Nowadays, we all know that a diabetic diet, in common with any diet, should have a high fibre content and not include too many saturated fats. It should also contain the correct number of calories to maintain your body weight at the acceptable average for your height, sex and age, or to achieve this level if you are overweight.
The diabetic diet is fundamental to the treatment of diabetes and should be one of the first lessons learned by all new diabetics, whether it is their only treatment or whether they also need oral hypoglycemic pills or insulin injections. However carefully you manipulate your insulin or oral hypoglycemic treatment, lack of attention to diet can lead to poor glucose balance both immediately and in the long term.
If you have non-insulin-dependent diabetes it is likely that you are overweight. This makes your body resistant to the action of insulin. The most important part of your treatment is to return to the ideal body weight for your height and stay there, by eating healthy high fibre foods and avoiding sugary foods and excessive amounts of saturated fats.
Nowadays, we all know that a diabetic diet, in common with the diet advised for the whole country, should contain lots of starchy carbohydrate with plenty of fibre, very little saturated fat or sugar and some protein. You should eat the amount needed to keep your weight within the acceptable range for your height. This weight should give you a body mass index of about 22. You can calculate this from your weight in kilogrammes and your height in metres. (1 kg = 2.2 lbs. 1 inch = 2.54 cm.) The body mass index (usually abbreviated to BMI) is your weight divided by your height squared. Thus John who weighs 15 stone (95.5 kg) and is 6 foot (1.83 m) tall has a BMI of 95.5/1.83×1.83 = 28.5. He should weigh 73.7 kg.
At least 55 per cent of the total calories should be starchy carbohydrates or pulses, with over 30g fibre a day, fat should account for less than 35 per cent of the total calories (10 per cent saturated, 20 per cent polyunsaturated or monounsaturated), and between 10-15 per cent protein. Sugar should be less than 4 teaspoons of sucrose or the equivalent, added salt less than 3g daily.
Many of you will have been taught to weigh your food and to count exchanges of carbohydrate, and even of fat or protein. If you feel comfortable with this then continue, but nowadays dietitians are moving away from such rigid dietary control. I once met someone who dipped a urine testing strip into everything she drank to see if it was too sugary. She felt she needed an extremely strict diet to manage her diabetes and became very distressed when she was away from home and unable to calculate her exchanges exactly. She had become a prisoner of her diabetic diet.

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It is important to eat a high carbohydrate and low-fat diet The following practical tips which we have set out in an easy A to Z format will help you reduce the fat content of some of your favourite recipes at the same time as you are lowering their G.I. factor.

Alcohol. Although excessive alcohol consumption can be fattening, as an ingredient in a recipe, alcohol itself won’t create a high kilojoule dish. Alcohol evaporates during cooking, so you lose the kilojoules and are left with the flavour. A little wine in a sauce can give a delicious flavour, and sherry in an Asian style marinade is essential.

Bacon. Bacon is a valuable ingredient in many dishes because of the flavour it offers. You can make a little bacon go a long way by trimming off all fat and chopping it finely. Lean ham is often a more economical and leaner way to go. In casseroles and soups, a ham or bacon bone imparts a fine flavour without much fat.

Cheese. At around 30 per cent fat (23 per cent of this being saturated)) cheese can contribute quite a lot of fat to a recipe. Although there are a number of fat-reduced cheeses available, many of these lose a lot ricotta from a deli—you may rind the texture and flavour more acceptable than that of the ricotta available in tuba in the supermarket, flavoured cottage cheeses are ideal low-fat toppings for crackers. Try ricotta in lasagne instead of a creamy white sauce.

Cream and sour cream. Keep to very small amounts as these are high In saturated fat. A 300 ml container of cream can be poured into icecube trays and frozen providing small serves of cream easily when you need it Adding one ice-cube block (about 20 ml) of cream to 9 dish, adds only 7 grams of fat.

Dried beans, peas and lentils. These are all low in fat and very nutritious. Incorporating them in a recipe, perhaps as partial substitution of meat, will lower the fat content of the finished product Canned beans, chick peas and lentils are now widely available. They are very convenient to use and a great time saver. They are comparable in food value to the dried ones that you soak and cook yourself.

Eggs. Be conscious of eggs in a recipe as they can add fat. Sometimes just the beaten egg white can be substituted for the whole egg.

Filo pastry. Unlike most other pastry, filo is low in fat. To keep it that way brush between the sheets with skim milk instead of melted butter when you prepare it. Look for it in the freezer section of the supermarket with other prepared pastry and use it as a pie topping or a strudel map.

Grilling. Grill tender cuts of meat, chicken and fish rather than fry. Marinating first will add flavour, moisture and tenderness.

Health food shops. Health food shops can be traps for the unwary. Check out the high fat ingredients, such as hydrogenated vegetable oil, nuts, coconut and palm kernel oil in the products such as muesli bars, nut bars, health cakes and pies (even if made with wholemeal flour) that they stock on their shelves.

