Diabetes Diet


Description
An in-depth report on how people with diabetes can eat healthy
diets and manage their blood glucose.
Alternative Names
Dietary Recommendations
Major Food Components

Carbohydrates

Compared to fats and protein, carbohydrates have the greatest

impact on blood sugar. Evidence now suggests that it is the total
amount of carbohydrates rather than the specific type that most
directly affects blood glucose.

Carbohydrate types are either complex (as in starches) or simple

(as in fruits and sugars). One gram of carbohydrates equals four
calories. The current general recommendation is that
carbohydrates should provide between 50% and 60% of the daily
caloric intake.

Complex Carbohydrates. In all cases, complex carbohydrates

found in whole grains and vegetables are preferred over those
found in starch-heavy foods, such as pastas, white-flour products,
and potatoes. Most of these are high in fiber, which is important
for health. Whole-grains specifically are extremely important for
people with diabetes or at risk for it. [For specific benefits, see
Box Whole Grains, Nuts, and Fiber-Rich Foods and see Table
Some Examples of Healthy Foods.]

Simple Carbohydrates (Sugar). Sugars are generally one of two

types:

 Sucrose (table sugar). Sucrose has also been associated

with higher triglycerides and harmful cholesterol levels.
And a 2002 study suggested that a high level of sugar
consumption may reduce levels of HDL cholesterol, the
so-called good cholesterol.
 Fructose (sugar molecule found in fruits). Fructose may
produce a slower increase in blood sugar than sucrose,
which may have some advantages for people with
diabetes. Dark-colored fruits are rich in important
 vitamins and other nutrients, and studies continue to report
their benefits for the heart and health in general. Other
fruits, such as apples and grapes also have important food
chemicals. (As with any sugar, however, excess use of
fructose is associated with triglycerides and harmful
cholesterol levels.)

Sugar itself, either as sucrose or fructose, adds calories, increases

blood glucose levels quickly, and provides no other nutrients.
High level of sugar consumption--whether fructose or sucrose--
has been associated with higher triglycerides and lower levels of
HDL cholesterol, the so-called good cholesterol. And the high
consumption of sugar is most likely one of the factor in the
current obesity epidemic. Soda, other sweetened beverages, and
fruit juice in fact may be singled out as major contributors to
childhood obesity.

People with diabetes should continue to avoid products listing

more than 5 grams of sugar per serving, and even fruit intake
should be moderate. If specific amounts are not listed, patients
should avoid products with either sucrose or fructose listed as one
of the first four ingredients on the label. [See Box Fat Substitutes
and Artificial Sweeteners.]

Of increasing interest to researchers in the study of possible harm

from sugar are advanced glycation end-products (called AGEs),
which are end-products of the chemical reaction between sugar
and protein. This reaction occurs most intensively when cooking
at high temperatures--particularly animal fats. (Steaming or
cooking food in water does not produce these chemicals. Low,
slow cooking also produces fewer AGEs.) AGEs can also be
formed by chemical reactions in the body itself. They are now
believed to promote factors in the inflammatory response that
cause a number of diseases or their complications, including
diabetes and other serious conditions (e.g., Alzheimer's,
atherosclerosis, cataracts, and osteoporosis).

Whole Grains, Nuts, and Fiber-Rich Foods

Fiber is an important component of many complex carbohydrates.

It is almost always found only in plants, particularly vegetables,
fruits, whole grains, nuts, and legumes (dried beans, peanuts, and
peas). (One exception is chitosan, a dietary fiber made from
shellfish skeletons.) Fiber cannot be digested but passes through
the intestines, drawing water with it and is eliminated as part of
feces content. The following are specific advantages from high-
fiber diets (up to 55 grams a day):

 Insoluble fiber (found in wheat bran, whole grains, seeds,

nuts, legumes, and fruit and vegetable peels) may help
achieve weight loss. Consuming whole grains on a regular
basis appears to provide many important benefits, and
especially to people with type 2 diabetes. They are
associated with insulin sensitivity, a lower risk for heart
disease, and possibly even weight loss. They may even
lower the risk for type 2 diabetes in the first place.Of
special note, nuts, such as almonds, macadamia, and
walnuts may be highly heart protective, independent of
their fiber content. One study reported that high
consumption of nuts or peanut butter was also associated
with a lower risk for type 2 diabetes. (Peanuts are not
technically nuts but are legumes.)
 Soluble fiber (found in dried beans, oat bran, barley,
apples, citrus fruits, and potatoes) has important benefits
for the heart, particularly for achieving healthy cholesterol
levels and possibly reducing blood pressure as well.
Evidence on the heart benefits of beans continues to grow.
For example, a 2001 study indicated that eating beans four
or more times a week reduced the risk for heart disease by
22%.

 Soluble fiber supplements, such as those that contain

psyllium or glucomannan, may be beneficial. Psyllium is
taken from the husk of a seed grown in India. It is found in
laxatives (e.g., Metamucil), breakfast cereals (Bran Buds),
and other products. In one 2002 study, for example,
patients with type 2 diabetes who consumed psyllium
(Plantaben) for breakfast for 11 weeks experienced lower
total and LDL cholesterol. There was no difference in
glucose of HbA1c levels. Of note, although there were no
changes in mineral and vitamin levels, there was an
increase in sodium after consuming psyllium. People who
increase their levels of soluble fiber should also increase
water and fluid intake. (Some human and animal studies
suggest, however, that psyllium increases triglyceride
levels in postmenopausal women.)

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Fat Substitutes and Artificial Sweeteners

Replacing fats and sugars with substitutes may help many people
who have trouble maintaining weight. In fact, in one 2003 study,
people with type 2 diabetes used the artificial sweetener sucralose
and a beta-glucan fat replacer (derived from oats) as part of a low-
calorie diet. At the end of the four weeks, they achieved better
weight, glucose control, and HDL levels than those on a standard
diabetic diet.

