Food.
It
has been a dominant passion my entire life.
Growing up in rural Bloomington, Minnesota, my parents owned a house on
an acre of land that had vegetables, fruit, and flowers bulging in every corner
that wasn’t reserved for play space for my three siblings and me. I have many fond memories of picking fresh
strawberries for the evening’s shortcake, vibrant leaf lettuce for our sandwiches,
and succulent red rhubarb for the flavorful sauce we would put on our toast at
breakfast or made into Mom’s best jam.
My love for rhubarb apparently started quite early in my life. Mom would tell me it was not uncommon for her
to find me straying from my sandbox to the rhubarb patch where I would sit
sucking on the stalks. To this day,
rhubarb pie holds its place as my first choice for favorite desserts. Even now, my husband Alexx is amazed that
when our family gathers, our dominant conversation is food. We never leave the table without discussing
what will be on the menu of the next meal.
Given this joy of food, it comes as no surprise that I love
to cook. Seriously, love it. If I am energized, I create recipes using
unique ingredients or try new combinations of standard foods in my refrigerator. If I am tired or distressed, I find myself in
the kitchen making soup or sauces that require lots of chopping or stirring so
my mind can relax with the routine. The kitchen is my favorite room in
the house. It’s where I head first thing
in the morning, take breaks in the afternoon to experiment with new recipes,
and where I close the day with dinner preparations and getting the next day’s
meals in order. It is always the focal point of our entertaining. People love
my food and I love dazzling them.
What I don’t love is cleaning up or doing dishes, so when I
met Alexx, I knew this match was made in heaven. He not only loved to eat, but he was a wizard
at organization and was happy to trade the chore of cooking for cleaning
up. I just need to get the dishes in the
sink and keep the counters clear and he takes care of the rest. When he tires of what can some days seem like
an endless pile of pots, pans and measuring cups, he will suggest we frequent
some new or favorite restaurants where I always can find new ideas for future
meals.
For twenty years, our routine was going quite well except
for some weight gain that was bound to occur for both of us as our metabolism
slowed and my kitchen creativity increased.
Alexx has always had a sweet tooth and a love of any kind of bread, so
despite my propensity for soups, salads, and meat dishes, I added a skill of
bread making and ice cream creations to my repertoire after Alexx found two
appliances that allowed me to keep my focus on creation and not kneading or
churning. But things came to a halt a year ago, and now, like the forgotten
Velveteen Rabbit, the bread and ice cream makers sit dormant on the shelf. Strike dramatic chord.
October
10th
has always been a great day of celebration in my life. It is my mother’s birthday. Birthdays have been major events in our family
because the person of honor was able to name exactly what they wanted for
dinner. While I pretty much stuck to the
same menu every September 23rd for my birthday dinner of bar-b-que ribs,
scalloped potatoes, lima beans, crescent rolls, perfection salad and rhubarb
pie, Mom’s birthday was exciting because she would make something different each
year that she wanted to try. Yes, I come
by my love of the kitchen naturally. Mom
loved cooking her own birthday dinner and we were always excited when her
special day rolled around to see what the new creation would be. I still can remember when she made sweet and
sour pork and a Harvey Wallbanger cake. We
had never tasted anything so unusual and yet so wonderful. The
Harvey Wallbanger cake became my sister’s annual birthday cake from then on.
But October 10th, 2011, brought a different kind of
excitement. Mom was miles away
celebrating her birthday with my sister while Alexx and I were in a new
doctor’s office having his chart reviewed after his trip to the emergency room
on October 8th. Alexx had
refused to be admitted but agreed to see this doctor on Monday morning. We were about to get a diagnosis that would
change our lives. Alexx had Type 2
Diabetes Mellitus. We had no idea what this meant, but because his dad
had died at the early age of 73 of complications from diabetes, we knew we
needed to pay serious attention.
Type
2 diabetes can occur for as much as 10 years before someone is
diagnosed with it, so we had no idea what damage Alexx might have
incurred. We first needed to figure out,
just what was going on in his body and what if anything we could do to slow
things down, stop it, or even reverse any complications that had resulted from
the disease. So I hit the books...well,
the internet first...to see if I could understand what was happening to his
body. In short, Alexx's body wasn't able
to tolerate glucose (the sugar) in his blood and move it effectively to his
cells that needed it for energy. The
body has special cells called beta cells that create insulin. The insulin is the key that unlocks the cells
to allow the glucose to enter. The
glucose feeds the cells and keeps them healthy.
If they aren't fed they die. Therein
lies the problem. Alexx's cells weren't
being fed because he didn't have enough beta cells that were generating enough
insulin to move the glucose through his system and into his cells. As he continued to eat foods that had a high
glucose level his system became overwhelmed with glucose that couldn't get to
the cells. So the body did it's best to
store that excess glucose in the form of fat.
Even with that storage method, his blood was thick with glucose and so
it traveled slowly causing him to be tired and sluggish much of the time and
with a strong thirst. His body constantly
needed more liquid to try to dilute the glucose ridden blood. Normally, a
person's glucose level in their blood should be between 100 and 126mg after
fasting or after 2 hours from eating. We found out Alexx's levels were
much higher.
Before
that Diagnosis, Alexx had not been to the doctor in 10
years. He was never a fan of annual doctor visits despite my
encouragement. He believed his constant
exercise, whether it was on the ball field or walking 3 miles a day, would keep
him in an indestructible state. He also
resented the high costs associated with visiting doctors and felt if there was
something wrong with his body, he would know it. One of his favorite sayings
was, "I'm as healthy as a horse."
