Attention, patients of diabetes mellitus! Do you know that in addition to medicines, diet forms an integral part of diabetes management? Are you aware that diet can act as a therapy and can control diabetes in about 40% of patients without medicine? Do you often get confused from conflicting advice you get from your friends ? If your answer is YES, then this post is meant for you. If you disagree, then please read it twice to understand the importance of diet in diabetes. In this post I will discuss various components of a diabetic diet.
Food is the essence of life and diabetics are no exception. The diabetics do not require a special diet, however certain modifications in the diet are required to control blood sugar level. Correct dietary practices will keep the blood sugar within controlled limits as well as reduce the dosages of anti-diabetic medication. It will not only delay the complications, but also save your pocket. For proper control of diabetes, a patient should be aware of the principles of a diabetic diet. It is a common observation that large number of diabetics are unaware of dietary modifications. Don’t eat potato, don’t eat rice, take Karela (bitter gourd) juice etc are some of the advises a diabetic often gets from people. Some advocate high protein and low carbohydrate diet. Some people avoid carbohydrates altogether. A lot of confusion thus exists, specially from an Indian perspective. Before the dietary modifications in diabetes are discussed, it will be worthwhile to discuss diet components in a normal diet.
A balanced diet consists of energy (measured in calories), proteins, carbohydrates, fats, vitamins and minerals in proper proportions. Each component is essential for proper growth, repairs and other body functions. As per recent guidelines, total energy requirements should follow the following principles:-
- Total calorie requirement is equal to 20 cal/kg/day (overweight persons) and 30 cal/kg/day (normal weight persons).
- Carbohydrates should provide 60-70% of total energy
- Proteins should provide 10-15% of total energy
- Fats should provide 15-30% total energy
Dietary Modifications in Diabetes
Traditional Indian diet is diabetes friendly. The diet of a diabetic person should be like a diet of a healthy individual. A diabetic diet should have adequate amount of proteins, carbohydrates, fats as per the guidelines. The crux of diabetic diet lies in following principles:-
- Control of calories (For most of the diabetics 1500-1800 Kcal per day diet will suffice).
- Avoid foods which raise the blood sugar level quickly.
Obesity is dangerous. It exposes you to numerous diseases. (Read post Obesity Harms for dangers of obesity). Since obesity is an important risk factor for diabetes, a diabetic must reduce his weight (better to be slightly underweight than overweight) and bring his BMI to below 25. One has to restrict calories to maintain weight (Read the post lose weight and be healthy for weight reduction). The total calorie requirement of an overweight/obese diabetic will be 20 calorie per kg per day. A normal weight individual will require 30 calories per kg per day. If you are above 50, then reduce total calorie requirement by 10% for each decade. A diabetic should not exceed his total calorie requirement under any circumstance.
Carbohydrate Intake in Diabetes
Diabetes complications are primarily due to high blood sugar level over prolonged periods. It is a common belief that diabetics should avoid carbohydrates. Some people advocate low carbohydrate and high protein diet to reduce blood sugar level. Nothing can be more dangerous than this. It is a well established fact that a high carbohydrate and high fibre diet improves glucose tolerance, reduces diabetic symptoms and reduces the dose of anti diabetic drugs. In diabetic diet, carbohydrates should provide 60-70% of energy akin to non diabetics. Diabetics should avoid those foods which raises the blood sugar level quickly (foods with high glycemic index) and for prolonged times. Glycemic index (GI) is the ability of food to raise the blood sugar level after ingestion, with glucose as reference. Generally cereals like wheat, rice, potato and carrots have high GI (65-75). Legumes & lentils like dried beans, peas, green gram and bengal gram have low GI. Bengal gram also helps in reducing cholesterol and triglycerides level in blood. Fruits have intermediate GI (45-55). The glycemic response of different foods depends upon its physical form and nature of cooking. For eg white bread has a higher GI than traditional chapatti. Detailed information on GI of foods is available at http://ajcn.nutrition.org. Foods with high GI raise the blood sugar quickly and should be avoided. Foods with simple sugars (eg sucrose or table sugar) belong to this category and must be avoided at all cost. One should avoid sweets, biscuits, candies, cakes, soft drinks and fruit juices. Fruits should be taken in natural form by diabetics instead of juices. Complex carbohydrates obtained from whole grain cereals, pulses, fruits have intermediate to low GI and release sugar slowly in the blood. They should form an integral part of a diabetic diet. During consumption of these food items, total calorie intake limit should not be forgotten. All foods laden with fats and carbohydrates like pizza, french fries, ice creams, energy drinks should be avoided. Intake of tea, coffee and other drinks has to be moderate. The best drink for diabetes is plain water. Diets with low glycemic index are generally rich in fibre. Traditional Indian diet of cereals, pulses and vegetables are rich in fibre and additional fibre is generally not required. People, who consume non vegetarian foods and bakery foods, can increase fibre content of the diet by addition of purified fibre supplement as wheat bran, guargum, tracanth, oat meal or ispaghul to the diet. Fenugreek seeds are also rich in fibre.
The Myth of Diabetic Sweets and Biscuits
Now a day’s diabetic sweets and biscuits are available in markets. People have erroneous impression that these can be taken in any amount. They can be taken once in a while but total calories must be kept in mind. One can replace sugar with artificial sweeteners. The crux of a diabetic diet is; limit calorie intake and limit foods with simple sugars.
