (for fast-food main dishes/meals). (continued) -_ SECTION 3 Medical Nutrition Therapy –—342 Table 17-3 Continued Alcohol Alcoholic Beverage Serving Size Count as Beer light (4.2%) 12 fl oz 1 alcohol equivalent ½ carbohydrate regular (4.9%) 12 fl oz 1 alcohol equivalent 1 carbohydrate Distilled spirits: vodka, rum, gin, 1½ fl oz 1 alcohol equivalent whiskey 80 or 86 proof Liqueur, coffee (53 proof) 1 fl oz 1 alcohol equivalent 1 carbohydrate Sake 1 fl oz ½ alcohol equivalent Wine dessert (sherry) 3½ fl oz 1 alcohol equivalent 1 carbohydrate dry, red or white (10%) 5 fl oz 1 alcohol equivalent The foods within each list contain approximately equal amounts of calories, carbohydrates, protein, and fats. This means that any one food on a particular list can be substituted for any other food on that particular list and still provide the client with the prescribed types and amounts of nutrients and calories. The amounts of nutrients and calories on one list are not the same as those on any other list. Each list includes serving size by volume or weight and the calorie value of each food item, in addition to the grams of carbohydrates, and, when appropriate, proteins and fats. The number of calories needed will determine the number of items prescribed from any particular list. These lists also can be used to control calorie content of diets and are thus appropriate for low-calorie diets. The total energy requirements for adult diabetic clients who are not overweight will be the same as for nondiabetic individuals. When clients are overweight, a reduction in calories will be built into the diet plans, typically allowing for a weight loss of 1 pound a week. The diet is given in terms of exchanges rather than as particular foods. For example, the menu pattern for breakfast may include 1 fruit exchange, 1 meat exchange, 2 bread exchanges, and 2 fat exchanges. The client may choose the desired foods from the exchange lists for each meal but must adhere to the specific exchange lists named and the specific number of exchanges on each list. Vegetables (nonstarchy) are relatively free and can be eaten in amounts up to 11 ⁄2 cups cooked or 3 cups raw. If more than this amount is eaten at one meal, count the additional amount as one more carbohydrate. Snacks are built into the plan. In this way, the client has variety in a simple yet controlled way. When there are changes in one’s physical condition, such as pregnancy or lactation, or in one’s lifestyle, the diet will need to be modified. A change in job or in working hours can affect nutrient and calorie requirements. When such changes occur, the client should be advised to consult her or his physician or dietitian so that calorie and insulin needs can be promptly adjusted. Source: Reproduction of the Exchange Lists in whole or part, without permission of the American Dietetic Association or the American Diabetes Association, Inc., is a violation of federal law. This material has been modified from Choose Your Foods: Exchange Lists for Diabetes, which is the basis of a meal planning system designed by a commitee of the American Diabetes Association and the American Dietetic Association. While designed primarily for people with diabetes and others who must follow special diets, the Exchange Lists are based on principles of good nutrition that apply to everyone. Copyright © 2008 by the American Diabetes Association and the American Dietetic Association. -_–— CHAPTER 17 Diet and Diabetes Mellitus 343 ¶ sucralose a sweetener made from a molecule of sugar SPECIAL CONSIDERATIONS FOR THE DIABETIC CLIENT Fiber The therapeutic value of fiber in the diabetic diet has become increasingly evident. High-fiber intake appears to reduce the amount of insulin needed because it lowers blood glucose. It also appears to lower the blood cholesterol and triglyceride levels. High-fiber may mean 25 to 35 grams of dietary fiber a day. Such high amounts can be difficult to include. High-fiber foods should be increased very gradually, as an abrupt increase can create intestinal gas and discomfort. When increasing fiber in the diet one must also increase intake of water. An increased fiber intake can affect mineral absorption. Alternative Sweeteners Sucralose is the newest sweetener to gain approval by the FDA. Sucralose is made from a sugar molecule that has been altered in such a way that the body will not absorb it. Aspartame is the generic name for a sweetener composed of two amino acids: phenylalanine and aspartic acid. The FDA removed the sweetener saccharine from its list of products that could cause cancer. Research indicates that all these sweeteners are safe. All have been approved by the FDA, and their use has been endorsed by the American Diabetes Association. Dietetic Foods The use of diabetic or dietetic foods is generally a waste of money and can be misleading to the client. Often the containers of foods will contain the same ingredients as containers of foods prepared for the general public, but the cost is typically higher for the dietetic foods. There is potential danger for diabetic clients who use these foods if they do not read the labels on the food containers and assume that because they are labeled “dietetic,” they can be used with abandon. In reality, their use should be in specified amounts only, as these foods will contain carbohydrates, fats, and proteins that must be calculated in the total day’s diet. It