4. Currently, nutrition guidelines are flexible and offer a wide variety of food choices. True or false?
See APPENDIX A for the answers.
People with diabetes must avoid all foods that contain sugar.
JUDY: I was just diagnosed with diabetes right before moving to this area. My former doctor told me to stay away from any foods with sugar—I can’t even eat carrots! She also told me to see a registered dietitian but didn’t tell me how to find one.
DIETITIAN: You must be feeling completely overwhelmed by your new diagnosis. You must also feel very limited with your food choices. The good news is that the main goal of medical nutrition therapy for those with diabetes is not to avoid sugar, but to eat a healthy balance of foods spread out over the day.
JUDY: I remember that my grandmother had diabetes for years and could never eat desserts or foods with sugar. Even after depriving herself for years, she still had many complications related to diabetes. And to make matters worse, I’m addicted to sugar!
DIETITIAN: Actually, new nutrition guidelines were introduced by the American Diabetes Association in the 2000s. Each year, the nutrition guidelines are updated based on the most current research. So, not only can sugar be added into any healthy eating plan, but we now have many new treatment options for people with diabetes to prevent or delay the complications of diabetes. There are two other pieces of good news. One is that you can certainly eat carrots! The second is that although people do like and desire foods with sugar, this does not qualify as an addiction.
WHAT’S NEXT?
The need to avoid sugar is one of the biggest misconceptions in diabetes management today. Like Judy, many people with diabetes mistakenly work extremely hard to eliminate all foods with sugar. Judy learned that this was nearly an impossible task because many healthy foods have some form of sugar in them. Some foods contain “added sugars,” whereas other foods naturally contain sugar. Many research studies completed over the past 30 years have shown that foods containing sugar can be part of a healthy diet, even for those people with diabetes, and can be fit into an eating plan, just like any other carbohydrate food.
After several diabetes appointments with the dietitian, Judy learned that sugar is not forbidden or harmful and began to feel more comfortable about fitting many new foods that contained sugar into her eating plan. Instead of feeling guilty about eating sugar and trying to avoid it at all costs, Judy was able to take control of her situation and manage to fit some foods with sugar into her eating plan.
THE OLD AND THE NEW
Nutrition therapy has always been the cornerstone in the self-management of diabetes; however, some people with diabetes have had little training in medical nutrition therapy and may have been told to “watch their diet” and to “stay away from sugar.”
A brief historic review reveals that hundreds of years ago, diabetes was attributed to eating an excessive amount of food with sugar and flour. This meant that mostly all carbohydrate foods were restricted and that those with diabetes were put on a “starvation diet” of mostly fat and some protein. From that time, until insulin was discovered in 1921, a person’s carbohydrate content came only from vegetables, such as onions, lettuce, radishes, cabbage, and mustard greens. Eventually, insulin was isolated in 1921, and the “starvation diet” took a giant step backward, while various nutritious food choices started taking baby steps forward. Although fruits were mostly restricted, carbohydrate intake was on the upswing, from 20% of calories from carbohydrate in 1921 to what the American Diabetes Association now recommends as that amount of carbohydrate based on each individual’s blood glucose, weight, and lipid goals. However, it wasn’t until the 1980s, when home blood glucose monitoring was introduced, that health professionals started to understand how certain carbohydrates really affected blood glucose levels.
For years, people with diabetes were taught to avoid concentrated sweets, known as simple sugars, because they were thought to overload the blood with sugar much faster than starches, which were known as complex carbohydrates. Dr. Elliot Joslin stated the general consensus about starch and sugar best in his early editions of Joslin’s Diabetic Manual for Doctor and Patient:
• Sugar enters the blood as fast as a child runs.
• Starch enters the blood as fast as a child walks.
• Starch in vegetables enters the blood as slowly as a child creeps.
This was the explanation used when emphasizing to people with diabetes how important it was to strictly avoid sugar, to carefully measure starchy foods, and to eat vegetables more freely. We followed the assumption that sugar was harmful to people with diabetes until the 1970s, when scientists started to look for clear evidence of how sugar and diabetes interacted. In the latter part of the 20th century, the American Diabetes Association and prominent researchers in the field of diabetes studied the published findings from many scientific studies on nutrition and diabetes. They concluded that there was little scientific evidence to suggest that sugar is more quickly digested and absorbed into the bloodstream or that sugar elevates blood sugar more than starch. Sugar, we learned, has an impact on blood glucose similar to that of any other carbohydrate. Therefore, the use of sugar as part of the total carbohydrate content of the diet is okay for people with diabetes as long as these sugar-containing foods are substituted for other carbohydrate foods as part of a balanced meal plan. Nutrition therapy is no longer about avoiding sugar but rather about well-controlled blood glucose levels. Finally, people with diabetes started being taught how to eat realistically instead of ideally.
WHAT IS SUGAR?
The three types of carbohydrate are sugar, starch, and fiber. These carbohydrates are all made up of a certain number of “sugar blocks.” Some are single blocks, some are double, and some are many blocks connected together in long chains. Carbohydrates do, however, vary in their chemical structure and in the number of units (or sugar blocks) that are put together to make them. The carbohydrates with only one or two sugar blocks are called simple carbohydrates. The carbohydrates with many sugar blocks connected together are called complex carbohydrates (see Chapter 3).
There are six important sugars in nutrition. Three are single sugars (monosaccharides) and three are double sugars (disaccharides).
The single sugar blocks are the monosaccharides: glucose, fructose, and galactose. The double sugar blocks are the disaccharides: maltose (glucose + glucose), sucrose (glucose + fructose), and lactose (glucose + galactose).
Starch and fiber are called polysaccharides and are composed of straight or branched chains of the single sugars called monosaccharides. In this chapter, we