Ice cream. A source of carbohydrate, calcium, riboflavin, retinol and protein and low-fat varieties have the lower G.I. factor—definitely a nutritious and icy treat.

Jam. A dollop of jam on toast contains far fewer kilojoules than a smear of butter or margarine on toast. So, enjoy your jam and give fat the flick!

Keep jars of minced garlic, chilli or gingerin the refrigerator to spice up your cooking in an instant.

Lemon juice. Try a fresh squeeze with ground black pepper on vegetables rather than a dob of butter. Lemon Juice provides acidity that slows gastric emptying and lowers the G.I.

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Children’s parties and a diabetic diet

Your child can have parties.

Arranging a child’s birthday party if he has diabetes may demand some ingenuity, but can be readily done. If it is his own party you will not want your child singled out so that everyone else can have cake except him, so you will use only foods suitable for those with diabetes, and tell your child (beforehand if he is old enough, but unobtrusively if you are handing round the food at the time) how much he can have. In general you will rely on savory foods such as nuts, potato chips, party size pies and cocktail sausages. You may have to allow a little more carbohydrate at the party and make adjustment at the next meal. You can make a sugarless sponge or use diabetic jellies or an ice-cream cake as the birthday cake.

Coping with a diet when travelling

Try to keep the diet while travelling. Be prepared for delays.

Usually, when planning a trip it is possible to manage the schedule to fit in with usual meal times, and no special changes in diet are necessary. Always be prepared for delays, however, by carrying food with you, so that if it is not possible to keep to a timetable, the carbohydrate part of the diet at least can be given on time, and the risk of the glucose in the blood becoming too low is avoided. Even if you expect to be only a little late for a meal, it is best to give some of the carbohydrate at the right time and allow for this when the proper meal is taken later.

If your child is prone to travel sickness you may be wise to give an anti-sickness tablet before starting off, and your doctor will prescribe a suitable one for him. It is always essential to carry extra glucose or sugar (such as barley sugar) with you so you can cope with a possible hypo reaction or vomiting.

In long distance travelling, such as overseas air travel, it may be necessary to rearrange the meal plan to fit in with changes in local time. This can be quite easily done, but should be discussed with your dietitian or doctor when you know the flight schedule. Once again, a supply of dry biscuits or crackers will be a good precaution against unexpected delays.

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One, two or more injections a day?

Whether your diabetes is best controlled by one or more injections a day is a matter on which your physician will advise you. What may be best for one person may not be for another. Some people need two injections a day and some can get by on one, while others are best controlled on four.

Insulin, given by injection once a day, can never act in exactly the way that insulin which is naturally produced by the body. This is partly because the pancreas produces a rather steady flow of insulin throughout the day and night with extra amounts every time you eat. The extra amount depends on how much food is eaten. Considering this, it is remarkable that insulin injections work so well, but it is not surprising that we believe the ideal system would be to have insulin injections before each meal. This may not be convenient, but it may be necessary for someone who is seeking very precise control. It may also be necessary for some people whose diabetes is unstable with variable mealtimes and lifestyle.

Insulin antibodies

In the early years of insulin production, it was not as highly purified as it is now, and the insulin made from beef or pork was slightly different to human insulin. The body reacted to injections of insulin by producing antibodies to insulin. These antibodies were capable of reacting against the insulin and changing the way it worked, but usually this did not matter. The antibodies were provoked either by impurities in the insulin or by the beef or pork species itself. With modern techniques of purification and the use of human insulin, antibodies should not develop. This might be an advantage theoretically, but in practice the antibodies did not appear harmful.

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Recognizing hypos

Sometimes your toddler will behave in a way that resembles a hypo – but isn’t. This can be confusing for you. Perhaps she becomes tired and goes to sleep in the middle of a visit to her grandmother. Perhaps she throws a tantrum on the floor of the supermarket, or becomes cross and bad tempered on an outing. Is this just two-year-old behaviour or is the blood glucose level low?

With time and experience you will probably learn to recognize which is which, although sometimes both occur as the blood glucose value varies and influences her mood. If in doubt however, it is usually best to treat it as a hypo. It won’t do any harm to give a little sugar even if the blood glucose is not low.

If you are at home of course, it is sometimes best to do a blood glucose to help you to decide. If you give sugar every time your child has a tantrum it might seem like a reward for bad behaviour and encourage it!

Perhaps a compromise is to give an exchange as a drink for the hypo but then don’t react with any additional attention to her bad behaviour.

Have a break sometimes

Living with a toddler with diabetes can be a full-time job. If you get the chance, meet with other parents of a toddler with diabetes. Check if there is a local playgroup you can attend. Make sure your child is on the waiting list for your local kindergarten, and if there is a difficulty, discuss this with your doctor or social worker. Sometimes special consideration can be given to a child with a special problem like diabetes.

