Pelekhrienuo Kire Dietitian, Christian Institute of Health Sciences and Research (CIHSR) Are you living with diabetes and constantly asking yourself, "What can I eat?" Living with diabetes doesn't have to mean feeling deprived. Learning to make healthy food choices and changing your lifestyle can help manage diabetes. Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin, a hormone that regulates blood sugar, gives us the energy that we need to live. If it cannot get into the cells to be burned as energy, sugar builds up to harmful levels in the blood.Over time, high blood sugar can seriously compromise every major organ system in the body, causing heart attacks, strokes, nerve damage, kidney failure, blindness, impotence and infections that can lead to amputations. According to WHO report in 2008, an estimated 347 million people in the world had diabetes and the prevalence is growing, particularly in low- and middle-income countries. And as per 2015 data, India had 69.2 million people living with diabetes (8.7%). Of these, it remained undiagnosed in more than 36 million people. Managing diabetes includes diet therapy, timely medication and physical activity or medical nutrition therapy. Medical nutrition therapy (MNT) includes a nutrition prescription tailored for people with diabetes based on medical, lifestyle, and personal factors. MNT is an integral component of diabetes management and diabetes self-management education. The nutritional goals for people with diabetes are to: • Address individual nutrition needs, incorporating personal and cultural preferences, willingness to change, and maintenance of the pleasure of eating by restricting choice only when clearly appropriate • Maintain blood glucose levels as near-normal as possible by balancing food intake with activity and medications or insulin • Achieve optimal blood pressure and lipid levels (blood cholesterol) • Provide appropriate calories for achieving and maintaining a healthy, desirable body weight • Manage risk factors and prevent complications of diabetes, both acute (hypoglycemia and short-term illness) and long term (gastroparesis, cardiovascular disease [CVD], renal disease, and other consequences of micro- and macrovascular disease) Some concerns and frequently asked questions by patients regarding diabetic diet here at our hospital, CIHSR, are: 1. Why are here so many restrictions in a diabetic diet? With diabetes, you do need to keep a closer watch on calories consumed, especially the quantity of carbohydrates, fats, and protein you eat. But your new way of eating may not require as many changes as you think. Certain food itemswhen consumed can increase your blood sugar levels rapidly. For example, some carbohydrates like refined sugars and refined flour are easier for your body to absorb andconvert into glucose, (the sugar your body uses for energy) than the carbohydrates in vegetables and whole grains whichare digested slowly. Patients who are not careful in choosing their food carefully are likely to have uncontrolled blood sugar levels even with regular medications and exercise. 2. Is it required to prepare a special diabetic meal separately for a diabetic patient? The food that is prepared for a diabetic patientis also a healthy choice for the rest of the family. It is important to note that the nutrition goals for diabetes are similar to those of an individualwho strives to be healthy by incorporating this into their lifestyle. When diet is planned carefully, all members of the family should be able to eat most of the same itemswith minimal modifications in the types of food items used and by adopting heathier cooking methods. The only difference is the diabetic patient will have to limit the quantity they eat and focus on the frequency and timing of the meals. 3. Can I still enjoy non-vegetarian food? Non-vegetarian food items include chicken, fish, beef, pork, mutton, egg, milk, cheese, curd etc. which are rich sources of protein. Protein may not affect your sugar as much as carbohydrates do but you will have to care fully choose the type of protein rich foods included in your meal. Food containing high quantities of saturated fat (like pork, beef, whole milk, butter, sausage,bacon, etc) can accumulate in your blood vessels and will eventually affect your heart and brain, so it is best to avoid or decrease the quantity and frequency of red meat consumption with a preference to fresh as compared to processed meat.On the other hand, there are other non vegetarian food items like fish, poultry (without skin), and low fat milk products which are preferred to red meat. 4. Is alcohol and cigarette safe for a diabetic patient? If you have diabetes and drink occasionally, practice caution when drinking. It is best for a diabetic to avoid drinking alcohol but for those who are contemplating quitting, it is very important for you to be extremely moderate in your consumption of alcohol and to always avoid drinking on an empty stomach. Even if you are very careful with the rest of your diet, anything more than very light, occasional drinking will make it extremely difficult, if not impossible, for you to get control of your diabetes. Smoking is especially dangerous for people with diabetes because it narrows the blood vessels. Anyone who smokes has triple the risk of having a heart attack. But when patients with diabetes smoke, they increase their risk of having a heart attack by about 10 times. 