Transcript
EPISODE 18: HEALTHY EATING TIPS
Rita Kalyani, MD: Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes. I’m your host, Dr. Rita Kalyani at Johns Hopkins. We developed this podcast as a companion to our Patient Guide to Diabetes website. If you want a trusted and easy-to-understand resource for diabetes or to listen to previous podcasts, please visit hopkinsdiabetesinfo.org.
Today, we welcome Asha Gullapalli to Diabetes Deconstructed. Asha earned her master’s degree in clinical nutrition from the University of Central Arkansas, and is a registered dietitian with over 30 years of experience in the field of nutrition and dietetics. She’s also a certified diabetes educator and an insulin pump trainer. Welcome, Asha.
Asha Gullapalli, MS, RD, LDN, CDE: Thank you.
RK: We are so excited for you to be here today, Asha. And I was wondering if you could perhaps start off by telling us how you approach dietary management in a person with diabetes, particularly type 2 [diabetes]. What kind of things do you tell them when you meet them for the first time?
AG: When I’m talking to a patient with diabetes, I don’t want to make them feel like, you know, they have this horrible disease or they’re doing everything wrong. You want to know how they’re managing their diabetes at home. So that’s where we start. And then I want to know how they’re going about treating their diabetes with medications, with diet, with exercise or nothing. I mean, if they’re happy where they are, that’s fine, too. But we need to know where to start. I start off by asking them, “Do you take your medications daily?” “What kind of diet?”… I mean, diet may be a very long word so I just asked them, “What do you eat during the day?” And you want to meet the patient where they are. You don’t want to stand there and tell them, “Do this, this and this.” You know, you want to tell…ask them if they even want to make any changes to their diet and start there. And making one or two changes in that first meeting will help a great deal.
RK: It’s so interesting what you said about the use of the word ‘diet’. It is somewhat of a misnomer isn’t it…
AG: It is.
RK: …That when we talk about “the diabetes diet”… First of all, there isn’t a one-size-fits-all. And it’s not a diet where you have to be restrictive or aim to necessarily reduce calories in a directed way. I think that is a clarification that perhaps I’m sure you must have to go through when you talk to patients for the first time.
AG: Yes. All the time. They don’t want to hear the word ‘diet’ because most times they don’t want to hear a dietitian coming in either.
RK: Yeah, it really is about changing eating patterns, isn’t it?
AG: Yeah. Even if they make one or two changes, because habits don’t change in a day or two. Usually, even when we’re treating our babies or children, they usually say that a habit is changed in a week, not in a day. The same thing. Even if we make our patients make one small change while they’re here, we’ve made progress.
RK: In your practice, what are some of the most common changes to eating patterns that you’ve seen be most effective or be most useful?
AG: So it’s amazing when you talk to your patients and you ask them basic things like grocery shopping: “how many times a month do you grocery shop?” You’ll be surprised to know that people actually don’t do much grocery shopping because they’re relying on fast foods, convenience foods, and so they’re not going to the grocery store. You also want to make sure that your patients are eating at least one or two things from all the five food groups that we normally talk about. Like you said, it’s not a restrictive diet. We’re not here to tell them don’t eat this, don’t eat that. But maybe changing some of their eating habits to less processed foods, making sure they’re adding more fiber to their diet; eating less sugar in their diet. Again, not saying that you should not eat any sugar; eating a fruit instead of juice, eating an English muffin instead of a blueberry muffin, making those small changes to their diet.
RK: It really is about making one small change at a time isn’t it so that it’s not so overwhelming to begin with? For any of our listeners that might be interested in making changes to their own eating patterns, such as cutting down on unhealthy foods or junk foods, what would you recommend to them as an effective strategy to do that?
AG: I think the first main thing is do a little meal prep at home. That’s your key. Once you have groceries in your home, you tend to actually cook. Otherwise, every day once you finish your work, you’re like, “Alright, where can we stop now? Which fast food place am I gonna stop?” It’s important to do a little bit of prepping your meals on your day off and getting your meal started that way. Including more vegetables in your diet, including more fiber in your diet is important. I always tell my patients, “Try to shop at the in the periphery of the grocery store and not within the aisles because that’s where you see the most processed foods.” And then they start thinking, “You’re right, it’s all in boxes in the aisles,” whereas on the periphery, that’s where you have fresh fruits, vegetables, milk products, and fresh breads.