But in October of 2011, he knew something was not quite
right. For the previous six months or
so, Alexx was continually thirsty and his trips to the bathroom were not only
frequent at night but also during the day. He seemed to be losing weight despite not
trying, and he was experiencing tingling in his legs and feet. Given these symptoms, he decided that when we
were at the Huntsman Senior Games in St. George, Utah, we should take advantage
of the free health screening being offered to the players and spouses. We decided to
go the morning of the last day of the
games. Alexx’s softball team was playing for the championship that
afternoon, but we would have time to walk through all the wellness screenings.
We moved through the area quickly as they checked our
balance, our body mass index and hearing among other things. At some point we seemed to get separated as I
was longer in the audio testing and Alexx was longer in the glucose
testing. Apparently the glucose monitor
they were using wasn’t working right, as it scored Alexx’s blood glucose at 576
(Remember, a normal count should be between 100 and 126. Granted, Alexx had just consumed a big
breakfast that included a huge cinnamon roll, double hot chocolate, eggs,
potatoes, and sausage, but still, the number was way too high.) They asked him to wait five minutes and they
would check it again with a different device. The second check was 580. The student attendants were thrown into a
panic and flagged the nurse on duty. She
found me coming out of the audio screening and sat me down for a serious
discussion. Alexx needed to go to the
emergency room immediately as she was concerned he could go into a coma at any
minute. I looked over her shoulder and
saw him standing and shaking his head. He had a championship game to play in two
hours and he wasn’t going anywhere but to the field. Alexx assured me that he felt fine and that
given the large breakfast we had just consumed, it was probably just an
aberrant reading. He felt fine and gave
me his non-verbal signal, “Let’s go.”
So we left for the ball field despite everyone’s
concern. Alexx promised the nurse he
would go to Urgent Care after the game. His
team lost the championship and by the time the game finished, Urgent Care had
closed. We had a long drive to get back
to our home in Scottsdale, but Alexx was comfortable leaving in the morning and
promised me he would go to Urgent Care near home. But Urgent Care closes early on Saturdays and
by the time we arrived, they were closed for the weekend.
I had my computer with me in Utah and had been reading about
the dangers of high glucose levels in the blood since the nurse had cornered
me. The threat of Alexx becoming
comatose was a little overwhelming and now I really wanted him to get some
medical attention. To satisfy me, he
agreed to go to the emergency room when we found the Urgent Care center was
closed. Given that we were leaving the
following Tuesday for our cruise, he reminded me that we still had packing to
do for the trip and hoped this “medical emergency” would not take long. But similarly to the response of the student
attendants earlier, the medical staff at the hospital was concerned when we
told them Alexx’s glucose reading the previous day was 580. They checked him and it was over 400 so they
put him on a saline drip to hydrate him and tested him again. It then lowered to 340. After another bag of saline, it lowered again
to 300. The medical staff wanted to
admit Alexx for further monitoring and education on diabetes, but Alexx
refused. He said he would see a doctor
on Monday morning as he had to pack for the cruise. The nurses advised against doing anything
until his blood sugar was under control, but there was no discussion as far as
he was concerned. We took more pamphlets
on diabetes and scheduled an appointment to see the doctor on Monday morning in
his office.
"You
are Diabetic!" That
dreaded official diagnosis was handed over on our formerly beloved day of
October 10th. Alexx’s glucose level was
checked that morning and despite our efforts of strictly following the food
plan on the American Diabetes Association (ADA) pamphlets for one day, his glucose
had only lowered to 300. The doctor was
understanding about our desire to board our cruise ship the next day but
cautioned that Alexx was not out of danger and needed to be diligent about
managing his diet. We left the office
with a prescription for Metformin and a glucose monitoring kit as well as more
literature from the ADA with a low-fat/healthy carbohydrate meal plan. He told Alexx to check his glucose every
morning with a goal of getting it to 100.
The doctor also told us about another test that would help
us monitor Alexx's progress. It's called
Hemoglobin A1c and it measures the average amount of glucose that clings to the
hemoglobin over a 3-month period. Hemoglobin
is what carries oxygen to the cells so although some glucose will stick to the
hemoglobin, it shouldn't be burdened with much. A good A1c reading is 3.5-5.0. Alexx's level was 12.1. The doctor compared Alexx’s blood with
dirty oil that was sluggish and not
moving well through your car. Consequently
his body asked for lots of water to loosen things up, but since he had very
little insulin to move the glucose away from the hemoglobin and through his
bloodstream he ended up just peeing away the water. His body couldn’t catch a break no matter how
much water he drank. He needed less
glucose in his system to have to process and more insulin to move efficiently
to the cells what glucose he had.
We could see we had a challenge ahead of us and were
pretty sure we were ill equipped for managing this journey. From our previous cruise experience, we knew
Holland America would provide endless rows of mouthwatering temptations of
sugar-based delicacies on their cruise ship. Oh the horror!
More
Investigation! Knowing
the computer is my friend, I was not too upset at the lack of direction I felt
our doctor gave us for navigating the road ahead. While Alexx began packing for the cruise, I
reviewed the ADA webpages and Googled “diabetic meal planning”. I called Holland America Cruise Line and they
assured me they would work with us on meeting dietary restrictions. So I thought if I was prepared with a plan of
action, our vacation would not be a hindrance to getting Alexx on the road to
wellness.
The ADA website made things pretty
simple to follow. We only needed to
manage these five things Using a dinner plate, put a line down the middle of
the plate. Then on one side, cut it
again so you will have 3 sections on your plate. Fill the largest section with
non-starchy vegetables such as spinach, carrots, lettuce, greens, cabbage, bok
choy, broccoli, cauliflower, tomatoes, mushrooms, peppers or turnips. Then in one of the small sections choose
starchy foods such as whole grain breads, rice, pasta, tortillas, cooked beans,
peas, potatoes, corn, sweet potatoes, winter squash, snack chips, low fat
crackers or fat free popcorn. Finally,
on the other small section put meat or meat substitutes such as chicken,
turkey, fish, seafood, beef, pork loin, tofu, eggs or low-fat cheese. Then add an 8-oz glass of nonfat or low fat
milk, a small roll or 6 ounces of light yogurt.
