Braille Monitor                                                    October 2009

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Carbohydrate Counting and the Exchange List

by Anna Smith

From the Editor: Anna Smith, a dietitian and diabetes educator with the Diabetes Management Program at Clark Memorial Hospital in Jeffersonville, Indiana, gave an expanded version of the following article as the keynote address at the 2003 annual conference of the Diabetes Action Network at the National Federation of the Blind convention June 30, 2003. A transcription of her speech appeared in the Winter 2004 edition of the Voice of the Diabetic. Its content was updated in June 2009.

I am handing out tennis balls and paper plates to illustrate how you can use these and your hand to identify food portion sizes. But first let's review a bit of background about basic nutrition. Our topic today is carb counting and the diabetes exchange list. Today I will give you sound nutritional information you can use with the diabetes exchange list or, if you do carb counting using other methods, to show you how you can do that. Your body is like a car. In order for that car to go anywhere, it has to have fuel, but we have to fuel our bodies every day, not like a car that you might fill up once a week. The body needs fuel several times a day.

Several things (your lifestyle, how your medications work, and whether you sleep at night or during the day) determine how often and how much you need to eat. We know the energy in our food (measured in calories) comes from three sources: carbohydrates, protein, and fats. The only other place that we get any caloric content at all is alcohol, which is a separate matter.

The carbohydrates are your first main category of nutrients. What is their role? Carbohydrates are your body’s number one fuel base. If someone’s telling you not to eat carbohydrates, please don’t listen. Don’t be an advocate of the Atkins diet. That is not the safest or the healthiest way of meeting your nutritional needs. Carbohydrates play a very important role for us. When we look at how they affect the blood sugars, we can see that carbohydrates in food quickly converts into sugar in your bloodstream.

Two different carbohydrates make up most of the foods we eat. The first is simple carbohydrates--we sometimes call these the sugars. With these we see a very fast conversion to sugar, and all of them have a 100% conversion into glucose in the bloodstream. That isn’t bad, however, because you do need them. Remember, this is your body’s number one nutrient source for fuel.

In planning a diabetic diet, I usually set the carbohydrate level at about 50 percent of your estimated caloric needs. For instance, for someone on a 1,200-calorie-a-day diet with about 50 percent of the calories coming from carbohydrates, I’d plan on about 150 grams of carbohydrates a day.

The other carbohydrates are complex--the ones we sometimes call the starches. You often hear that starch is bad for you, that you should never eat potatoes, bread, etc. But starches, the complex carbohydrates, can actually be part of a well-balanced and nutritious diet.

Here is where we begin to look at the best types of complex carbohydrates, the ones with some fiber coming on board with them. Where do we find fiber? In whole grain cereals, fruits, and vegetables. Beans are a good high-fiber carbohydrate.

Beans can be an economical source of both starch and protein. When we look at the conversion of these high-fiber complex carbohydrates into sugar, we see that they are much slower than those without fiber. This means they break down anywhere from about an hour to an hour and a half after your meal. So that bowl of beans gives a much slower rise in your blood sugar than a bowl of fruit, a piece of candy, or even a piece of white bread. That’s why the complex carbs are the ones we recommend as part of any meal.

What happens if your meal consists of mostly carbohydrates? We know even very complex carbs break down about an hour or an hour and a half after the meal. A typical breakfast for many of us is cereal, fruit, milk, and maybe toast. What category do all of those foods fit in? Carbohydrates. Have you noticed being hungry again an hour or two after that kind of breakfast? The reason that happens is that such a breakfast consists of quick fuel that gives your brain the fuel you need and your body a lot of the essential nutrients that come on board with those carbohydrates. But how long will that fuel stay with you? What happens if your meal is only carbohydrate-based foods?