Fat Substitutes

Fat substitutes added to commercial foods or used in baking,

deliver some of the desirable qualities of fat, but do not add as
many calories. It should be stressed that eliminating all fats from
ones diet can be harmful to general health. Some include the
following:

 Stanols. Stanols are plant compounds used in margarines

(Benecol, Take Control). Benecol is derived from pine
bark and Take Control from soybeans. Two servings a day
of either brand as part of a low-fat diet can lower LDL and
total cholesterol by impairing its absorption in the
intestinal tract. Some studies have reported that their use
can allow lower doses of statins--cholesterol lowering
agents. These products do not appear to block absorption
of fat-soluble nutrients or vitamins, as olestra does [see
below]. They can be hydrogenated, however, and can
contain some trans-fatty acids.
 Olestra (Olean) passes through the body without leaving
behind any calories from fat. Studies suggest that it
improves cholesterol levels and helps people lose weight
when it is used to replace a third of normal dietary fats.
(Simply adding snacks containing olestra do not appear to
have any effect on cholesterol or weight loss.) Early
reports of cramps and diarrhea after eating food containing
olestra have not proven to be significant. Of greater
concern is the fact that even small amounts of olestra
depletes the body of certain vitamins and nutrients that
may help protect against serious diseases, including
cancer. The FDA requires that the missing vitamins be
added back to olestra products, but not other nutrients. The
adverse health effects, if any, are unknown.
  Beta-glucan is a soluble fiber found in oats and barley.
Products using this substance (e.g., Nu-Trim) may reduce
cholesterol and have additional health benefits.

A number of other fat-replacers are also available. Although

studies to date are not showing any significant adverse health
effects, their effect on weight control is uncertain, since many of
the products containing them may be high in sugar.

Artificial Sweeteners

Many artificial or low-calories sweeteners are available. A 2002

study confirmed that people who consumed artificial sweeteners
in beverages and foods and reduced their sugar intake weighed
less over time than those who ate similar types and amounts of
drinks and food containing sugar. It should be noted that using
these artificial sweeteners should not give dieters a license to
increase their fat intake. Studies indicate that consuming some
sugar is not a significant contributor to weight gain as long as the
total caloric intake is under control. There is some public concern
about chemicals used to produce many of these sweeteners and
adverse effects in studies using rats. Natural low-calories
sweeteners are available that may be more acceptable to many
people.

 Saccharin (Sugar Twin, Sweet n’Low, Sucaryl, and

Featherweight). Saccharin has been used for years but is
not used as commonly now. Some studies found that large
amounts of saccharin cause bladder cancer in rats.
Although the rats were fed huge amounts that do not apply
to human diets, some evidence suggests that people who
have six or more servings of saccharin per day may have
an increased risk.
 Aspartame (Nutra-Sweet, Equal, NutraTase). Aspartame
has come under scrutiny because of rare reports of
neurologic disorders, including headaches or dizziness,
associated with its use. People with phenylketonuria
(PKU), a rare genetic condition, should not use it. Studies
have not reported any serious health dangers, but some
people may be sensitive to it.
 Sucralose (Splenda). Sucralose has no better aftertaste and
works well in baking, unlike other artificial sweeteners. It
is made from real sugar by replacing hydroxyl atoms with
chlorine atoms. Some people are concerned because
chlorinated molecules used in major industrial chemicals
have been associated with cancer and birth defects. Over
 100 studies have been conducted on sucralose over a 20-
year period with no reports of such risks.
 Acesulfame-potassium (Sweet One, SwissSweet, Sunette).
It has been used in the US since 1988 with no reported
adverse effects.
 Neotame (Neotame). Neotame is a synthetic variation of
aspartame but was developed to avoid its side effects. The
association with aspartame has raised some concerns.
Studies to date have reported no effects that would cause
alarm and it appears to be safe for general consumption.
 D-tagatose (Tagatose). This reduced calorie sweetener is a
novel low-calorie sweetener derived from lactose, which
is found in dairy products and other foods. It may be
specifically beneficial for people with type 2 diabetes and
have additional benefits that aid the intestinal tract.
 Alitame (Aclame) is formed from amino acids. It has the
potential to be used in all products that contain sugar,
including baked goods.
 Stevioside (Stevia). This is a natural sweetener derived
from a South American plant. It is available in health food
stores. People with diabetes should avoid alcohol-based
forms. It has not been rigorously tested.

Others being investigated include, glycyrrhizin (derived from

licorice), and dihycrochalcones (derived from citrus fruits).

The Carbohydrate Counting System. Some people plan their

carbohydrate intake using a system called carbohydrate counting.
It is based on two premises:

 All carbohydrates (either from sugar or starch) will raise

blood sugar to a similar degree. In general, one gram of
carbohydrates raises blood sugar by 3 points in people
who weigh 200 pounds, 4 points for weights of 150
pounds, and 5 points for 100 pounds.
 Carbohydrates have the greatest impact on blood sugar;
fats and protein play only minor roles.

In other words, the amount of carbohydrates eaten (rather than

fats or proteins) will determine how high blood sugar levels will
rise. There are two options for counting carbohydrates: advanced
and simple. Both rely on the collaboration with a physician,
dietitian, or both. Once the patient learns how to count
carbohydrates and adjust insulin doses to their meals, many find it
more flexible, more accurate in predicting blood sugar increases,
and easier to plan meals than other systems.