5. I tend to miss my meals on most days as I have a very busy schedule and finally end up eating a heavy meal whenever I get time. Is it ok to do so? If you take tablets or insulin injections for diabetes, it pays to think about whenand what you'll eat. If you eat more carbohydrates than your insulin supply can handle, your blood sugar level willincrease and If you eat too little, your blood sugar level may fall too low. Thus, it is importantyoudon’t skip meals, or stay on an empty stomach for more than four or five hours without eating during the day. Maintaining a proper meal timing or a consistent eating routine can help avoid dramatic peaks and valleys in blood glucose ranges and can help you reach a more stable blood glucose level from morning to night. This means eating frequent, small but wholesome meals about every three to four hours which includes 5 to 6 small meals a day or three square meals with small snacks in between. The end goal of such eating pattern is to never feel too full after eating and to go into your next meal not feeling hungry or famished. Eating consistently and choosing nutritious foods filled with fiber, protein and healthy fats can help to keep blood glucose and energy levels stable throughout the day. The main symptoms of low blood sugar (hypoglycemia) are dizziness, trembling, shakiness, extreme hunger, confusion, headache, and breaking out into a cold sweat. If your blood sugar goes down low enough (usually below 60), you can lose consciousness and possibly have convulsions or seizures. You can avoid problems with hypoglycemia (low sugar) by planning ahead. 6. Are “sugar free” products safe for a diabetic patient? An artificial sweetener also called low-calorie sweeteners, sugar substitutes or non-nutritive sweeteners is a food additive that is an artificial sugar substitute, which imparts a sweet taste similar to natural sugar and satisfies your sugar cravings, but with much less calories. U.S. Food and Drug Administration (FDA) and the Food Safety and Standards Authority of India (FSSAI) has approved six artificial sweeteners, namely, Saccharin, Aspartame, Acesulfame potassium, Sucralose, Neotame and Advantame. Also, with the exception of aspartame, all of the sweeteners listed below cannot be broken down by the body. They pass through our systems without being digested so they provide no extra calories. The artificial sweeteners will also provide some calories and carbohydrate from other ingredients. That means foods that carry claims like "sugar-free," "reduced sugar" or "no sugar added" are not necessarily carbohydrate-free or lower in carbohydrate than the original version of the food. Other sugar substitute like sugar alcohols (sorbitol, xylitol, lactitol, mannitol, and maltitol) are often used to sweeten sugar-free candies and gum and increase blood glucose levels slightly. Anything ‘artificial’ cannot be good for you in large quantities. Even if you do shift to artificial sweeteners, use these wisely and in small quantities to enjoy the low calorie benefits of these sweeteners. Some unhealthy side effects of artificial sweeteners are weight gain, diarrhea and some chronic diseases. While eating too much sugar alcohol at one time can also cause cramping, gas, and diarrhea. As well, consumption is not recommended for women who are breastfeeding, as the sweetener is not currently approved for infant consumption. 7. Is exercise important in the management of diabetes? Physical exercise has been considered as one of the cornerstones in the treatment of diabetes mellitus along with nutrition and medication since the last 100 years. When you are active, your cells become more sensitive to insulin so it can work more efficiently. Your cells also remove glucose from the blood using a mechanism totally separate from insulin during exercise. So, exercising consistently can lower blood glucose and improve your A1C (3months average blood glucose level). When you lower your A1C, you may be able to take fewer diabetes pills or less insulin. Before you begin your exercise plan set realistic goals. And also take into consideration any other medical conditions like high blood pressure or blocked arteries or diabetes-related complications—retinopathy (eye complication) or neuropathy (Nerve complications). There are three main kinds of exercise—aerobic (walking, jogging, running, tennis, basketball, etc), strength training (lifting weights, pull-ups, push-ups), and flexibility work (stretching). You should aim to have a good balance of all three. You will also need to find a way to exercise that you actually enjoy, because if it’s not fun, you will not do it. It’ll be harder to stay motivated, even if you know all the benefits of exercise. You can consider to find a friend to walk or run with or take group classes at the gym. Having someone else exercising with you does make it more fun and motivating. Some other benefits of regular physical activity to your body are: • Lowers blood pressure and cholesterol • Lowers your risk for heart disease and stroke • Burns calories to help you lose or maintain weight • Increases your energy for daily activities • Helps you sleep better • Relieves stress • Strengthens your heart and improves your blood circulation • Strengthens your muscles and bones • Keeps your joints flexible and healthy • Improves your balance to prevent falls • Reduces symptoms of depression and improves quality of life In conclusion… Being diagnosed with diabetes does change your life, but making small changes with your meal timing, food habits and lifestyle modification can help you manage your blood sugar level. Weight management and building up a steady exercise routine will also contribute to better management of diabetes. Leading authorities and professional organizations have concluded that proper nutrition is an important part of the foundation for the treatment of diabetes. However, the relative importance of each nutritional goal varies with individual patient characteristics. While one of the reasons for inadequate attention to the prescribed diet is inability to understand it and, the bulk of the patients receiving advice on dietary management for diabetes seems to consider the diets as very intricate, in spite of all the explanations and instructions. The modern diet for the individual with diabetes is now based on concepts from clinical research, portion control, and individualized lifestyle changes. It cannot simply be delivered by giving a patient a diet sheet in a one-size-fits-all approach. The lifestyle and diet modification guidance and support needed requires a team effort, which is best led by an expert in this area.