Diabetes and a Vegetarian Diet
by Virginia Messina, M.P.H., R.D.
Topics in this article:
This article is for you if you are a
vegetarian who has just developed diabetes, or if you are a diabetic
who would like to try a vegetarian diet. If you are a diabetic, be
certain to work with a registered dietitian when planning your diet,
especially if you are a new diabetic.
The earliest diabetes diet was described in Egypt around 1550 B.C.E.
and suggested the use of "wheat grains, fresh grits, grapes, honey,
berries, and sweet beer," in other words, a high carbohydrate diet.
However, by the late 18th century, a British surgeon was
recommending "animal food and confinement with an entire
abstinence from every kind of vegetable matter." Almost every type
of diet that falls between these two extremes has been recommended
at one time or another. Our understanding of the best diet for diabetes
is ever evolving. We do know, as did our ancestors, that diet is
important in the control of this disease.
Diabetes, or Diabetes Mellitus as it is properly called, is the inability
to process food properly. Much of what we eat is digested and
converted to glucose, the sugar found in blood. Glucose, carried
through the blood to the body organs, is transported into individual
cells, where it is used as an energy source. Most of the body's organs
require the hormone insulin to get glucose into cells. In diabetes,
insulin is either absent, present in insufficient amounts, or ineffective.
Therefore, cells cannot get enough glucose. As a result, glucose
builds up in the bloodstream. When blood glucose (blood sugar) is
high, it is called hyperglycemia.
Short-term effects of hyperglycemia may include thirst, frequent
urination, weakness, lack of ability to concentrate, loss of
coordination, and blurred vision. With very high levels of blood
glucose, loss of consciousness is possible.
Diabetes is much more than high blood glucose. The effects of the
disease are far-reaching, sometimes unexplained, and potentially
devastating. Diabetics often have high levels of blood lipids
(cholesterol and triglycerides) and are at increased risk for developing
atherosclerosis, or blocked arteries. Untreated diabetes results in
increased risk for heart attack, stroke, and vision problems, including
blindness. Some experts feel that the long-term complications of
diabetes may result from years of high blood glucose.
As ominous as this sounds, there is good news about diabetes.
Diabetes can be controlled. A look at the diet recommended for
diabetics can help us to see why vegetarians may have the advantage
in controlling this disease.
Much confusion about diabetes arises from the fact that it is really two
separate diseases. Type I diabetes is also called insulin dependent
diabetes mellitus (IDDM) and was formerly referred to as juvenile
onset diabetes. Those with type I diabetes produce no or very little
insulin. There is no cure for this type of diabetes although proper diet
and exercise can decrease insulin needs.
Type II diabetes, or non-insulin dependent diabetes mellitus (NIDDM),
used to be called adult-onset diabetes. About 90% of all diabetics fall
into this category. Obesity is believed to be a major risk factor for
type II diabetes. Some type II diabetics produce insufficient insulin
and may benefit from insulin injections. More typically however,
these individuals produce sufficient or even excess insulin; but their
cells are resistant to the insulin. These diabetics may take medications
called "oral hypoglycemic agents" to help lower blood glucose. In
many cases weight reduction alone will help to normalize blood
glucose levels. Regardless of the type, diet is a critical factor in
attaining normal blood glucose levels in diabetes.
There are four goals of the diabetic diet.
- 1. To Achieve and Maintain Normal Blood Glucose Levels.
- Blood glucose levels are affected by the type and amount of
food consumed, and for people taking insulin, by the timing of the
meals.
- 2. To Achieve and Maintain Acceptable Blood Fat Level.
- Since diabetics are at higher risk for atherosclerosis and
associated problems, blood levels of cholesterol and triglycerides are
important.
- 3. To Provide Good Nutrition.
- The nutritional needs of
diabetics are the same as those of all other individuals.
- 4. To Maintain an Appropriate Weight
- This is especially
important for type II diabetics, many of whom are overweight.