For dessert have a 1/2 cup of fresh, frozen or canned (in light syrup or
juice) fruit.
This all sounded simple enough and with the exceptions of
Alexx not liking most green vegetables and eliminating desserts, I thought we
would be fine finding him plenty to eat that satisfied his palate on the cruise
and afterwards. However, given Alexx’s
size of 6’3” and 219 pounds, he was used to more than one plate of food at a
meal. These smaller portions would be a
challenge, but given they suggested adding two snacks a day, I thought we could
make things work.
I also enlisted the help of Sparkpeople.com, a website that
I had used for my own meal planning and weight management. I found they had a diabetes meal planning
tool, so I printed a number of their meal plans that were based on ADA
guidelines. I was sure these plans would
help us navigate the buffet lines on the cruise ship. They targeted a caloric intake of 2000-2300
with a daily range of carbohydrates being 245-289 grams, daily fat intake at
65-77grams, and daily and protein at 98-116 grams.
When we followed these guidelines, a
typical day of food on the ship and later at home looked something like this:
Breakfast:
(Goals were 490-578 Calories; 61-72 Carbs; 16-19 Fat; 25-29 Protein)
Goat
Cheese, soft, 1 oz
Blueberries,
fresh, 1 cup
Milk,
nonfat, .5 cup
Egg
white, fresh, 3 large
Oatmeal
cooked (plain), .5 cup, dry
Whole
Wheat Thin Bread, 1 serving
Butter,
salted, 1 pat (1" sq, 1/3" high)
Breakfast TOTALS: 537
Calories; 70 Carbs; 14 Fat; 29 Protein
Lunch: (Goals were 490-578
Calories; 61-72 Carbs; 16-19 Fat; 25-29 Protein)
Olive
Oil, 1 tbsp
Asparagus,
fresh, 4 spears, small
Soy
Sauce, 2 tbsp
Green
Onion, ¼ cup
Turkey
(light meat) 60 grams
Brown
Rice, medium grain, 1 cup
Sugar
Free Vanilla Ice Cream, .5 cup
Lunch TOTALS: 540
Calories; 71 Carbs; 17 Fat; 29 Protein
Afternoon Snack: (Goals were 245-289
Calories; 31-36 Carbs; 8-10 Fat; 12-14 Protein
Cheddar
Cheese, 1 oz
Apples,
fresh, 1 medium (2.75” dia)
Ry-Krisp
Crackers (2 crackers)
Turkey
Breast, 98% fat free deli slices, oven roasted – 1 slice
Afternoon
Snack TOTALS: 286 Calories; 32 Carbs; 11 Fat; 13 Protein
Dinner: (Goals were
490-578 Calories; 61-72 Carbs; 16-19 Fat; 25-29 Protein
Iceberg
Lettuce, 1 cup, shredded
Dressing,
Ranch, fat free, Walden Farms 2 Tbsp
Fish,
Halibut, baked, 75 grams
Extra
Virgin Olive Oil, 1 tbsp
Asparagus,
Fresh, 1 cup
Brussel
Sprouts, 10 sprouts
Wild
Rice, 1 cup
Jello,
sugar free w/fruit, 1 serving
Dinner
TOTALS: 492 Calories; 64 Carbs; 17 Fat; 28 Protein
Late
Snack:
(Goals were 245-289 Calories; 31-36g Carbs; 8-10g Fat; 12-14g Protein)
Goat
Cheese, soft, 1 oz
Pears,
fresh, 1 medium
Walnuts,
.5 oz or 7 halves
Finn
Krisp, Caraway Crackers, 1 serving
Late
Snack TOTALS: 289 Calories: 33 Carbs; 16 Fat; 9 Protein
DAILY
GOALS:
1960-2310 Calories; 245-289 Carbs; 65-77 Fat; 98-116 Protein
TOTALS
FOR THE DAY:
2144 Calories; 271 Carbs; 75g Fat; 108 Protein
Based on what Alexx was eating and how closely he was
following the ADA meal plan guidelines for a diabetic, we expected his glucose
numbers to come into a normal range in no time and be able to reduce his
medication. But despite his new approach
to eating, Alexx’s progress was very slow.
His fasting glucose was still from 150-175 (remember, the target is
100-126) and his weight loss the first month was three pounds. The hardest parts for Alexx were the loss of
sweets and generally feeling hungry all the time. His doctor felt his progress was fine and
Alexx was willing to stay the course, but I was not satisfied and continued to
do more investigating.
Enter
Low-Carb Meal Planning. I
started reading about the success of low-carbohydrate meal planning and the
impact it had on blood sugar. Dr.
Richard K. Bernstein appeared to have a strong research base for his theory so
I purchased his book, Diabetes Solution.
I wasn’t convinced that switching Alexx
to a low carbohydrate meal plan was in his best interest, but given that Dr.
Bernstein was a medical doctor, inventor of the glucose monitoring system
widely used today, and that he has been a Type 1
diabetic (his body could not produce insulin and was therefore dependent on
injecting insulin for his body to use) since the age of 12, I
thought his work was worth pursuing.
Despite the hundreds of testimonials from Dr. Bernstein’s
diabetic patients who had found success in lowering their blood sugar levels
with his low carbohydrate diet, it concerned me that his meal planning
recommendations were so different from what the American Diabetes Association
outlined in their brochures. I also
wasn’t willing to ignore the recommendations of Alexx’s medical doctor, but I
did think it was time to seek a second opinion.
