What is a Balanced Diet For a Type 2 Diabetic?

This question came up on one of the forums I am on recently. There were many conflicting responses, often including discussion about various macronutrients (fat, protein, carbohydrates) and micronutrients (minerals, vitamins etc), the evils of sugar, cholesterol and saturated fats, the need for lots of fruit or grains etc etc. A lot of people also went into great detail about maximum and minimum percentages for fats, carbs and protein.

I believe in KISS, so I try to keep it simple with easy to follow rules for my way of eating. As I have to eat this way for the rest of my life I do not want an excessively complicated food selection system.

My definition of a balanced diet for a type 2 diabetic (me) is pretty basic and not in terms of percentages of anything. The basic description is simple, although the personal investigation creating the way of eating I follow today was fairly complex. The links at the foot of this post describe the journey to this point.

The simple version:

• I let my meter show me my carbohydrate limits for the time of day and the meal.
• I let common sense and satiety limit my protein and fat portions.
• I include a reasonably wide variety of vegetables in my menu, favouring fresh and seasonal vegetables where possible.
• I also include fruits but those are limited to minimise blood glucose spikes.

In applying those basic rules for myself I also take these factors into account:

• Variety in choices of meats, fish, seafood, dairy, vegetables and fruits makes the menu interesting and also improves the chances of getting all needed vitamins and micronutrients.
• Excess of any macronutrient is not wise.
• Excessive restriction of any macronutrient is just as unwise.

 These links to past posts expand on those points and others: 

• Food, Farmers and Factories
• Test, Review, Adjust
• Are Carbs Really Necessary?
• Vegetables
• Grazing
• Red, Red Wine
• Yoghurt
• Eggs, Carbs and Cholesterol
• Cinnamon, Spices, Herbs and Similar
• Food and Recipes

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter 
There Is Nothing I Could Eat I like More Than my Eyes

I Think I May Have Diabetes...

"I think I may have diabetes....and I don't want to die..."

The wording varies but I see this question with increasing frequency on all the forums I read. I have written replies to these posts so often I felt it was time to archive a standard response.

The web is a wonderful source of information but too often people who really should be asking questions like this of their doctor are asking strangers on the net. 

My usual answer is very brief and says exactly that: see your doctor. I highlighted that because it needs to be emphasised.

Unfortunately that isn't always immediately possible for everyone. There can be many reasons for that.  The most common excuses are lack of money, lack of availability of medical support or simply fear of hearing bad news. 

For those with an urgent need and obvious hypo or hyper symptoms or who have tested repeatedly high on a glucometer the suggestion changes from "see your doctor soon" to "get to an ER (emergency room) fast". 

For others unable to see their doctor soon I urge them to at least make the appointment. Do what is necessary to find the money or time or courage but not seeing the doctor can turn out to be much more expensive in the long term. 

Another variant has appeared recently. Some doctors appear hesitant to diagnose if A1c is OK but fasting or casual blood glucose are just over diagnostic thresholds even when the patient has some symptoms. Too many doctors appear to have forgotten that A1c was only recently approved as a diagnostic tool because the patient can be diabetic if other indicators are high despite a normal A1c. I see an increasing number of posts from people in those circumstances who were told they are “borderline” - whatever that means - or “you are not diabetic yet, just eat healthy and exercise and you'll be fine” without a meter or other advice being prescribed.

At this point I will remind readers: I am a diabetic, not a doctor, and only a doctor can diagnose diabetes.

What follows are suggestions for people whose situation is not urgent, who have a long wait to see their doctor or who have seen their doctor but are still unsure. 

Part 1. Discovery

Obtain a home blood glucose test meter and an adequate supply of test strips. How you do that will vary depending on your local health support system. In the US cheap meters and strips are available from several sources; Walmart's Relion Prime was one of the first cheap meters but you may find others if you search. Note that the cost of test strips will be more important than the cost of the meter in the long term. In Australia you will have to pay full price until you are officially diagnosed, but check with the chemist because there are often discount specials.

When you get your meter read this (click on it): Painless Pricks.

 

Test four times a day for two or three days: immediately on waking (fasting) and one hour after your last bite of breakfast, lunch and dinner. The results you are hoping for are as follows:

• Fasting: 4 to 5.5 mmol/l (Australia, Canada, UK or other millimole countries) or 70 to 99 mg/dl (USA and other milligrams countries).
  