The basic goal is to balance insulin with the amount of

carbohydrates eaten in order to control blood glucose levels after
a meal. The steps to the plan are as follows:

The patient must first carefully record a number of factors that are
used to determine the specific requirements for a meal plan based
on carbohydrate grams:

 Multiple blood glucose readings (taken several times a

day).
 The time of meals.
 Amount in grams of all the carbohydrates eaten.
 Time, type, and duration of exercise.
 The time, type, and dose of insulin or oral medications.
 Other relevant factors, such as menstruation, illness, and
stress.

The patient works with the dietitian for two or three 45 to 90

minute sessions to plan how many grams of carbohydrates are
needed. There are three carbohydrate groups:

 Bread/starch.
 Fruit.
 Milk.

One serving from each group should contain between 12 and 15

carbohydrate grams. (Patients can find the amount of
carbohydrates in foods from labels on commercial foods and from
a number of books and web sites.)

The dietitian creates a meal plan that accommodates the patient's

weight and needs, as determined by the patient's record, and
makes a special calculation called the carbohydrate to insulin
ratio. This ratio determines the number of carbohydrate grams
that a patient needs to cover the daily pre-meal insulin needs.

Eventually, patients can learn to precisely adjust their insulin

doses to their meals.

It should be noted that patients who choose this approach must

still be aware of protein and fat content in foods. They may add
excessive calories and saturated fats. Patients must still follow
basic healthy dietary principles.

The Glycemic Index. The glycemic index has been developed to

determine which carbohydrate-containing food raise blood
glucose levels more or less quickly after a meal. The index uses a
scale of numbers for specific foods that reflect greatest to least
delay in producing an increase in blood sugar after a meal. The
lower the index number, the better the impact on glucose levels.
Some evidence suggests that the benefit of foods with a low
glycemic index is due to their ability to increase insulin levels
quickly and so remove blood sugar rather than their ability to
slow the release of blood sugar itself.

There are currently two indexes in use. One uses a scale of 1 to

100 with 100 representing a glucose tablet, which has the most
rapid effect on blood sugar [SeeTable The Glycemic Index of
Some Foods.] The other common index uses a scale with 100
representing white bread (so some foods will be above 100).

A major 2003 analysis suggested that choosing foods with a low

glycemic index scores may have a small but significant effect on
controlling the surge in blood sugar after meals. Many of these
food are also high in fiber and so have heart benefits as well.
Substituting low- for high-glycemic index foods may even help
prevent weight gain.

One easy way to improve ones glycemic index is simply to

replace starches and sugars with whole grains and legumes (e.g.,
dried peas, beans, and lentils). However, there are many factors
that affect the glycemic index of foods, and maintaining a diet
with low glycemic load is not straightforward. The following are
some considerations:

 The numbers attributed to each carbohydrate-rich food are

not additive. In other words, adding All Bran cereal (index
of 49) to a banana (index of 61) does not equal 110.
 Adding certain fats to a food, for example butter to potato,
can slow down the potato's impact on blood sugar. One
study reported that when patients ate fatty foods first, their
blood glucose levels were significantly lower an hour after
 the meal than when carbohydrates were eaten first.
 Adding foods with organic acids (e.g., pickles, yogurt) to
meals may reduce the impact of foods with high glycemic
scores on blood sugar. (It should be noted that yogurt
alone, however, has the same high glycemic index as
regular milk.)

No one should use the glycemic index as a complete dietary

guide, since it does not provide nutritional guidelines for all
foods. It is simply an indication of how the metabolism will
respond to certain carbohydrates. Some experts believe it is too
complicated to be practical and that simply tracking
carbohydrates, eating healthily, and maintaining a healthy weight
is sufficient. Nevertheless, a study on children with type 1
diabetes suggested that it offered as many choices as the exchange
diet and they did not report feeling any greater limitations.

The Glycemic Index of Some Foods

Based on 100 = a Glucose Tablet Â
BREADS Â
pumpernickel 49
sour dough 54
rye 64
white 69
whole wheat 72
GRAINS Â
barley 22
sweet corn 58
brown rice 66
white rice 72
BEANS Â
soy 14
red lentils 27
kidney (dried and boiled, not canned) 29
chickpeas 36
baked 43
DAIRY PRODUCTS Â
milk 30
ice cream 60
CEREALS Â
oatmeal 53
All Bran 54
Swiss Muesli 60
Shredded Wheat 70
Corn Flakes 83
Puffed Rice 90
PASTA Â
spaghetti-protein enriched 28
spaghetti (boiled 5 minutes) 33
spaghetti (boiled 15 minutes) 44
FRUIT Â
strawberries 32
apple 38
orange 43
orange juice 49
banana 61
POTATOES Â
sweet 50
yams 54
new 58
mashed 72
instant mashed 86
white 87
SNACKS Â
potato chips 56
oatmeal cookies 57
corn chips 72
SUGARS Â
fructose 22
refined sugar 64
honey 91
Note. These numbers are general values, but may vary widely
depending on other factors, including if and how they are cooked
and foods they are combined with.

Protein

In general, experts recommend that proteins should provide 12%

to 20% of calories. This daily amount of poses no risk to the
kidney in people without signs of nephropathy. Protein is
important for strong muscles and bones. Protein intake in diabetes
is complicated, however:

 Some evidence also suggests that a high-protein diet

lowers post-meal blood sugar more effectively than
standard diets. This might be specifically help for patients
with type 2 diabetes.
 On the other hand, protein restriction may be important
 for insulin-dependent diabetic patients with kidney
disease. Evidence now strongly indicates that even
moderate restriction of proteins may help slow the
progression of nephropathy. A 1999 study indicated that a
strict-low protein diet may even delay the need for dialysis
in patients with kidney failure. All major studies on
restricting protein have used insulin-dependent patients as
subjects. It is not yet known if lowering protein would
have the same benefits for diabetics with nephropathy who
are not insulin-dependent. (Note: Diets that are severely
low in both protein and salt and coupled with high fluid
intake increases the risk for hyponatremia, a rare condition
that can cause fatigue, confusion, and, in extreme cases,
can be life-threatening.)

