March is National Nutrition Month, celebrated by the Academy of Nutrition and Dietetics. In part one of this two part series, experts Alison Evert and Gretchen Benson discuss weight management, carbohydrates, and the importance of a heart-healthy eating plan.
Figuring out what to eat with diabetes can be daunting – so we spoke with leading Registered Dietitian Nutritionists (RDNs) who are also Certified Diabetes Care and Education Specialists (CDCESs) to gain some insight into what they recommend.
They’ve spent years caring for and counseling people with diabetes, and are involved nationally in myriad volunteer efforts to communicate the art and science of diabetes care.
Evert is the assistant director of Nutrition Services for University of Washington Medicine Primary Care. She was also the co-lead author in 2014 and again in 2019 for the American Diabetes Association’s (ADA) nutrition recommendations.
Question: You now work in primary care after having worked in an endocrinology clinic for years. Most people with diabetes, particularly type 2 diabetes, receive their diabetes care in primary care. How do you suggest people with diabetes learn what optimal care is and advocate to get it?
Evert: I encourage people to be proactive. For people with type 2 diabetes, ask your PCP for a referral to a registered dietitian nutritionist (RDN) with experience in diabetes care and education (a CDCES). I work in a health system in which nutritionists and CDCES are part of our primary care clinics. This works well because people can see these providers at the same location they see their PCP.
In addition, a lot of people, especially since the pandemic, can get this counseling using telemedicine. People get to choose the day and time that is convenient for them! Plus, they can walk to their kitchen and show us the foods from their cupboards or refrigerator they enjoy, or have questions about.
If you have type 1 diabetes, work with a PCP to assist you with your general healthcare needs and try, if possible, to work with an endocrinologist to help you manage your diabetes.
Question: How much weight does the research show people need to lose to impact their glucose, lipids and/or blood pressure?
Evert: Research studies on this topic continue to reveal that overweight and obesity are closely linked with type 2 diabetes. It should also be noted that rates of overweight and obesity are increasing with type 1 diabetes, too. Healthy lifestyle changes that result in losing 5% from a person’s starting weight can improve blood pressure, lipids, and/or glucose, along with other health parameters.
Regarding weight loss to prevent type 2 diabetes, the weight loss goal is greater than 7%. If remission of prediabetes or type 2 diabetes in the early years after diagnosis is a goal, research shows that the health benefits can be progressive. The more weight that is lost, the greater the health benefits. The DiRECT trial, a study done in primary care practices in the UK, showed that people with recent-onset type 2 diabetes who lost 15 percent or more from their starting weight could experience type 2 diabetes remission. However, what’s critical is to keep as many of the lost pounds off as possible to continue to experience the health benefits.
I find it helpful to translate percentage goals into actual numbers. For example, if a person’s weight is 240 pounds, 7 to 15% of their weight would be 17 to 36 pounds. Being told by a healthcare provider that you need to lose 50 to 100 pounds, or more, is frankly disheartening. I also find that helping people set realistic weight loss goals is important. I don’t want people to give up before they get started!
Question: What are the top evidence-based strategies that people with type 2 diabetes who have overweight or obesity can put into action to lose a few pounds and keep those lost pounds off to prevent or delay diabetes progression?
Evert: Research continues to show that insulin resistance, and the loss of beta cell function (the cells that make insulin in the pancreas) that results from excess body fat, can lead to elevated glucose levels. Unfortunately, type 2 diabetes is a chronic condition, and people seem to progressively lose beta cell function over time.
My job is to help people with diabetes create an eating plan that fits their lifestyle. In the case of type 2 diabetes, that’s an eating plan that helps keep beta cells functioning well for as long as possible. However, there is not one eating pattern (from lower carbohydrate to Mediterranean to vegan) that works well for everyone.
The key is to find a healthy eating plan that works for you over the long haul. For sure, your choices may change overtime. I believe that food is medicine. Get the ongoing support you need from healthcare providers, as well as peers, to balance healthy eating and long term weight management.
Benson is the program director for the Women’s & Cardiovascular Health Science Centers at the Minneapolis Heart Institute Foundation. She has been involved in diabetes care for 20 years. Over the past two years, she has served on the ADA’s Professional Practice Committee, the committee that reviews and revises ADA’s annually updated Standards.
Question: What is the current guidance from ADA regarding the amount of carbohydrate people with diabetes should eat?
Benson: There’s not an ideal amount of carbohydrate (or protein/fat for that matter) for people with diabetes. Many studies have found that people with diabetes who ate a low-carbohydrate diet (less than 26 percent of total calories) were more effective in reducing their A1C and weight in the short-term (over about six months), but there was less difference between a variety of eating patterns, including higher carbohydrate, at one year.
When it comes to the amount of carbohydrate you eat, it’s important to personalize this based on your eating preferences and overall diabetes care plan and find an eating pattern that you can sustain over the long term. If you are interested in following a low/lower carbohydrate eating pattern, talk to your healthcare provider. Also note that based on the amount of carbohydrate you eat and the glucose-lowering medications you take, you may need adjustments with these medications to prevent hypoglycemia.