So I returned to the computer and began a search of medical doctors in
the Phoenix/Scottsdale area who specialized in treating Type 2 diabetes (This
was Alexx’s diagnosis. Type 2 typically
occurs in adults and is not necessarily insulin dependent.) This led me to Dr. Helen Hilts, M.D. with a
family medical practice in Scottsdale. Dr. Hilts was diagnosed with Type
2 diabetes
in 2007, and through her personal study and change in meal planning, was able
to lower her A1c level to 5.0 (remember the desired range is between 3.5 and
5.0) and eliminate diabetes medication. Because of her empathy for her diabetic
patients, she takes a special interest in this area of her practice.
Alexx agreed to see Dr. Hilts and listen to what she had to
say about his health and how we could better manage his diabetes while still
enjoying eating. She spent more than an
hour with us describing what impact diabetes has on the body and the benefits
of a low carbohydrate diet. She gave her
personal testimony to the success of Dr. Bernstein’s research, having spent a
number of months as a visiting physician in his clinic so she could better
understand his work and success with patients.
After this experience, she decided to place a large focus of her medical
practice on patients with diabetes and changed her clinic’s name to
“Diabevita.”
She reviewed the meal plan that Alexx had been following for
the past month and believed that with a change to a low carbohydrate diet, he
would see a reduction in his fasting glucose levels, but more importantly that
his A1c level would show a significant change within 3 months. (Alexx’s A1c on October 10th, 2011, was
12.1.) She cautioned that he would lose
quite a few of the foods that he was currently enjoying, but he would also get
to add more fat in his diet which would give him a greater level of
fullness. He liked the idea of not
always feeling hungry.
These are the guidelines we were to follow as they appear on
Dr. Hilt’s Diabevita website:
Include PROTEIN in every meal:
·
If
it walks, swims or flies, it’s protein! Includes meat (beef, pork, etc.), fish
and chicken
·
Eggs
& cheese
·
Beans
– in small quantities because they also contain carbohydrates
·
Nuts
& nutty seeds (sunflower, pumpkin, sesame)
·
Soy
Include 2-3 VEGGIES in every meal:
Lettuce, spinach, cabbage, squash, broccoli, cauliflower, peppers, chilies,
avocados, eggplant, okra, celery, cucumber are a few examples. Small amounts of
onion or tomato are fine.
·
Always
eat a meal within 2 hours of waking up - keep
carbohydrates to 15 -20 grams or less.
·
Snacks
should be protein or veggies, too
·
Keep
good tasting, healthy foods ready, handy and visible, and take some with you
·
Use
bland vegetables in place of pasta or rice, under sauces
·
“Honey,
can I have a bite of yours?” An occasional bite of someone else’s dessert is OK
·
If
you splurge, go for a walk right away (No big splurges unless you’re climbing
mountains)
·
Roots:
Potatoes, sweet potatoes, carrots, beets (a little onion/garlic for flavor is
OK)
·
Fruits:
Oranges, apples, pears, grapefruit, cherries, peaches, melon, pineapple.
·
Fruit
Juices - an 8 ounce glass of juice contains the equivalent of 8-10 teaspoons of
sugar
·
Grains:
Wheat (even whole wheat), bread, corn, rice, oats (including oatmeal &
breakfast cereal)
·
No
Milk: Not even non-fat or 2%. The lactose in milk is milk sugar
These recommendations are from Dr. Hilt and what she has
found to be most effective with her patients.
After her work with Dr. R. K. Bernstein and studying the research he had
conducted with his patients, she was convinced that by significantly lowering
the intake of her patients carbohydrates (limiting intake to 5% - 20% of their
diet) and increasing their fat intake (increasing to 50-75% of mono-unsaturated
and saturated fat with very low percentage of polyunsaturated fat) would help
her patients better manage their diabetes.
Being a diabetic herself, she also adopted the meal plan and found so
much benefit, she was able to eliminate all prescription drugs and manage her
diabetes with food and exercise. She
also gave us a copy of the book The Art and Science of Low Carbohydrate
Living which was written by Jeff S. Volek, a registered dietician-scientist
and Stephen D. Phinney, a physician-scientist. Their research in this area as well as their
review of other studies demonstrate that eating fat as a primary maintenance
fuel can successfully manage diabetes and in many cases eliminate the need for
prescription drugs by putting the disease in remission.
Alexx liked the idea of more protein and fat in his diet but
the loss of bread, rice, and potatoes was of even greater concern to him than
losing sugar. But after learning about the
potential complications of other health factors as a result of his diabetes he
was motivated to work on lowering his blood sugar levels. The thought of losing his eye sight, having a
heart attack, or losing a limb due to poor circulation was enough for him to
give me the go ahead to start a new approach to meal planning. We agreed that Dr. Hilts would now be his
family physician. Between the documents
she gave us explaining the disease as well as many suggested recipes, her
website, and personal availability by phone and email, we felt we had someone
who was going to help us figure things out making this disease and a change in
lifestyle less overwhelming.
And
so it began. By January 10th, just three months
after his initial diagnosis, and two months of eating a low-carb/high-fat meal
plan, Alexx’s A1c level was down to
6.2. Three months later it was 5.5, and on October 10th, 2012, one year
after his initial diagnosis, Dr. Hilts referred to Alexx as her “poster child”
who was now measured with an A1c level of 5.2.
His lipid panel had also improved with his overall cholesterol levels
recording in the normal range and his blood pressure continuing to be
normal. His weight loss was 25 pounds. His insulin intake remains at 11cc's once a
day, administered before bedtime and 1000 mg of Metformin taken twice a
day. Although his prescription
medication has not been eliminated it is considered to be a low dosage. Since
we have no idea how long Alexx had undiagnosed diabetes, it is likely that he
has few beta cells left to produce adequate insulin and therefore will need to
continue to take the medication. Only
time will tell.
I continued to search for recipes that would give us the
balance that Alexx needed for carbohydrates, protein and fat. I found many on internet sites and a few in
the bookstores. Some of my favorites included www.elanaspantry.com , www.againstallgrain.com , www.lowcarbdiets.about.com , and
George Stella's cookbook, Livin' Low Carb.