One gram of protein contains four calories. Protein is commonly

recommended as part of a bedtime snack to maintain normal
blood sugar levels during the night, although studies are mixed
over whether it adds any protective benefits against nighttime
hypoglycemia. If it does, only small amounts (14 grams) may be
needed to stabilize blood glucose levels.

Fish. Fish is probably the best source of protein. Evidence

suggests that eating moderate amounts of fish (twice a week) may
improve triglyceride and help lower the risks for death from heart
disease, dangerous heart rhythms, blood pressure, a tendency for
blood clots, and the risk for stroke.

It should be noted that a French study reported a higher incidence

of heart attack in men who ate fish daily. Such findings may be
due to mercury toxicity, which has harmful effects on the heart.
High mercury content has been observed in swordfish and shark
and, to a medium extent, in tuna, trout, pike, tilapia (tile fish) and
bass.More research is needed to further define the risks and
benefits of fish, but at this time most evidence for eating fish two
or three times a week is highly positive for most people. [See
Beneficial Fats and Oils under Fats and Oils, below.]

Soy. Soy is an excellent food. It is rich in both soluble and

insoluble fiber, omega-3 fatty acids, and provides all essential
proteins. Not all studies are consistent, but the majority has shown
an improvement in at least one of the cholesterol components in
people who consumed at least 25 grams of soy protein. Soy may
also reduce other heart risk factors, including blood pressure, at
least in certain populations.In one 2002 study, soy was associated
with better control of blood sugar and lower LDL levels in
postmenopausal women with type 2 diabetes. The best sources are
soy products (tofu, soy milk) or whole soy protein. Adding soy to
lean ground beef may still provide heart benefits and be more
acceptable for people who object to soy's taste or its "veggie"
image. (Note: Tablets of individual isoflavones--chemicals, such
as genistein or daidzein, found in soy--do not appear to offer any
advantages. Soy sauce is also not a good source. It contains only a
trace amount of soy and is very high in sodium.)

More research is important to determine if soy has long-term

complications. Of possible concern, a high intake of soy during
pregnancy may have some adverse effect on the fetus, although
only animal studies have suggested this.

Meat and Poultry. For heart protection, one 1999 study suggested
that it didn't matter if you chose fish, poultry, beef, or pork as long
as the meat was lean. (Saturated fat in meat is the primary danger
to the heart.) The fat content of meat varies depending on the type
and cut. It is best to eat skinless chicken or turkey. However, the
leanest cuts of pork (loin and tenderloin), veal, and beef are
nearly comparable to chicken in calories and fat and their effect
on LDL and HDL levels. It should be noted, however, that even
chicken and lean meat do not improve cholesterol levels, and, in
terms of cardiac health, fish is a more desirable choice.

Dairy Products. A 2002 study reported a lower incidence of

factors related to type 2 diabetes and heart disease (insulin
resistance, high blood pressure, obesity, and unhealthy
cholesterol) with a high intake of dairy products, including those
with a high-fat content. Some researchers suggest the calcium in
dairy products may be partially responsible for these benefits. The
effects of extra calcium on blood pressure, however, are mixed
with some even showing higher pressure. Because many dairy
products are high in saturated fats, which are related to heart
disease, this study requires confirmatory evidence.

Fats and Oils

Some fat is critical in everyone's diet, but certain fats have good
or harmful effects on health, depending on their chemistry. All
fats, good or bad, are high in calories compared to proteins and
carbohydrates. In order to calculate daily fat intake, multiply the
number of fat grams eaten by nine (one fat gram is equal to 9
calories, whether it's oil or fat) and divide by the number of total
daily calories desired. One teaspoon of oil, butter, or other fats
equals about five grams of fat. All fats, no matter what the source,
add the same calories.

People should strive to replace saturated (animal fats) and

transfatty acids (commercial fats) with unsaturated fats from plant
and fish oils. The American Heart Association and other experts
now recommend that the source of most of these unsaturated fats
should come from omega-3 fatty acids, which are found in fish
and plant sources.

The Chemistry of Fats and Cholesterol. Most of the cholesterol in

the body does not come from food but is produced by the liver--
stimulated by saturated fats. The dietary key to managing
cholesterol, then, lies in understanding some of the major
compounds in fats and oils that are becoming important in health:

 Fatty Acids. All fats and oils found in foods are made up
of chains of molecules called fatty acids. There are three
major chains: saturated fatty acid (found mostly in animal
products) and two unsaturated fatty acids--
monounsaturated and polyunsaturated fatty acids (found
in plant products). The oils and fats that people and
animals eat are nearly always mixtures of these three
chains, but one type of fatty acid usually predominates in
specific oils or fats.
 Essential Fatty Acids. In addition, there are three chemical
subgroups of polyunsaturated fatty acids called essential
fatty acids: omega-3 and omega-6 polyunsaturated fatty
acids, and omega-9 monounsaturated fatty acids.
 Transfatty Acids. To complicate matters, there are also
trans-fatty acids, which are not natural but are
manufactured by adding hydrogen atoms to
polyunsaturated fatty acids (called hydrogenation).

Harmful Fats. Reducing consumption of saturated fats and trans-

fatty acids is the first essential step in managing cholesterol levels
through diet.

