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DR. BERNSTEIN’SDR. BERNSTEIN’S

A COMPLETE GUIDE TO ACHIEVING NORMAL BLOOD SUGARS

This document and its contents are Copyright 2000 by Richard K. Bernstein, M.D., Little, Brown & Company, and/orother copyright holders as may apply. No portion of this document may be reproduced in whole or in part without theexpress written consent of Little, Brown & Company and/or Richard K. Bernstein, M.D. and/or any other respectivecopyright holder(s).

Chapter 10: Diet Guidelines: Treatment for All Diabetics

Perhaps someday there will be a miraculous replacement for the burned-out beta cells of yourpancreas, but until then, if you're going to control your diabetes and get on with a normal life,you will have to change your diet. No matter how mild or severe your diabetes, the key aspect ofall treatment plans for normalizing blood sugars and preventing or reversing complications ofdiabetes is diet. In the terms of the Laws of Small Numbers, the single largest "input" you cancontrol is what you eat.

The Fundamental Importance of a Restricted-Carbohydrate Diet

The next several pages may well be the most difficult pages of this book for you to accept—aswell as some of the most important. They're full of the foods you're going to have to restrict oreliminate from your diet if you're going to normalize your blood sugars. You may see some ofyour favorite foods on our No-No list, but before you stop reading, keep in mind a few importantthings. First, toward the end of this chapter we discuss the foods you can safely eat. Second,while you will have to eliminate certain foods, there are some genuinely sugar-free alternatives.One purpose of blood glucose self-monitoring is to learn through your blood sugar profiles howparticular foods affect you. Over years of examining these profiles, I've observed that somepeople are more tolerant of certain foods than other people. For example, bread makes my ownblood sugar rise very rapidly. Yet some of my patients eat a sandwich of thin bread every daywith only minor problems. This is inevitably related to delayed stomach-emptying (see Chapter21). In any case, you should feel free to experiment with food and then perform blood sugarreadings. It's likely that for most diabetics all of our restrictions will be necessary.

Patients often ask, "Can't I just take my medication and eat whatever I want?" It almost seemslogical, and would be fine if it worked. But, as explained earlier, it doesn't work, so we have tofind something that does. We have.

Many diabetics can be treated with diet alone, and if your disease is relatively mild, you couldeasily fall into this category. Some patients who have been using insulin or oral hypoglycemicagents find that once on our diet they no longer need blood sugar–lowering medication. Even ifyou require insulin or other agents, diet will still constitute the most essential part of yourtreatment.

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Think small inputs. You may recall from prior chapters that the impairment or loss of phase Iinsulin response makes normalizing blood sugars impossible for at least a few hours after a high-carbohydrate meal. Even eating small amounts of fast-acting carbohydrate raises blood sugar sorapidly that any remaining phase II insulin response cannot promptly compensate. This is true ifyou're injecting insulin or if you're still making your own insulin.

Any sensible meal plan for normalizing blood sugar takes this into account and follows thesebasic rules:

• First, eliminate all foods that contain simple sugars. As you should know by now—but itbears repeating—"simple sugar" does not mean just table sugar. Most breads and otherstarchy foods, such as potatoes and grains, become simple sugars so rapidly that they cancause serious postprandial increases in blood sugar.

• Second, limit your total carbohydrate intake to an amount that will work with yourinjected insulin or your body's remaining phase II insulin response. In this way, youavoid a postprandial blood sugar increase, and avoid overworking any remaining insulin-producing beta cells of your pancreas (research has demonstrated that beta cell burnoutcan be slowed or halted by normalizing blood sugars).

• Third, stop eating when you no longer feel hungry, not when you're stuffed. There's noreason for you to leave the table hungry, but there's also no reason to be gluttonous.Remember the Chinese Restaurant Effect (page 87).