What would provide longer-lasting fuel that won’t spike the blood sugar? Protein. If we look at the breakdown on protein, we see a much slower conversion of protein to glucose than we do for carbohydrates. The conversion begins thirty to forty-five minutes after you actually begin eating protein. At its peak, in the two-to-four hour range, that protein has only made about a 50% conversion to sugar. That glucose level does not continue to spike the blood sugar; it’s an ongoing fuel source. So to provide more satisfaction in a meal and longer-lasting fuel that does not continue to spike the blood sugar, always add some protein to your meal. Typically breakfast is the meal in which we miss that. Usually lunch and dinner include some protein, just because that’s the way our culture usually eats. So remember, at breakfast it is very important to put some protein on board.

The last nutrient that I want to talk about is fat. Fat often has a very bad rep. You've heard it all: it makes us gain weight and causes clogged arteries, and it’s just not good stuff. Good news about fats is on the horizon. Some good fats should be added to your daily intake of healthy foods. Some of my favorite fats now are nuts and natural peanut butter. I eat olives, I use olive oil, and I love avocados. Those are some of the healthiest fats.

When we look at how fat breaks down and turns into glucose in the bloodstream, we see that it is a very slow-converting nutrient. Fat breaks down over the course of several hours. But when you look at the amount of fat that actually turns into sugar, it’s only about 10 percent. So very little of the fat actually turns into glucose at all. The healthiest fats are nuts, avocados, and olives, and the three best types of oils (those richer in the mono-unsaturated fats) are canola, olive, and peanut oils. Those are the top-of-the-line, absolutely very best kinds of fat. What about nuts? Any kind of nuts. We’ll talk about portion size in just a minute.

Remember, when we’re looking at how fat affects the blood sugar, very little ever actually turns into sugar. So by itself fat does not greatly affect your blood sugar. But it breaks down very slowly, and, if we look at the energy fat provides, one gram of fat provides nine calories, so we get a lot of calories with those grams of fat. The new guidelines for healthier eating actually reflect a benefit of making about 30 percent of your calories be from grams of fat because fats actually give your meal what I call the “satiety factor.” Satiety means satisfaction. So, even if you add a piece of really lean chicken to a meal that already has the correct number of carbs, you may still find that you’re hungry three to four hours later. Ask yourself if that meal had some fat. This is where we get the combination fuel that can give you a five-hour span between meals.

So how do we put this fuel together so you’re getting the immediate energy you need, some protein to give you a little hold-over as well as building and repairing nutrients, and some fat for staying power--the satiety factor to help you last from five to six hours before eating again? The three nutrients (carbohydrates, protein, and fats) are your key fuels. When we look at the exchange list, we see that carbohydrates are made up of several food groups: fruits, starches, the low-carb vegetables (the starchy, higher-carbohydrate vegetables are in the starch category), and dairy, which includes milk and yogurt only. Cheese and cottage cheese are not included in dairy because they contain so much protein that they go in the protein group. Cheese and cottage cheese are considered protein-based foods with a little carbohydrate in them.

Most exchange guidelines include another category called other carbohydrates. That’s a group with foods that don’t fit in any of the other categories, like ice cream, angel food cake, jam, jelly, honey, tortilla shells, and tostito chips—even hummus, which has a little protein and some fat, but is mostly complex carbs from the chickpeas used to make it.

These then are the five carbohydrate categories in the Diabetes Exchange List. When you put together a meal plan, generally your dietitian or diabetes educator will give you either a certain number of carbs or, as I sometimes do, a certain number of carbohydrate choices. For instance, on a 1,200-calorie meal plan, you would generally have about three carbohydrate choices per meal. In a 1,500-calorie meal plan, you might have four carbohydrate choices per meal, With an 1,800-calorie meal plan, you might have four to five, depending on whether or not you have planned snacks between meals.

Why is it important to space those carbohydrates out from meal to meal, and not do the Weight Watchers concept, in which it doesn’t matter when you have them as long as you have the same number of points at the end of the day? Why would you not want to do that with your carbohydrate foods? Why would you not want to have them all in dinner? What happens to your blood sugar if you have all your carbohydrates in the evening meal? It’s going to skyrocket, and it will still be high at bedtime and more than likely the next day. Your doctor puts together your medication to accommodate and treat your diabetes. Then we match that with a meal plan to correspond to the way your medication affects the timing of meals and how many carbohydrates you should have at that particular meal.