RK: What other tips might you have for individuals as they’re shopping in the grocery store?
AG: So again, trying to find more fresh fruits and vegetables, trying to stay away from juices; any of the process foods have a lot of salt in it, too. So we’re not only concentrating on sugar, but we want them to reduce their sodium intake. And most of the processed foods have a lot of sodium in them. We’re trying to help them restrict their sodium. Most patients will tell you, “We don’t add salt to our diet.” But what they’re forgetting or don’t realize is that most of these foods that are processed already have a lot of salt. And staying away from canned foods and vegetables. That’s important because canned fruits are very high in sugar and canned vegetables are very high and salt; fresh and frozen vegetables are a way to go. Anything that’s white, like white bread, cereals, pastas, staying away from those kinds of foods is also very important.
RK: And what about looking at nutrition labels? Is there anything in particular that you tell individuals to look for when they’re looking at labels?
AG: Yes. So when we talk about food labels, usually we’re asking them to look at sodium and the total carbohydrates in their food and how to read a food label. Always look at portion sizes because what’s listed up there, it’s for the portion size, it’s not for the whole box. So people don’t realize that they’re actually doing more than what they’re supposed to do.
RK: Is there a general carbohydrate range that you recommend for patients or is it individualized?
AG: It’s usually individualized. And again, going back to restrictive diets, we don’t want to tell our patients, you know, “Just stick with 45 grams or 60 grams of carbohydrates.” Then, we’re starting to lose them. What I tell my patients is, “Be consistent with your intakes for carbohydrate.” So if you’re taking 2-3 servings of carbohydrate with each meal, stick to that. Don’t eat 3 servings for your lunch and 6 servings for your dinner because then you will see a big fluctuation in your blood glucose levels. It’s important to make sure that it’s reasonable when you’re telling them, “You can stay with what you’re eating, just change a few things: include more fiber in your diet, reduce salt in your diet, try to look at portion sizes, and be consistent.”
RK: That’s so true that consistency really is the key, especially when you’re taking the same amount of medication every day to have consistency in your diet and activity patterns really ensures that the glucose levels remain relatively stable. What about organic versus non-organic foods? What do you say about that?
AG: I think some organic foods are okay. But fruits for instance, if you have skins on them, is it really necessary to do organic foods? It’s not. In terms of meats, some meats are you know, depends on where you shop, how fresh they are… organic is okay. But it’s not something that I usually discuss with my patients. Plus, the clientele we have can’t afford any of those organic foods.
RK: So it sounds like it’s personal preference, especially since it can be often more costly than other foods and really focusing on just healthy food choices in general. Is there a time of day that you recommend people go grocery shopping? You know, we often hear that, “you shouldn’t go when you’re hungry.” You know, “your eyes might be bigger than your stomach.” What do you think? I always tell my patients, “Have a little snack before you go grocery shopping because you don’t want to buy everything that you see,” like you’ve said, sometimes your eyes are bigger than your stomach and you think and you’re gonna eat all this stuff and also you sort of tend towards your comfort foods when you’re hungry and you’re like, “Okay, I’ll just buy this one little, you know, pint of ice cream today because this is what I’m really hungry for.” So to avoid that, just either go after you finish eating or eat a little snack before you go grocery shopping.
RK: Yeah, I think that’s a good tip for everyone to keep in mind. You know, one of the things I often hear from my patients is that the idea of having to watch their food or eat healthier foods sometimes can make the food seem relatively bland, but there are so many different ways to, ‘spice it up’. And I wonder if you could talk a little bit about the use of spices in a meal plan for a person with diabetes. And are there certain ones that you recommend or what do you usually suggest?