Testing for Glucose or Sucrose in Foods

Sometimes you'll find yourself at a restaurant, hotel, or reception where you cannot predict iffoods have sugar or flour in them. Your waiter may have no idea what's in a given recipe. I'vefound that the easiest way to make certain is to use the Clinistix or Diastix that should have beenchecked off on your supply list (Chapter 3). These are manufactured to test urine for glucose. Weuse them to test food. If, for example, you want to determine if a soup or salad dressing containstable sugar (sucrose) or a sauce contains flour, just put a small amount in your mouth and mix itwith your saliva. Then spit a tiny bit onto a test strip. Any color change indicates the presence ofsugar. Saliva is essential to this reaction because it contains an enzyme that releases glucose fromsucrose or flour in the food, permitting it to react with the chemicals in the test strip. This is howI found that one restaurant in my neighborhood uses large amounts of sugar in its bouillon whileanother restaurant uses none.

Solid foods can also be tested this way, but you must chew them first. The lightest color on thecolor chain label of the test strip indicates a very low concentration of glucose. Any color palerthan this may be acceptable for most foods. The Clinistix/Diastix method works on nearly all thefoods on our No-No list except milk products, which contain lactose. It will also not react withfructose. If in doubt, assume the worst.

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No-No Foods: Eliminating Simple Sugars

Named below are many of the common foods that contain simple sugars, which rapidly raiseblood sugar or otherwise hinder blood sugar control and should be eliminated from your diet.Virtually all grain products, for example—from the flours in "sugar-free" cookies to pasta—areconverted so rapidly into glucose by the enzymes in saliva that they are, as far as blood sugar isconcerned, essentially no different than table sugar. There are plenty of food products, however,that contain tiny amounts of simple sugars and will have a negligible effect on your blood sugar.One gram of carbohydrate will not raise blood sugar more than 5mg/dl for most adults. A singlestick of chewing gum or a single tablespoon of salad dressing made with only 1 gram of sugarcertainly poses no problems. In these areas, you have to use your judgment and your blood sugarprofiles. If you're the type who, once you start chewing gum, has to have a new stick every 5minutes, then you should probably avoid chewing gum. If you have delayed stomach-emptying,chewing gum may help facilitate your digestion.

Powdered Artificial SweetenersSweet'n Low, Equal, The Sweet One, Sugar Twin, and similar powdered products in paperpackets usually contain about 96 percent glucose and about 4 percent artificial sweetener. Theyare sold as low-calorie sweeteners because they contain only 1 gram of glucose as compared to 3grams of sucrose in a similar paper packet labeled "sugar." More suitable for diabetics are tabletsweeteners such as saccharin, cyclamate, and aspartame (Equal in the United States). Note thatthe same brand name can denote two different products: Equal is a powder containing 96 percentglucose and also a tablet containing no glucose. Stevia powder and liquid (sold in health foodstores) contain no sugar of any kind.

So-Called Diet Foods and Sugar-Free FoodsBecause U.S. food-labeling laws have permitted products to be called "sugar-free" if they do notcontain common table sugar (sucrose), the mere substitution of another sugar for sucrose permitsthe packager to deceive the consumer legally. Most so-called "sugar-free" products were, formany years, full of sugars that may not promote tooth decay but most certainly will raise yourblood sugar. If you've been deceived, you're not alone. I've been in doctor's offices that havecandy dishes full of "sugar-free" hard candies especially for their diabetic patients! Sometimesthe label will disclose the name of the substitute sugar.Here is a partial list of some of the many sugars you can find in "sugar-free" foods. All of thesewill raise your blood sugar.

• carob• honey• saccharose• corn syrup• lactose• sorbitol• dextrin• levulose• sorghum

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• dextrose• maltose• treacle• dulcitol• mannitol• turbinado• fructose• mannose• xylitol• glucose• molasses• xylose

Some, such as sorbitol and fructose, raise blood sugar more slowly than glucose but still toorapidly to prevent a postprandial blood sugar rise in people with diabetes.Other "diet" foods contain either sugars that are alternates to sucrose, large amounts of rapid-acting carbohydrate, or both. Many of these foods are virtually 100 percent rapid-actingcarbohydrate (e.g., sugar-free cookies), so that even if they were to contain none of the aboveadded sugars, consumption of a small quantity would easily cause rapid blood sugar elevation.There are exceptions—most diet sodas, sugar-free Jell-O brand gelatin desserts, and No-Calbrand syrups (available in the New York metropolitan area). All of these are made without sugarof any kind. These you need not restrict. See the "So What's Left to Eat?" section later in thischapter.

