Diabetic diet

There is much controversy regarding what diet to recommend to sufferers of diabetes mellitus. The diet most often recommended is high in dietary fiber, especially soluble fiber, but low in fat (especially saturated fat). However, recommendations on the fraction of total calories to be obtained from carbohydrates range from 1/6 to 75%. Patients may be encouraged to reduce their intake of carbohydrates that have a high glycemic index (GI). (In cases of hypoglycemia, they are advised to have food or drink that can raise blood glucose quickly, followed by a long-acting carbohydrate (such as rye bread) to prevent risk of further hypoglycemia.) But others question the usefulness of the glycemic index and recommend high-GI foods like potatoes and rice.

Early history of diabetic diet

There has been long history of dietary treatment of diabetes mellitus - as Ramachandran & Viswanathan (1998) note, dietary treatment of diabetes mellitus was used in Egypt as long ago as 3,500 B.C., and was used in India by Sushruta and Charaka more than 2000 years ago. In the eighteenth century, these authors note, John Rollo argued that calorie restriction in the diabetic diet could reduce glycosuria in diabetes. However, more modern history of the diabetic diet may begin with Frederick Madison Allen, who, in the days before insulin was discovered, recommended that people with diabetes ate only a low-calorie diet to prevent ketoacidosis from killing them. This was an approach which did not actually cure diabetes, it merely extended life by a limited period. The first use of insulin by Frederick Banting in 1922 changed things, and at last allowed patients more flexibility in their eating.

Exchange scheme

In the 1950s, the American Diabetes Association, in conjunction with the U.S. Public Health Service, brought forth the "exchange scheme". This was a scheme that allowed people to swap foods of similar nutritional value (e.g. carbohydrate) for another, so, for example, if wishing to have more than normal carbohydrates for dessert, one could cut back on potatoes in one's first course. The exchange scheme was revised in 1976, 1986 and 1995 (Chalmers & Peterson, 1999, p85).However, not all diabetes dietitians today recommend the exchange scheme. Instead, they are likely to recommend a typical healthy diet: one high in fiber, with a variety of fruit and vegetables, and low in both sugar and fat, especially saturated fat. A diet that is high in plant fibre was recommended by James Anderson (Anderson & Ward, 1979; cited in Murray & Pizzorno, 1990). This may be understood as continuation of the work of Denis Burkitt and Hugh Trowell on dietary fibre,^[1] which in turn, may be understood as a continuation of the work of Price (Murray & Pizzorno, 1990).

In 1976, Nathan Pritikin opened a centre where patients were put on programme of diet and exercise (the Pritikin Program). This diet is high on carbohydrates and fibre, with fresh fruit, vegetables, and whole grains. A study at UCLA in 2005 showed that it brought dramatic improvement to a group of diabetics and pre-diabetics in only three weeks, so that about half no longer met the criteria for the disease.^{[2] [3] [4] [5]}

On the other hand, in 1983, Dr Richard K. Bernstein began treating diabetics and pre-diabetics successfully with a very low carbohydrate diet, avoiding fruit, added sugar, and starch. Both the Pritikin approach and the Bernstein approach prescribe exercise.

Carbohydrates

In humans, carbohydrate metabolism is not uniform. For diabetics, the most significant is glucose which is found as a digestible component of some sugars, but most importantly, in starch. Some carbohydrates are not digested or absorbed at all -- cellulose is an example which can be digested by ruminant animals and by termites (both using gut flora) -- but not by humans. In humans, cellulose and related carbohydrates are roughage, or dietary fibre, and pass through the human digestive system effectively unchanged, though not without effect (widely believed to be beneficial). Humans lack the enzymatic machinery needed to digest dietary multi-saccharides; we can handle only one or two di-saccharides (eg, sucrose and for some people, lactose) and no larger ones except starch or glycogen. All other multi-saccharides are carbohydrates, but contribute to human nutrition only after pre-processing by gut flora, with accompanying gas and other effects. At least one estimate is that less than 10% of caloric input is from fermentation by gut flora of unabsorbed nutrients in the colon. The classic unfortunate example is lactose, which most adult humans cannot digest, having lost lactase production after childhood; the gastro-intestinal effects (eg, cramping, bloating, diarrhea) which sometimes follow for the lactose-intolerant can be significant. Indeed, only a few of the mono-saccharides can be absorbed by humans; most cannot. And of those, at least one, fructose, is somewhat problematic. It is metabolized only in the liver, and in men, in sperm, since only those tissues contain the fructase needed. The liver is affected by high levels of dietary fructose by, among other things, characteristic unfavorable alterations in blood lipid profiles, and possibly in a connection to insulin resistance and so to Type 2 diabetes mellitus.

