A Dialogue on Diabetes Nutrition

The Diabetes Health Team interviews Ms Sheryl Salis on the importance of Diabetes Nutrition and talks about her latest book that aims to educate people about the right approach to Diabetes diet

How important is it for a person with Diabetes to know about nutrition?

The world is undergoing rapid nutritional transition resulting in excess consumption of calories, saturated and trans fats, simple sugars, salt and low intake of fibre. Such dietary transitions and a sedentary lifestyle have led to an increase in obesity and diet-related non-communicable diseases like Diabetes, heart disease, hypertension, among others. Nutrition is the cornerstone of Diabetes management. What, when and how much we eat has a major impact on our blood sugar levels, weight and other blood variables. Nutrition knowledge is therefore important for everyone, more so when an individual has Diabetes. Nutrition is one of the four pillars of Diabetes self-management, along with physical activity, blood sugar monitoring and medication, with Diabetes education being the thread connecting these four pillars.

How do carbohydrates, proteins and fats impact blood sugar levels?

Carbohydrates by far have the greatest short-term impact on blood sugar levels, more than protein or fat. Protein and fat take several hours (up to three to four hours) to show up as blood glucose, so they play a minor role in short-term blood glucose control.

When we eat carbohydrates, they are broken down into glucose immediately which enters your bloodstream. Blood sugar levels begin to rise fifteen minutes after eating carbohydrates and most of it is broken down into glucose within the first two hours of eating. This is why carbs are known to raise blood sugar levels faster than any other nutrient and have the maximum influence. The rise in blood sugar levels depends on the amount and the type of carbohydrate (complex, simple, refined) one eats.

Protein intake in small portions has little effect on blood sugar levels. But if one consumes large amounts of protein in a meal (>25 g per serving), it may delay the absorption of carbohydrates and will cause the blood sugar levels to increase after a few hours of the meal.

Fat in small amounts has a minimal effect on blood sugar levels. However, if fat is present in high amounts (>30 g per serving), it can slow down the absorption of glucose from the meal. The best example is that of ice cream. If you eat ice cream and test blood sugar after two hours, the chances are that you will not see a spike in blood sugar levels; however, if you test after a few hours, blood sugar levels may be higher. Hence, monitoring in case of a high-fat meal needs to be done for up to 4-6 hours after consuming the meal.

In such situations, frequent blood glucose monitoring (SMBG) or continuous glucose monitoring is recommended to see the impact of carbs, protein, and fat on blood sugar levels.

Why is carb counting important for a person with Type 1 Diabetes?

Carbohydrate counting also referred to as carb counting is a way of estimating the amount of carbohydrate in different foods. For people with Type 1 Diabetes, carbohydrate counting is the key to maintain normal blood sugar levels. One can count the carbohydrates before having a meal and then adjust the dosage of insulin to 'balance out' the carbohydrates to precision. By doing this, one tries to mimic the healthy pancreas and release just the right amount of insulin to cover the carbohydrates eaten. With the right balance of carbohydrates and insulin, blood sugar levels usually stay in the target range.

Carbohydrate counting has also shown to improve compliance with treatment because it allows flexibility in food choices. It is one of the tools that may empower children and adolescents to manage their Diabetes more effectively within their lifestyle.

What points to keep in mind while choosing cooking oils?

It is important to note that all oils have similar calories and should be used judiciously. One should focus on both the quality and quantity of oil. It is important to note that all oils – olive, rice bran, sunflower or any other oil have similar calories and should be used judiciously. On an average, an individual is recommended 3 level teaspoons or 1 level tablespoon a day.

Changing oils regularly or using commercially available blended oils can help acquire a balance of fatty acids and offer maximum health benefits. The National Institute of Nutrition recommends a combination of groundnut/sesame/rice bran + mustard oil or groundnut/sesame/rice bran + soybean oil to maintain the desired Omega-6 to Omega-3 ratio.

One should look out for words such as "shortening", "partially hydrogenated vegetable oil" or "hydrogenated vegetable oil" in the ingredients as these are sources of trans-fats and should be avoided.

When the oil is heated past its smoke point, (the point at which bluish smoke emerges from the oil), it generates toxic fumes and free radicals which are extremely harmful to the body. Hence, oil with low smoking points such as extra virgin olive oil and flaxseed oil should not be used for frying foods.

How superfoods are helpful to a person with Diabetes?

To quote Hippocrates, the father of medicine, "Let food be thy medicine and medicine be thy food." Certain foods that are easily available in our kitchen have bioactive compounds and have shown immense benefits in improving blood sugar levels in people with prediabetes and Diabetes. Some of these superfoods are cinnamon (dalchini), fenugreek seeds (methi), Indian gooseberry (amla), flaxseeds (alsi), kidney beans (rajma), sweet potato (shakarkand), drum sticks (moringa) and apple cider vinegar. It is important to follow a healthy lifestyle even if one incorporates superfoods in the diet.

Also, what suits one person may not suit another as some of them can cause certain side effects if taken in excess or may be contraindicated in certain conditions like pregnancy, lactation, co-morbid conditions or when on certain medications like blood thinners. Hence, it is important to consult your doctor and a qualified dietician before you start anything new. Do not fall prey to quacks and self-proclaimed health experts and social media influencers.

How important is it to read the nutrition labels?