• Post-meal: 4 to 8mmol/l or 70 to 140mg/dl.
  

If all your tests are inside those ranges, relax. Diabetes is most unlikely to be your problem. Don't throw your meter away because it may be wise to occasionally test in future years to see if anything has changed. In that case be aware that test strips have an expiry date.

If any of your results are outside those ranges immediately wash your hands and re-test. If, after re-testing, it is still out of range just record it the first time. If a second test at another time is out of range make an appointment with the doctor for qualified diagnostic testing. 

Part 2. Action.

If your tests were outside the ranges read this while you wait for your appointment with the doctor: Getting Started

 

For those unable to obtain a meter, this may help while waiting to see the doctor: What to Eat at First

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter 

There is nothing I could eat I like more than my eyes

Blood Glucose Targets 2015

Several years ago I investigated the different targets suggested by three major respected US diabetes authorities. As a result I wrote this: Blood Glucose Targets. My 2006 summary included this comparison table:

Over the years those have changed very little. The 2015 comparison noting significant changes in bold is:

Sources: ADA, Joslin (up-dated 2018), AACE. 

The ADA and Joslin now agree on the looser 2hr post-prandial target of 180(10) and both have also lowered the threshold for fasting. The AACE guidelines are unchanged. If you read the details on the linked pages all add caveats concerning relaxation of targets in case of other medical conditions, age etc.

Thirteen years after diagnosis, thankfully still free of complications, I see no reason to significantly change my closing remarks originally written nearly ten years ago.

The AACE advise much tighter post-prandial targets. I doubt that anyone would consider the American Association of Clinical Endocrinologists, a professional community of several thousand physicians specializing in endocrinology, diabetes, and metabolism as a bunch of fanatical radicals. Nor would they be promulgating guidelines impossible to be attained by the majority.

Unfortunately, nobody but pro-active type 2 diabetics talks much about 1hr PP targets. My personal logic is that I treat their 2hr as my recommended max peak for any post-prandial, as I discussed in When To Test? Those AACE guidelines then agree very closely with Jennifer's Test, Test, Test advice. Make your own judgment on which of those guidelines you think will lead to fewer complications.

Sadly, it appears that only 1/3 of senior diabetics are achieving even the loose ADA targets, but that is a discussion for another topic.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter

Catering For Different Tastes When Cooking

I see variations on this question asked many times on the various forums I am on:

Being head cook and bottle washer, I have a question. Having D, I need certain foods, my son has become a meat and potatoes guy, my wife eats most anything, except a variety of veggies. I do not want to have to cook 3 separate plates to satisfy all. How do you cater to each taste, or do you? Is there a happy middle?

The same problem occurs for the person who is not the cook but does not want to offend the person who is. This may help those people: Cooking as a Survival Skill. But I realise that is not possible or practical for some.

Here is my own method for dealing with the situation. I am the cook in our household, mostly just for the two of us. Mum is invited for dinner a couple of times a week.

It is important to keep in mind that I am the only person with diabetes. Although I may believe others would benefit from my way of eating it is not my role or place to force them to eat as I do. We each have our own food likes, dislikes, aversions or allergies.

I am diabetic and careful about carbohydrates but otherwise omnivorous. My wife has a very limited menu, by choice, and a long list of foods she detests. For example, she will not eat fish or seafood, eggs, steak, many vegetables, milk, the list goes on. Her likes are basically meat (other than steak), starchy vegetables, peas, tomatoes and silverbeet (chard). My mother is omnivorous but, like most people, has a few foods she prefers to avoid.

If I restricted myself to cooking only the foods we all like my menu would become very limited and boring. I also actively seek to include fish and a wide range of seasonal vegetables in my diet. Therefore, at most meals for the two of us I cook three types of foods. Those I can eat, those my wife will eat, and those we both eat. The other night was a typical example. In the steamer I had potato and pumpkin (winter squash) simmering in the bottom section with silverbeet, carrots, cabbage and broccoli in the top. I cooked two loin lamb chops under the grill (broiler) for her and when they were almost cooked I seared and fried a fillet of Atlantic Salmon in a small skillet for myself.

At the table I put the salmon on my plate, the lamb chops on hers, and all the vegetables on a platter in the middle. We served ourselves from the platter. She had most of the potato and silverbeet; I took most of the rest.