That’s why it’s important for diabetics (and Weight Watchers wasn't created for people with diabetes) to have more or less constant carbs, where you have a consistent, constant amount of carbs from one meal to the next. For instance, if your educator has told you to have fifty to sixty grams of carbs, or four carb choices per meal, that would mean making some food choices within the carbohydrate category.

Let’s put a breakfast together—I have a few samples of food models here to do some meal planning with. Let’s put together a breakfast with four carb choices and see how we do. Orange juice? Let’s see. I forgot to bring my juice, but I brought an apple--we will consider that the fruit. Which one would be a better choice based on what we said earlier about fiber? Yes, the apple or a whole orange—more fiber than juice. Now comes portion size. Remember the tennis ball I gave you? Hold it in your hand and actually cup your fingers around it. Think about how that feels. That is what we call "an average portion of fresh fruit." That would be one fruit choice or one fruit exchange, a tennis-ball-sized piece of fruit.

One fruit choice generally has about fifteen grams of carbohydrate in it. We said our goal was to have about sixty in this meal, four carb choices. What else could we include in our breakfast? Cereal, yes, how about some oatmeal? "Oatmeal warms the heart"—have you ever heard that? We know that among the complications of diabetes are heart disease and high cholesterol. What do we know about oatmeal? The soluble fiber in oatmeal actually clinically lowers your LDL (bad) cholesterol. So it very much warms the heart, and it helps keep cholesterol down. Now I actually have a one-cup bowl of oatmeal here. One cup of cooked oatmeal would be two carb choices because a half-cup of cooked oatmeal is one carb choice in the starch category. If you eat the whole cup of cooked oatmeal, those carbs also double.

To make oatmeal, start with a half cup of dry oats and add one cup of water. That makes a whole cup of cooked oatmeal. We need one more carb choice since we have three now; how about milk? Or you can have a light or plain yogurt. That would be your choice in the milk category. One cup of light or plain yogurt has about the same carbs, about fifteen, as you would find in an eight-ounce glass of milk. An eight-ounce glass of milk has only about twelve grams of carbs, but in our carb choices we would still call that one carb choice.

So we now have our four carb choices, what are we missing? Protein. Remember I said earlier that nuts are a really good type of fat, but they also have protein in them. When we know we want some good fat in a meal and we also need some protein, cup your hand with those fingers closed, and you have a small handful of nuts. That would give you the equivalent of the protein in one egg or one ounce of meat. So, if you put nuts in your oatmeal or eat them on the side, you have now satisfied your needs for both protein and some of that good fat.

Here is one of my favorite breakfasts: two pieces of whole grain bread toasted—and, by the way, reduced-calorie bread has more fiber than the same amount of whole grain bread, and you get two slices for the same fuel value as one slice of regular bread. Generally a two-slice portion of reduced-calorie bread has about five grams of dietary fiber. So, if you use reduced-calorie bread, it’s a two for one in the starch category. You get two slices for one carb choice.  Back to that breakfast. If we toast two pieces of regular whole grain bread, one starch in each slice, we have used two starch choices.

We can spread some natural peanut butter (the kind that lists only peanuts and salt in the ingredients) onto that sandwich and spread a small amount of regular jam or jelly--a teaspoon has five grams of carbohydrates—and make a sandwich.
Regular peanut butter, by the way, like Jif or Skippy or your store brand, has a whole multitude of ingredients, including sugar, but the number-one ingredient that’s not good for you is hydrogenated oil. Those partially or fully hydrogenated oils are what we know now as the worst substance in our fuel system. Congress is asking for more information on products containing those. So I suggest you try to use the natural peanut butter instead. Natural peanut butter is separated when you open the jar (the oil separates from the solids). Here’s the trick--put it in your refrigerator upside down overnight. By the next day it will already have started distributing and mixing. When you take it out and open the jar, stir it with a knife all the way to the bottom. Remember, it has no preservatives. When you take the hydrogenated oil out, it will not stay on your pantry shelf forever like regular peanut butter. Store it in the refrigerator to preserve it. If you want it to spread more easily, set it out a few minutes before you make your sandwich so it can warm, and it will spread much better.