Arrange for a relative, perhaps a grandparent, to learn about diabetes so that you can get a break sometimes. Try to have some time off from your toddler each week to relax. Check with your doctor or social worker whether you are eligible for a government allowance which would help with baby-sitters and extra help in the house.

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HbAIc is the chemical abbreviation for a compound of glucose and hemoglobin in the blood. Hemoglobin is the red pigment inside red blood cells, and some of it has glucose attached, though most of it does not. We measure this substance in blood as a regular check on young people with diabetes.

The test for hemoglobin A1c

The purpose of the test is to help estimate the quality of control of diabetes over the previous 4-6 weeks. This is helpful in deciding if we should be satisfied with the way we are looking after you or your child with diabetes. We believe that trying to obtain good control is an important way to protect health in later life.

The test measures the quantity of hemoglobin in red cells that has glucose attached to it – glycosylated hemoglobin.

How does the glucose become attached to hemoglobin?

Glucose circulates in the blood, and some passes into the cells in the blood where it attaches to various proteins including hemoglobin. Some of this glucose becomes fixed to the hemoglobin and gradually accumulates over a period of several weeks. The amount that accumulates depends on the average levels of blood glucose concentration over that period of time.

In people who do not have diabetes there will only be a small proportion of glucose hemoglobin. For those with diabetes whose control is not good there will be a high proportion. In this way the proportion or quantity of glucose hemoglobin indicates how close glucose levels are to normal values over the period of time.

Why don’t blood tests at home tell you the same thing?

Blood glucose levels can vary a lot during the day and night, and although we usually only test before meals, they can be quite high after meals or during the night.

The blood tests at home tell us only part of the picture. They are very important however in helping with the day to day management of diabetes and in preventing hypos.

The relationship of HbAlc test and blood glucose tests at home

Both HbA1c and home blood tests tell us about how well we are controlling diabetes. Usually someone who can keep blood tests at home within a satisfactory range (most between 4 to 8mmol/l) will also have a satisfactory level of HbA1c. Sometimes however, the blood tests at home don’t match up with the HbA1c level. There are several possible reasons for this. Perhaps the blood tests at home are inaccurate: the test strips may be out of date or improperly stored. The meter may need calibrating. The child may not be putting enough blood on the strip. It is also possible that blood glucose levels done before breakfast and evening meal are not representative of other times. Thus, someone with a satisfactory HbA1c value, may have high blood tests during the day but low blood glucose levels during the night.

Sometimes teenagers get so fed up with doing blood tests and the disapproval from their parents when the tests are high, that they just make up their results and write down normal values of blood glucose on a test record. Even adults do this sometimes!

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Exercise helps control diabetes

Energetic activities play an important part in the healthy life of the child with diabetes. Activity increases the use of glucose formed from food, and helps insulin in maintaining a correct balance of sugar in the blood.

Exercise also helps insulin work properly by increasing its efficiency. It may also help in the absorption of insulin, particularly if the physical activity involves the part of the body where the injection had been given that morning.

Plenty of exercise is good

Your child should be encouraged in outdoor play, and in joining in sport and games with other children. With regular activity, insulin dosage will be kept lower and good control will be easier. It is important, of course, that exercise should be as regular as possible. Some children are naturally active, and this is no problem. Others prefer to watch television and sit around in their spare time, and if your child is like this he should be encouraged to spend some time each day in outdoor activity. Walking, cycling and skipping are good forms of exercise. Swimming is excellent, and although you will want to arrange that he is with someone responsible when swimming, you should certainly allow him this recreation. Do not restrict school sports, such as ball games, athletics, swimming or P.E. Encourage sports that can be continued through adult life.

Take extra carbohydrate before strenuous activity

Very strenuous sports, or unusual activities (such as a sports day or football match) will use up unusually large amounts of glucose for energy. You will need to give extra carbohydrate.

The type of carbohydrate used will depend on the type of activity.

For strenuous activities of short duration

For strenuous activities such as swimming, sprinting – some form of sugar which is absorbed rapidly should be taken just before the activity. For example, fruit juice, barley sugar or soft drink. Extra amounts may be taken during the activity – e.g. at half time at football.

For activities of longer duration

For longer activity, e.g. hiking, long distance running or jogging, additional complex carbohydrate or a combination of simple and complex carbohydrate which will be absorbed and enter the blood stream at a slower rate is more suitable.

The amount of carbohydrate required will vary not only with the type and duration of the activity but also between individuals: some young people seem to need a lot of extra sugar, and some hardly any at all. Your child will soon work out what is best by experience and discussion with you and your doctor. Follow these rules until you have this experience.

As a general rule allow approximately 1 carbohydrate exchange per hour of activity.

All children with diabetes should have an extra exchange of sugar in some form before swimming. Make sure that such people as the sports teacher and swimming instructor know your child has diabetes, and know what to do if a hypo should occur.

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