Advancement in technology has made it possible to have access to food that can cater to the preferences, tastes and health requirements of an individual. A person with Diabetes is often seen spending more time at the supermarket than others looking for healthier options with words like 'sugar-free', 'diet', 'baked not fried' and even 'Diabetes friendly'. Regular chips and soda cans are replaced with diet-friendly foods and traditional home-cooked meals with 'Diabetes friendly' meal options. Yet frustratingly, many a time these changes do not seem to reflect on the blood sugar levels. This is where a lack of understanding of the nutrition labels comes in. Picking up boxes that have words like 'sugar-free', 'diet', 'baked not fried' and even 'diabetes friendly' may seem like healthier options, but, seldom are.

With so many options available in the market today, it is a challenge to understand the best choice for one's health. This is where the nutrition labels come to the rescue. A deeper look at the nutrition label information like serving size, ingredients, nutrients in the food and their quantity can help the consumers make an informed and wise decision while buying any food product. Reading the nutrition label is a skill that needs to be developed to make informed food choices that contribute to health.

It is recommended that every time you are at a grocery store, you take that extra minute to look at the food labels of the items you are buying. Reading the nutrition label is the only way to know if the product is healthy or a scam. Choose products that are low in refined flour, sugar and sodium and high in fibre, protein and healthy fats.

How can people prepare their meal plate every day to achieve a balance of the macronutrients as well as micronutrients?

Understanding the food plate or the food that we eat on a day-to-day basis is important. Food provides important nutrients like carbohydrate, protein, fat, fibre, vitamins and minerals. Choosing from the variety of options from each food group helps ensure that one gets the right amounts of all the good nutrients required to maintain good health. This is called diet diversity.

The American Diabetes Association recommends choosing a 9" plate instead of a 12" plate for every meal. Fill half the plate with vegetables and salads, 1/4^th of the plate with starch and unpolished cereals, starchy vegetables and millets and the remaining 1/4^th plate with protein-rich food sources. How you consume your meal also affects the post meal blood sugar response. Several studies have shown that if you eat protein and fibre first followed by carb containing foods, the post meal blood sugar response will be better. For example, if you have chicken, fish, paneer or dal with vegetables first followed by rice or chapatti, the post-meal blood sugar spike will be blunted.

What is the inspiration behind your book 'Diet in Diabetes Simplified: Your Personal Diabetes Nutrition Coach'?

In today's times with so many myths and misconceptions around food, especially in the field of Diabetes, people resort to online research or advice from well-wishers or self-proclaimed nutritionists/health experts which may often be incorrect and misleading, resulting in complications. As healthcare professionals, half of our time in the clinic and otherwise is spent responding and clarifying these social media forwards from friends, family and clients. I used to receive many forwards from doctors which they received from their patients asking for clarification.

Once, I was discussing this with my mentor and guide Late Dr Vijay S Ajgaonkar, a renowned diabetologist, when he asked me, "Why don't you write a book, putting in your experience in the field of Diabetes?" He felt the need for a simplified book on nutrition in Diabetes by an Indian author who would address the concerns and queries of people with Diabetes and their families, providing correct, scientific advice. He encouraged and persuaded me to write this book.

It was clear in my mind that I wanted to write a book for Indians living in India and overseas as many books are focusing on western diets but not many on Indian diets, especially on Diabetes. I then approached Notion Press and they agreed to publish the book and the rest is history. Just before the lockdown, the book was released in Bangalore by late Dr Vijay S Ajgaonkar, Mr C.N. Ashwath Narayan (Deputy Chief Minister of Karnataka) and Mr Tejasvi Surya (Member of Parliament, Bangalore South) among children with Type 1 Diabetes and their parents at the Type 1 Diabetes Foundation launch. I feel blessed that the person responsible for the genesis of this book, Dr Ajgaonkar released it before his unfortunate demise in August 2020.

My father has been my role model and inspiration in serving and contributing to society as he did a lot of philanthropic work. His 25^th death anniversary had coincided in May 2020 and I thought it was the best tribute to my late father. I started a non-profit organisation called George Salis Foundation in his name and pledged the profits from the sales of the book to support underprivileged children with Type 1 Diabetes for their education and medical needs.

This book aims to disseminate the right evidence-based knowledge, focusing on traditional wisdom to help people lead a healthy, active and better life with Diabetes. This book is my giving back to society with all my learning from my patients over the last 20 years. It is a small effort on my part to reduce the burden of Diabetes and its complications in our country and support more people in need.

The book is available in both hard copies as well as in e-book form on Amazon, Kindle and Flipkart. It also answers the most frequently asked questions on nutrition, dispels myths and misconceptions, presents real-life case studies and examples and easy to make recipes to enjoy.

How has awareness of Diabetes changed in India over the years?

Awareness about Diabetes is improving with the efforts and initiatives taken by the Government, medical and nutrition associations as public bodies. The burden of Diabetes is also increasing with the condition not being restricted to the elderly but also young children succumbing to the disorder due to unhealthy eating, inactivity and lifestyle. Timely screening and diagnosis are important to prevent complications from occurring due to uncontrolled blood sugar levels.

Making people aware that there is no "Diabetic diet" but a healthy "meal plan" that can be followed by the entire family can help improve compliance. With the boom in technology, newer drugs and advancement in research, Diabetes management has become easier than before. Management of Diabetes is teamwork. It requires the physician, dietician, diabetes educator, nurse and psychologist to work as a team and keep the person with Diabetes at the centre to help him or her achieve their health goals.

Following a meal plan for Diabetes does not mean avoiding your favourite foods and special family meals. Eating to beat Diabetes is about making smart choices while focussing and bringing back the joy of eating and living with Diabetes. Follow a meal plan which has no expiry date and is sustainable in the long run. Choose foods grown on plants rather than manufactured in plants. Do not fall prey to social media forwards or information coming from social media influencers or self-proclaimed health experts without authenticating the same with your doctor and dietician.