Candies, Including "Sugar-Free" BrandsA tiny "sugar-free" hard candy containing only 2 1/2 grams of sorbitol can raise blood sugaralmost 13 mg/dl. Ten of these can raise blood sugar 125 mg/dl. Are they worth it?

Honey and FructoseIn recent years a number of "authorities" have claimed that fructose (which is now sold as apowdered sweetener) and honey are useful to diabetics because they are "natural sugars." Well,glucose is the most natural of the sugars, since it is present in all plants and all but one knownspecies of animal. These substances will raise blood sugar far more rapidly than either phase IIinsulin release, injected insulin, or oral hypoglycemic agents can bring it down. Just eat a fewgrams of honey or fructose and check your blood sugar every 15 minutes. You will readily provethat "authorities" can be wrong.

Desserts and PastriesWith the exception of sugar-free Jell-O and similar gelatin products marked "carbohydrate—0"on the nutrition label, virtually every food commonly used for desserts will raise blood sugar toomuch and too fast. This is not only because of added sugar, but also because flour, milk, andother components of desserts are very high in rapid-acting carbohydrate.

Bread and CrackersOne average slice of white, rye, or whole wheat bread contains about 12 grams carbohydrate.The "thin" or "lite" breads now available in U.S. supermarkets are usually cut at half the

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thickness of standard bread slices and contain half the carbohydrate. So-called high-proteinbreads contain only a small percentage of their calories as protein and are not significantlyreduced in carbohydrate unless they are thinly cut. Brown bread, raisin bread, and corn bread allcontain as much or more fast-acting carbohydrate as rye, white, or whole wheat. Some diabeticswith gastroparesis (Chapter 21) can tolerate the inclusion of 1–2 slices of thin bread or a fewcrackers as part of their low-carbohydrate meal limits. Unfortunately, most of us experience veryrapid increases of blood sugar after eating any product made from any grain (bread, crackers,pastry shells, et cetera).

Rice and PastaAlthough pasta is made from flour, much pasta is derived from a different kind of wheat (durumsemolina) than is used in bread. Both pasta and wild rice (which is actually not a true variety ofrice but another grain entirely) are claimed by some nutrition authorities to raise blood sugarquite slowly. Just check your blood sugar levels after eating them and you'll prove these"authorities" wrong. Alternately, you might try the Clinistix/Diastix test described on page 123.Like wild rice and pasta, white and brown rices also raise blood sugar quite rapidly for most ofus and should be avoided.

Breakfast CerealsAll cold cereals, like snack foods, are virtually 100 percent carbohydrate. Many contain largeamounts of added sugars. Since they are made from grain, small amounts, even of whole-graincereals, will cause a rapid rise in blood sugar.Cooked cereals generally contain about 10–25 grams of fast-acting carbohydrate per half-cupserving. I find that even small servings make blood sugar control impossible.

Snack FoodsThese are the products in cellophane bags that you find in vending machines and supermarkets.They include not just cookies and cakes, but pretzels, potato chips, taco chips, tiny crackers, andpopcorn. These foods are virtually 100 percent carbohydrate and frequently have added sucrose,glucose (the label may say dextrose), corn syrup, et cetera.

Milk and Cottage CheeseMilk contains a considerable amount of the simple sugar lactose and will rapidly raise bloodsugar. Skim milk actually contains more lactose per ounce than does whole milk. One or 2teaspoons of milk in a cup of coffee will not significantly affect blood sugar, but 1/4 cup of milkwill make a considerable difference to most of us. (Cream, which you have probably beenavoiding, is okay. One tablespoon has only 0.4 gram of carbohydrate.) The powdered lightenersfor coffee contain relatively rapid-acting sugars and should be avoided if you use more than ateaspoonful at a time or drink more than 1 cup of coffee at a meal. An excellent coffee lighteneris Westsoy brand soybean milk, which is sold in health food stores throughout the United States.Although several Westsoy flavors are marketed, only the one marked "unsweetened" isunsweetened. It contains 4 grams of carbohydrate in 8 ounces. Soybean milk can be stored in theunopened container for up to one year without refrigeration. Once opened, however, it must berefrigerated. One catch—it curdles in very hot coffee or tea.Cottage cheese also contains a considerable amount of lactose because, unlike most othercheeses, which are okay, it is only partly fermented. I was unaware of this until several patients

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showed me records of substantial blood sugar increases after consuming a small container ofcottage cheese. It should be avoided except in very small amounts, say about 2 tablespoons.