You have to prepare for tasting it by saying "this isn’t my old peanut butter." It’s not going to be as smooth as shortening, and it’s not going to taste sweet. It’s going to taste like ground up, salted peanuts, which is what it is. But I can tell you from my own experience, once you make that switch to natural peanut butter, you will not go back to the other. I buy the store brand, the Kroger’s natural peanut butter--it’s also made by Smucker’s--but the store brand is about a dollar a jar cheaper.

If we put that sandwich together, we now have two carb choices, and we can make the other two be a serving of fruit and a glass of milk. What goes better with a peanut butter sandwich than a glass of milk? That breakfast will stay with you a good five hours. This is one of the main breakfasts I’ve found will stay with me through a morning of teaching without my stomach’s growling. When I’m teaching people about what and how to eat, I don’t need to have my stomach growling in the middle. The fat in the peanut butter is my satiety factor for that meal.

How many calories per gram are there in each of the different nutrients? Carbohydrates and protein both have four calories per gram, and fat, as I mentioned earlier, has nine calories per gram. When you break down a nutrition label and see the serving size, the calories in a serving come from the protein, the carbohydrates, and the fat. There are no other sources of calories in the food. You can actually do the math and multiply the total grams of carbohydrate and protein each by four and the total fat grams by nine. Don’t get bogged down in the percentages of daily calories--you know, the percentage column over to the right side. Just ignore that. Those percentages are based on an arbitrary 2,000-calorie-a-day diet, which is a token number they chose to represent an average American diet.

When we’re looking at carbohydrates, the serving portion is very, very important. Someone may say, “There are only ninety calories in this," but not if what you have on your plate is the whole can rather than the half-cup portion listed as the serving size. If the serving you have on your plate is more or less than the serving size listed on the container, you must do the math. If ninety  calories are in a serving and you have three times that serving, your total calories would be 270. If fourteen grams of carbohydrate are in the recommended serving and you doubled your serving, you now have twenty-eight grams of carbohydrates, or, using exchanges, that would be two carb exchanges. Each one of those carb choices in the categories I mentioned is approximately fifteen grams of carbohydrate. So one starch, one fruit, one milk, and with vegetables that actually multiplies. A serving of vegetable like broccoli or green beans or a tossed salad has very small amounts of carbohydrate. Unless you’re eating a whole lot of veggies or salad, don’t even consider the low-carb vegetables in your meal plan. Most people aren’t going to eat more than they can enjoy, and that won’t be a problem for their blood sugar. Also we know those vegetables have a lot of fiber. If we actually look at the glycemic effect of those vegetables on the blood sugar, it’s very low. Even if you snack on baby carrots, you’re not going to get into a problem with your blood sugar. So the low-carb vegetables are freebies.

How many of you have problems with blood pressure? This is important for diabetics to keep under good control. Another reason those low carb vegetables are so beneficial to you is that they actually help give you better blood pressure. The natural potassium, magnesium, and fiber in them are important natural nutrients. This information came from a really good study a few years back called the DASH diet. It stands for the dietary approaches to stopping hypertension. Part of the approach was to eat lots of those vegetables and fruits every day as part of your overall basic meal plan. They recommended five to nine servings a day.

You can’t have all of those five to nine servings in fruit because that would be a whole lot of your carb choices. I generally recommend two to three servings of fruit a day for diabetics. Some people may go as high as three to four, but the fruit category of carbohydrates gets some people in trouble with high blood sugars. Here we also often tend to have problems with portion control. That’s why I gave you the tennis ball today as a reminder of your portion of fruit. The low-carb vegetables are very, very healthy--include a lot of them in your meal plan. With the starchy vegetables watch portions. Make a fist. That fist is the size of a one-cup portion of food. That would also be about the size of a medium baked potato, which is about two starches, so how many carbohydrates in that medium baked potato? Thirty. So we say it’s about thirty carbs or two of your carb choices in the starch category. So potatoes aren’t bad. If you know it's scrubbed well, eat the peel with it because you’re getting some fiber in it.