 Saturated Fats. Saturated fats are found predominantly in

animal products, including meat and dairy products. They
are strongly associated with higher cholesterol level and
have been associated with a higher risk for type 2
diabetes. They may be even more dangerous in women
than in men. Avoiding fats during the evening meal may
be especially helpful. High-fat meals are associated with
 sudden surges in triglyceride levels and other lipids along
with impaired blood flow in the arteries to the heart. (The
so-called tropical oils, palm, coconut, and cocoa butter, are
also high in saturated fats. Evidence is lacking, however,
about their effects on the heart. The countries with the
highest palm-oil intake, Costa Rica and Malaysia, also
have much lower heart disease rates and cholesterol levels
than Western nations.)
 Trans-fatty Acids. Trans-fatty acids are manufactured fats
created during a process called hydrogenation, which is
aimed at stabilizing polyunsaturated oils to prevent them
from becoming rancid and to keep them solid at room
temperature. Studies report that high consumption of these
fats reduces HDL cholesterol levels, has harmful effects
on the linings of the arteries, and may increase the risk for
diabetes type 2. In one study, women whose diets were
high in trans-fatty acids had a 53% increased risk for heart
attack compared to those who consumed the least of those
fats. Some experts believe that these partially
hydrogenated fats are even worse for the heart than
saturated fats. They may also pose a risk for certain
cancers. Hydrogenated fats are used in stick margarine and
in many fast foods and baked goods, including most
commercially produced white breads. (Liquid margarine is
not hydrogenated and is recommended.) The FDA has
now required that food labels include information on
trans-fatty acids.

Beneficial Fats and Oils. It should be noted that some fat is

essential for health, and fat is essential for healthy development in
children. Public attention has mainly focused on the possible
benefits or hazards of monounsaturated (MUFA) and
polyunsaturated (PUFA) fats.

 Polyunsaturated fats are found in safflower, sunflower,

corn, and cottonseed oils and fish.
 Monounsaturated fats are mostly present in olive, canola,
and peanut oils and in most nuts. (Canola is the most
unsaturated of all the fats.) Some studies have reported
that replacing carbohydrates with monounsaturated fats
improves glucose control after meals and reduces
triglycerides in people with type 2 diabetes.A study on
type 1 patients also reported improved cholesterol levels.
Diabetic patients who are overweight, however, should be
conscious of the calories in any oils.
Researchers are most interested in the smaller fatty-acid building
blocks contained in both oils, which may have more specific
effects on lipids. Three important fatty acids are the essential fatty
acids omega-3, omega-6, and omega-9.

Omega-3 fatty acids are found in fish oil (docosahexaenoic and

eicosapentaneoic acids) and plants (alpha-linolenic acid).

 Docosahexaenoic (DHA) and Eicosapentaneoic (EPA)

Acids. DHA and EPA are found in fish oils, and evidence
suggests that they have significant benefits for the heart,
including reducing sudden death from heart disease,
dangerous heart rhythms, inflammation, blood clotting
factors, blood pressure, and improving triglyceride levels.
Fish oil has little effect on LDL or HDL levels. Its effects
on blood glucose levels in people with type 2 diabetes are
unclear. These fatty acids may also reduce risks for other
disorders, including stroke, rheumatoid arthritis, asthma,
ulcerative colitis, some cancers, and mental decline. Three
capsules of DHA-EPA supplements are about equivalent
to eating one serving of fish.The richest sources of omega-
3 fatty acids are oily fish, such as salmon, mackerel, or
sardines. [For more information, see Fish under Protein.]
 Alpha-linolenic Acid. Alpha-linolenic acid is a plant
precursor of DHA, which means the body can convert it to
DHA. Sources include canola oil, soybeans, flaxseed, and
certain nuts and seeds (walnut, flax, chia and sometimes
pumpkin seed). Some, but not all, studies suggest that oils
or foods containing these oils may also be heart-
protective. Supplements or foods containing these oils
may also protect the heart. For example studies have
reported heart protection from flaxseed supplements and
also from nuts, such as almonds, macadamia, and walnuts.
Nuts are high in calories, although studies in 2002
reported that replacing usual snacks with almonds did not
affect the daily diet and significantly reduced cholesterol
and other heart disease risk factors. Still, people must be
aware of that nuts are not low-calorie snacks.

Omega-6 polyunsaturated fatty acids are found in corn, safflower,

soybean, and sunflower oil. PUFA oils containing omega-6 fatty
acids constitute most of the oils consumed in the US. Some
omega-6 fatty acids are important for health. However, high
intake of these fats was associated in one study with weight gain
in the abdomen (the so-called apple shape), a risk factor for heart
disease.High consumption is also associated with a higher risk for
certain cancer and some chronic diseases.

Omega-9 monounsaturated fatty acids are contained in canola and

olive oil. Both oils have been associated with health protection.

Research suggests that a healthy balance of all these fats may be

important and that our current Western diet contains an unhealthy
ratio of omega-6 to omega-3 fatty acids (10 to 1). Omega-9 fatty
acids may also contain chemicals that block harmful factors found
in omega-6 fatty acids. Researchers are finding then that the most
benefits may be found in mixture of all three fatty acids found in
both poly- and monounsaturated oils, but in modest amounts that
do not add too many calories.

Fat Substitutes. Fat substitutes added to commercial foods or used

in baking, deliver some of the desirable qualities of fat, but do not
add as many calories. [See Box Fat Substitutes and Artificial
Sweeteners.]

Dietary Cholesterol

The story on cholesterol found in the diet is not entirely

straightforward. Cholesterol is found only in animal tissues, with
high amounts occurring in meat, dairy products, egg yolks, and
shellfish. The American Heart Association recommends no more
than 300 mg of cholesterol per day. One study estimated,
however, that reducing dietary cholesterol intake by 100 mg/day
would only produce a 1% decrease in cholesterol levels. Of note,
however, are studies indicating that although dietary cholesterol
itself does not appear to increase the risk for heart disease in most
individuals, people with diabetes, especially type 2, may be an
exception. Until more research is done, they should consider
avoiding eating eggs or other high-cholesterol foods (such as
shrimp) more often than once a week.