Fruits and Fruit JuicesThese contain a mixture of simple sugars and more complex carbohydrates. A few experimentswith blood sugar measurements will show you how rapidly these foods can raise your levels.Bitter-tasting fruits such as grapefruit and lemon contain considerable amounts of simple sugars.They taste bitter because of the presence of bitter chemicals, not because sugar is absent.Although deleting fruit from the diet can be a big sacrifice for many of my patients, they usuallyget used to this rapidly, and they appreciate the effect upon blood sugar control. I haven't eatenfruit in twenty-five years, and I haven't suffered in any respect. Some people fear that they willlose important nutrients by eliminating fruit, but that shouldn't be a worry. Nutrients found infruits are also present in the vegetables you can safely eat.

Vegetables• Beets. Like most other sweet-tasting vegetables, beets are loaded with sugar. Sugar beets

are a source of table sugar.• Carrots. After cooking, carrots taste sweeter and appear to raise blood sugar much more

rapidly than when raw. This probably relates to the breakdown of complex carbohydratesinto simpler sugars by heat. Even raw carrots should be avoided. If, however, you areserved a salad with a few carrot shavings on top for decoration, don't bother to removethem. The amount is insignificant, just like a teaspoon of milk.

• Corn. Nearly all of the corn grown in the United States is used for two main purposes.One is the production of sweeteners. Most of the sugar in Pepsi-Cola, for example, comesfrom corn. The other purpose is animal feed, e.g., fattening up hogs, cattle, and chickens.Corn for consumption by people, as a vegetable or as snack foods, comes in third.Diabetics should avoid eating corn, whether popped, cooked, or in chips—even 1 gram ofcorn will rapidly raise my blood sugar by about 5 mg/dl.

• Potatoes. For most people, cooked potatoes raise blood sugar almost as fast as pureglucose, even though they may not taste sweet. Giving up potatoes is a big sacrifice formany people, but it will also make a big difference in your postprandial blood sugars.Raw potatoes, if you happen to like them, as well as sweet potatoes or yams, should alsobe on your nix list.

• Tomatoes, Tomato Paste, and Tomato Sauce. Tomatoes are actually a fruit, not avegetable, and as with citrus fruits, their tang can conceal just how sweet they are. Theprolonged cooking necessary for the preparation of tomato sauces releases a lot ofglucose, and you would do well to avoid them. If you're at someone's home for dinnerand are served meat or fish covered with tomato sauce, just scrape it off. The smallamount that might remain should not significantly affect your blood sugar. If you arehaving them uncooked in salad, limit yourself to one slice or a single cherry tomato percup of salad.

• Commercially Prepared Soups. Believe it or not, most commercial soups marketed in thiscountry can be as loaded with added sugar as a soft drink. The taste of the sugar isfrequently masked by other flavors—spices, herbs, and particularly salt. Even if therewere no added sugar, the prolonged cooking of vegetables can break down the longchains of complex, slow-acting carbohydrates and cellulose, turning them into simple

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sugars. There are still some commercial soup possibilities that fit into our scheme. Seethe corresponding heading in the "So What's Left to Eat?" section on page 132.

• Health Foods. Of the hundreds of packaged food products that you see on the shelves ofthe average health food store, perhaps 1 percent are low in carbohydrate. Many aresweetened, usually with honey or other so-called natural sugars. Since the health foodindustry shuns artificial (nonsugar) sweeteners like saccharin or aspartame, if a foodtastes sweet, it probably contains a sugar. There are a few foods carried by these storesthat are unsweetened and low in carbohydrate. You'll find some of these listed later inthis chapter.

So What's Left To Eat?