I also referred to the ADA website for information and recipes, but
I adapted these and all other recipes to meet the requirements outlined by
Alexx's doctor. A typical day of eating
for Alexx in his first 6 months on the low-carb diet is reflected below. This meal plan targeted goals of 20% Protein:
10% Carbohydrates; 70% Fat.
Breakfast: (Goals were 590-700
Calories; 10-15g Carbs; 50-60g Fat ; 30-45g Protein )
Goat
Cheese, hard, 1 oz
Olive
Oil, 1 tbsp
Kale,
finely diced, 1 leaf (3g)
Green
Bell Pepper, chopped, 1 tbsp
Egg
(cage free, vegetarian fed) 2 large
Red
Onion, finely diced, 1 tbsp
Cottage
Cheese, ¼ cup, 4% fat
Flax
seed Oil, 1 tbsp
Cinnamon,
ground, 1 tsp
Walnuts,
coarsely chopped, 1 tbsp
Breakfast
TOTALS:
702 Calories; 10 Carbs; 61 Fat; 32 Protein
Lunch: (Goals were 650-725 Calories; 15-25
Carbs; 55-60g Fat; 25-35g Protein)
Olive
Oil, 1.5 tbsp
Sesame
Oil, 1 tsp.
Asparagus,
fresh, ½ cup
Soy
Sauce, 2 tbsp
Green
onion, ¼ cup chopped
Almonds,
slivered, 2 tbsp
Chicken
(light meat), 4 ounces
Cauliflower,
chopped finely, steamed, ¼ cup
Carb
Smart ice cream bar, 1
Lunch
TOTALS: 656 Calories; 21 Carbs; 50 Fat; 35 Protein
Afternoon Snack: (Goals were 250-313 Calories; 10-15
Carbs; 25-30 Fat; 12-14 Protein
Romaine
lettuce, 1 cup
Blue
Cheese Dressing, 1 tbsp
Tunafish,
2 oz drained
Strawberry
slices, 4 fresh small
Walnuts,
7 halves
Afternoon
Snack TOTALS: 328 Calories; 10 Carbs; 25 Fat; 20 Protein
Dinner: (Goals were 590-725 Calories;
15-25 Carbs; 55-60 Fat; 25-35 Protein
Iceberg
Lettuce, 1 cup shredded
Kale,
¼ cup torn
Avocado,
¼ of fruit
Egg,
hard boiled, ½
Almonds,
¼ oz
Dressing,
Blue Cheese, 2 tbsp
Fish,
Salmon, baked, 3 ounces
Extra
Virgin Olive Oil, 1 tbsp
Asparagus,
fresh, 1 cup
Sugar
free jello, flavored,½ cup
Heavy
whipping cream, whipped, 1 tbsp
Dinner
TOTALS: 768 Calories; 18 Carbs;
62 Fat; 38 Protein
Late Snack: (Goals were 250-312 Calories; 5-10
Carbs; 25-30 Fat; 12-14 Protein)
Hormel
Natural Choice Turkey Slices, 3
Pistachio
Nuts, 1/8 cup shelled
Late Snack TOTALS:
139 Calories: 5 Carbs; 8 Fat; 13 Protein
DAILY GOALS: 2693; Calories; 67 Carbs
(10%); 209 Fat (70%); 135 Protein (20%)
TOTALS
FOR THE DAY: 2593 Calories; 65 Carbs, 207 Fat; 138 Protein
Following
the low carbohydrate and high fat meal plan, Alexx was able to better manage
his glucose levels and still satisfy his hunger and caloric needs for reducing
and then maintaining his weight. We
followed Dr. Hilts recommendations very closely for the first 6-months but when
his A1c level dropped to 5.2 and his glucose levels were regularly between 100
and 126, we started experimenting with carbohydrates that came from fruit and
whole grains. We have since found that
he can incorporate small amounts of fruits and brown rice without spiking his
glucose numbers when they are combined with proteins and fats. This has made meals much more enjoyable for
Alexx and he doesn’t feel nearly as deprived of the foods he so enjoys. He also can handle small amounts of dark
chocolate, sugar free cocktails and light beer on occasion. Now we balance his meal plan with a ratio of
20% carbs; 50% Fat; 30% Protein.
Trouble Brewing Elsewhere. Unfortunately, the diabetes had been a part
of Alexx’s health profile for a number of years before it was detected. Because
he hadn’t been to a medical doctor in 10 years, he wasn’t aware that he also had
trouble in his arteries. Despite his
blood sugars being managed after his first three months on the low-carbohydrate
meal plan, the damage to his arteries had already occurred. In January he had a tightening in his chest
every time he did his daily walk and one time it was severe enough that we went
to the hospital emergency center. Three
of his arteries were blocked to 99% and consequently triple by-pass surgery was
necessary to help the flow of blood to and from his heart. Following surgery and recovery, his
cardiologist worked closely with Dr. Hilts and us in making some adjustments to
the meal plan which allowed Alexx to further reduce saturated fats from his
diet while keeping the fat content high enough to feed his cells.
Now I was not only learning about meal planning for diabetic
but also for heart patients. There was
some frustration in that the American Heart Association (AHA) was recommending
a low-fat diet which of course was contrary to the diet we were finding
successful for managing Alexx’s diabetes.
Instead of changing what was working, we continued with the plan of
low-carbohydrate and high-fat meal planning, but we monitored the amount of
animal fat that Alexx consumed. We
eliminated all beef that was not certified grass-fed due to the research that
showed grass-fed beef to be lower in cholesterol and saturated fat than
grain-fed beef. For precautionary
purposes, we also eliminated any processed meats from his diet that included
sodium nitrates. Research from Mayo
Clinic had indicated that the nitrates could be damaging to the heart and
recommended that only lean meats be consumed by heart patients. Consequently in addition to switching to
grass fed beef, we eliminated processed meats and changed our sausage
selections to nitrate-free and minimally processed meats, chicken or vegetarian
based products. We eliminated many cheeses but kept sheep and goat milk cheeses
or nut based cheeses that are lower in saturated fat. With these
adjustments, Alexx’s cholesterol levels reached the normal level within the year.
