To make this educational site easier to navigate here are a list of modules that you are likely to need for the different types of glucose metabolism problems.
Online Course
How To: Learn About Metabolic Syndrome
This section lists some of the medical conditions that can occur with excess abdominal fat. This will be of interest to anyone who is overweight or whose parents and grandparents had diabetes, high blood pressure or cardiovascular disease. After completing this section please proceed to the How to follow a low carbohydrate diet section.
You can skip this section if you are thin AND your parents and grandparents were thin and lived to ripe old ages. You may like to proceed to the How To: Follow a Low Carbohydrate Diet.
Metabolic syndrome is a collection of disorders of metabolism which share a common outcome – much earlier deterioration of your blood vessels.
The major factors related to metabolic syndrome are insulin resistance, hypertension, low HDL, high triglycerides, high oxidised LDL, atheroma formation, gout, polycystic ovary syndrome, renal disease, ischaemic heart disease, dementia, peripheral vascular disease, central obesity, high inflammatory markers in the blood stream, non alcoholic fatty liver disease, and defective insulin secretion or action so that blood sugars rise too high particularly after meals.
Some of these effects you will see, some your doctor has to pick up doing tests and some are illnesses in their own right.
The problem is that if you have one of these you are more likely to get others.
So how do you improve things or stop them getting worse?
Broadly diet and excercise.
For most people wanting to lose weight they can restrict fat or calories as they like. For people with metabolic syndrome or diabetes there are considerable benefits to be had from a low carbohydrate, moderate protein, high fat diet. This is because other factors such as insulin resistance, high blood pressure and lipids also get better on such a diet. These factors are even independent of weight loss.
Exercise can be geared to activities to improve your cardiovascular fitness such as brisk walking or cycling and also for muscle building activities such as weight training as this particularly improves insulin resistance.
To know what a low carbohydrate diet is all about you need to know what sorts of food contain carbohydrates, protein and fats. What can you eat freely? What can you eat in small amounts? What do you have to avoid?
Quick Quiz:
1. Three of these are features of metabolic syndrome…
a High blood pressure.
b Fat round the middle.
c Thirst.
d High triglycerides.
2. You are more at risk of metabolic syndrome or type two diabetes if your parents or grandparents had one of these..
a Type two diabetes.
b Type one diabetes.
c Osteoarthritis.
d Hearing Loss.
3. Insulin resistance causes three of these…
a Heart disease.
b Lung cancer.
c Fluid retention.
d Low levels of HDL (good cholesterol).
Have you got it?
1. ABD are correct. Thirst is more associated with the high blood sugars that occur in diabetes types one and two.
2. A is correct. It has also been recently discovered that tinnitus (ringing in the ears) and hearing loss are strongly correlated with metabolic syndrome and type two diabetes.
3. ACD are true. Smoking is a major cause of lung cancer. An association between type two diabetes and various types of cancer is emerging eg colon cancer. Type ones have recently been found to be at higher risk of pancreatic cancer.
Reference Info:
- Drs Michael and Mary Dan Eades have written several helpful books about the evolution of obesity to increasing insulin resistance and metabolic syndrome and type two diabetes.Protein Power: The High-Protein/Low Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health-in Just Weeks! gives clear scientific and anthropological evidence, advice on how to change your genetic destiny and a great low carb recipe section.
Where to Next?
Head on over to the How To: Follow a Low Carbohydrate Diet section.
How To: Find Information Online
We now come to a sad part of the course. It’s time to say goodbye to those who are simply overweight and who have or are at risk of metabolic syndrome.
Your first run through is really to familiarise yourself with the information.
Your second run through is where you are starting to consider what options are right for you.
Your third run through is to form a definite action plan.
How will your eating change at each meal? What recipes are you going to try? Will you buy a new pair of trainers? Will you go to that class? Would any of your friends like to join you in your new activities?
On your fourth run through we want to hear from you. How are you doing? Have you discovered any other helpful sites, books or dvds? Would you like to contribute one of your own recipies to the site?
To our type twos and type one diabetics who are breathless with anticipation about what I’ve got in store for you next here it is:
For all type twos and any type ones who KNOW they have insulin resistance please now to to How To: Look after yourself.
For all type ones with no known insulin resistance please proceed to How To: “Eat to Meter”
This is a collection of websites that may help you to improve your low carb know how, cookery skills, exercise routine and knowledge about glucose metabolism disorders and diabetes.
Glucose metabolism disorders and diabetes
www.diabetes-normalsugars.com *meet the Bernies at the forum*
www.dsolve.com * the Bernie’s sister site*
www.bcchildrens.ca/Services/SpecialisedPediatrics/EndocrinologyDiabetesUnit/ForF amilies
www.care.diabetesjournals.org/cgi/content/full/diacare; 27/9/2266
http://www.phlaunt.com/lowcarb/bio.php
Low carb cooking
D-solve free to download 300+ pages of Recipes
http://www.lowcarb.ca/low-carb-recipes.html
www.carb-lite.au.com * my favourite*
www.genaw.com/lowcarb/index.html
www.recipegoldmine.com *go to low carb recipies on list*
www.solitarydancer.wordpress.com
ww.steviva.com/steviva.recipies.html
www.wilstar.net/lowcarbpavilion
Carb counting
www.carbs-information.com/carbs-in-flour-baking-ingredients
www.dietfacts.com/fastfood.asp
Exercise
www.amazon.co.uk *dvd rental and books*
www.diabetes.ca/files/Riddell-Final.pdf * for type ones*
Blogs
http://weightoftheevidence.blogspot.com/
http://livinlavidalocarb.blogspot.com/
http://diabetesupdate.blogspot.com/
http://hike2health.blogspot.com/
http://solitarydancer.wordpress.com/
http://www.diabetesamerica.org/diabetesamerica.html
Where to Next?
To our type twos and type one diabetics who are breathless with anticipation about what I’ve got in store for you next here it is:
For all type twos and any type ones who KNOW they have insulin resistance please now to to How To: Look after yourself with Type 2 diabetes.
