Lecture at the Guam Diabetes Association last 8 November 2009 for patients with diabetes

1. Practical Dietary Prescriptions
in Type 2 Diabetes
Iris Thiele Isip Tan MD, FPCP, FPSEM
Clinical Associate Professor, University of the Philippines College of Medicine
Section of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital

2. Outline
What What is What is
is a portion on the
healthy control? food
diet? label?

3. Outline
What What is What is
is a portion on the
healthy control? food
diet? label?

4. What is a “healthy diet?”
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

5. How much carbohydrate is needed?
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

6. How much carbohydrate is needed?
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

7. It is wrong to avoid
plant-based foods
as “they will turn
into sugar.”
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

8. Add dried Cook dried fruit in hot
fruit to cereal and sprinkle Top yogurt with
cereal wheat germ or flax seed dried fruit or nuts
Consume more fiber
(at least 20-35 g/day)
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

9. Choose whole
Use cooked beans, peas and grain alternative
lentils in soups, salads etc. whenever possible
Consume more fiber
(at least 20-35 g/day)
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

10. Fish contain omega-3 fatty acids
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

11. Fish contain omega-3 fatty acids
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

12. Nonpredator, fatty, dark meat fish i.e.
salmon, sardines, mackerel, herring
Eat 2-3 servings of fish/week
or other foods that contain omega-3 fatty acids
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

13. Plant sources i.e. flaxseed, soybeans and walnuts
Eat 2-3 servings of fish/week
or other foods that contain omega-3 fatty acids
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

14. Limit saturated fat
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

15. Limit saturated fat
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

16. Smaller and fewer meat
Leaner cuts of meat i.e. servings i.e. ~6 oz/day
beef/pork tenderloin, fish or (after cooking);
poultry (without skin) 4-5 oz for women
Lower intake of saturated fat
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

17. Limit high-fat meat servings to 2-3 times/week
i.e. luncheon meat, frankfurters, sausage,
bacon and prime cuts of meat
Lower intake of saturated fat
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

18. Use plain nonfat
Drink fat-free yogurt as in salad
or 1% milk dressings or dips
2 tbsps yogurt
< 20 calories
2 tbsps
sour cream
50 calories
2 tbsps
mayonnaise
Use low fat 200 calories
cheese
Lower intake of saturated fat
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

19. Use soft margarine
rather than butter
Should list a liquid oil as a first ingredient
i.e. corn, safflower or soybean oil
Lower intake of saturated fat
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

20. Use canola or olive oil Broil, bake or roast
When frying or sauteing,
use nonfat cooking spray or a
small amount of vegetable oil
Lower intake of saturated fat
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

21. Decrease total fat intake
Decrease saturated fat intake
vegetable shortening, margarine,
Trans fats from
potato chips, crackers, cakes,
hydrogenation
pies, doughnuts,
that solidifies
liquid oils
Decrease trans fats
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

22. Alcohol is allowed
<2 drinks/day for men
<1 drink/day for women
1 drink = 15 g alcohol
12 oz beer
5 oz wine
1.5 oz distilled spirits
Add to regular
meal plan. If you
Do not omit food. don’t drink,
Regular beer is counted
as 1 carbohydrate serving. don’t start!
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

23. Severe
hypertension, Diabetic Diabetic
edema or and without
kidney disease hypertensive hypertension
Sodium Sodium Sodium
<2,000 mg/day <2,400 mg/day 2,4000-3,000
mg/day
Limit sodium intake
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

24. Remove the Try herbs, spices,
salt shaker lemon juice, garlic and
from the table onion to flavor food
Cook with
less salt
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

25. Limit high-sodium foods
i.e. dill pickles, sauerkraut, potato/
corn chips, processed meats,
canned soups and sauces (ketchup,
soy sauce and steak sauce)
Limit fast food
which tend to be higher
in sodium than food at
sit-down restaurants
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

26. Eat unprocessed food
prepared at home more
often than processed and
restaurant food
When eating out, choose
plain foods (e.g. grilled
chicken and baked potato)
rather than combination
foods (e.g. chicken potpie)
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

27. Use fresh or frozen
instead of canned
vegetables
Choose fresh meat (eg.
pork loin) instead of
cured meat (ham)
Include fruit.
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