AG: I think these days the palate of regular person has changed quite a bit over the years; it’s either because we have more diverse foods that are available to us or people are experimenting with a lot of spices. I do tell my patients that salt is not the only ingredient that can be used. You can use many other spices that can enhance the flavors of your food. So whether you’re cooking an Italian meal, you can use your nice wholegrain pasta. You can use your homemade tomato sauce with it. You know, I tell them you can grind up a few greens and then add it to your sauce so that way you’re getting your vegetable along with your tomato sauce. You’re not getting all that sodium so your tomato sauce is fresh. You can add nice oregano; you can add some basil to it; you can add a little bit of sage; or just buy the Italian seasoning if that’s easy for you without the salt and then add it to your pasta along with lean meat and that’s your good meal. Now if you’re going for any Asian preparations you can always use… you know if you’re doing Indian then you can go with your cumin, your coriander, your pepper, your chili powder, fenugreek, mustard, ginger, garlic… These are very good and you know, turmeric has a lot of anti-inflammatory properties, so it’s really good for you. So is ginger. So these spices can be used on a regular basis in your vegetables, in your meats. And try not to add too much chili powder to your meal because then what happens is you tend to eat a lot more rice or the carbohydrate, either your tortillas or chapati or rice. So if you make it less spicy, the tendency is to eat less rice, as well.
RK: You mentioned different types of ethnic diets and there’s so much variety in the types of food that people eat around the world. Some diets are more heavy in rice, some are more heavy in breads. For someone with diabetes, we often talk about kind of moderating carbohydrates. So how do you tailor your recommendations to people who eat different ethnic diets?
AG: Well, people always ask me, “Should I be switching to brown rice versus white rice?” White rice is nothing but brown rice that has been milled and polished — and so it’s white and then usually that rice has been fortified with some iron and B vitamins in it. So it’s okay for people to eat white rice who have digestion problems and can’t tolerate brown rice or don’t like that nutty flavor. But brown rice has more fiber in it. You know, in the olden days, people with money ate white rice and everybody else ate the brown rice. But brown rice is actually more nutritious. You’re not getting rid of all the vitamins while polishing it. You have additional fiber in it. You have a little more protein in it. Brown rice is so much better. Now how do you restrict rice? Because of the fiber in your carbohydrates, you tend to eat less because you have that satiety really faster than eating white pastas or white rice. It’s important to make sure that you tell your patients “That’s why we want you to eat brown rice or whole grain flour or whole grain breads.” Now how do you restrict eating those carbohydrates? Usually, I tell my patients like one thing is reducing the spice level in your food. That way you eat less rice. The second is making sure that you have more vegetables along with your meal so that way at least two cups of vegetables with lunch and dinner and then you reduce your intake of carbohydrates to a smaller portion. Making sure that your portion size is actually… when you make your either tortillas or rice, just make sure that you scoop out the exact amount onto your plate and don’t go for seconds. When you go back for seconds, you can only replenish your vegetables and a little bit of meat. The other thing is… there’s not much research done but I think there is some research there… when you tend to eat more cold rice, the starch is not active—resistant starch. And that helps, too. Not eating very hot rice or hot baked potato but leaving it to cool off a little bit and so that way you can have better blood sugars with that.
RK: So resistant starch is the idea that, as you said, you don’t eat it right away when it’s warm or hot, you let it cool. And then perhaps a few hours later eat it?
AG: Yeah, or even not piping hot, but at room temperature.
RK: And what does that do to the food? Why is that preferable?
AG: Because your starch is not in the active form that you tend to not have that spike in blood sugar.
RK: So it actually has a more prolonged release, it sounds like.
AG: Correct.
RK: That’s so interesting, and it’s such an easy change to make.
AG: It is.
RK: The other question I wanted to ask you is that often people see grocery shopping or preparation of food at home as potentially cumbersome; it can be time-consuming. I wonder what would you say to that to someone who’s hesitant to prepare their own food at home?
AG: You’re right. Not many people like cooking these days. But I think when you actually make cooking a part of the process of eating, it makes a difference because you enjoy it more. You’re the one that’s in charge of what goes into that meal. You also know how much effort goes into that meal. So you may want to portion yourself and keep it for the next day or two. I think the process of just sitting down and making that food with your loved one is better. And you can use a few convenience things like you can get chopped vegetables now in the grocery store; you don’t have to sit and chop those vegetables. You can use meats that are already marinated sometimes, making sure that they don’t have too much sodium in it; simple sauces; you can grill your meat or marinate your meat for a week at a time, you know, portion them out. You can even marinate and freeze them and take them out as portions to make it easy. So just spending a little more time with preparation rather than going out… with gas has become so expensive, and so has food. So might as well cook and enjoy prepping your meals and eating more healthy foods at home.