Some Examples of Healthy Foods

Foods Phytochemicals Vitamins Benefits
and Carotenoids and other
valuable
food
components
Apples. Flavonoids. Â May have activity
 against certain
cancers (lung).
Also may help
maintain healthy
cholesterol. May
protect against
asthma.
Beans. Flavonoids. Folate, iron, Some experts
potassium, believe beans are
and zinc. the perfect food.
Berries, all Ellegic Acid. Vitamin C, May protect the
kinds of dark minerals. aging brain. (In
colored. one study
blueberries were
most effective.)
Broccoli Flavonoids, Vitamin C, Anticancer
(also kale, isothiocyanates, folate, fiber, properties.
Brussels lutein, beta and and Protective against
sprouts, alpha carotene. selenium. heart disease and
cauliflower).Note: Young stroke.
sprouts of broccoli
and cauliflower
contain much
higher levels of
isothiocyanates
than their mature
forms.
Carrots and Lutein, beta Vitamin A Protects eyes,
other bright carotene and other (converted lungs. (Cooking
yellow provitamin A from carrots may
vegetables. carotenoids. carotenoids), increase the
Vitamin C. potency of food
nutrients.)
Chocolate, Flavonoids. Â Heart protective
dark. Note: (may improve
Milk lipids and help
chocolate prevent blood
does not have clotting. May
benefits. have protective
properties against
lung cancer (not
other cancers).
Eggs. Lutein. Many B Although egg
vitamins, yolks are high in
Vitamin A, cholesterol, very
Vitamin D. little of it has a
 negative effect on
people with
normal levels.
And the health
benefits of eggs
are now known to
be very high.
(People with
diabetes or those
with high
cholesterol should
restrict eggs,
however.)
Fish, oily  Vitamin B3, Heart and brain
(mackerel, B12. protective.
salmon, Essential
sardines). fatty acids,
selenium.
Garlic. Allium  Possibly
(organosulfurs). protective against
certain cancers,
heart diseases,
and infection.
Heating garlic can
reduce benefits.
Allowing crushed
fresh garlic to
stand 10 minutes
before heating,
however, may
preserve
beneficial
chemicals while
cooking.
Ginger. Zingiberaceae. Â Cancer fighting
properties.
Grains Lignans Vitamin B, May help reduce
(whole). (phytoestrogens). selenium the ability of
(important cancer cells to
antioxidant invade health
mineral), tissue.
fiber, folate.
Grapes, Flavonoids, Â Fight heart
including (resveratrol, disease and
purple grape quercetin and cancer. May help
juice, and red catechin). lower the risk for
wine asthma. May
benefit people
with diabetes.
Nuts (such as  Vitamin E, May lower
almonds, Vitamin B1, cholesterol levels,
macadamia, essential fatty reduce sudden
and walnuts). acids, folate, death rates from
fiber. heart disease, and
help prevent
stroke and type 2
diabetes.
Nuts. Â Vitamin E, Protects the heart
Vitamin B1, and may help
essential fatty prevent stroke.
acids, folate.
Onions. Flavonoids, allium  May have activity
(organosulfurs). against certain
cancers (lung).
Oranges. Monoterpenes. Vitamin C, Many health
folate, benefits.
potassium. Increases HDL
levels.
Potatoes  Vitamin C, Many health
(Sweet). Vitamin E, benefits.
Vitamin A.
Soy. The best Isoflavones  May have effects
products are (phytoestrogens), similar to
tofu, soy flavonoids, estrogen,
milk, or phytosterol, including
whole soy phytate, saponins. maintaining bone
protein. and benefiting the
heart in women.
May also be
protective against
prostate cancer
and possibly other
cancers. More
studies are
needed. Effects
on breast cancer
are uncertain.
(Note: Soy may
have different
effects in men
than in women.
Of some concern
 is one study
reporting more
mental decline in
men who
consume greater
amounts of tofu.)
Spinach and Zeaxanthin, beta Vitamin C, Protects lungs and
other dark carotene. folate, brain.
green leafy Vitamin A
vegetables. (converted
from
carotenoids).
Tea (Both Flavonoids  Cancer fighting
black and (primarily properties,
green tea are catechins). particularly in
beneficial. green tea, which
Best results may be especially
associated beneficial for
with green smokers.
tea.)
Both black and
green tea may
protect against
heart disease and
stroke, although
studies are mixed.

Tea drinking also

may help with
weight control
and help prevent
osteoporosis.
Tomatoes. Lycopene, Vitamin C, Studies link to
Flavonoids. biotin, reductions in
minerals. prostate and other
cancers. Infection
fighters.
Note on Organic versus Inorganic Products. There is some
evidence that organic produce has higher levels of antioxidants
and that some agricultural chemicals may destroy flavonoids.
Nevertheless, organic produce is expensive, and fruits and
vegetables, no matter how they are grown are still filled with
healthful nutrients.

Â
Vitamins and Supplements

The value of specific vitamins on health in general and for

individual diseases is unclear. Nevertheless, of interest was a
2003 study reporting a significantly lower rate of infections
(17%) in people with type 2 diabetes who took a multivitamin and
mineral supplement compared to those who took a placebo (93%).