For all type ones with no known insulin resistance please proceed to How To: 'Eat to Meter'
How To: Keep Healthy with Diabetes
This section is for everyone.
Self-monitoring of Blood Glucose
Use of Insulin and Diabetes Medications
You need to be confident about…
Overview
The Joslin Diabetes Centre have a check list so you can see what sort of things you need to know to look after yourself with diabetes. This list covers type one and type two diabetes. For each heading I will list what we have already covered on this course and what we will be covering in more depth in the Type One Section *
There is a considerable overlap between both types of diabetes. To start with most people with insulin dependent diabetes diagnosed in childhood or young adulthood are not overweight or insulin resistant. As time goes on this may change so Type Ones would benefit from reading the earlier sections to see if any of it applies to them. The majority of the carb counting methods have also already been covered in the Metabolic and Type 2 section.
For type twos who start off on diet or oral medications they may find that after a while this is no longer sufficient to maintain normal blood sugars. You may benefit by reading on to find out how to deal with insulin now or in the future.
If you don’t feel really confident about any of the things I have listed please take advantage of some of the books and internet resources in the help sections. It is important that you know what to do ahead of any emergency developing so please contact your diabetes support team for further personal training.
MEAL PLANNING
Your own meal plan
know how carbs, proteins* and fats affect the body
special foods and occasions
dining out
portion control
label reading
how to fit in treats*
alcohol*
SELF MONITORING OF BLOOD SUGAR
blood glucose goals
how to use the meter
monitoring schedule*
storing supplies*
interpreting blood glucose values and making decisions in diabetes treatment plan*
USE OF INSULIN AND DIABETES MEDICATIONS
Action and side effects of medication*
timing and schedule*
insulin injection techniques*
storage, refrigeration and disposal of supplies*
what to do if you miss a dose*
EXERCISE
What type, how long, how hard, how often and when.*
snacking adjustments*
preventing high and low blood sugars*
KNOWLEDGE OF HIGH AND LOW BLOOD GLUCOSE
Factors that cause high and low blood glucose*
symptoms*
how to treat*
when to call a healthcare provider*
how to prevent*
FOOT CARE
daily foot care*
emergency treatment for cuts, sores and abrasions.
how to do a proper foot exam*
proper footwear
URINE TESTING FOR KETONES
When and how to check for ketones*
What ketones mean*
When to call a doctor*
YOUR HEALTH TEAM WILL DO THESE ANNUAL CHECKS AND TESTS
A1C ( 2-4 times a year)*
kidney function*
cholesterol, ldl, hdl, triglycerides*
foot exam*
eye exam*
blood pressure*
general health check eg thyroid, tests for coeliac disease and anything relevant to you*
YOU NEED TO BE VERY CONFIDENT ABOUT…
Your own meal plan
The medication you are taking
Your glucose monitoring system
The treatment of high and low blood sugars
How to manage your sick days
Your risk factors for developing other health problems
Your foot care
Quick Quiz:
1. A test type twos should have done every six months is…
a Liver function and creatine kinase.
b Hbaic.
c Fasting lipids.
d Sex hormone binding globulin.
Have you got it?
1. You must have your hbaic checked every 3-6 months. If statins are being taken, fasting blood lipids, liver and creatine kinase levels may be taken episodically.
Where to Next?
Please all proceed to the How To: Safely Dispose of Needles and Other Sharps section.
How To: Take Care of Your Feet
This section is for everyone. You must treat your tootsies like little babies. You must be constantly vigilant that they are safe and warm but not too hot. Just like you would call your mum you must call your doc at any sign of anything that looks wrong.
Nerve damage to the feet due to the effects of high blood sugars takes between 5-20 years to become evident from diagnosis for most diabetics. Lack of sensation makes your feet more vulnerable from things that you may not even feel like tight shoes or a little gravel in the shoe. High blood sugars provide a nice growing medium for bacteria. Blood vessel damage to the area supplying the feet make injuries take much longer to heal in diabetics.
Dr Bernstein runs a specialist wound clinic for diabetics and has studied the causes of injury which have led to amputations. His book Diabetes Solution has a long list of dos and don’ts some of which you may know and others which you may not. I have not included every tip but would encourage you to buy the book and follow them.
Some tips are:
- Buy your shoes late in the day and make sure they do not pinch.
- Before putting on your shoes shake them out and make sure the linings are smooth.
- Have at least two pairs of shoes that you alternate every few days.
- Examine your feet for any injury or undue redness every day or get someone else to.
- Apply vegetable or animal oil every day to keep the skin soft eg olive or almond oil.
- Don’t smoke.
- Keep your feet away from direct heat and avoid overly hot or prolonged baths.
- Wear warm socks when it is cold.
- Avoid beta blockers if you have dry feet.
- Don’t file down or shave callouses or corns. These are natures way to protect you from abnormal pressure. Get appropriate insoles, padding or bigger shoes. A specialist podiatrist or biomechanical evaluation may be required for this.
- Get someone who can see what they are doing to trim your toenails if your vision is poor or not that flexible. Get a podiatrist to teach you how to care for your feet and nails.
- See an experienced nurse or doctor if you get any foot injury right away. It can be a disaster if infection gets hold. You may require high dose antibiotics, dressings and even hospital admission.
Ayrshire and Arran Health Board Podiatry Service have some additional information on foot care.
Washing your feet:
Wash feet every day but avoid keeping them in water for any longer than necessary.
If you intend to cut your toenails keep them in water for up to five minutes to let the nails soften.
Dry carefully between the toes.
If you have sweaty feet apply a light dusting of talc.
Footwear Advice:
Have your feet measured for length and width.
Everyday walking or working shoes should have:
Heels no higher than 3.5 cm or 1.5 inches.
Have lacing, buckles or velcro to hold the foot securely and prevent unnecessary movement.
The toe should be round or square.
Uppers should be made of a breathable material such as leather.
Soles should be thick and cushioning not thin and unyielding.