Diabetics are prone to heart diseases due to enhanced atherosclerosis and lipids abnormalities. A diabetic diet must address these issues as well. Judicious intake of fats will help to reduce lipid abnormalities and progression of atherosclerosis. Detailed dietary guidelines are discussed in my post “Are fats really harmful“. Diabetics should avoid high cholesterol foods like red meat, organ meat and maintain blood cholesterol below 200 mg/100 ml of blood. In addition, diabetics with hypertension or cardiovascular diseases should reduce salt intake to less than 3 gms per day. (Dietary guidelines for cardiovascular diseases will be published in due course of time).
How Many Meals In A Day?
It is important to have regular and smaller meals. Fasting is not advised to avoid hypoglycemia. The total calorie intake should be divided into three equal meals and two snacks. The normal saying that breakfast should be heaviest and dinner should be lightest, does not apply to diabetics. Each meal should comprise of 25% of total calories and remaining 25% Cal to be divided for snacks. Most of the carbohydrates should be derived from starch.
The dietary guidelines for diabetic diet can be summarized as under
- Food to be used freely; Vegetables, Green leafy vegetables, spices and high fibre foods
- Foods to be used in moderate amounts; Fats, nuts, cereals/roots/tubers, pulses, fruits, milk and milk products, meat, eggs & artificial sweeteners.
- Foods that must be avoided; sugars, sweets, honey, jams and jellies, cakes & pastries, sweetened juices and soft drinks.
Studies conducted at National Institute of Nutrition (NIN), India have proved that fenugreek seeds (Methi in Hindi & Guajarati, Mentikora in Telugu and Uluba in Malyalam) are effective in diabetic control. Fenugreek seeds are rich in fibre (about 20-50%) and contain substance called trigonelline. Trigonelline is known to reduce blood sugar. Fenugreek seeds powder in diet reduces blood sugar and urine sugar resulting in improvement in glucose control in NIDDM as well as IDDM. It also helps to lower cholesterol and triglycerides. Fenugreek seeds taken before meals reduce the glycemic index by 10-20%. Fenugreek leaves have no anti diabetic action. A booklet ‘Diet and Diabetes’ published by NIN has given numerous recipes on fenugreek seeds.
The dose of fenugreek seeds will vary from 25 gm to 50 gm depending upon the severity of disease. To start with 12.5 gm of seeds can be taken two times a day along with lunch and dinner. The seeds can be taken as such with water after overnight soaking for 15 minutes before meals. It can also be made into powder which can be incorporated in preparations like chapattis, rice, dal and vegetables or in drinks like butter milk or water. The bitter taste is a drawback, but can be masked by intelligent preparations of food. Few may develop diarrhea or excess flatulence on consumption of fenugreek seeds. These symptoms subside after some time. If they persist the dosage of seeds should be reduced. One must remember that fenugreek seeds should be used as a supportive therapy only and usual diabetic treatment should be continued as advised by doctor.
Now I will discuss some myths or wrong beliefs about diabetic diet.
Belief number 1. Diabetics can eat wheat but not rice.
It is not true. Both increase blood sugar level to a similar extent. It does not matter whether rice or wheat is taken as long as the total quantity is restricted and calorie intake is not exceeded. Imagine the problem faced by a South Indian, who is advised to eat chapatti and not rice as part of dietary management. For some it may be convenient to count chapattis (Indian bread) than measure the amount of rice consumed.
Belief Number 2. Person with diabetes should avoid carbohydrates.
Diet of diabetics should mimic normal diet with 60-70% carbohydrates. A high carbohydrate diet improves insulin action. Complex carbohydrates derived from whole grain cereals, pulses are better than those derived from simple sugars.
Belief Number 3. Diabetics should not eat potato, banana etc.
The glycemic index of banana and potato is similar to rice or wheat. It can be taken in moderate amount provided total calorie intake is not exceeded.
Belief Number 4. Diabetic can take diabetics sweets and biscuits as much they want.
Diabetic sweets and biscuits have low calorie and sugar content than conventional sweets or biscuits. They usually contain artificial sweeteners like saccharin as sweetening agent. They can be occasionally taken by diabetics provided the total calorie intake is not exceeded.
Belief Number 5. Diabetics should not eat fruits or can have any amount of fruits as per their desire.
Fruits contain fructose not glucose. Insulin is required for control of glucose in the blood not fructose. Fructose levels are not affected by insulin. Thus having fruits will not increase blood glucose level. However fructose is a carbohydrate and will add to the total calorie intake. Diabetics may not restrict fruits intake and can consume fruits in limited amounts. Fresh fruits are advised. Fruit juices must be avoided to avoid intake of concentrated dose of calories. We all know excess calories consumed will add to the weight and make control of the disease difficult.
In the article, I have discussed about dietary precautions that must be followed by diabetics. Unfortunately, In my experience a large number of people do not adhere to proper diet. They listen to their tongue and eat to glory exposing themselves to danger of early onset of complications. Adherence to dietary principles is the need of the hour to delay complications and save money. It will also help you to combat heart diseases. These dietary guidelines are applicable to diabetics without kidney involvement. Once kidneys are affected, dietary precautions for renal patients are also to be incorporated. Diabetes once contracted cannot be reversed to normal, but with proper self care (read my post about self care tips for diabetics) and diet, a patient of diabetes can live a healthy and disability free long life.
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