28. Outline
What What is What is
is a portion on the
healthy control? food
diet? label?

29. Outline
What What is What is
is a portion on the
healthy control? food
diet? label?

30. Eat 25% less than your
current intake
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

31. Palm = 3 oz
Tight fist = 1/2 cup Handful = 1 cup
Thumb = Thumb tip
2 tbsp = 1 tsp
Hand guides or 1 oz
for portion
control

32. What are servings?
grain fish
fruits & >6 se products 2- 3 servings/
vegetables rving
s/day week
>5 servings/day
Limit
servi ed
ngs o
low-fat lean
meat f Minimal or
dairy poult
ry or healthy fat
2 servings/ choices
day
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

33. Diabetic Exchanges (“Servings”)
Starch Meat/meat Vegetables
substitutes
Fruit Milk Fats

34. Free Food
Less than 20 calories and
5 grams of carbohydrate
diet softdrinks
sugar-free gelatin dessert
sugar-free ice pops
sugarless gum
sugar-free syrup

35. 1 cup
1 cup pasta 1/2 cup rice corn flakes
= =
crackers 8 pcs corn 1 pc wheat bread
5 x 4 x 1/2 cm 12 x 4 cm 2 pcs
11 1/2 x 8 x 1 cm
= =
ONE Starch Serving

36. Shrimps 5 pcs Chicken leg
12 cm each 13 1/2 cm x 3 cm
1 chicken egg
= =
Cheddar Lean pork
Fish 1 slice cheese 1 slice 1 slice
6 x 3 x 2 cm 6 1/2 x 3 x 1 1/2 cm
= =
ONE Meat Serving

37. Carrot Cabbage Peas
1/2 cup raw or cooked 1 cup raw or
1/2 cup cooked 1 tbsp
= =
Tomato
1 cup raw or Squash
1/2 cup cooked 1/2 cup raw or cooked Mushroom
1/3 cup
= =
ONE Vegetable Serving

38. Watermelon Grapes Mango ripe
1 cup or 10 pcs (2 cm) or 1 slice 12 x 7 cm
1 slice (12 x 6 x 3 cm) 4 pcs (3 cm ) or 1/2 cup
= =
Banana Apple Strawberry
1 pc 9 x 3 cm 1/2 of 8 cm diameter 1 1/4 cup
= =
ONE Fruit Serving

39. Avocado Olive oil 1 tsp Butter 1 tbsp
1/2 of 12 x 7 cm
= =
Mayonnaise 1 tbsp Bacon 1 strip Margarine
10 x 3 cm
1 tbsp
= =
ONE Fat Serving

40. ONE Milk Serving
Whole milk
Milk, evaporated 1/2 cup undiluted
Milk, fresh 1cup
Milk, powdered 4 level tbsp
Low fat milk
Powdered 1/4 cup or 4 level tbsp
Light low fat milk 1 tetra brick
Skimmed (nonfat)
buttermilk
Liquid 2/3 cup
Powdered 1/4 cup or 4 level tbsp
Longlife skimmed
Milk 1 cup
Yogurt 1/2 cup

41. Idaho Plate Method
Milk or
or yogurt
Brown et al Diabetes Spectrum 2001

42. Idaho Plate Method
9-inch plate
Lunch/Dinner
provides
1200-1500 calories Brown et al Diabetes Spectrum 2001

43. TIP #1
When purchasing
produce (fruits,
vegetables,
starches), buy the
smallest ones.
for smal l apples,
Look tatoes.
banana s and po
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

44. TIP #2
Use smaller plates,
such as a lunch-size
plate.
r plates
rge dinne lling.
La
promo te overfi
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

45. TIP #3
Do not prepare too
much food.
If you plan on leftovers, put
the extra food away before
serving.
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

46. TIP #4
Do not place bowls,
pots or casserole
pans on the table
people get up if within easy reach.
Make conds.
they want se
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

47. giant double
grande triple
supreme double-
extra large decker
jumbo king-size
super
TIP #5
Do not order large
servings unless you
plan to split them.
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

48. junior regular
single petite
queen kiddie
TIP #6
Order small menu
items.
Do not upsize!
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