High heeled, pointed toe shoes, mules or strappy sandals are best avoided. If you want to wear them for a special event keep them to short periods. Don’t have sandals that have thongs between the toes.
Ensure your socks fit well. Change your socks once or twice a day and throw out any that are too small or which have holes. Don’t darn the darned things. Get rid of them!
Measuring your feet:
Your feet should be measured from the heel to the tip of your longest toe. For some people this is the second toe not the big toe. Congratulations if this is you. The Ancient Greeks regarded this as a sign of beauty.
You can check the length of your shoe by standing bare foot on a piece of thin cardboard and marking the place reached by the longest toe. Then place a thin strip of this into the shoe. There should be a one centimeter gap between the end of the cardboard and the heel of the shoe.
Your shoe width should match your foot width.
If you have a diabetic foot ulcer:
If your foot swells, changes colour or becomes more painful you must seek prompt medical attention. This means the out of hours or accident and emergency services if your doctor’s office is shut.
Podiatrists usually need to look at your feet very regularly and change dressings. You may be advised to shower or bathe less frequently and may need to stay off the foot more than usual. For some daily tasks you could be advised to sit instead of stand.
Healing will be more difficult if your blood sugar control is poor, you don’t rest the foot as advised, your footwear is not suitable, you forget to take medication as prescribed, you miss appointments, you interfere with dressings, or you continue to smoke.
Ulcers heal best when they are not taking your physical weight. Rest, elevation, special shoes, orthotic devices, crutches, zimmers, wheelchairs or plaster casts may be required at one time or another.
If you or a carer has been trained to do so, you may find that doing your own dressings is more convenient. A key component of this is knowing when and how you need help. There is always a risk that a serious foot infection can develop.
The most important factors in healing foot ulcers are achieving normal blood sugars and avoiding unnecessary pressure.
Antibiotics:
If you are prescribed antibotics you must take them. For most diabetics the courses of treatment will involve several different antibiotics at much higher doses and for much longer than the equivalent infection in a fit non diabetic person.
One estimate is that it takes 50 times the amount of blood to heal a diabetic ulcer than a non diabetic ulcer.
Certain organisms found in probiotic drinks have been found to reduce the chances of getting diarrhea or diarrhea from a serious bacterial strain such as Clostridium difficle. The names of some of these probiotics are Lactobaccillus casei, L bulgaricus and Streptococcus thermophilus. Some commercially available yogurt drinks have probiotic organisms in them. It may be worth your while speaking to your doctor about taking such a preparation if you need a prolonged course of antibiotics. Remember to look out for any extra carbohydrate in the preparations. Sugar is often added to make them more palatable.
Typical antibiotic regimes:
Superficial ulcers:
Co-amoxiclav aka Augmentin 625mg three times a day.
or
Ciprofloxacin aka Ciproxin 500mg twice a day.
For 10-14 days.
Deep Ulcers
Clindamycin aka Dalacin 150 or 300mg four times a day.
and
Co-amoxiclav aka Augmentin 625mg three times a day.
and
Metronidazole aka Flagyl 400mg three times a day.
Duration of triple therapy depends on the severity of the ulcer but generally should be considered for six weeks.
Deep ulcer plus active cellulitis (skin infection):
Give the same sort of triple therapy regime but also add intravenous antibiotics. This could be Augmentin and Metronidazole. The choice of antibiotic is guided by the patients sensitivity and a medical microbiologist can help to choose the most effective regime.
For patients with penicillin allergy Erythromycin 500mg four times a day or Clarithromycin 500mg twice a day can be substituted.
A medical microbiologist will need to be consulted if the wound does not heal or there is active infection in the skin or bone.
Flucloxacillin is a typical penicillin which is used in non diabetics with soft tissue infections. In diabetic ulcers it simply cannot kill the range of bacteria that are likely to be present and so must not be used as a single agent.
Antibiotics can have nasty side effects such as diarrhea, stomach upsets, rashes, the growth of other pathogenic bacteria and liver and blood disturbances. They are given to you in the hope that a foot ulcer can be successfully treated before an amputation is required. If you are not able to take them as prescribed it is extremely important that you discuss this fully with your doctor so that alternatives or medication to counteract the worst of the side effects can be arranged for you.
The old saying, “An ounce of prevention is worth a pound of cure” has never been more apt when it comes to foot care for diabetics.
Please strive for normal blood sugars and be extra respectful and vigilant when looking after your precious feet.
Quick Quiz:
1. Regarding your shoes you should do one of these…
a Wear the same pair every day to make the leather softer.
b Buy shoes early in the day when your feet are less smelly.
c Buy shoes late in the day when your feet are more swollen.
d Buy shoes from the internet or from a catalogue to save walking around shops.
2. Nerve damage causes one of these…
a The feet become more sensitive to pain.
b Bacteria and fungus grow between the toes.
c The feet become abnormally sweaty.
d The feet become less sensitive to pain.
3. You should do three of these things to maintain foot health. What one should you avoid?
a Examine them every day using a mirror if necessary.
b Get corns and callouses regularly paired by a podiatrist.
c Rub animal or vegetable oil into the feet daily to keep skin supple.
d See an experienced doctor or nurse immediately if you get a foot injury or infection.
Have you got it?
1. C is true. Dr Bernstein gives comprehensive advice in his book Diabetes Solution about foot care that you may not hear from your diabetic clinic. Neuropathy can develop within five years for type ones and is often present at diagnosis for type twos as they may have been unaware of having the condition for years.
2. D is correct. It is a sad thing but despite the fact that neuropathy pain can become so intense that it needs opiate and anti-epleptic medications to control it, high blood sugars cause the nerves to be less sensitive to touch and external trauma that would cause pain in a non diabetic person’s foot. Bits of gravel, a seam from a sock and simply overtight shoes can cause friction damage that may go unnoticed unless you make the effort to troubleshoot every day.