is advisable for the diabetic client to use foods prepared for the general public but to avoid those packed in syrup or oil. The important thing is for the diabetic client to read the label on all food containers purchased. Alcohol Although alcohol is not recommended for diabetic clients, its limited use is sometimes allowed if approved by the physician. However, some diabetic clients who use hypoglycemic agents cannot tolerate alcohol. When used, alcohol must be included in the diet plan. ¶ aspartame artificial sweetener made from amino acids; does not require insulin for metabolism -_ SECTION 3 Medical Nutrition Therapy –—344 Figure 17-2 This young diabetic client is self-injecting insulin. ¶ exogenous insulin insulin produced outside the body Exercise Exercise helps the body use glucose by increasing insulin receptor sites and stimulating the creation of glucagon. It lowers cholesterol and blood pressure and reduces stress and body fat as it tones the muscles. For clients with type 2 diabetes, exercise helps improve weight control, glucose levels, and the cardiovascular system. However, for clients with type 1 diabetes, exercise can complicate glucose control. As it lowers glucose levels, hypoglycemia can develop. Exercise must be carefully discussed with the client’s physician. If done, it should be on a regular basis, and it must be considered carefully as the meal plans are developed so that sufficient calories and insulin are prescribed. Insulin Therapy Clients with type 1 diabetes must have injections of insulin every day to control their blood glucose levels (Figure 17-2). This insulin is called exogenous insulin because it is produced outside the body. Endogenous insulin is produced by the body. Exogenous insulin is a protein. It must be injected because, if swallowed, it would be digested and would not reach the bloodstream as the complete hormone. After insulin treatment is begun, it is usually necessary for the client to continue it throughout life. Human insulin is the most common insulin given to clients. This insulin does not come from humans but is made synthetically by a chemical process in a laboratory. Human insulin is preferred because it is very similar to insulin made by the pancreas. Animal insulin comes from cows or pigs and is called beef or pork insulin. These insulins are rarely used because they contain antibodies that make them less pure than human insulin. Various types of insulin are available. They differ in the length of time required before they are effective and in the length of time they continue to act. ¶ endogenous insulin insulin produced within the body -_–— CHAPTER 17 Diet and Diabetes Mellitus 345 ¶ insulin reaction hypoglycemia leading to insulin coma caused by too much insulin or too little food This latter category is called insulin action. Consequently, they are classified as very rapid-, rapid-, intermediate-, and long-acting. Those most commonly used are intermediate-acting types that work within 2 to 8 hours and are effective for 24 to 28 hours. For type 1 diabetes, insulin is often given in two or more injections daily and may contain more than one type of insulin. Injections are given at prescribed times. More insulin-dependent diabetic clients are using insulin-pump therapy for better blood glucose control. Pumps deliver insulin two ways: the basal rate and a premeal bolus. The basal rate is a small amount of short-acting insulin delivered continuously throughout the day. This insulin keeps blood glucose in check between meals and during the night. Premeal boluses of short-acting insulin are designed to cover the food eaten during a meal. This allows more flexibility as to when meals are eaten. Insulin pumps are not for everyone. An endocrinologist and diabetes educator can determine the best candidates for pump therapy. Insulin Reactions When clients do not eat the prescribed diet but continue to take the prescribed insulin, hypoglycemia can result. This is called an insulin reaction, or hypo-glycemic episode, and may lead to coma and death. Symptoms include headache, blurred vision, tremors, confusion, poor coordination, and eventual unconsciousness. Insulin reaction is dangerous because if frequent or prolonged, brain damage can occur. (The brain must have sufficient amounts of glucose in order to function.) The physician should be consulted if an insulin reaction occurs or seems imminent. Conscious clients may be treated by giving them a glucose tablet, a sugar cube, or a beverage containing sugar followed by a complex carbohydrate. If the client is unconscious, intravenous treatment of dextrose and water is given. It is advisable for the diabetic client to carry identification explaining the condition so that people do not think he or she is drunk when, in reality, the person is experiencing an insulin reaction. CONSIDERATIONS FOR THE HEALTH CARE PROFESSIONAL It is important to point out to the diabetic client that one can live a near-normal life if the diet is followed, medication is taken as prescribed, and time is allowed for sufficient exercise and rest. The importance of eating all of the prescribed food must be emphasized. It is important for meals to be eaten at regular times so that the insulin–glucose balance can be maintained. It is imperative that the client learn to read carefully all labels on commercially prepared foods. Adjustments must be made in shopping, cooking, and