RK: Enjoying the process helps and enjoying the food as well contributes to the joy of eating and being more mindful about your eating too is what it sounds like you’re talking about.
AG: Right. Exactly.
RK: I wonder if you could talk a little bit about the Mediterranean diet. You know, we hear a lot about the benefits of the Mediterranean diet. What is it and what is its role for people with diabetes?
AG: Mediterranean diets usually are for people right near the Mediterranean Sea. And that’s, you know, they eat a lot of lean meats like seafood, basically. They’re also gatherers and so their food includes a lot of nuts, and green leafy vegetables, and just clean eating, basically. Eating in season — eating what is available for you that is fresh is what is really a Mediterranean diet. It’s low in carbohydrate; it’s nice, clean protein; it’s high biological value protein in their diets and their fats, because it’s all seafood and nuts. You have good omega three fatty acids, and it’s cardio-protective. And it also reduces blood sugars because they’re not eating way too many carbs.
RK: So for someone who wanted to try the Mediterranean diet, what would be the foods that would be allowed on this diet or recommended?
AG: Usually you want lean meats, mostly seafood; cheese (the low fat cheeses, the softer cheeses); you want more fresh vegetables, right; fresh fruits, and a lot of nuts; and of course good bread, like a nutty bread, whole grain breads that they make that are fresh.
RK: And do you see that this kind of diet helps with blood glucose management?
AG: So there’s a lot of research that’s been done and Mediterranean diets along with your DASH diets, which are very similar, they have shown to reduce blood sugars and also your hemoglobin A1Cs, so it’s very effective.
RK: That’s great. Since you mentioned the DASH diet, could you briefly talk about what that is?
AG: DASH diets are sodium-restrictive diets for hypertension usually, and they’re very similar to our Mediterranean diets. We stay away from highly processed meats like breakfast meats and emphasizing more lean meats. Not so much as the seafood but it could be 90% fat-free meats. You have very low sodium. Your sauces, your ketchup, your soy sauce, canned vegetables… all these are eliminated on a DASH diet. More high fiber foods.
RK: Yeah, the DASH diet and the Mediterranean diet, I think, are the two where there’s been the greatest number of studies looking at its benefits, particularly to reduce inflammation, and blood pressure, and blood glucose, as well. What about other kinds of fads or popular diets such as the Atkins diet?
AG: We’re in a society where we’re constantly dieting, and very popular first of the year, people go into gyms and they have a new diet that they want to follow — one quick fixes. And it also, again, going back to diabetes, it has a lot of stigma that you’re taking, you know, medications for your diabetes, and you’re not able to lose weight. A lot of research is being done now on intuitive eating: staying away from all these fad diets, because we can sustain ourselves on these fad diets. We cannot go on for long periods of time on these diets. And they’re not even healthy. Like I tell our diabetic patients, we don’t want you to give up carbohydrates because that’s what gives you energy. We just wants you to make the right choices of carbohydrate. Do not go back to, “Oh, should I do Atkins diet?” You’re increasing the amount of fat in your diet and you cannot sustain that diet for long periods of time without eating your carbohydrates. So what do you do after about a month or so? You start binging. And so your blood sugars go up and down. So you don’t want that. You want to make lifestyle changes: eat healthy, eat what you want, make those small changes every day. I had a patient who was diagnosed recently with type 2 diabetes. And he was so excited because he lost a lot of weight. And he was in the process of being diagnosed with type 2 diabetes. He came back again after a few months and he had gained his weight back and he was very upset. And he said, “It’s because you put me on insulin that I gained this weight.” Well, there may be some truth to that. But what I had to tell him was, “Now you’re actually absorbing all the nutrients and you’re doing well. You’re looking healthy, you’re feeling better, aren’t you?” And he said, yes, he’s feeling much better now than he did when he lost weight and was feeling dizzy and sick. You know, it’s important to help your patients feel good where they are, and then go through the process of making small changes.