When my mother or other people are dining with us I use the same method. I find out whether anyone has specific protein likes or dislikes and serve that appropriately, letting them select their own vegetables and starches from the centre of the table. For major feasts such as Christmas dinner everything is served buffet-style for diners to select as they wish.

It really isn't as difficult as it sounds, with a small amount of extra thought and effort keeping everyone at the table happy and healthy.

Konjac and Shiritaki Noodles

I have heard and read this question many times: "what food can I eat to lower my blood glucose levels?"

My standard answer has always been to advise that there is no such food and the dietary way to lower blood glucose levels is to select carbohydrate portions that do not raise blood glucose levels excessively. 

I may have to add a caveat to that response in future. For the past three years I have been making occasional experiments with an unusual food called Konjac. This food has several other names in different parts of the world.

Scientific: Amorphophallus konjac. Also known as:

• Konjac
• shiritaki
• Glucomann
• devil's tongue
• voodoo lily
• snake palm
• elephant yam

You can read more about the plant and its variants here on wiki: Konjac and Shiritaki noodles.There are several forms: powder, noodles, gel and cake. The version available locally to me is noodles, which are packaged in a brine solution.

 

The noodles look like pasta but are quite different in texture. After draining, separating and rinsing to remove the slightly fishy odour they have a slippery feel and are more chewy than the equivalent spaghetti or fettucine. They do not soak up sauce juices in the same way as pasta, consequently I have learned to reduce my sauces more when preparing konjac dishes.

Despite those differences, my experiments show that for me they are a taste worth acquiring.  These are extracts from posts on the ADA forum since I started experimenting with konjac. 

1.

I rinsed 120gm (4oz) Konjac several times and then let it drain in a sieve for 30 minutes. In my wok I stir-fried 2/3 cup of shredded cabbage and half a medium sliced onion in a splash of peanut oil. When the onion was starting to caramelise I added 50gm shredded ham, warmed it through and then transferred the ham and veges mix to my serving bowl.

I fried the Konjac in a tablespoon of peanut oil until the noodles started to separate and dry out and occasionally "popped". They never went hard or dry, but became a little more springy and less moist. I returned the veges and ham to the mix. I continued to stir as I cooked for a couple of minutes until the veges were softened and thoroughly mixed with the noodles. I transferred it to the bowl, adding 15gm (1/2 oz) of shredded cheddar and a splash of cream, stirring it well. 

It was surprisingly good. The noodles shape was similar to thin spaghetti but the texture was chewier and springy. The noodles seemed to have no flavour of their own but took on the flavours of the other foods in the recipe.

Here comes the good news.

• Pre-meal: 5.8 mmol/L (105 mg/dl)
• 45 minutes post-meal: 5.3 mmol/L (96 mg/dl)
• 75 minutes post-meal: 5.3 mmol/L (96 mg/dl)

The post-meal numbers may have been aided by 150ml (5oz) of Shiraz between the end of the meal and the 45 minute test.

2.

The next experiment with Konjac was not quite as successful. But it was educational.

I made up my usual bolognaise sauce, using some mince steak (ground beef to the trans-Pacificans). I browned the meat, then added a cup of my Napoli Sauce and cooked it for a while to incorporate it. When used as a sauce with pasta it is delicious with a dusting of grated parmesan.

I prepared 200 gm of the Konjac noodles in the same way, rinsing, draining, separating and lightly frying in olive oil. However, when I added the sauce and tried to “cook it in” as I usually do with wheat pasta the mixture stayed too liquid. Unlike pasta, Konjac noodles do not absorb the sauce liquid.

The result was edible but chewy and not terribly appetising. Next time I will cook the Konjac longer and reduce the sauce a lot more, to thicken it and remove a lot of the liquid. After the meal I drank my usual glass of Shiraz.

On the other hand, the good news was:

• Pre-meal: 5.7 (103)
• 1hr post-meal: 5.5 (99)

3. 

Two days earlier I bought a Thai green Chicken curry for dinner. It was a large serve and I only ate half of it, followed by my usual glass of wine post-dinner. I was 5.4(97) pre-meal and 6.9(124) after. I expected that because there is always some starch in the local Thai curries.