49. TIP #7
Be creative with
menus.
Don’t automatically
order a main course.
soup and salad
salad and appetizer
appetizer and soup lf portion
Order a ha
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

50. TIP #8
Use portion
estimating
abilities.
If the portion served will
be too large, ask for a
take home container.
Put away the extras
before starting the meal.
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

51. Outline
What What is What is
is a portion on the
healthy control? food
diet? label?

52. Outline
What What is What is
is a portion on the
healthy control? food
diet? label?

53. Sugar free
<0.5 g/serving
“Sugar free” does not
necessarily mean calorie- No fructose
free or carbohydrate-free or lactose
Reduced sugar
<25% of
regular version
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

54. Gum, sugar-free candy,
cookies and ice cream
Polyols or sugar alcohols No calorie sweeteners
Sorbitol Saccharin Neotame
Lactitol Acesulfame K Sucralose
Mannitol Aspartame
Polydextrose
Laxative effect with
excess consumption Is it safe?
“GRAS”
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

55. No-calorie sweetener
2 calories per sweetness
equivalent of a teaspoon of
sucrose (16 calories)
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

56. Regular Diet
12 oz
140 calories Zero calories
35 g carbohydrate 0 g carbohydrate
~ 9 tsp sugar
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

57. Pay attention to serving sizes!
Some foods sweetened with
no-calorie sweeteners have
practically no calories.
Others contain
calories from
other ingredients.
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

58. May have low impact on
Low Fat calorie saving (low fat but
higher carb content)
Taste may be less than
desirable.
Fat free
<0.5 g fat/serving
Fat replacers Low fat
Modified food starch <3 g of total fat
Guar gum
Xanthin Reduced saturated fat
Maltodextrins <25% of regular version
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

59. Nutrient Claims and % Daily Value
Free Low Reduced
Calorie <5 cal/serving <40 cal/serving
<0.5 g fat or
3 g or less of
Fat saturated fat/
total fat
serving
<0.5 g saturated at least 25% less
Saturated fat fat or trans fat
1 g or less than regular version
at least 25% less
Sugar <0.5 g/serving than regular version
140 mg Na or
at least 25% less
Salt <5 mg Na/serving less, very low than regular version
35 mg or less
at least 25% less
Cholesterol <2 mg/serving 20 mg or less than regular version

60. High Fiber Whole grain bread
3 g fiber/serving
Whole grain cereal
3 g fiber/serving
Consider cereal mixture
with >7 g fiber/serving
Whole grain crackers
>2 g fiber/serving
Excellent source of fiber
> 5 g/serving
Good source of fiber
2.5-4.9 g/serving
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

61. macaroni & cheese
Read
the
label!

62. The nutrients in the Nutrition Facts are
provided by one serving of the food
Estimate the amount of carbohydrate
in the portion you will actually eat

63. Eat just the serving
size of the food given
in the food label
Food label serving sizes are not necessarily the
same as diabetes (exchange/choice) servings
Food Diabetes Serving Food Label Serving
Milk 1 cup / 8 oz 1 cup / 8 oz
Bread 1 slice / 1 oz 1 slice / 1 oz
Fruit juice 1/2 cup / 4 oz 1 cup / 8 oz
Margarine 1 tsp regular stick 1 tbsp regular stick
Pastors et al. Diabetes Nutrition Q&A for Health Professionals, 2003

64. The number of servings you General Guide
consume determines the number
of calories you actually eat Low
40 calories
Moderate
100 calories
High
>400 calories
If you ate the whole package, that would
be 500 calories and 220 calories from fat!

65. You can use the
% DV to make
dietary trade-offs
1 serving
2 servings

66. “I look upon the diabetic as a charioteer, and his
chariot is drawn by three steeds named Diet,
Insulin and Exercise. It takes will to drive one
horse, intelligence to manage a team of two, but
a man must be a very good teamster who can
get all three to pull together.”
Elliott P. Joslin, MD
1869-1962

67. One, Two ... Count my food.
Three, Four ... Exercise more.
Five, Six ... Small meals I fix.
Seven, Eight ... Now how’s my weight?
Nine, Ten ... Start again.
Brown et al Diabetes Spectrum 2001
Thank You
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