RK: And that’s so important, I think, to meet individuals where they are and see what works for them. What about things like intermittent fasting or the keto diet? Those have gained quite a bit of enthusiasm in the general public. Do you discourage or encourage people with type 2 diabetes who might be interested in that, particularly if they’re on insulin? Or what do you usually say?
AG: Again, like you said, no type fits all. There are patients who will tell me, “Can I try intermittent fasting?” And it’s for those patients who are constantly eating. When you explain to them what intermittent fasting is… you know, this intermittent fasting is new in the Western world, but it has been used a lot for religious purposes in different parts of the Eastern world. It reduces binging for some patients, and that’s who I actually suggest to because then you can eat in a certain period of time, and it helps them reduce the amount of calories because they cannot consume all what they’ve been eating in 24 hours in a shorter period of time. Again, there was a recent study done where people realize… people in that study ate 10% less than what they were normally eating, and that’s what helped with their weight loss and reducing blood sugars. But we always have to be more careful with those patients because if they’re on insulin or if they’re taking sulfonylureas, you don’t want to… want them to have hypoglycemia.
RK: Around the holidays or when people are eating out, sometimes it can be difficult to maintain the same principles of healthy food eating, particularly the portion size I think becomes more difficult. What do you usually recommend to people around those times when they’re in social settings or around festive gatherings?
AG: First thing is you don’t go to a restaurant when you’re ravenous. You don’t want to go there being very, very hungry where you want to eat your appetizers, you want to eat your main course and dessert. So try to eat a little snack before you head out so you’re not hungry. The second thing is as we know that our portion sizes are large, share your meals. If you’re going with somebody, share an appetizer, share a main course and be done. If you don’t want to share your main course, you can always tell the waiter, “Please split my meal into half.” Box the half up, I’ll take it home and just eat the other half, so that way, you don’t have it in front of you. Limiting alcohol is also important. So usually, we tell our women to have one drink a day, whether it’s 12 ounces of beer, one and a half ounces of hard liquor, or five ounces of wine. For men, it’s two drinks a day. So limiting your alcohol intake is also helpful. When you’re drinking, please make sure to have a little snack. Don’t drink on an empty stomach.
RK: And are most restaurants pretty friendly for people with diabetes in terms of the meal options they have or how would someone with diabetes know what might be better for them versus not?
AG: Again, having diabetes, we don’t have to restrict anything. All we want them to do is be mindful of the portion sizes and how much carbohydrate they’re taking in and their sodium levels. So making sure that you can cut down… like if you’re in a Chinese place, you can always say I just want half a cup of rice — which can be brown rice instead of white rice — and then add more vegetables to my diet and limit the amount of meat that I’m getting. If you’re eating a steak, make sure that you’re eating a smaller portion of steak and not a 14-ounce steak on the menu. Those choices are very, very important to make. Always making sure that you have at least two vegetables with your meal instead of just one.
RK: Thank you so much, Asha, for being here with us today. I’ve learned I know so much about different eating patterns and how to incorporate, really in very small ways, but ways that have a big impact of healthier food choices into the diet. And I know that this information will be useful for our listeners as well. Just for some parting words, what would your advice be to someone who is wanting to eat healthier but might be a little reluctant to start?
AG: I want to tell my patients to be happy with their food intake, make small changes to your diet, and don’t think of it as a diet but a lifestyle change that you’re eating healthy for yourself and for your family.
RK: Thanks so much, Asha. I’m so glad you could be with us here today.
AG: Thanks for having me.
RK: I’m Dr. Rita Kalyani. And you’ve been listening to Diabetes Deconstructed, a companion podcast to the Johns Hopkins Patient Guide to Diabetes website which has all kinds of useful information about diabetes, including videos and animations, a lifestyle and nutrition blog, and a comprehensive diabetes glossary among other topics. For more information, visit hopkinsdiabetesinfo.org.
We would love to hear from our listeners. The email address is hopkinsdiabetesinfo@jhmi.edu. Thanks for listening. Be well and see you next time.
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