3. ACD are the right things to do. Removing or paring callouses can increase your risk of infection and therefore amputation. The callous is a sign of too much pressure on that part of the foot. It is much better to PREVENT the possibility of amputation by leaving the callous alone and taking steps to change your footware or insoles so that it gradually goes itself.
Reference Info:
Most of the information in this section has been obtained from Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars
Where to Next?
Everyone needs to have a good time every so often. A diabetic person’s feet need special care on a regular basis. So you all know exactly how to make your tootsies happy little babies please go to the How To: Give Your Feet a Pedicure section next.
How To: Give Your Feet a Pedicure
This section is for all of you. If you want to treat your ten little tootsies this is how.
Its lovely to have nice looking, comfortable, happy feet. After you’ve been doing all that exercising your feet could do with a little pampering. The more you can make this part of your daily routine the happier your feet will be. You may soak your feet for up to five minutes if you intend to cut your nails.
Fill a basin or bath with some warm water.
Test it with your hand to see its not too hot.
Add a good sprinkle of salt.
Add some bath gel, liquid soap or use a bar of soap.
Add a favourite aromatherapy oil – just a few drops – if you like.
Put your feet in and give them a gentle wash.
You may leave them to soak for up to five minutes.
Take your feet out and put them on a towel.
Give them a thorough dry particularly between the toes.
Place your feet where you can see them and if you are not flexible enough to see the sole of your foot use a mirror.
Are there any rough areas, unusually reddened areas?
Any sores? Any cuts? Any blisters?
How are your nails?
Any breaks in the skin between your toes?
If any problems are apparent you may need to deal with them yourself, see your podiatrist within the week or even see a doctor as an emergency if you suspect you have an infection.
Do your nails need cut?
To cut them use nail clippers or scissors. Be sure to look exactly where you are going with the scissors. Cut the big nail straight across so the nail edge does not cut into your skin.
Now for a massage.
Bring out your container of vegetable or animal oil. Pour some into your palms and then stroke it all over your feet.
Rub it into the nails, between the toes, and on the sole of your foot.
Give the ball of your foot which takes a lot of pressure a good massage.
You can extend the massage up your leg to your knee. Sweep your hand upwards towards the heart. The shin area and round the ankle area can be affected by poor circulation in later years so keeping the skin supple here is helpful.
To finish off gently use the towel to absorb any excess oil on your legs or feet.
Put on a fresh pair of socks for a while. This will keep your carpets, bedcovers and shoes from becoming oily.
Make a date with your feet to have the same loving experience very soon.
Quick Quiz:
There is no quiz in this section. The only thing you need to ask your tootsies is what soaps and oils they like best.
Reference Info:
Acknowlegements to my ten little friends and to my podiatrist Simon Littlejohn.
Where to Next?
Did you enjoy that? I hope you did. Your happy feet can now toddle along to the next section How To: Know What Things Beyond Food Can Affect My Blood Sugar.
How To: Eat from a Hospital Menu
This section is for everyone. It could happen to you!
Ironically one of the most risky places for a diabetic to eat is as an inpatient in a hospital.
Because you are a diabetic you will be told by nursing and dietetic staff that you must choose from the “Healthy Eating” section of the menu. This “Healthy Eating” section is specifically designed to be high in carbs, lowish in protein and very low in fat. I’m not at all sure what kind of metabolism is suitable for this sort of diet but it it’s certainly not a good idea if you have the sort of metabolism that cannot handle sugar and starch. This is the situation for all those people with glucose intolerance or diabetes. Yes. You!
It is necessary for you and your relatives to be very firm at the outset that you must be able to choose from the whole menu, be able to choose large or small portions as you desire and to bring in supplementary food items if necessary. This could include olive oil and vinegar to dress your salads, fresh temperate grown fruits, cheese, cooked meats, oatcakes and diet drinks.
For breakfast ignore the toast and cereals and porridge and go for the cooked breakfast and eggs in a large portion. Supplement this with a small portion of fresh fruit. Grapefruit and mandarin orange segments are often offered on hospital menus but they are usually tinned and sweetened with sugar so are best avoided.
Instead of digestive biscuits as a midmorning and midafternoon snack try some cheese and oatcake with butter. Many hospitals routinely offer diabetics snacks as this used to be necessary with twice daily insulin regimes. You may not really need a snack however. If you are hungry at a snack time you may not have eaten as much protein and fat as you really needed to at the previous meal. If you are insulin dependent you will need to have lucozade or gatorade or snacks available for low blood sugar treatment. A longer acting carb and some protein can work well provided you are not too low.
For lunch and dinner pick large portions of meat, fish, poultry, cheese and egg dishes with vegetables or salad. Ignore any potatoes, chips, rice, pasta or bread items. Avoid deep fried battered food if possible due to the high hydrogenated fat content and carb content of the batter.
Before bedtime toast and biscuits are about the only thing that is offered in hospital. These are likely to be too high glycaemic for you and cheese and cold meat or cheese and oatcakes usually work better to prevent a blood sugar spike or nightime lows.
Despite the difficulties in getting fed properly in hospital it is well worth the effort to keep your sugars normal. Your infection rate is decreased and your recovery will be faster.
Quick Quiz:
1. Maintaining normal blood sugars by following a low carb diet in hospital results in three of these. What won’t happen?
a Less post operative infection.
b More chance of surviving a life threatening illness.
c Faster discharge from hospital.
d Getting on the dietetic staff’s Christmas card list.
2. In hospital suitable breakfasts for a diabetic are…
a Whatever the nurse thinks looks good from the healty eating section of the menu.
b Porridge, skimmed milk, fresh orange juice with cholesterol lowering margarine.
c Toast, butter, boiled eggs, tinned grapefruit and mandarin oranges.
d Bacon, scrambled eggs, tomato, half a grapefruit.
3. The most risky eating situation for a diabetic is…
a As an inpatient in hospital.
b As a passenger in an aeroplane.
c From a roadside snack shack.
d As a guest at a dinner party that includes Miss Marple, Hercule Poirot, Ellery Queen, Lord Peter Whimsey and Detective Columbo.