It's a good question, and the same one I asked myself twenty-five years ago as I discovered thatmore and more of the things I had been eating made blood sugar control impossible. In thefollowing pages, I'll give you a broad overview of the kinds of food my patients and I usuallyeat. Please remember that with the exception of the no-calorie beverages and moderate portionsof sugar-free Jell-O, there are no "freebies." Virtually everything we eat will have some effectupon blood sugar if enough is consumed. You may discover things I've never heard of that havea benign effect on your blood sugar. If so, feel free to include them in your meal plan (and let meknow about them).

VegetablesMost vegetables, other than those listed in the No-No section, are acceptable—such as asparagus,avocado, broccoli, brussels sprouts, cabbage and sauerkraut, cauliflower, eggplant, onions (insmall amounts), peppers (any color), mushrooms, spinach, string beans, summer squash, andzucchini. As a rule of thumb, 2/3 cup of cooked vegetable or 1 cup of mixed salad acts uponblood sugar as if it contains about 6 grams of carbohydrate. Remember that cooked vegetablestend to raise blood sugar more rapidly than raw vegetables. On your self-measurements, notehow your favorite vegetables affect your blood sugar. Raw vegetables can present digestiveproblems to people with gastroparesis.

Meat, Fish, Fowl, Seafood, and EggsThese are usually the major sources of calories in the meal plans of my patients. The popularpress is currently down on meat and eggs, but my personal observations and recent researchimplicate carbohydrates rather than dietary fat in the heart disease and abnormal blood lipidprofile of diabetes. If you are frightened of these foods, you can restrict them, but deprivingyourself will be unlikely to buy you anything. Appendix A details the current controversy andthe shaky science behind the present, faddish high-carbohydrate dietary recommendations, andlays out my concerns and opinions.

Tofu, and Soybean Substitutes for Bacon, Sausage, Hamburger, Fish, Chicken, and SteakAbout half the calories in these products come from vegetable fat, and the balance from equalamounts of protein and slow-acting carbohydrate. They are easy to cook in a skillet ormicrowave. Protein and carbohydrate content should be read from the labels and counted in yourmeal plan. Their principal value is for people who are vegetarian or want to avoid red meat.Health food stores stock many of these products.

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Certain Commercially Prepared and Homemade SoupsAlthough most commercial and homemade soups contain large amounts of simple sugars, youcan learn how to buy or prepare low- or zero-carbohydrate soups. Many but not all packagedbouillon preparations have no added sugar and only small amounts of carbohydrate. Check thelabels or use the Clinistix/Diastix test as described on page 123. Plain consommé or broth insome restaurants may be prepared without sugar. Again, check with Clinistix/Diastix.Homemade soups, cooked without vegetables, can be made very tasty if they are concentrated.You can achieve this when making stock by barely covering the meat or chicken with waterwhile cooking. Do not fill the entire pot with water, as is the customary procedure. Alternately,let the stock cook down (reduce) so you get a more concentrated, flavorful soup. You can alsouse herbs and spices, all of which have negligible amounts of carbohydrates, to enhance flavor.See "Mustard, Pepper, Salt, Herbs, Spices," below. Clam broth (not chowder) is usually very lowin carbohydrate. In the United States you can also buy Snow's Clam Juice (not Clamato), whichcontains only 2 grams of carbohydrate in 3 fluid ounces.

Cheese, Butter, and CreamMost cheeses (other than cottage cheese) contain approximately equal amounts of protein and fatand small amounts of carbohydrate. The carbohydrate and the protein must be figured into themeal plan, as I will explain in Chapter 11. For people who want to avoid animal fats, there aresome special soybean cheeses. Cheese is an excellent source of calcium. Every ounce of cheesecontains 1 gram carbohydrate, except cottage cheese, which contains more.Butter will not affect your blood sugar significantly, and shouldn't be a problem as far as weightis concerned if you're not consuming a lot of carbohydrate along with it. One tablespoon ofcream has only 0.4 gram carbohydrate—it would take 8 tablespoons to raise my blood sugar 16mg/dl.