Your portion of meat, especially at the main meal of the day, is about three ounces. Use the palm of your hand, don't count the fingers, and stop at the wrist. That’s about three ounces of cooked lean meat, fat removed and no skin or bones. In your other meals you can have one to two ounces,  which is a much smaller portion. Remember meat has no carbs unless breading or something has been added, so we do not count meats as carb-based foods. Most of the time fats would not be considered carbohydrate food choices. Here is an exception: some people automatically choose fat-free salad dressings, but some of these have a lot of added sugar. The carbohydrates in those fat-free dressings may actually be as high as one of your carb choices. They may have fifteen to sixteen grams of sugar, of total carbohydrates, in perhaps two tablespoons of salad dressing. So beware of those dressings. Even if a dressing is identified as fat-free and sugar-free, look at the label. See if total carbohydrates are listed. Don’t be deceived by words like "sugar-free," "dietetic," or "no sugar added." They are not necessarily carbohydrate-free. The automatic assumption is that, because it’s sugar-free, I can eat all I want. Not true.

Dextrose, corn syrup, and fructose? These are sugars. Fructose is actually fruit sugar in a syrup form. High-fructose corn syrup is one of the more common ingredients you will see. Sorbitol is a sugar alcohol that is a little different from other forms of sugar. The forms of sugar in a product will generally end in “-ose” like dextrose, sucrose, fructose, maltose, or levulose. There are also some other names like corn syrup and maltodextrin. But when I teach carb counting, I really don’t even have you worry about the detail of where those sugars come from. You simply go to the nutrition facts label and see how many total carbohydrates there are in one serving of food. Don’t even go down to the sugars—look at the total carbohydrates because that is what affects your two-hour blood sugar. That’s why we have a more liberal approach to diabetes meal-planning now, and we even say you could have a teaspoon of honey or something with regular sugar in your meal, if you have counted that as part of the total carbohydrates in your meal. We now know the total carbohydrate in your meal matters—it’s not that you have to avoid all sugars or simple sugars—it is the total carbohydrates. So, when you’re looking at a product, even ice cream, it can be part of your carbohydrates within a meal—in a portion allotted in your guidelines. It’s the total carbohydrates in that meal that makes a difference on what that two-hour blood sugar will look like.
What about the so-called diet foods that have all the fake stuff in them like Olestra? Olestra is a fake fat. It doesn’t absorb as a fat but is supposed to make food taste as if it has fat in it. It hasn’t been very popular because it has the detrimental side-effect in many people of diarrhea. Personally I choose to use baked chips and baked items instead of Olestra fat-free products like the WOW chips. You can use baked chips (and you still count your carbohydrates in them), but they’re baked, without having oils added to them, and some pretty good-tasting items are on the market now. You can use them as part of your carbohydrates in a meal.

What about the sugar alcohols? Sugar alcohols are ingredients many manufacturers use in sugar-free or no-sugar-added foods. They can make this claim legally by simply taking the sucrose out of the product. That opens a can of worms about what that food can contain. Producers often add sugar alcohols as a substitute sweetener. These are still considered a carbohydrate, and the FDA now requires them to be so listed.

Remember that regular carbs have four calories per gram. Sugar alcohols have two calories per gram. If they are present in a food (as part of the sweetening), then manufacturers must now list them under total carbohydrates. The label should say “so many grams of sugar alcohol.” Lots of manufacturers actually list the ingredient: sorbitol, maltolol, zalitol, manitol--hear the “ol” ending in those ingredient names? Those are the sugar alcohols. If they are present, they will show up in the total carbohydrates of that food.