When it comes to your selection of foods that contain carbohydrates, let quality be your guide. Focus on non-starchy vegetables, fruits and whole grains, as well as dairy products with minimal added sugars (all types of sugars added to foods and beverages when manufactured).
Question: We know people with diabetes often have, or are at risk for, heart and blood vessel problems. What are a few relatively easy changes people can make in their food choices and eating habits to manage these problems?
Benson: The most important factor to change the way you eat is to find actions you can live with long term. When it comes to eating, there is no “one size fits all approach.” Find what works for you. Start with small, realistic changes and build on them over time.
There are a variety of ways to increase nutrient-dense foods as detailed in the tips below. And, of course, it’s important to honor and appreciate your personal and cultural preferences as highlighted in the 2022 National Nutrition Month theme.
Eat more fruits and vegetables. The average American eats way fewer than the recommended five or more servings of fruits and vegetables per day — only one in 10 Americans meets this guideline. An eating pattern high in fruits and vegetables is associated with a lower risk of heart attacks and strokes, as well as a lower risk of premature death. If you don’t get close to the five or more servings – start to add one more serving a day. Move vegetables and fruits to the top drawers of your refrigerator for easier visibility. Wash and cut up fruits and vegetables in advance for easy additions to meals and snacks.
Eat more plant-based meals. Eating mostly plant-based doesn’t mean you need to give up all meats or dairy products. A plant-based eating pattern includes mostly fruits, vegetables, whole grains, nuts, seeds, legumes and beans. It limits processed foods. This eating plan may include small amounts of animal products, such as meat, fish and seafood, eggs and dairy. Limiting animal protein and replacing it with plant protein (think beans, nuts and whole grains) can help improve cardiovascular risk factors, such as blood pressure and cholesterol. It may even help lower glucose through increasing insulin sensitivity and help with weight management. Start with Meatless Mondays and add other plant-based meals from there. (search “Meatless Mondays” for recipe ideas).
Eat more whole foods. Whole, fresh foods, like whole grains, vegetables and fruits; contain more nutrients and vitamins than their processed counterparts. Yes, they’re nutrient dense. Conversely, heavily processed foods frequently contain excess salt and/or added sugars. Practical pointer: eat more foods that don’t have a label or ingredient list. Think salmon, apples, spinach, and walnuts.
Eat high quality fats and oils. Healthy fats and oils are an essential part of a heart-healthy eating pattern and overall health. Olive oil, nuts and seeds contain mainly fat, but due to the types of fat they have, they seem to lower your risk of heart disease and stroke. All fats, regardless of their quality, have the same number of calories, but some fats and oils are healthier than others.
Put these tips into action:
Choose foods with unsaturated fats, like olives, peanuts, almonds, avocados and sesame seeds.
Limit foods high in saturated fat, like fatty cuts of meat, sausage, bacon and cheese. Replace saturated fat with oils that contain poly- and/or mono-unsaturated fats, like olive oil, canola oil or nut oil; rather than replacing those calories with carbohydrates, particularly refined ones, to get maximal heart health benefits.
Avoid trans-fats added to foods, like commercial baked goods and fried foods (read nutrition facts labels).
Question: Why has the measurement of LDL-cholesterol (LDL-C) become such an important measure of risk for heart and blood vessel diseases?
Benson: According to the CDC, if you have diabetes, you’re twice as likely to have heart disease or a stroke than someone who doesn’t have diabetes…and at a younger age. A high LDL-C level is associated with a higher risk of developing heart and blood vessel diseases. However, your LDL-C number should not be the sole factor to guide your treatment to prevent a heart attack or stroke.
The best place to start is to ask your healthcare providers to estimate your overall risk. Most adults with diabetes 40 years of age or older can benefit from taking a statin medication along with practicing healthy lifestyle behaviors. LDL-C is important because it can be measured before and then after starting a statin to see if the amount of statin medication is at the right dosage. Lowering LDL-C further has been shown to be beneficial even with normal or low cholesterol levels. Recent reports suggest that there is no such thing as lowering cholesterol ‘too much’.
Question: Why is regular physical activity such an important component of a holistic approach to type 2 diabetes care and prevention/delay of complications?
Benson: Regular physical activity is an essential element of diabetes care and prevention of complications. Most people with diabetes should get 150 minutes or more of moderate to vigorous aerobic activity per week (or 30 minutes at least five days per week). People should not go more than two consecutive days without being physically active. Add to this the goal of reducing sedentary behaviors by interrupting it with regular breaks.
In people with insulin resistance, common in type 2 diabetes, regular physical activity can improve glucose levels by improving the sensitivity of the body’s cells to insulin. This allows cells to use glucose in the body more effectively. Physical activity also improves cardiovascular risk factors, [in addition to glucose], like blood pressure and lipids and can help delay diabetes complications, like heart disease and stroke.
Regular physical activity can assist with weight loss and, even more so, it helps keep lost pounds off. It also can positively impact your mood, sleep pattern and overall sense of wellbeing.
Good news: you can hit your physical activity goals by accumulating bouts of shorter durations (i.e. ten minutes at a time). Find ways to be physically active that you enjoy and flexibly fit into your life to benefit from the sustained impact.