We decided to have the leftover Asian meals for dinner two nights later. This time I prepared about 125gm of Konjac noodles first by rinsing, draining and pan-frying until they were dried out but still supple. I added them to the re-heated Thai chicken curry, which was exactly the same size as the previous serve. The resulting dish was quite tasty, although I still prefer other noodles for taste and texture at the moment. 

I was a little high before the meal at 7(126); I can't recall why but presumably had a forgotten snack. Or maybe it was gremlins. Here is the surprise:

• 1hr: 5.8 (105)
• 2hr: 6.3 (114)

4.

Continuing the trial...

I had leftover meatball casserole for lunch. It is a fairly low-carb recipe, but I had it on a slice of toast which added about 15gms of carb. On past experiments at that time of day I would have expected that combination to raise me from my usual pre-meal of 5.5-6 (100-108) to somewhere between 7(126) and 8(144).

I added 120 gm of Konjac noodles, preparing them in the same way as before.

• Pre-meal: 5.8 (105)
• 1hr Post-meal: 6.8 (123)

I still can't form any definite conclusions, beyond the fact that Konjac definitely does not increase my blood glucose levels and may limit or even decrease the effects of other foods. But still only "may".

Since those early experiments I have continued to use konjac once or twice a month together with low-carb ingredients. In almost every case my post-meal blood glucose was equal to or lower than my pre-meal. 

Last night I ate the same recipe as experiment #1, using 150gm of chopped bacon instead of ham. I also added a few strands of my wife's wheat fettucine to provide a better texture; probably about 15gms of extra carb. I probably made the portions too large, we were very "full" when we finished the meal. My pre-meal level was a little high at 7.6 (134) as I had indulged in a cookie half an hour earlier. My one-hour post-meal was 6.7 (120).

I emphasise that these experiments were personal and may only apply to me. My only recommendation is to do your own experiments if you are interested in trying this food. I have no commercial interest in any firm selling konjac in any of its various forms.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter 

What's In a Name? Am I a Diabetic or A Person With Diabetes?

A very brief post today about a regularly recurring question. Lately I have seen several posts on different forums from people getting upset about being referred to as a diabetic.

The bard put it, as usual, so well:

What's in a name? that which we call a rose
By any other name would smell as sweet;
So Romeo would, were he not Romeo call'd,
Retain that dear perfection which he owes

   Romeo and Juliet, Act II, Scene II, by William Shakespeare.

I don't get precious about labels. Many will disagree with me, but I also tend to be a bit old-fashioned about many of the politically correct terms that have entered our language since I went to school.

Context matters. I rarely care about the word that is used to refer to me if the context is appropriate and the speaker or writer's intentions are good. For example, I am:

• a father
• a son
• a brother
• a husband
• an engineer
• ex-RAAF
• retired
• ex-military officer
• a pensioner
• aged 66 
• an oldie
• a senior 
• an ancient 
• a child (to my mother) 
  
• a traveller 
• a seeker after wisdom 
• an omnivore 
• a curmudgeon (at times ) 
• a man 
• a baldy 
• a six-footer 
• a diabetic
• a leukaemiac 
• a hypogammaglobulinemic
• and many other things

All of them are descriptively accurate, none define me. I object to none of those words in the proper context. To me the intent in context of the writer or speaker is far more important than any of the specific words. I cringe sometimes when I see the unwieldy "person with diabetes" or even "person with type 2 diabetes" when diabetic or "type 2" may be simpler, more succinct and probably more apt, especially when used by a medical professional, another diabetic or some-one who cares for the diabetic. There are times when the longer description may be more appropriate, but not many in my opinion.

Stop worrying so much about words. If a word offends you, look deeper than the word to discover the cause before reacting. Be more concerned about correcting ignorance than the words used to display it. For years I used my own version of Hanlon's Razor before I found others had discovered it before me:

• Never assume malice when stupidity will suffice.
• Never assume stupidity when ignorance will suffice.
• Never assume ignorance when forgivable error will suffice

There are more important things in life and diabetes.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter  

I'm a New Type 2. Do I Really Have to Test so Much?

I see that question a lot. 

The answer is no, nobody has to.   

But I believe it is wise to. Your meter, properly used, is the bright beacon that will light your way through the dark and confusing maze of food advice that bombards type 2 diabetics. You will get advice from every side. If you have not encountered the Food Police yet, you will. Expect to be told that you should change your diet in all or any of the following ways: low fat; low carb; lots of wholegrains; lots of fruit; vegetarian; vegan; raw; no red meats; avoid sweeteners; sugar-free; no dairy; add expensive herbs and supplements; the list goes on and on. What is right and wrong for you? Is no food safe?