Antioxidant Vitamins E, C, and A. Deficiencies in Vitamins E and

beta carotene have been linked to heart disease and also to higher
blood glucose levels. These nutrients as well as vitamins C and A
have antioxidant effects and other properties that should benefit
the heart. However, a number of studies have found no reductions
in heart disease in people who have taken antioxidant vitamins. In
2003, the US Preventive Service Task Force concluded that, to
date, evidence is insufficient to confirm or refute the benefits of
supplements of any of these vitamins in protecting against heart
disease. It is important to note, in addition, that each of these
supplements may even be harmful to the heart in high doses. [See
Box Antioxidants: Pros and Cons.]

Folate and B12 Vitamins. Deficiencies in the B vitamins folate

(known also as folic acid) and B12 have been associated with a
higher risk for heart disease in some (but not all) studies. Such
deficiencies produce elevated blood levels of homocysteine, an
amino acid that has been associated with a higher risk for heart
disease, stroke, and heart failure. Some studies in 2002, suggest
that any risk posed by homocysteine or benefits from folic acid
for heart disease are at most modest. One study, however,
reported lower failure rates after angioplasty in patients who took
folic acid and vitamins B12 and B6. And a major 2002 suggested
that lowering homocysteine levels with folic acid would reduce
the risk for heart disease by 16% and stroke by 24%. More
evidence is needed to determine whether homocysteine plays a
causal role in cardiovascular disease and whether the B vitamins
are protective. Folate improves blood flow through the arteries,
which may be important for the heart, regardless of its effect on
homocysteine.

Niacin. Niacin (vitamin B3) is used for lowering unhealthy

cholesterol levels. Although vitamin B3 is available over the
counter, it can have significant side effects. A physician should
prescribe niacin in order to ensure its safety and effectiveness.

[For more information, see Well-Connected Report #39 Vitamins,

Carotenoids, and Phytochemicals.]

Antioxidants: Pros and Cons

Description of Oxygen-Free Radicals (Oxidants)

Currently, the most important benefit claimed for vitamins A, C,

E, and many of the carotenoids and phytochemicals is their role as
antioxidants, which are scavengers of particles known as oxygen-
free radicals (also sometimes called oxidants). These chemically
active particles are by-products of many of the body’s normal
chemical processes. Their numbers are increased by
environmental assaults, such as smoking, chemicals, toxins, and
stress. In higher levels, oxidants can be very harmful in the
following way:

 They can damage cell membranes and interact with

genetic material, possibly contributing to the development
of a number of disorders including cancer, heart disease,
cataracts, and even the aging process itself.
 Oxygen-free radicals can also enhance the dangerous
properties of low-density lipoprotein (LDL) cholesterol, a
major player in the development of atherosclerosis.

Description of Antioxidants and Warnings on High-Dose

Supplements

Antioxidant vitamins (A, C, and E), carotenoids, and many

phytochemicals can neutralize free radicals. Unfortunately,
although it is clear that vitamins are required to prevent
deficiency diseases, to date, there is no strong evidence that
antioxidant supplements offer any real protection. Everyone
should try to obtain these nutrients from dark colored fresh fruits
and vegetables, which contain balanced teams of antioxidant
vitamins and nutrients.

In fact, there is some increasing evidence that high doses of

vitamin C, vitamin E, and beta carotene supplements may have
pro-oxidant effects, which can be harmful in certain cases.

The strongest evidence on negative effects to date are studies

reporting an increase in lung cancer and overall mortality rates
among smokers who took beta carotene supplements. In
determining reasons for this disturbing effect, one animal study
suggested that beta carotene increased enzymes in the lungs that
actually promote cancerous changes. A 2000 study also reported a
higher risk for cancer in male smokers who took multivitamins
plus A, C, or E.

And, even more worrisome, in people with existing cancer, high

doses of antioxidant vitamins, such as vitamin C or beta carotene,
may actually protect cancer cells (just as they do healthy cells).
For example, a 2003 study reported a higher risk in melanoma in
people with vitamin-C rich diets.

Some evidence also exists that high doses of vitamin C may speed
up atherosclerosis. In a 2003 study, women with heart disease
who took antioxidant vitamins had a higher risk for heart attack or
death than those who didn't take one.

A 2002 study, also reported a higher incidence and greater

severity of respiratory infections in older adults who took 200 mg
of vitamin E daily. Some researchers speculate that certain
immune factors generate oxidants to fight bacteria. These
antioxidant vitamins then may block that action.

Salt and Sodium

Most experts recommend salt restriction in people who are

hypertensive. Some people, however, are much more sensitive to
harmful effects from salt than others:

 People at Risk for Salt-Sensitivity (African Americans,

Diabetics, the Elderly). About half of people with
hypertension have blood pressure that reacts significantly
to salt. Such people are known to be salt-sensitive. High-
salt diets in anyone who is salt-sensitive may harm the
heart, kidney, and brain and increase the risk for death,
regardless of their blood pressure. (Even people with
normal blood pressure can be salt-sensitive.) Among those
at highest risk for salt sensitivity are African Americans,
people with diabetes, and elderly people. A 2001 study, for
example, reported that reducing sodium intake in older
people, including African Americans, was very effective in
controlling their hypertension. Still because testing for
salt-sensitivity is not easy, experts recommend that
everyone proactively restrict their daily salt-intake.
 Overweight People. Overweight individuals may absorb
 and retain sodium differently from people with normal
weights. In fact, one 1999 study reported that high sodium
intake was associated with an increased risk of heart
disease and all cause mortality in overweight, but not in
normal weight, people. Unfortunately, because overweight
people generally consume more calories, they are also
likely take in more sodium.

Simply eliminating table and cooking salt can be beneficial. It

should be noted, however, that about 75% of the salt in the typical
American diet comes from processed or commercial foods, not
from food cooked at home, so the benefits of table-salt substitutes
are likely to be very modest. Some sodium is essential to protect
the heart, but most experts agree that the amount is significantly
less than that found in the average American diet. If people cannot
significantly reduce the amount of salt in their diets, adding
potassium-rich foods might help to restore a healthy balance.