The American Diabetes Association in 1994 recommended that 60-70% of caloric intake should be in the form of carbohydrates. As mentioned above, this is controversial, with some researchers claiming that 40%^[6] or even less is better, while others claim benefits for a high-fiber, 75% carbohydrate diet.^[7]

An article summarizing the view of the American Diabetes Association^[8] contains the statement "Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake." Sucrose does not increase glycemia more than the same number of calories taken as starch. Although it is not recommended to use fructose as a sweetener, fruit should not be avoided because of its fructose content. Benefits may be obtained by consumption of dietary fibre in conjunction with carbohydrate; as Francis (1987) points out, evidence suggests that carbohydrate consumed with dietary fibre will have a less major impact on glycemic rise than the same amount of carbohydrate consumed alone.

What has not generally been included in diabetic diet recommendations is the variation in effect from different carbohydrates.

Despite a common belief that table sugar contributes to the development of diabetes, it has medium (55-69) glycemic index that actually produces lower blood glucose levels than the same amount of calories obtained from some other sources of carbohydrates. The Canadian Diabetes Association recommended that table sugar be included as part of the diabetes diet.^[9]

Low-carbohydrate alternatives

Some studies show that a low-carbohydrate diet or low GI diet may be effective in dietary management of type 2 diabetes, as both approaches prevent blood sugars from spiking after eating.^[10][11]

Dr. Richard K. Bernstein is harshly critical of the standard American Diabetes Association diet plan. His plan includes very limited carbohydrate intake (30 grams per day) along with frequent blood glucose monitoring, regular strenuous muscle-building exercise, and, for diabetics using insulin, frequent small insulin injections if needed. His treatment target is "near normal blood sugars" all the time.^[12]

Another critic of the ADA program is Ray Kurzweil, who together with Dr Terry Grossman, co-author of "Fantastic Voyage - Live long enough to live forever", (pub 2004) describes the ADA guidelines as "completely ineffective".^{[citation needed]} Their observations are that the condition, particularly in its early stages can be controlled through a diet which has sharply reduced carbohydrate consumption.^{[citation needed]} Their guidelines for patients with type 2 diabetes is a diet that includes a reduction of carbohydrates to one sixth of total caloric intake and elimination of high glycemic load carbohydrates.^{[citation needed]} As a previously diagnosed diabetic who no longer has symptoms of the disease, Kurzweil is a firm advocate of this approach.^{[citation needed]}

Vegan and Raw/Live Foods alternatives

Recent studies have shown that a vegan diet may also be effective in managing type 2 diabetes. Raw food protocols for treating Type 2 diabetes can be found in the book "There Is a Cure For Diabetes" by Dr Gabriel Cousens and the documentary he appears in with six diabetics and other doctors, "Simply Raw: Reversing Diabetes in 30 Days". Also of note are the writings of Victoria Boutenko whose son's diabetes disappeared after converting to a raw foods diet.^[13][14]

Timing of meals

For people with diabetes, healthy eating is not simply a matter of "what one eats", but also when one eats. The question of how long before a meal one should inject insulin is asked in Sonsken, Fox and Judd (1998). The answer is that it depends upon the type of insulin one takes and whether it is long, medium or quick-acting insulin. If patients check their blood glucose at bedtime and find that it is low, it is advisable that they take some long-acting carbohydrate before retiring to bed to prevent night-time hypoglycemia.

Special diabetes products

Recently, Diabetes UK have warned against purchase of products that are specially made for people with diabetes, on the grounds that:^[15]

• They may be expensive,
• They may contain high levels of fat
• They may confer no special benefits to people who suffer from diabetes.