But this all did not come about without challenges. My love of spending hours in the kitchen
creating culinary delights had turned into hours of trying to come up with
meals that were flavorful, filling and fun to eat! I didn’t think it would be that difficult to
find substitutions for the things Alexx could no longer eat, but given his
limited enjoyment of vegetables, it was much more challenging than I had
imagined.
Score! It’s a Four! Through the cooperation of many other people
who have faced these challenges and shared their discoveries through journals,
books and blogs, Alexx and I have found a number of meals which do indeed meet
the criteria of flavorful, filling and fun! (We give these foods a rating of 4
on a scale of 1-4.) It is for that
reason that I decided to write a cookbook. This cookbook is to be the
compilation of the best of the best in Alexx’s opinion in five categories:
breakfast, lunch, dinner, snacks, and his most favorite category, desserts. 15 entries in each category will need to
achieve his “Four” ranking and comply with evidence based research as well as
the ADA guidelines, in order to make it into my cookbook.
Wait –
What? ADA guidelines? Prior to 2008, the ADA guidelines only supported
low-fat, calorie-restricted diets but didn’t recommend
low-carbohydrate diets because of a lack of evidence supporting their safety and
effectiveness for weight loss and managing diabetes. However, the 2008 ADA Clinical Practice
Recommendations include low-carbohydrate meal planning in the guidelines! Specific recommendations for quantities of
carbohydrates and fat are not given, however, they do recommend that protein
not exceed 20% of dietary consumption which means the remaining 80% must come
from carbohydrates and fat. The
guidelines recommend carbohydrates come from fruits, vegetables, whole grains,
legumes and low-fat milk. The specific
guidelines for fat consumption include less than 7% of total calories
come from saturated fat, intake of
trans fat should be minimized, and
two or more servings a week of fish which provide Omega 3 polyunsaturated fatty
acids.
Cholesterol should be limited to
less than 200 mg/day.
Consequently, the
majority of the fat incorporated in Alexx’s diet comes from vegetable, nut and
seed sources such as olive, flaxseed sesame seeds, and walnuts.
Ann Albright,
PhD, RD, and president of health care and education for the ADA, in
a prepared statement expressed, “The evidence is clear that both
low-carbohydrate and low-fat calorie restricted diets result in similar weight
loss at one year. We’re not endorsing either of these weight-loss plans over
any other method of losing weight. What we want health care providers to know
is that it’s important for patients to choose a plan that works for them, and
that the health care team supports their patients’
weight loss efforts and provides appropriate monitoring of patients’ health.”
(Diabetes in Control)
The ADA guidelines specify the use of low carbohydrate diets for weight loss by
diabetics and do not reference the diets for managing diabetes, however the
recommendations do specify that low-carbohydrate dieters make sure their blood lipids (cholesterol and
triglycerides), kidney function, and medication levels are monitored. (American Diabetes
Association). Given the successful
management of Alexx’s blood lipids his doctor recommends Alexx continue with
the low carbohydrate meal planning.
Diedre
Cooks Lo-Carb!
Consequently, I am creating a cookbook that only includes recipes that
meet Alexx’s rating of “four” and follow a low-carbohydrate meal plan that is
supported by research. We are following
Albright’s encouragement to “choose a plan that works” for Alexx and hopefully
a few other diabetics like him. With the
support and medical monitoring of Dr. Hilts at Diabevita and my love of cooking,
Alexx and I created a plan to select 15 breakfasts, 15 lunches, 15 dinners, 15
snacks and 15 desserts that are filling, flavorful and fun! (The fun part
means it makes Alexx smile when he is eating it and I enjoy making it.)
Desserts get their own category because Alexx likes his
dessert as one of his snacks so that he can savor the goodness all by
itself. So his dinner entrees will not
include a dessert. This meal planning allows
us to stock our fridge and pantry with a set amount of food to create these
meals on a rotating basis, thus saving time and money. (It also provides Alexx
with some independence in meal planning and preparation in the event I’m not
available to do the cooking.)
This blog allows us to prepare for the publication of the
cookbook by incorporating feedback from our readers. It would be helpful to know if others agree
with what Alexx considers to be a “Four” of the meal plans. We plan to rotate these meal plans throughout
the next six months as we travel the country in our RV. Our continual assessment and the feedback from
our readers will help us determine if the meal plans continue to keep Alexx’s
glucose in the normal range, and that they continue to hold a “four” rating.
Each meal will list the nutrition values as well as tips for
variations to the meals. We hope our
followers of this blog will provide testimonials and feedback regarding any
recipes that are tried. We are also
interested in feedback on the clarity of directions and ease in preparation of
each recipe. The joy of these meals will be that they are good for
everyone! There is no reason that a
“special” meal needs to be prepared for a diabetic. These meals are healthy and enjoyable for
everyone who is interested in following a low carbohydrate meal plan.
Evidence
Supports More than One Option.
Managing weight is only one aspect of meeting the needs of a diabetic. More important is managing blood glucose
levels. Many of us look first to the
American Diabetes Association for guidance as they are the forerunners in
gathering evidence on the care and treatment of diabetic patients. The ADA uses the information from this
evidence collection to publish a position statement (The Standards for Medical
Care in Diabetes, 2008) and a supplement (ADA Clinical Practice
Recommendations) to print pamphlets, provide educators with information for
classes, sponsor a website for education (dLife.com), a publication (Diabetes
Forecast) and provide reviews and recommendations on the ADA website (www.diabetes.com). However, all of this information can be
overwhelming to the patient and it certainly was to Alexx and me. The predominant message is for diabetics (as
well as everyone else) to
follow a low-fat and carbohydrate controlled diet. But when that diet was not helping to lower
Alexx’s glucose readings to the desired level, we needed to consider other
options.