Have you got it?
1. ABC have been proven to result from good glycaemic control in hospital. Sadly D is something that is not as likely from low carbing in hospital. Well there is a first time for everything and sooner or later dieticians will come on board. If you are the first patient to get a card in these circumstances we MUST hear about it!
2. D is correct. The others are too high in sugar and starch. At least with option C you could eat the boiled eggs. Unfortunately the “Healthy Eating Menu in hospitals usually entails LOW FAT. The sugar content is usually high and the protein content is usually low. Most hospital dieticians and nurses will automatically dragoon you into choosing from this menu unless you make it very clear that you object.
3. These are all very risky eating situations. How do you choose between them? In hospitals and aeroplanes you have a very restricted choice of meal. Snack shacks may not be as hygeinic as you would wish. And someone always get poisoned when these super sleuths are near. The only way to deal with these risky situations is to plan ahead and that often means bringing your own meal.
Reference Info:
Acknowlegements for this section to John Gibson the first of my patients who stood up up to the dietetic staff in the hospital I work in. I am also grateful to hospital administrative staff who did their absolute best to bully me into backing down. I would never have believed what was necessary to secure a guarantee of freedom from the “Healthy Eating Plan.” To cut to the chase YOU MUST THREATEN TO SUE THEM. If they don’t back down. It’s okay. Call your lawyer and sue the pants off them.
Where to Next?
All of you need to know about the next topic. March this way to the How To: Take Care of Your Feet section.
How To: Cook and Bake the Low Carb Way
This section is for everyone.
Looking at Ingredients: Carbohydrate
How do I successfully substitute ingredients?
Overview
There are two ways of cooking and baking the low carb way.
By far the easiest way is simply to use ingredients that are naturally low in total carbohydrate and in glycaemic index and cook the way you usually do. For example many meat, fish, poultry and egg dishes can be made just the same as usual and served with plenty of low starch vegetables and butter or olive oil instead of rice, pastry, pasta, bread or potatoes.
The more tricky way is to substitute lower carb ingredients for the higher glycaemic, high carb items such as sugar, flour, potatoes, rice and bread. This tends to be a lot more expensive and there is often some compromise regarding the texture and flavour of these dishes.
Learning how to cook and bake low carb well is a pleasure not only for the cook but for those who get to eat the end result. You need not give up old favourites entirely. You simply enjoy them in a different way.
Before my son was diagnosed with type one diabetes I often bought entire meals from the cook chill cabinets at the supermarket. My son loves cakes and desserts and to maintain excellence in blood sugar control without an apparent restriction in these food items I now make time to have a regular cooking and baking slot about twice a week.
LOOKING AT INGREDIENTS: CARBOHYDRATE
What carbs raise your blood sugar very little and what ones raise it rapidly and a lot?
I have listed some of the commoner ingredients which Dr Atkins has listed according to how generous or restricted you should be with them.
FOODS TO EAT REGULARLY
Asparagus, green beans, bok choy, broccoli, brussels sprouts, butter beans, cabbage, cauliflower, celery, chard, collards, cucumber, aubergine, fennel, lettuce, mushrooms, okra, onion, mangetout, snow peas, peppers, radishes, rutabaga, saukerkraut, spinach, sprouts, courgettes, tomato, water chestnuts.
Cottage cheese,ricotta.
Almonds, brazil nuts, coconut, hazelnuts, macadamias, pecans, pine nuts, pistachios, pumpkin seeds, sesame seeds, sunflower seeds, walnuts.
Chickpeas, hummus, kidney beans, lentils, lentil soup, minestrone soup, peas dried or split, soybeans, unsweetened soy milk, tofu.
Apple, blackberries, blueberries, cherries, cranberries, grapefruit, unsweetened grapefruit juice, oranges, peach, pear, plum, raspberries, strawberries, tangerine.
All bran, cooked barley, low carb bread and muffins, low carb pasta, old fashioned oatmeal, wheat bran.
EAT IN MODERATION (ie infrequently or in small portions)
Carrots, green peas, mashed pumpkin, buttenut squash, tomato juice, tomato soup.
Whole milk, unsweetened yoghurt.
Cashew nuts, peanuts.
Black eyed beans.
Apricots, grapes, kiwifruit, mango, melon, papaya, pineapple.
Bran flakes, 100% wholegrain bread, pumpernickel bread, rye bread, sourdough, buckwheat, bulgur, whole wheat couscous, egg fettucine, melba toast, no sugar added muesli, pasta, popcorn, raisin bran, brown rice, taco shell.
EAT VERY SPARINGLY (these are the “bad guys”)
Sweet corn, parsnips, pea soup, potato
Full fat ice cream with sugar
Baked beans
Apple juice, bananas, cranberry juice, tinned fruit cocktail, grape juice, orange juice, prunes, raisins.
White bread, wholewheat supermarket brand breads, cornflakes, couscous, semolina, crackers, croissants, pita bread, pizza, pretzels, most breakfast cereals, all white rice, shredded wheat.
WHAT FATS SHOULD I USE ?
Use lard, butter and macadamia nut oil in preference to refined vegetable cooking oil and margarine for frying and in baked goods.
Use extra virgin olive oil, unrefined flax oil, hazelnut oil, walnut oil and macadamia nut oil for dressing salads.
Use grapeseed oil and canola oil for cooking at higher temperatures but stir fry instead when you can.
WHAT PROTEIN SHOULD I USE?
Free range meat, poultry, fish and eggs are best as they usually contain healthier fats and have less hormones and antibiotics added.
Cold and cured meats may contain added sugar and preservatives that are not beneficial.
Lightly grill meats and fish and avoid getting them black.
Partly cook your barbeque meats in the oven to minimise the black on the outside and raw on the inside health risks.
Use marinades to tenderise meat. Marinades with reduced levels of oil can reduce flaming that burns the meat. Trimming fatty meat can reduce this too.