Research has shown the Maitake mushroom (Grifola frondosa) has a hypoglycemic effect, and may be beneficial for the management of diabetes.^{[16][17][18][19][20][21]} The reason Maitake lowers blood sugar is due to the fact the mushroom naturally acts as an alpha glucosidase inhibitor.^[22] Other mushrooms like Reishi,^[23][24] Agaricus blazei,^{[25][26][27][28]} Agrocybe cylindracea^[29] and Cordyceps^{[30][31][32][33][34]} have been noted to lower blood sugar levels to a certain extent, although the mechanism is currently unknown.

Alcohol and drugs

Moderation is advised with regards to consuming alcohol and the use of some drugs. Alcohol inhibits the glycogenesis in the liver and some drugs inhibit hunger symptoms. This, together with impaired judgement, memory and concentration caused by some drugs can lead to hypoglycemia.

Specific diets

The Pritikin Diet consists of fruit, vegetables, whole grains, and so on, and is high in carbohydrates and roughage. The diet is accompanied by exercise.

G.I. Diet - lowering the glycemic index of one's diet can improve the control of diabetes.^[35][36] This includes avoidance of such foods as potatoes cooked in certain ways, and white bread, and instead favoring multi-grain and sourdough breads, legumes and whole grains—foods that are converted more slowly to glucose in the bloodstream.

Low Carb Diet - It has been suggested that the gradual removal of carbohydrates from the diet and replacement with fatty foods such as nuts, seeds, meats, fish, oils, eggs, avocadoes, olives, and vegetables may help reverse diabetes. Fats would become the primary calorie source for the body, and complications due to insulin resistance would be minimized.^[12] However, it's vitally important that such a diet is low in saturated fats. The American Diabetes Association explains: "saturated fat raises blood cholesterol. High blood cholesterol is a risk factor for heart disease. People with diabetes have more frequent heart disease."^[37]

High fiber diet - It has been shown that a high fiber diet works better than the diet recommended by the American Diabetes Association in controlling diabetes, and may control blood sugar levels with the same efficacy as oral diabetes drugs.^[38][39][40]

See also

• Diabetes management
• Low GI Diet
• Food guide pyramid
• Glycemic index

Further reading

• Francis, Dorothy Brenner (1987). Diets for sick children. London: Blackwell Scientific Publications. pp. 128–44. ISBN 0-632-00505-X. OCLC 18781984. 
• Thomson, W.; Ireland, J. T.; Williamson, John (1980). Diabetes today: a handbook for the clinical team. New York: Springer. pp. 112–20. ISBN 0-8261-3491-2. OCLC 300560258. 
• Bowling, Stella (1995). The Everyday Diabetic Cookbook. Grub Street Publishing. ISBN 1-898697-25-6. 
• Peterson, Amy Rachel; Karen Hanson Chalmers (1999). 16 Myths of a Diabetic Diet. Alexandria, VA: American Diabetes Association. ISBN 1-58040-031-0. 
• British Diabetic Association. Festive Foods and Easy Entertaining. British Diabetic Association. ISBN 1-899288-70-8. ^{[verification needed]}
• Govindi, A.; Myers, J. (1995) [1992]. Recipes for Health: Diabetes. Low fat, low sugar, carbohydrate counted recipes for the management of diabetes. London: Thorsons/Harper Collins. ISBN 0-7225-3139-7. OCLC 33280079. 
• Murray, M. & Pizzorno, J. (1990). Encyclopaedia of Natural Medicine. London: Littlebrown and Company. ISBN 1-85605-498-5^{[verification needed]}
• Ramachandran, A.; Viswanathan, M. (1997). "Dietary management of diabetes mellitus in India and South Asia". in DeFronzo, Ralph A.; Alberti, K. G. M. M.; Zimmet, Paul. International textbook of diabetes mellitus. London: J. Wiley. pp. 773–7. ISBN 0-471-93930-7. OCLC 32628217. 
• Sönsken, Peter; Fox, Charles; Judd, Sue (1998). Diabetes at Your Fingertips (Fourth ed.). London: Class Publishing. ISBN 1-872362-79-6. OCLC 41019837. 

References

External links

• Low GI Cooking and Recipes