Let me warn you about sugar alcohols if more than five grams are listed in a serving, which is common in sugar-free desserts, sugar-free ice creams, sugar-free cookies, sugar-free syrup. Sometimes you will see as much as twenty-five to twenty-eight grams of sugar alcohol in one serving.  Like the Olestra I mentioned earlier, sugar alcohols can have a detrimental side effect. In many folks they cause gas, stomach distension, and diarrhea. So just beware that sugar-free gums and mints have a little carbohydrate in them, but it’s usually only two or three grams in a portion or a serving. It’s not a lot, so it probably won’t affect you unless you eat a whole package at one time. In small amounts they're fine, but, if you’re counting carbs and it’s something that has twenty-five or thirty grams of sugar alcohol, don’t spend your carbs on that food; spend it on a smaller portion of something that tastes better with the real stuff in it. That’s the beauty of counting carbs.

We talked about cereals; what about cereals other than oatmeal? Any time you try out a new cereal, look at the serving size. This is the time to get out the measuring cups and get the feel for the estimated portion size to know what one serving of that cereal would be and how many carbohydrates it would account for because cereals can vary widely, and the number of carbs goes up tremendously when sugar is added. One cup of raisin bran has about forty-three grams of carbohydrates. Not only are there carbohydrates in the whole wheat flakes, the raisins  are coated with sugar, so one cup of raisin bran would be three carb choices in that meal. The milk for the cereal would be the fourth carb choice if you are on sixty per meal.

What about sugar substitutes? If you’re baking cookies, what kind of sugar substitute can you use? You can use any cookie recipe if it lists the carbs per serving in the nutritional breakdown. The cookies don’t have to be sugar-free. My favorite sugar substitute is Splenda. It is made from sugar, and it tastes like sugar, but it is a non-nutritive sweetener. You can buy it in large pourable containers and use it measure for measure. It measures exactly like sugar in a recipe. It doesn’t have an aftertaste. You can use Equal or Sweet’n’Low of course, but the taste is not going to be as true, and the baked goods won’t be as tasty. Also cooking sometimes alters these sweeteners; it does not with Splenda. The price of Splenda is coming down, and we’re finding it in more and more products.

How do raisins stack up as a snack? I always caution people with diabetes about how often and what they’re having for snacks. The way your meal plan is structured will determine what snacks can consist of. If you are using insulin but your insulin regimen is only covering the carbohydrates in planned meals, and you’re not on any additional insulin (to reduce excursions), you're probably using a rapid-acting insulin like Novolog or Humalog. Those insulins cover and process what you’re eating anywhere from thirty minutes to about two hours. That’s the in-and-out time of that quick form of insulin. It will cover the carbohydrates in a given meal. But if three hours later you snack on a handful of raisins or other dried fruits, the portion size must be reduced, or you'll blow your control. A quarter cup of raisins has about the same amount of carbohydrates as that tennis-ball-sized piece of fresh fruit--the sugar is still there; you just took out the water. Be very careful about using raisins as snacks unless you have carbohydrate snacks worked into your meal plan. If you use carbohydrates for snacks, you should test your blood sugar two hours after a meal.

If you’re not in the really good recovery zone of under 140 and then you have a carbohydrate snack in two and a half or three hours with a blood sugar 200, what will happen? Your blood sugar will go way up. So snacks can be part of your meal plan, but work with your educator to incorporate appropriate snacks in your meal plan.

What about cashews as a snack? Cashews are wonderful, but remember portion control—a palmful. Any nuts are very good, some are a little higher in the mono-unsaturated fats, some a little higher in the polyunsaturated, but any are good. An excellent study was done in Salt Lake City by the Mormons because of their vegetarian diet. They did a study on the health value of nuts and reported any kind of nuts can be used as part of a healthy meal plan.

What size banana is one carb choice? A small banana or half of a large banana is one fruit choice. A small banana is only five to six inches long. By the time you peel it, you’ve got four to four and a half inches of banana.