If you eat about the palm of your hand size minus the fingers of lean protein three times a day your are having about the right amount for you.
HOW DO I SUCCESSFULLY SUBSTITUTE INGREDIENTS?
Some things lend themselves to substitution better than others.
Rice
Grate cauliflower and then gently fry it to simulate fried rice or steam it briefly to simulate boiled rice.
Mashed potatoes
Steam or boil the cauliflower cauliflower for at least 7 minutes till it is tender and then mash with butter and cream. You can add grated cheese or fried shallots or finely cut onions to taste. This can also be used to top cottage pie and moussaka.
Pasta
Low carb pasta can be purchased in certain specialist stores. It usually has a high gluten content. It seems to become high glycaemic again when it is overcooked or reheated so just cook lightly and once.
Spaghetti squash can be baked and then used in pasta dishes to mimic spaghetti.
Sauces
Instead of using flour to thicken sauces use cream instead of milk for white sauces. Very small quantities of xanthan powder can also be used to thicken sauces.
Bread
For a traditional loaf which is low in carbs you could make Graeme’s version which is in the downloads section of this site. He even includes a photograph.
For a microwave bread which is faster to prepare see the recipe section at our sister site www.diabetes-normalsugars.com. Mandy, a fellow “Bernie” has spent a lot of time perfecting this recipe (requires login) and has some variants you may wish to try.
Pancakes
Instead of using flour use ground almonds and instead of sugar use a substitute.
Muffins
Instead of flour use such items as flaxseed meal, whey protein powder, soya flour, ground almonds.
Cheesecakes
These are very easy to low carb because the texture depends on the fat rather than the sugar. They can have no base or a low carb pastry base can be made.
Chocolate
Dark chocolate is a very versatile and healthy ingredient when a high cocoa content, 70% or above , version is used.
Cakes and Shortcrust Pastry
Such items as courgettes, almonds, ground hazelnuts, soya flour and whey protein powder are used in various combinations as flour substitutes.
Because of oxidative damage caused by an excess of omega six vegetable oils and margarines it is better to use unsalted butter, lard and macadamia nut oil for many baked goods. Hydrogenated fats have the advantage of being cheaper and they produce lighter textured baked goods with a longer shelf life. On the long run though we are aiming at not only improving your blood sugars but also your general health. As hydrogenated vegetable fat consumption is related to higher obesity, diabetes, heart disease and cancer risks it is better to avoid them. As my friend Rosie puts it, “If bacteria are smart enough to know not to eat hydrogenated fats I’m certainly not going to either.” Baked goods may be heavier than you would like as a result. Beating egg whites separately till they peak and then adding them in ito the cake mix is a technique that can help.
If you have a favourite family recipe that you can’t de carb successfully it is often possible to compromise and use half the high glycaemic flour or sugar and substitute the rest. It is the texture that is more commonly affected than the taste by going full low carb.
Sugar
All of the sugar substitutes are more expensive than sugar. There is not the same caramelisation and texture benefits or the range of sugar substitute types. To mimic brown sugar you can add a small quantity eg a teaspoon of black treacle or black strap mollasses to eg a carrot, passion cake or gingerbread recipe along with the sugar substitute.
To mimic white granulated sugar I have found the best one to be Steviva Blend.
To mimic icing sugar I have found Splenda to be the best. This is also more available and cheaper than Steviva Blend. I find this sweeter than sugar and would recommend you use about half a cup or half the weight of the amount of granulated sugar you would normally use in a recipe.
SUGAR CONVERSIONS
I packet of sucralose (eg Splenda) = 2 teaspoons sugar in bulk but = 4 teaspoons in sugar of sweetness.
24 packets of sucralose (eg Splenda) = one cup splenda = 2 cups in sweetness
Use half the usual bulk of sugar that you would normally use when using Splenda for your first go. You can increase or decrease the amount according to taste at your next baking session.
Two tablespoons of Stevia Plus = one cup sugar
One cup of Steviva Blend = one cup sugar
One and a half tablespoons of Sweet and Slender = one cup of sugar
*any other sugar substitute conversions would be very welcome here*
RECIPE BOOKS
These are my personal selection of books that I cook from regularly.
344 Pages of Low Carb Recipes500 Low-Carb Recipes Dana Carpender
500 More Low-Carb Recipes Dana Carpender
The Low-Carb Gourmet Karen Barnaby
Low Carb Italian Cooking Francis Anthony
Low-carb Vegetarian Celia Brooks Brown
The Illustrated Atkins New Diet Cookbook Robert Atkins
Extreme Lo-Carb Meals On The Go Sharron Long
Low Carb Sinfully Delicious Desserts Victor Kline
George Stella’s Livin’ Low Carb George Stella
Eating Stella Style George Stella
INTERNET LOW CARB COOKING SITES
I have listed some helpful sites for you in the metabolic section. My favourite is:
The Bernies have been experimenting for years and have a very varied selection of recipies for you.
Bernie Forum Recipes (requires registration)
Quick Quiz:
There is no quiz for this section. I hope you now know that almost anything can be lower carbed with a bit of effort. As Dr Atkin’s was fond of saying. “This is not deprivation diet.”
Reference Info:
Much of this section is from Atkins for Life.
Where to Next?
“From the sublime to the ridiculous” is another saying. No matter how healthy you think you are, you never know when. In the next section we all need to get to grips with that most chilling of subjects, How To: Eat from a Hospital Menu.
How To: Monitor My Blood Sugar Appropriately
This section is for everyone. It is somewhat more applicable to type one diabetics but type twos need to know some of this too.
Normal blood sugars for fit young non diabetics are 4.7 on waking and prior to meals and bedtime provided no snacks have been eaten. Two hours after a meal such a persons blood sugar will be down to five or six. Blood sugars should not normally go below 4.0 even if a person has not eaten or has been exercising. A healthy young person can expect to have a hbaic of less than 5.0 although the range given in laboratories takes the not so fit into consideration and often gives an upper limit of normal as 6.0.