Obesity is a significant risk factor for diabetes
Based on these goals, the principles of the diabetic diet are as follows.
- 1. Low-Fat, Specifically Low Saturated Fat.
- This is the most important principle of the diabetic diet.
Foods high in fat are also high in calories, and therefore contribute
to obesity. Additionally, high fat, high saturated fat diets are
associated with atherosclerosis.
- 2. High Carbohydrate.
- Many people are surprised to learn that diabetics can and
should eat starches such as potatoes, bread, pasta, and legumes.
A high complex carbohydrate diet helps to control
blood glucose. The American Diabetic Association recommends that
at least 55 - 60% of the calories consumed be from carbohydrate.
- 3. High Fiber.
- Fiber seems to be especially effective in normalizing blood
glucose levels and lowering blood lipid levels, as we shall see.
The hottest area in diabetes in the past decade has been the effect of
fiber on blood glucose levels. Fiber is found only in plant foods.
Foods derived from animals do not contain any fiber.
Some researchers have been able to show that the total level of
complex carbohydrate (starch and fiber) is more important than the
level of fiber alone. Indeed, several studies have shown that when the
level of carbohydrate is held constant, varying levels of fiber have no
effect on blood glucose levels. However, the majority of studies
support a role for fiber in regulating blood glucose.
There are two types of dietary fiber. Insoluble fiber has little effect
on blood glucose. Soluble fiber, however, has been associated with
improved blood glucose control in diabetics and with lowering of
blood cholesterol levels. The best sources of soluble fiber are shown
in the chart on the next page.
What level of dietary fiber should be used in the diabetic diet?
Different amounts have been proposed. The American Diabetes
Association recommends 40 grams of dietary fiber per day. For com-
parison purposes, the average American consumes between 10 and 15
grams of dietary fiber per day. The American Diabetes Association
does not make a recommendation for a specific amount of soluble
fiber.
The panel of National Institutes of Health Consensus Development
Conference on Diet and Exercise in NIDDM (Non-Insulin Dependent
Diabetes Mellitus) believes the evidence for increasing fiber in
the diabetic diet is inconclusive. However, Dr. James Anderson,
whose research helped to establish a role for fiber in control of
diabetes, recommends very high intakes of fiber. He states that the
"ideal" diabetic diet could include as much as 70 grams of dietary
fiber per day. Some health professionals suggest caution in the use of
very high fiber diets. In some studies, dietary fiber, when consumed
at very high levels, has been shown to bind minerals such as iron and
calcium, making them unavailable to the body.
Although there is no consensus on the amount of fiber to be eaten,
health professionals agree that many Americans do not eat enough
dietary fiber. Vegetarians are more likely to achieve the recom-
mended increase in fiber intake because of their reliance on plant
foods. Replacing non-fibrous foods such as meat, cheese, and eggs
with grains and legumes is an excellent way to increase dietary fiber.
While a high-fiber diet is difficult for many Americans to achieve, it
is a way of life for most vegetarians.
dry or cooked oat bran
cooked oatmeal
black eyed peas
kidney beans
pinto beans
split peas
butter beans
lentils
fresh peas
baked potato with skin
Brussels sprouts
corn
zucchini
prunes
apricots
bananas
blackberries
barley
Note: Dr. Anderson from the University of Kentucky
has compiled
data for the amount of soluble fiber in the above foods. However,
since data on soluble and insoluble fiber in foods has not been agreed
upon by experts on fiber, we have not included amounts per serving.
Increasing your intake of soluble fiber is really quite easy. Be sure to
include a serving of legumes in your diet daily -- they are the best
food source of soluble fiber, and black eyed peas are the best of the
beans! Tofu does not count since it does not include the fibrous
portion of the soybean. Experiment with oat bran. See Bobbie
Hinman's article in the March, 1989 Vegetarian Journal.
Replace 1/4 - 1/2 of the flour in baked products with raw oat bran.