What about pizza? This is where I suggest to people that you modify your previous thinking. Pizza is a combination food. It has a lot of carbohydrates from the starch in the crust and from the tomato sauce. With a meat topping you will have a lot of protein but also a lot of fat--lots of fat partnering with those carbs. If pizza is the only thing you have in that meal, your portion will probably be much more than you need in order to satisfy your stomach for quantity of food. What happens to that blood sugar later? It’s going to be high, and people typically report blood sugars are still very high the next morning. Here’s part of the problem with pizza. It’s not just the amount of carbohydrates, but also the amount of fat partnered with them. I said earlier that some fat in the meal is a good idea, but too much fat partnered with the carbs will actually delay the conversion of the carbs to sugar, which keeps the blood sugar higher at the two-hour mark, and those sugars are on for the ride. Those are the ones that get held over until the next morning, and they affect your A1c. So I suggest that you change your thinking about pizza. Always have a nice big salad before you start eating the pizza. Be sure that salad has some light dressing. Better yet, dip your fork into the dressing before spearing a bit of salad so you’re not adding much fat in the dressing. Then up to two pieces of pizza would be your max to keep you in good control.

What about using olive oil and lemon juice as a salad dressing? Is that good? Yes. Lemon juice is a freebie; it’s rich in ascorbic acid, citric acid, so that’s a freebie in the diabetes realm. Use olive oil in very small amounts because one teaspoon of olive oil has five grams of fat. Use a maximum of one tablespoon of olive oil. When you add herbs and spices to olive oil, they enhance the flavor without adding more carbs or fats or anything. Those are free in your meal plan. Use very little salt. Instead use spices, garlic, onion, basil, thyme. All of those kinds of herbs and spices are wonderful for enhancing the flavor--and they do not add any more caloric value. Vinegar is also a freebie.

When you hear statements like, "There's no such thing as a diabetic diet," the experts are saying that diabetics do not eat separate foods; rather a person with diabetes can simply eat healthy meals. A diabetic meal should not be much different from a regular meal. You can make wise substitutions, like choosing fruit instead of the regular dessert or grilled chicken when others get fried chicken. In the broad scope of diabetes meal planning, I always teach people to modify any given meal to make it fit into your meal plan.

One of the other visuals I gave you was a paper plate. The choices in a meal will be a serving of meat, a starch (potato, rice, pasta, whatever), and some sort of brightly colored vegetable--green beans, broccoli, carrots, summer squash, zucchini, or greens. These brightly colored vegetables are generally the nonstarchy ones. I suggest to serve a healthier meal fill about half of that plate with those nonstarchy vegetables. About a fourth of that plate (a fistful) should be starch, and meat should fill the other fourth of the plate. This is the healthiest way of eating--that’s why we say there’s no such thing as a diabetic diet anymore. You're eating the same things nondiabetics are, just in appropriate, balanced moderation.

When people come to me, they think I’m going to give them a diet sheet. The first thing I tell them is, "You are not here to get a diet." I will teach you how to eat more healthily, so don’t call this a diet. Instead you will be eating in the healthiest way for a person with diabetes, and you don’t need special foods to do that. Don’t buy all those sugar-free products. Our goal is healthy eating, so everyone should be broiling and grilling and sautéing in a nonstick skillet using a little olive oil cooking spray, stir frying with lots of vegetables and lean meats, and limiting starchy foods because too many of them gets us in trouble with our blood sugar two hours later. So more vegetables, less of the starch, and round out the meal--assuming you have saved some of your carbohydrate choices for that meal with a small portion of regular dessert. That way you’re not singled out because you have diabetes.

Some have even said that, if everybody ate the diabetic diet, nobody would be diabetic. There’s a certain amount of truth to that for people with type 2 diabetes, but you’d also have to consider lifestyle. It really is a partnership between what we eat and how active we are. A sensible diet would be a very good start to preventing diabetes, but in a diabetes prevention program published last year the key element was exercise. Thirty minutes of walking, about two miles, five times a week prevented overt diabetes in the folks who had the genetic predisposition for type 2. They modified their lifestyle, and they ate more healthily, so it was a partnership.


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