What we are trying to achieve with type one and type two diabetes is a replication of normal blood sugar patterns as much of the time as is achievable for you.
In the non diabetic person the pancreas secretes a small amount of insulin all the time. This small amount stops the liver from converting body proteins such as the muscles and vital organs such as the heart into sugar. This is called basal insulin. About the only time this is switched off completely is during very vigorous exercise.
When a meal is eaten an immediate surge of stored insulin enters the blood stream and tells the cells to grab hold of any glucose molecules that are circulating. This is called a first phase insulin response.
As eating continues the pancreas makes as much insulin as it needs to keep the blood sugar normal and it makes this insulin to order as it goes along. This is called the phase two insulin response.
There have been some advances recently in drugs and transplants that will help diabetics of both types one and two get better control or even cure the disease. Meanwhile, unless you are a mouse with a very good health insurance policy, you are best to take charge of your diet and glucose monitoring. Lower carbohydrate diets particularly can help you keep damage from high or swinging bood sugars minimal.
What you want to get from a tight food plan and monitoring schedule
- Normal blood sugar levels – or as near as you can get.
- Improvements in hbaic, lipids and kidney tests.
- Achieve a suitable weight for you.
- Reverse at least some diabetic complications
- Reduce the frequency and severity of low blood sugars.
- Relief from mild neurological problems associated with high blood sugars such as chronic fatigue and short term memory impairment.
- Blood pressure reduction.
- Reduced demand on pancreatic beta cells – this is important for type 2s and type ones in honeymoon or earlier in the disease process.
- Increased strength, stamina and sense of well being.
- Sleep better.
- Have fewer infections.
- Have healthier skin.
When do I test my blood sugars?
In order to find out how well your body is dealing with your diet and any medication you are taking blood sugars need to be taken:
- On waking
- Immediately before breakfast
- Before each meal
- Two hours after each meal
- At bedtime
When you are testing out new foods to see how they affect you testing every half hour or alternately at one hour after eating, two hours after eating and three hours after eating. This gives you a good idea of what types and dosages of insulin may be needed to cover that food successfully. See the “Eat to Meter” section in the type two diabetes section of this course for more information on this.
You also need to check blood sugars before, during and after exercising till you know how that particular sport, duration and intensity of exercise affects you.
Shopping and running errands can drop your blood sugar so have your meter and glucose handy.
It is extremely important to check your sugars before you drive and after every hour of driving.
Intense brain work such as sitting an exam can use up glucose but adrenaline can also raise it. Better check before the exam when you can correct a little or eat something.
Whenever you are hungry or suspect your blood sugars are running higher or lower than expected you should check.
It is useful to teach a toddler a nursery rhyme or song and get them to repeat it often. If you suspect a low blood sugar get them to repeat the song. If they get muddled up they may well have a low blood sugar. Test to check this system works for you a few times and if it is reliable for you you may omit the fingerstick.
If your vision for small print starts to go this can be a sign of low blood sugars so check.
For new college students or those in new or different jobs from usual increased walking to different places and different work schedules can put your sugars way out. You need to check your blood sugars more frequently than usual if your work pattern changes.
Shift work is a whole big problem area for diabetics. Your patterns will change with each type of shift and the transition periods will be particularly difficult as lack of sleep can seriously affect blood sugars too.
Women’s blood sugar patterns shift a lot in relation to their menstrual cycle, some hormonal methods of contraception and of course in pregnancy. You will need to check more frequently during these periods.
If you drink alcohol always eat along with it and be moderate. Alcohol can cause low blood sugars but sugary mixes can raise your blood sugar. You must again test more frequently and of course before you go to sleep no matter how late or early you get in.
Tell people you see regularly that you can get quite crabbit with high and low blood sugars and ask them not to take it personally. Make a deal to check your blood sugar if they ask you to.
Finger prick testing is more accurate than arms pricks if your blood sugar is falling rapidly or if you are very low. If you think you are low test the finger tips or base of the thumb. If you think you are high test wherever you fancy.
How to I monitor my blood sugars in hospital?
Apart from times that your are under an anaesthetic or extremely unwell the person who should take responsibility for your blood sugar monitoring in hospital is YOU.
You must bring in all your kit and continue to look after yourself as if you were at home.
You must have your kit by your bedside or with you if you go off on a hospital trolley for any tests and do not allow it to be disposed of or hidden by the nursing staff.
To reduce the number of finger pricks you need get the nurses to check your figures against theirs. As long as the first few are reasonably similar they should give their agreement to accept your figures.
It is NOT SAFE to assume that the medical or nursing staff know more about your diabetes than you. Given the wide range of medications, insulins and delivery devices it is indeed unfair to expect them to know better than you do.
For insulin dependants it is very important indeed that you administer your own insulin if you are at all able to do this. There have been deaths from staff making mistakes with this.
For people on insulin that should be administered prior to food it may be best to wait till the trolley arrives on the ward or at your bedside before you inject. You may not get it delivered at the time you are expecting and you may also have to count the carbs and estimate the protein before injecting. You may need the food to be kept warm for you to get the optimal time for eating or for allowing a high blood sugar to drop if you need to.
What laboratory test may I need to have regularly?
Thyroid function tests
Type one diabetics are prone to the development of other autoimmune diseases so this test should be done every so often and particularly if you begin to feel particularly cold, tired, you gain weight unexpectedly, you have more hypos than usual or your cholesterol suddenly rockets.
Lipids and Liver Tests
All diabetics in the UK over the age of 40 are routinely put on drugs called statins whether they have a raised lipid level or not. Recent guidance is that this should be extended to all type ones over 18 who have one or more complications from their diabetes.
Statins work because they reduce inflammation in the lining of blood vessels and reduce atheroma and clot formation which damage blood vessels and blood supply. Statins can upset liver function and creatine kinase so these are tested routinely.