Your product
will be heavier, but delicious. Eat more berries. Experiment with
grains and breads. Barley and corn meal both have more soluble fiber
than brown rice.
Can diabetics consume sugar? And if so, how much? Historically,
the recommendation has been for diabetics to avoid all sugar. This is
because sugars have a simple chemical structure; they are digested and
absorbed quickly. It was thought that this could cause a dramatic rise
in blood glucose levels. Recent evidence shows that foods high in
sugar are not as harmful to diabetics as once thought. Several studies
have shown that sucrose (common table sugar) when fed as part of a
meal does not cause increases in blood glucose levels any more than
do most starches.
Does this mean that there are no restrictions on sugar in the diet of
diabetics? Well, not necessarily. For one thing, a number of studies
have linked sugar consumption by diabetics with an increase in blood
triglycerides, a type of fat. Although the actual significance of
increased blood triglycerides remains controversial, unlimited use of
sugar does not seem prudent.
What is more important is that foods high in sugar are often high in
saturated fat and calories and low in nutrients. For this reason,
diabetics, like everyone else, would do well to keep their intake of
sweets to a minimum.
The National Institutes of Health Consensus Development Conference
on Diet and Exercise in NIDDM states that it is acceptable for up to
5% of total calories to come from sugar. This means that for a person
on a 1500 calorie diet, with 60% of calories from carbohyrate,
approximately 2 and 1/2 teaspoons of sugar are allowable. While this
is a fairly small amount of sweetener, the allowance for some desserts
on the diabetic diet is a welcome and realistic one.
Use of alcohol should be limited on the diabetic diet. Alcoholic
beverages are high in calories and contribute little nutritional value to
a diet.
Your physician may allow occasional use of alcoholic beverages. If
you do drink alcohol, keep the following in mind.
Exercise is especially important for Type II diabetics. Research shows
that regular exercise can help to increase the body cells' sensitivity to
insulin. Remember that one problem in Type II diabetes is that cells
are not sensitive to insulin. So exercising diabetics may be better able
to regulate blood glucose. This effect is seen only when diabetics
exercise on a regular basis. Exercise has the added benefits of
improving cardiovascular fitness and aiding in weight reduction.
Both are of concern to the diabetic.
Diabetics who take insulin injections can certainly exercise also.
However, precautions need to be taken. Rigorous exercise must be
accompanied by an increase in food intake, or hypoglycemia (low
blood glucose) may result. A dietitian can help you plan appropriate
snacks for exercise. All diabetics should consult their physicians
before beginning an exercise program.
There are two types of diabetic pregnancies.
Gestational Diabetes is diabetes that develops for the first
time during pregnancy. It usually disappears after the baby is
delivered. Women who develop gestational diabetes are at greater risk
for developing Type II diabetes later in life.
Women Who Already Have Diabetes When They
Become Pregnant will experience some changes in blood
glucose control. If they are using insulin, they typically will
experience a decrease in insulin needs during the first half of
pregnancy, followed by an increase in insulin needs during the latter
part of pregnancy.
Each diabetic pregnancy is treated individually. Pregnant diabetics
need to be certain to consume adequate calories, eat frequent small
meals, check their blood glucose frequently, and follow their doctor's
advice. Well-planned vegetarian diets are appropriate for pregnant
diabetics.
Diabetes that occurs in childhood is almost always insulin dependent
diabetes (Type I). It is controlled with insulin injections. Diabetic
diets for children must contain adequate calories, fat, and nutrients to
ensure adequate growth, in addition to controlling blood glucose.
Diet planning with the help of a dietitian is especially important for
these children. A plant-based diet for diabetic children should meet
all of the above described needs while being acceptable to the child.
The glycemic index is a measure of the blood glucose response to a
particular food. Consumption of a food with a high glycemic index
value produces a significant rise in blood glucose levels. The theory
is that consuming foods with lower glycemic index values will help to
maintain a normal blood glucose level.