One of the most popular recommendations is related to the
amount (less fat and fat-rich foods) and type of the dietary fat consumed (less
saturated, more polyunsaturated fatty acids).
The National
Center for Biotechnology Information, U.S. National Library of Medicine website
references research on fat intake stating that high fat consumption
leads to more nutrients such as vitamins A, E, calcium and zinc, but a
decreasing intake of other nutrients like vitamin C, folate, and carotenoids. People with a high amount of fat in their
daily diet typically show a lower intake of carotenoids, folates and dietary
fibers which come from vegetables and grains, but a higher intake of saturated
fatty acids (SFA) and cholesterol which come from meat and dairy products. The study notes that a broad selection of daily
diet with reduced fat and SFA intake is an important approach for health
promotion. (Elmadfa, I.) This study
reinforced the need to continue consuming vegetables containing vitamin C,
folate and carotenoids, plus Alexx takes vitamin C, carotenoid, flavonoid daily
supplements as he would not be reducing his fat intake, only his amount of
saturated fats.
Another report on the National Center for Biotechnology
Information, U.S. National Library of Medicine (NCBI) website discussed
research conducted by the Institute of Internal Medicine and Metabolic
Diseases, University Federico II, Naples, Italy, entitled “A
high-monounsaturated-fat/low-carbohydrate diet improves peripheral insulin
sensitivity in non-insulin-dependent diabetic patients.” This study found that with the
high-monosaturated fat/low-carbohydrate diet, there is a decrease in glucose
and plasma insulin levels. Furthermore,
fasting plasma triglyceride levels were reduced following this diet. (Parillo,
M.) This study is supportive of what we
found for Alexx’s diet.
At the Centre Obesity Research and Epidemiology (CORE),
Faculty of Heath and Social Care, Robert Gordon University, Aberdeen, UK, a
systemic review focused on randomized controlled trials of low-carbohydrate
diet/high-protein diets compared with low-fat/high-carbohydrate diets for
obesity and cardiovascular disease risk. Evidence demonstrated that
low-carbohydrate/high-protein diets are more effective at 6 months and are as
effective, if not more so, as low-fat diets in reducing weight and
cardiovascular disease risk up to 1 year. The study determined more evidence
and longer-term studies are needed to assess the long-term cardiovascular
benefits from the weight loss achieved using these diets. (Hession)
As reported in the Arch Internal Medicine journal in a study
of the effects of a low-fat diet versus a low-carbohydrate diet on fasting
glucose values, it was found that glucose values were more efficiently lowered
in individuals on the low-carbohydrate diet after 6 months, but after 12 months
the difference was no longer detectable.
However, A1c values changed more favorably in individuals on the
low-carbohydrate diet than on the low-fat diet at 12 months by 0.6% after
adjustment for weight loss. (Nordmann AJ) This study supports our approach for
increasing the percentage of carbohydrates and lowering the percentage of fat in
Alexx’s meal plans now that he has been on the lowest ratio of carbs for over
12 months.
In Sweden, the Department of Medical and Health Sciences,
Linköping University, a study aimed to compare the effects of a 2-year
intervention with a low-fat diet (LFD) or a low-carbohydrate diet (LCD). The
primary outcomes in this study were weight and A1c values. Patients on the low
fat diet aimed for 55-60 per cent and those on the low carbohydrate for 20 per
cent from carbohydrate.
At 24 months, weight changes did not differ between the diet
groups. Insulin doses were reduced significantly more with the low carbohydrate
diet at 6 months, when compliance was good.
A1c fell in the low carbohydrate group only. At 6 months, HDL-cholesterol had increased
with the low carbohydrate diet while LDL-cholesterol did not differ between
groups. The study concluded that aiming for 20% of energy intake from
carbohydrates is safe with respect to cardiovascular risk compared with the
traditional low fat diet and this approach could constitute a treatment
alternative. (D. B.-L. Guldbrand H).
This is the percentage that Alexx does best with and that will be used
for the recipes we include in our cookbook.
Research conducted at Duke University Medical Center in
Durham, North Carolina, tested the hypothesis that a diet lower in
carbohydrates would lead to greater improvement in glycemic control over a
24-week period in patients with obesity and type 2 diabetes mellitus. The method was to randomize eighty-four
community volunteers with obesity and type 2 diabetes to either a
low-carbohydrate, ketogenic diet (<20 g of carbohydrates daily; LCKD) or a
low-glycemic, reduced-calorie diet (500 kcal/day deficit from weight
maintenance diet; LGID). Both interventions led to improvements in hemoglobin
A1c, fasting glucose, fasting insulin, and weight loss. The low-carbohydrate
group had greater improvements in hemoglobin A1c, body weight and high density
lipoprotein cholesterol compared to the low-glycemic group. The diet lower in carbohydrate led to greater
improvements in glycemic control and more frequent medication
reduction/elimination than the low glycemic index diet. The study concluded lifestyle modification
using low carbohydrate interventions is effective for improving and reversing
type 2 diabetes. (Westman EC)
Perhaps it’s because I’m a Minnesotan or perhaps it’s
because Alexx and I found the greatest challenge in lowering his morning
glucose reading to normal range that I especially enjoyed reading the results
of Mary C. Gannon and Frank Q. Nuttall’s work.