It is accepted by most doctors that there is a benefit in taking statins for people with diabetes and those with ischaemic heart disease. The problem is that a group benefit may not transfer into a personal benefit for YOU. One in 20 people get liver enzyme rises, muscle pain or general malaise and need to stop statins. They are dangerous to take if a woman is pregnant or at risk of becoming pregnant so women in their childbearing years need to think very carefully about them.
Kidney Tests
The albumin-creatinine ratio is as test that can detect early signs of kidney damage. If this or microalbumen tests in the urine are positive you may be asked for 24 hour samples and blood tests to clarify the extent of any problem.
The estimated glomerular filtration rate or eGFR is a new blood test done at the same time as the Urea and Electrolyte test. It gives an idea of what stage of kidney impairment may be going on.
ACE inhibitors or ARBs are new drugs that can reduce the rate of kidney deterioration. They end in “pril” or “sartan” respectively. They are also effective in reducing high blood pressure. If you start them for the first time you need a blood test after two weeks to see that they are not worsening kidney function. This can happen in some people who have a condition called renal artery stenosis which is hard to detect otherwise.
Coeliac Disease Tests
Coeliac disease is an autoimmune disease of gluten sensitivity. It can occur at any age. The symptoms can be very vague and it can take a very long time to develop the raised enzyme tests of endomysial antibody and tissue transglutamase and obvious anaemia. Tiredness and abdominal pains are probably the main symptoms. An easy and less expensive test to do is the ferritin level in the blood. This is the amount of stored iron and low levels occur frequently in coeliac disease.
CRP
The C reactive protein test is a non specific tests that indicates inflammation. It is often raised in metabolic syndrome and type 2 diabetes.
In the absence of any inflammatory condition or infection you could have high levels of this if you are a type one who is getting quite tubby round the middle and you seem to need a lot of insulin to get your sugars down. In other words it is a marker that you are getting both kinds of diabetes at once. A good exercise regime and lower carb diet is what you need to deal with this problem. High insulin levels cause damage to blood vessels too. Getting insulin and blood sugar levels reduces cardiovascular deterioration.
HbAIC
The hbaic must be the diabetologists favourite blood test. It is also known as the haemoglobin AIC or the glycosylated haemoglobin. It is a test of your average blood sugar over the last 3 months. A truly normal level is less than 5.0 and more accurately 4.2-4.8%.
The average UK figures for 10-18 year old diabetics is a whopping 9.5%
The American Association of Endocrinologists have set a target of 6.5 % or less for diabetics and the UK National Institute for Clinical Excellence are going to recommend that level quite soon. Diabetes UK have set the level at 7.4% or less for children and teenagers but less than one in 7 meet this target at present.
Control of 8.0 or over is considered to be poor and can be an indication that insulin is necessary in type 2s who are struggling on maximal oral therapy.
Diabetic complications can come on in people who have never been diagnosed with diabetes but who have had hbaics of 5.5 or more for many years. Type 2 diabetics are often discovered to have complications at the time of their diabetes diagnosis because of the slow and stealthy development of problems. Visual troubles, breathlessness on exertion and subtle coordination problems are often seen as something to do with middle age or complications can entirely asymptomatic as in kidney disease.
The American Diabetes Association have decided that from next year they will provide patients with a measure of their average blood sugar to help them understand more about what the hbaic test really means.
Here is a chart to help you:
hbaic = average blood glucose value UK / US
5 = 5 / 90
6 = 6.6 / 119
7 = 8.3 / 149
8 = 10 / 180
9 = 11.6 / 209
10 = 13.3 /239
11 = 15 / 270
12 = 16.6 / 299
13 = 18.3 / 329
14 = 20 / 360
It is in your best interest to keep as low as you can towards normal without risking severe hypoglycaemia. Fortunately this is achievable with a low carbohydrate diet.
Why not find out what tests you have been getting done by your doctor ?
If you keep a record of them you will be in a much better position to understand more about how the diabetes has been affecting you. This can help if you need to see a different doctor from usual or you take ill on holiday.
Quick Quiz:
There is no quiz for this section. Type ones however will be getting questions on it later!
Reference Info:
- Dr. Bernstein’s Diabetes Solution
- 487 Really Cool Tips for Kids with Diabetes
- A Low Carbohydrate Diet in Type 1 Diabetes: Clinical Experience
- The hbaic/average blood sugar chart is adapted from Diabetes For Dummies by Sarah Jarvis and Alan Rubin.
Where to Next?
Please move on to the How To: Know How Proteins, Fats, and Carbs Affect My Blood Sugar section next.
How To: Safely Dispose of Needles and Other Sharps
This section is for everyone.
Sharps are a problem because they can stick into other people legitimately handling your waste or animals who are raiding your garbage.
The worry that someone will get AIDs from being pricked by a used sharp is greatly in excess of the likelihood of this happening. But you never can tell. Hep C and B can also be transmitted from sharps and hepatitis C is the most transferable of these.
To treat a contaminated sharp injury in time a person has to get appropriate antiviral drugs within an hour. These are highly toxic and need to be taken for a month.
Please take the safest measures you can to dispose of your sharps. Here are the best ways:
Use a specially designed container. This is usually hard plastic with a lid that cannot be opened once it is locked. They can often be obtained from pharmacies or your diabetic clinic.
Some pharmacies and hospitals provide a sharp box swap system. You may have to pay towards this service.
You can clip off the needle or lancet tip with a needle clipping device that stores the needles inside. This can then be thrown away when full. If you do this dispose of your syringes appropriately too.
A “cin bin” or sharps box is easiest to use because the whole syringe and needle can be disposed of at once. They can be bulky so having a needle clipper for use outside the house can be a great help.
If you have to dispose of sharps in your garbage as a last resort you can use a heavy opaque plastic bottle eg a bleach bottle. When it is 3/4 full screw the lid back on and securely tape it down.
Keep your sharps and disposal box away from younger children or pets.
Reference Info:
Thanks to the BC (British Columbia) Children’s Hospital . They have a great selection of leaflets particularly aimed at younger type ones.
Where to Next?
Please all proceed to the How To: Monitor My Blood Sugar Appropriately section.