As interesting as the glycemic index is, most nutritionists consider it
to be of little use. For one thing, equal amounts of foods were
compared rather than normal serving sizes. Secondly, when foods are
served as part of a meal, along with other foods, this index changes
dramatically. Thus, a dinner of carrots alone might cause a surge in
blood sugar; but a meal of brown rice, lentils, and carrots will have a
very different response.
Note From the Editors: Since there is such conflicting
evidence concerning the glycemic index, our dietitians questioned
whether to include this section. However, we left it in, since the
glycemic index is mentioned in some of the popular literature. We
decided not to include glycemic index values, since they are
considered more theory than fact at this time.
In conclusion, recommendations for control of diabetes include a
diet low in fat, particularly animal fat, to control blood lipid levels and
weight, and high in carbohydrate and fiber to control blood glucose
levels. By replacing 6 ounces of meat with 1 1/2 cups of beans, an
individual can reduce dietary fat by over 10% and add 10 -25 grams
of dietary fiber! She or he might save up to 200 calories per day.
While few researchers actually recommend a vegetarian diet per se for
diabetes, it is clear that the vegetarian pattern is closer to the
recommendations than is the typical American diet. Research and
nutrition educators are concerned that individuals will not be able to
make the diet changes necessary to achieve a high-carbohydrate,
high-fiber diet. For most vegetarians, this type of diet is a way of life.
A strict or lacto-ovo vegetarian diet is not only allowable for diabetes,
it may be the preferred diet pattern.
Diabetics do not need special recipes. The key is to choose vegetarian
dishes that are low in fat and high in fiber. Most vegan recipes fit the
bill, but be careful with lacto-ovo recipes. Eggs, whole milk, and
cheese add lots of saturated fat and have no fiber.
Since the diabetic diet is one which is low in saturated fat and
cholesterol, look for cookbooks that emphasize low-fat cooking. Here
are a few recommendations to get you started.
Eat Smart for a Healthy Heart Cookbook, Copley and Moore, Barrons,
Woodbury, N.Y., 1987. Hardcover, $18.95
Dr. Anderson's HCF Diet: The New High-Fiber Low-Cholesterol Way
to Keep Slim and Healthy, Anderson, J. Available from HCF
Diabetes Foundation, Box 22124, Lexington, KY 40522. Softcover,
$5.00.
Low-Fat Cooking, Foley, L. (ed), Meredith Corporation, Des Moines,
IA. Hardcover, $6.95.
The Quick and Delicious Low-Fat, Low-Salt Cookbook, J. Williams
and G. Silverman, Perigee Books, N.Y.C., N.Y. Softcover, $8.95.
The American Heart Association Cookbook, R. Eshleman, M.
Winston, Ballantine Books, N.Y.C., N.Y.
The Oats, Peas, Beans and Barley Cookbook, E. Cottrell, Woodbridge
Press, Santa Barabara, CA.
Jane Brody's Good Food Book, J. Brody, Bantam Books, softcover
$12.95.
Anderson, et al. Professional Guide to HCF Diets, HCF Diabetes
Research Foundation, Inc., Lexington, KY., 1981.
Bantle, John. "The Dietary Treatment of Diabetes Mellitus," Medical
Clinics of North America, Vol. 72, No. 6, Nov. 1988, pp. 1285 -
1299.
Anderson, James, et al. "Dietary Fiber and Diabetics: A
Comprehensive Review and Application," Journal of the American
Dietetic Association, Vol. 87, No. 9, September 1987, pp. 1189 -
1197.
Wheeler, Madelyn. "Diet and Exercise in Noninsulin Dependent
Diabetes Mellitus: Implication for Dietitians from the NIH Consensus
Development Conference," Journal of the American Dietetic
Association, Vol. 87, No. 4, April, 1987, pp. 480 - 485.