Other Minerals

Calcium. Calcium supplements may be important in older patients

with diabetes to help reduce the risk for osteoporosis, particularly
if their diets are low in dairy products.

Potassium. Evidence now strongly indicates that a potassium-rich

diet can help achieve healthy blood pressure levels, and that
potassium supplements can lower systolic blood pressure by 1.8
m Hg and diastolic blood pressure by 1 mm Hg. In fact, there is
some evidence that a potassium-rich diet can reduce the risk of
stroke by 22% to 40%. Current expert guidelines now support the
use of potassium supplements or enough dietary potassium to
achieve 3,500 mg per day for people with normal or high blood
pressure (who have no risk factors for excess potassium levels).
This goal is particularly important in people who have high
sodium intake. The best source of potassium is from the fruits and
vegetables that contain them. Some potassium-rich foods include
bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas
and beans, nuts, potatoes, and avocados.

Of note, in this regard, certain kidney problems can cause

potassium overload. Medications commonly used in diabetes,
such as ACE inhibitors or potassium-sparing diuretics, also limit
the kidney's ability to excrete potassium. No one should take
potassium supplements without consulting a physician. The best
source of potassium is from the fruits and vegetables that contain
them.

Magnesium. Magnesium deficiency may have some role in

insulin resistance and high blood pressure. One study reported
that low magnesium levels as measured in blood tests were
associated with a higher risk for type 2 diabetes in whites but not
in African Americans. Dietary intake of magnesium, however, did
not appear to play any role in increasing or reducing risk for
either population group. It is more likely that diabetes may cause
magnesium loss. A major 2001 study on diet found no effect on
blood pressure from magnesium intake from foods. No
supplements are recommended at this time for patients with
adequate levels of magnesium. The recommended daily
allowance is 320 mg. Persons who live in soft water areas, who
use diuretics, or who have other risk factors for magnesium loss
or ectopic beats may require more dietary magnesium than would
others.

Chromium. Some studies have reported an association between

deficiencies in the mineral chromium and a higher risk for type 2
diabetes. Studies on fat rats that were given chromium reported
improvement in insulin sensitivity and glucose metabolism. Most
studies on type 2 patients, however, reported little or no effect on
glucose metabolism and some even reported adverse side effects.

Zinc. Many type 2 diabetics are also deficient in zinc; more

studies are needed to establish the benefits or risks of taking
supplements. Zinc has some toxic side effects, and some studies
have associated high zinc intake with prostate cancer.

Fluids: Water, Caffeine, and Alcohol

Water. Many heart risk factors, especially those associated with

blood clotting, are elevated with dehydration. In an interesting
2002 study, drinking five or more glasses of water a day was
significantly associated with a lower risk for fatal heart events
than drinking two or fewer glasses a day. More research is
warranted on this simple way of protecting health. (Other fluids,
including caffeinated and sugared drinks, were not protective.)

Alcohol. A number of studies have found protection from heart

disease and type 2 diabetes with light to moderate intake of any
type of alcohol. Some research suggests that alcohol has anti-
inflammatory properties that protect arteries from injury. Red
wine in particular may have specific benefits for people with type
2 diabetes. It has strong anti-oxidant effects that benefit the heart.
Some evidence also suggests that red wine may improve insulin
sensitivity and reduce blood glucose levels and may even protect
against type 2 diabetes. Note: In those taking insulin or
sulfonylureas, however, alcohol may cause a hypoglycemic
reaction, of which the drinker may not be aware. Women who are
pregnant or at risk for breast cancer and anyone at risk for alcohol
abuse should not drink alcohol.

Tea. Although it contains caffeine, tea, both black and green, is

often cited for its health benefits. Green tea is especially is rich in
chemicals that offer protection against damaging forms of LDL.
In one study, for example, higher intake, particularly by women,
was associated with a lower risk for severe coronary artery
disease. Black tea has also been associated with heart health. In
one study oolong tea, a partially fermented tea, was specifically
associated with lower blood sugar levels in type 2 diabetics.

Coffee. Coffee, like red wine, contains phenol, which helps

prevent oxidation of LDL cholesterol. Studies are finding no
association between coffee consumption and fatal or nonfatal
heart disease even after 10 years. In fact, in one study the highest
rates of fatal heart disease were in non-coffee drinkers, and
women who increased their coffee intake reduced their mortality
rates. On the downside, unfiltered coffee (Turkish coffee,
Scandinavian boiled or French pressed coffee, and espresso)
contains an alcohol called cafestol, which may raise cholesterol
and triglyceride levels. Filtered coffee does not contain this
residue. Coffee drinking is associated with small increases in
blood pressure, but the risk it poses is very small in people with
normal blood pressure. People with existing hypertension should
avoid caffeine altogether.

Of note, caffeine has specific effects on insulin and glucose that

may have an effect on people with diabetes, but the consequences
are not clear. Some studies suggest that drinking large amounts of
coffee may protect against diabetes. On the other hand, other
research indicates that caffeine may increase the risk for insulin
resistance. Some studies have reported a spike in insulin after
drinking caffeinated beverages, which can be dramatic in people
who are overweight. Research is needed to clarify the effects of
caffeine on diabetes. In any case, caffeine intake can affect a
person's awareness of hypoglycemia, since it reduces blood flow
in the brain even in the presence of sufficient blood sugar. People
with diabetes who drink even two or three cups of coffee may
even believe they are hypoglycemic when their blood glucose
levels are normal. On the positive side, coffee intake may increase
awareness of hypoglycemia in some people who have difficulty
recognizing its symptoms.