They are affiliated with Metabolic Research Laboratory and the Section
of Endocrinology, Metabolism and Nutrition, Department of Veterans Affairs
Medical Center, Department of Food Science and Nutrition, and
the Department of Medicine at the University of Minnesota,
Minneapolis, Minnesota. Their award
winning presentation at the American College of Nutrition in 2007, discussed
the overall objective of their clinical research to develop a diet that does
not require weight loss or medications, but still controls blood glucose in
people with type 2 diabetes. The goal is to enable the person with type 2 diabetes
to control their blood glucose by adjustment in the content rather than the
amount of food energy in their diet. (Nuttal F)
Nuttell and Gannon determined that, of the carbohydrates
present in the diet, absorbed glucose is largely responsible for the
food-induced increase in blood glucose concentration. They also determined that dietary protein
increases insulin secretion and lowers blood glucose. Fat does not significantly
affect blood glucose, but can affect insulin secretion and modify the
absorption of carbohydrates. Based on
this data, they tested the efficacy of diets with various protein:
carbohydrate: fat ratios for 5 weeks on blood glucose control in people with untreated
type 2 diabetes. The results were compared to those obtained in the same
subjects after 5 weeks on a control diet with a carbohydrate:fat:protein ratio
of 30:55:15. A 30:40:30 ratio diet
resulted in a moderate but significant decrease in 24-hour integrated glucose
area. A 20:50:30 ratio diet resulted in a 38% decrease in 24-hour glucose area,
a reduction in fasting glucose to near normal. Basically, a combination of
these incorporated into a diet they refer to as Low Biologically Available
Glucose Diets (LoBAG diets). The response to a 30:40:30 ratio diet was
similar and the researchers found the increase of carbohydrates to 30% provided
for a more palatable and sustainable diet for the participants. Alexx would agree with that, however his
glucose response is too high when he alters his ratio from 20:50:30.
The A1c value on the control diet remained stable during the
5 weeks of the study. However, when diet contained only 20% carbs, the A1c
value decreased continually during the five weeks and was still decreasing
linearly at the end of the study. This
was similar to Alexx’s situation of decreasing significantly from 12.1 to 6.1
in the first three months and then a steady decline to his current 5.2 reading
of his A1c.
On the control diet, the A1c was 9.8 and remained unchanged. On the LoBAG diet of 20% carbs, the A1c decreased from 9.8
to 7.6 over the 5 weeks of the study. Extrapolating the data to ~120 days (~15
weeks), theoretically, the glycohemoglobin would be 5.4%, which is within the
normal range (Nuttall FQ).
Alexx has followed a similar diet plan over the past year
which initially consisted of 10 (carbs):70 (fat): 20(protein) and now is
following 20:50:30. Despite the large
body of research that supports the low-fat diets, there is significant research
available (each of the studies cited in this paper in turn have numerous other
research studies which cited research supporting low carbohydrate diets) to
substantiate the use of low-carbohydrate diets to meet the healthy management
of diabetic patients. This evidence, and
our own assessment of what has been working for Alexx, has convinced us that
following a low carbohydrate meal plan is the best option for him.
In regards to the triple by-pass surgery that Alexx faced
following his diagnosis of Type 2 diabetes, there is evidence that diet alone
will not resolve coronary artery disease (CAD) issues. According to Contemporary Endocrinology: Type
2 Diabetes Mellitus: An Evidence-Based Approach to Practical Management (Duke
University Medical Center), optimal management of CAD in diabetic patients
requires multiple therapeutic interventions, incorporating a variety of
lifestyle interventions and medical therapies including surgery for revascularization.
Studies of diabetes mellitus has
demonstrated that glucose management alone is not associated with a reduction
in cardiovascular events. In contrast, multiple
therapies are necessary for prevention of subsequent cardiovascular events
(U.K. Prospective Diabetes Study Group). Therefore, the dietary emphasis for
this cookbook is being placed on management of glucose levels and lipid
lowering but will not attempt to address CAD issues through diet.
Why
a Cookbook?
Besides my passion for food and a desire to help my husband maintain his
management of his glucose and lipid levels through diet, I would like to make a
small contribution toward helping people who have become a part of one of the
largest health problems facing mankind in this century. The epidemic of type 2 diabetes continues to
grow worldwide. Current estimations are that 171 million individuals are
affected and that the number of cases may double by 2030 (King). According to
the Center for Disease Control, over 10.9 million Americans over the age of 65
(approximately 27%) were diagnosed with diabetes in 2010. In the U.S., diabetes was responsible for an
estimated $132 billion in direct and indirect costs in 2002 (Hogan P and ADA).
As the costs of medical care continue to escalate placing an ever increasing
burden on global healthcare systems, the development of effective strategies
for diabetes prevention has become of great interest. Well, that, and the fact that my friends keep
asking me for my recipes!
Providing tasty low carbohydrate options that aid in the
management of glucose levels will ensure Alexx is getting what he needs while
enjoying it too. If the meals aren’t eaten, all the research is for not. Consequently, the meals need to be flavorful,
filling and fun!
Although the low-fat diet continues to get the major amount
of support from evidence based research, there is definitely more information
becoming available on the benefits of a low-carbohydrate diet. At the University of Connecticut, Department
of Kinesiology, in Storrs, scientific and anecdotal data has been reviewed to
determine favorable metabolic responses to very low-carbohydrate diets. Professors Voleck and Westman believe these
diets have merit for weight loss and suggest criticism of these diets lacks
scientific evidence. (Voleck JS)
Ultimately, it goes back to ADA Ann Albright’s statement,
“What we want health care providers to know is that it’s important for patients
to choose a plan that works for them, and that the health care team supports their patients’
weight loss efforts and provides appropriate monitoring of patients’ health.”
(Diabetes in Control)
It is Alexx’s and my hope that our cookbook will not only
bring satisfaction in meal planning to our home, but that it will help others
find success in managing diabetes, pre-diabetes and perhaps preventing
non-diabetics from ever having to deal with the impact of the disease.
________________________________________________________________
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