Snowdon, David and Phillips Roland. "Does a Vegetarian Diet
Reduce the Occurence of Diabetes?" American Journal of Public
Health, May, 1984, Vol. 75, No. 5, pp. 507 - 512.
The Surgeon General's Report on Nutrition and Health, 1988. U.S.
Department of Health and Human Services
If you or someone you know is diabetic, you probably have heard
about the Exchange Lists for meal planning. This is a diet planning
tool used by many Type I diabetics to achieve a consistent daily meal
pattern. For a person who takes insulin, a consistent calorie and
carbohydrate intake at each meal is important.
The Exchange Lists contain six food groups (starch, meat (or protein),
vegetable, fruit, milk, and fat). Individuals are allowed a particular
number of servings in each group at each meal.
A quick look at the Exchange Lists reveals that while they are usable
by lacto-ovo vegetarians, their use by vegans is more complicated.
This represents a shortcoming of the Exchange Lists -- not the vegan
diet. The Lists are based on the habits of the average omnivore and
are not the only means of achieving diabetic control. Vegan diabetics
can use the list with some modifications and should insist on guidance
from their health care provider in doing so.
Vegan Diabetics: Vegan diabetics may substitute soy milk for
2% cow's milk in the milk exchanges. However, if you do not use
soy milk, you may eliminate the milk exchanges from your meal
planning and use only the remaining five lists. Be certain to include
plenty of tofu (with a calcium coagulant) and leafy green vegetables in
your diet to ensure adequate calcium intake.
FOOD SERVING SIZE EXCHANGES
brewer's yeast 3 TB 1 bread
carob flour 1/8 Cup 1 bread
kefir 1 Cup 1 milk + 1 fat
Loma Linda Veggie Links 1 oz 1 high-fat meat
Morningstar Farms Grillers 1 oz 1 high-fat meat
miso 3 TB 1 bread + 1/2 lean meat
seaweeds, cooked 1/2 Cup 1 vegetable
soy flour 1/4 Cup 1 lean meat + 1/2 bread
soy grits, raw 1/8 Cup 1 lean meat
soy milk 1 Cup 1 milk + 1 fat
tahini 1 teaspoon 1 fat
tempeh 4 oz. 1 bread + 2 protein
wheat germ 1 TB 1/2 bread (If you use
large amounts, may need
to add a fat exchange.
Speak to your dietitian.)
Remember that most diabetics are non-insulin dependent, and most do
not need to depend on exchange lists, though some may. While we
are including information about exchange lists, note that for most peo-
ple, Non-Insulin Dependent Diabetes can be controlled through a
low-fat, high-carbohydrate meal plan with calorie control -- and these
diabetics do not need to follow a rigid diet pattern using the
exchanges. Consult your health care provider for more information on
your situation, and for exchange lists if you need them.
Note to Dietitians: In my practice as a dietitian, I treat legumes
differently than the American Diabetes Association Exchanges do. I
always count 1/2 Cup of legumes as 1/2 protein and one bread
exchange, while ADA just counts them as a bread. For a vegetarian,
this needs to be modified.
This article was originally published in the
Vegetarian Journal, Volume 9, No. 1, Jan/Feb 1990, published by:
The Vegetarian Resource Group
P.O. Box 1463
Baltimore, MD 21203
(410) 366-VEGE
The Vegetarian Resource Group (VRG) is a non-profit organization
dedicated to educating the public on vegetarianism and the interrelated
issues of health, nutrition, ecology, ethics, and world hunger. In
addition to publishing the Vegetarian Journal,
VRG produces and
sells cookbooks, other books, pamphlets, and article reprints.
For more information, send a stamped self-addressed envelope to the
above address. Subscriptions to the Vegetarian Journal are $20 per
year (6 bi-monthly issues). All contributions above the $20
subscription are tax-deductible to the full extent allowed by law.
Contributions help VRG promote vegetarianism.
For general information on diabetes, see www.diabetes.com.
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