Let your meter guide you to the answer. 

There is no doubt that the Test, Test, Test method is a lot of testing at first when compared with the minimal testing prescribed for type 2s by most doctors. But I believe it is well worth it. The investment of time and test strips in a concentrated effort in the short term has tremendous long term benefits that will last you the for the rest of your hopefully longer, healthier life. And, fairly swiftly, the need to test so much is reduced. The initial period is the heaviest testing load because at that stage you have a blank slate. As you fill in the blanks the load swiftly decreases.

I recommend the following intensive testing routine for people newly diagnosed with type 2 diabetes. It can also be very useful for those who have been diagnosed for a while but who feel they have "hit the wall" in their progress towards good control. 

For the first couple of days test fasting blood glucose (on waking, before breakfast) and also at one and two hours after absolutely everything you eat, unless you eat again before the second test. That includes breakfast, lunch, dinner and all snacks. This may help if you are not used to testing so much: Painless Pricks

Log everything on the menu including drinks, sides and portion sizes. Every evening spend a few minutes reviewing that log and use it to plan the following day's menu with a view to achieving better results. 

Some people are adamant that you must also test before meals. I agree that it may help to know the starting point when assessing a rise, but I do not think it is necessary to add an extra half a dozen tests every day to an already heavy initial load when the other tests will still achieve your goal. 

On the evening of the second day take some time to review all the results. Some of them will seem crazy, but you should see some patterns emerge. The first thing to look for is the timing of your most consistent peaks. That may be a little different for breakfast, lunch and dinner. Is it closer to one hour or two? If you can pick the most consistent peak time then replace the one and two hour tests with just one test at the peak time after each meal. If the peak time is unclear then continue to test at one and two hours and re-assess each evening until it is clear. If necessary add tests at 30 or 90 minutes to be sure; you won't need to do those for long.

Use of the peak post-meal time reduces your test load to fasting and peak time after every meal and snack. My own peak time is about one hour after my last bite, but yours may be different. Over the next few days, using this Test, Review, Adjust technique you should be able to discover several "safe" menus for various meals. You will also find that some meals are OK for the morning but not for the evening or vice-versa. Treat breakfast, lunch and dinner as quite separate results. 

When deciding your goals I suggest you start with the targets suggested in Test, Test, Test:

Fasting............................Under 110
One hour after meals.......under 140
Two hours after meals.....under 120

or for those in the mmol parts of the world:

Fasting............................Under 6
One hour after meals......Under 8
Two hours after meals....Under 6.5

Do not be distressed if your starting numbers are much higher. It took you a long time to develop your diabetes; you should not expect to correct those numbers overnight. 

Give yourself some time. It may take a few weeks, or even a few months, but the investment in strips and testing you make now will pay you dividends for years or decades. Eventually, when you find you can easily hit those targets consider revising them as I did. See my present targets at the foot of Test, Test, Test. 

Proceed cautiously if you use insulin or one of the insulin-stimulating medications. You do not want to go from hyperglycemia to hypoglycemia. Make modest adjustments to your carbohydrate intake, test the results and continue modest changes every meal until you achieve your goals. Eventually you may need to discuss reduction of your insulin or medications with your doctor as the numbers improve.

During the second week repeat some of those safe meals. Before your post-meal test try to guess what the result will be. If you can usually predict good results note that menu for future use; you will only need to test after that meal occasionally in future for reassurance. That removes another test from your day.

Gradually, over successive weeks, your knowledge of safe meals and food portions will grow and your need to re-test them will reduce. Fairly swiftly you should be able to plan menus that you know in advance will not cause blood glucose spikes; as a consequence your need to test so often will drop quite dramatically within a few weeks. Also, as my fasting blood glucose became fairly predictable I reduced that to just a couple of times weekly. 

You are building a database that is unique to you. I know it seems like a lot of effort at first, but believe me it will be worth it. 

These days I sometimes don't test for several days unless I am trying a new menu item or a new restaurant. If you have insufficient strips, time, or motivation to do it that intensively, that is OK. This will work too, but it will take a lot longer: Testing on a Budget

Cheers, Alan

Everything in Moderation - Except Laughter.