eating habits so that the diet plan can be followed. Family meals can be simply adapted for the diabetic diet. The diabetic client soon learns which exchange lists are to be included at each meal and at snack times and the foods within each exchange list. (See Table 17-3 for the exchange lists, Table 17-4 for free foods, and Table 17-5 for seasonings that can be used.) ¶ coma state of unconsciousness EXPLORING THE WEB Search the Web for additional information on insulin therapies. What different types of therapies exist? Are there any experimental therapies currently being used and researched? What are some of the trial findings for these therapies? -_ SECTION 3 Medical Nutrition Therapy –—346 Table 17-4 Free Foods Allowed on the Exchange List FREE FOOD LIST A free food is any food or drink that contains less than 20 calories or less than 5 g of carbohydrate per serving. Foods with a serving size listed should be limited to three servings per day. Be sure to spread them out throughout the day. Eating all three servings at one time could affect your blood glucose level. Foods listed without a serving size can be eaten as often as you like. Fat-Free or Reduced-Fat Foods Cream cheese, fat-free 1 Tbsp Creamers, nondairy, liquid 1 Tbsp Creamers, nondairy, powdered 2 tsp Mayonnaise, fat-free 1 Tbsp Mayonnaise, reduced fat 1 tsp Margarine, fat-free 4 Tbsp Margarine, reduced fat 1 tsp Miracle Whip, nonfat 1 Tbsp Miracle Whip, reduced fat 1 tsp Nonstick cooking spray Salad dressing, fat-free 1 Tbsp Salad dressing, fat-free, Italian 2 Tbsp Salsa 1 ⁄4 cup Sour cream, fat-free, reduced fat 1 Tbsp Whipped topping, regular light 2 Tbsp Drinks Bouillon, broth, consommé* Bouillon or broth, low sodium Carbonated or mineral water Club soda Cocoa powder, unsweetened 1 Tbsp Coffee Diet soft drinks, sugar-free Drink mixes, sugar-free Tea Tonic water, sugar-free * 400 mg or more of sodium per exchange. Source: American Diabetes Association or the American Dietetic Association, Inc. Choose Your Foods: Exchange Lists for Diabetes. Copyright © 2008 by the American Diabetes Association and the American Dietetic Association. Sugar-Free or Low-Sugar Foods Candy, hard, sugar-free 1 candy Gelatin dessert, sugar-free Gelatin, unflavored Gum, sugar-free Jam or jelly, low-sugar or light 2 tsp Syrup, sugar-free 2 Tbsp Sugar substitutes, alternatives, or replacements that are approved by the Food and Drug Administration (FDA) are safe to use. Common brand names include: Equal (aspartame) Sprinkle Sweet (saccharin) Sweet One (acesulfame K) Sweet-10 (saccharin) Sugar Twin (saccharin) Sweet’N Low (saccharin) Condiments Catsup 1 Tbsp Horseradish Lemon juice Lime juice Mustard Pickles, dill* 11 ⁄2 large Soy sauce, regular or light* Taco sauce 1 Tbsp Vinegar -_–— CHAPTER 17 Diet and Diabetes Mellitus 347 Table 17-5 Useful Seasonings Read the label, and choose those seasonings that do not contain sodium or salt. Basil (fresh) Garlic Oregano Celery seeds Garlic powder Paprika Cinnamon Herbs Pepper Chili powder Hot pepper sauce Pimento Chives Lemon Spices Curry Lemon juice Soy sauce Dill Lemon pepper Soy sauce, low sodium (“lite”) Flavoring extracts Lime Wine, used in cooking (1 ⁄4 cup) (vanilla, almond, Lime juice Worcestershire sauce walnut, peppermint, Mint lemon, butter, etc.) Onion powder Source: American Diabetes Association or the American Dietetic Association, Inc. Choose Your Foods: Exchange Lists for Diabetes. Copyright © 2008 by the American Diabetes Association and the American Dietetic Association. SUMMARY The diabetic diet is used in treating diabetes, a metabolic disease caused by the improper functioning of the pancreas that results in inadequate production or utilization of insulin. If the condition is left untreated, the body cannot use glucose properly, and then serious complications, even death, can occur. Treatment includes diet, medication, and exercise. Diabetic diets are prescribed by the physician or dietitian in consultation with the client. DISCUSSION TOPICS 1. Explain why diabetes is a serious disease. 2. What is insulin? What is its use? Why can it not be taken orally? 3. What is the function of oral diabetes medication? For which type of diabetes is it usually prescribed? 4. Explain the differences between type 1 and type 2 diabetes. 5. Describe the symptoms of type 1 diabetes. Include the following terms: hyperglycemia, renal threshold, glycosuria, polydipsia, polyuria, polyphagia, ketones, ketonuria, and acidosis. 6. Explain why it is essential that diabetic clients read labels on food. 7. Why are “dietetic” foods not recommended for diabetic clients? 8. Discuss how an insulin reaction might occur. 9. How would pregnancy affect the diet of a client with type 1 diabetes? How would lactation affect the diet of a client with type 1 diabetes? 10. Discuss the effects of exercise on glucose utilization. SUGGESTED ACTIVITIES 1. Ask a physician or dietitian or diabetic educator to speak to the class on diabetes and its treatment. 2. Ask a diabetic educator to explain and demonstrate carbohydrate counting. -_ SECTION 3 Medical Nutrition Therapy –—348 3. Visit a local supermarket and compare regular and “dietetic” containers of food in terms of cost, calories, and nutrient content. 4. Invite someone with type 1 diabetes to talk to the class about his or her condition. 5. Invite someone with type 2 diabetes to talk to the class about his or her condition.