YogurtAlthough personally I don't enjoy yogurt, many of my patients feel they cannot survive withoutit. For our purposes the plain whole-milk yogurt, without fruit, is a reasonable food. A full 8-ounce container of plain, Erivan brand, unflavored whole milk yogurt contains only 11 grams ofcarbohydrate and 2 ounces of protein. You can even throw in some chopped vegetables and notexceed the 12 grams of carbohydrate limit we suggest for lunch. Do not use nonfat yogurt. Thecarbohydrate goes up to 17 grams per 8-ounce container. Yogurt can be flavored with cinnamon,with No-Cal brand syrups mentioned below, with baking flavor extracts, or with the powderfrom sugar-free Jell-O brand gelatin without affecting the carbohydrate content. It can besweetened with stevia liquid or powder. Erivan brand yogurt is available at health food storesthroughout the United States. If you read labels, you may find other brands, such as SummerfieldFarms, equally low in carbohydrate.

Soy MilkThere are any number of valuable soy products that can be used in our diet plan, and soy milk isno exception. It's a fine lightener for coffee and tea, and one of my patients adds a small amountto diet sodas. Others drink it as a beverage, either straight or with added flavoring such as theflavor extracts used for baking. Personally, I find the taste too bland to drink without flavoring.

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When used in small amounts (up to 1 ounce), soy milk need not be figured into the meal plan. Itwill curdle if you put it into very hot drinks.As noted in the No-No foods section, of the many brands of soy milk on the market, the Westsoy"unsweetened" flavor is the only unsweetened one I have been able to find. Other unsweetenedbrands are available in various parts of the country.

Soybean FlourIf you or someone in your home is willing to try baking with soybean flour, you will find a neatsolution to the pastry restriction. One ounce of full-fat soybean flour (about 1/4 cup) containsonly 7.5 grams of slow-acting carbohydrate. You could make chicken pies, tuna pies, and evenJell-O or chocolate mousse pies. Just remember to include the carbohydrate in your meal plan.Soybean flour usually must be blended with egg to form a batter suitable for breads, cakes, andthe like. Some recipes using soy flour appear in Appendix D.

Bran CrackersOf the dozens of different crackers that I have seen in health food stores and supermarkets, Ihave found only two brands that are truly low in carbohydrate.

• G/G Scandinavian Bran Crispbread, produced by G. Gundersen Larvik A/S, Larvik,Norway (distributed in the United States by Cel-Ent, Inc., Box 1173, Beaufort, SC29901). Each 9-gram slice contains only 2 grams of carbohydrate. If this product is notavailable locally, you can order it directly from the importer. Enclose a check for $39 toreceive one case containing thirty 4-ounce packages.

• Bran-a-Crisp, produced by Saetre A/S, N1411, Kolbotn, Norway (distributed in theUnited States by Interbrands, Inc., 3300 N.E. 164th Street, FF3, Ridgefield, WA 98642).Each 8.3-gram cracker contains 3 grams of carbohydrate. Bran-a-Crisp may be ordereddirectly from Interbrands, Inc., by mail if you cannot find it locally. Just enclose a checkin the amount of $36 for a case of twenty-four 4.4-ounce packages.*

Although some people eat these without a spread, to me they taste like cardboard. My preferenceis to enjoy them with cream cheese or butter. Bran cracker cereal can be created by crumblingtwo or three crackers into a bowl and covering them with cream or cream diluted with water.Add some Equal tablets (dissolved in a bit of hot water) or some liquid stevia sweetener andperhaps a baking flavor extract (banana flavor, butter flavor, et cetera).

If eaten in excessive amounts, bran crackers can cause diarrhea. They are not recommended forpeople with gastroparesis (delayed stomach-emptying), since the bran fibers can form a plug thatblocks the outlet of the stomach. The carbohydrate in these crackers is very slow to raise bloodsugar. They may be purchased at many health food stores and are great for people who need asubstitute for toast at breakfast.

Note: In the United States, labelling regulations require that undigestible fiber be listed ascarbohydrate. To determine the amount of digestible carbohydrate in a product (which will affectyour blood sugar), subtract the dietary fiber content from the carbohydrate content.

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Toasted NoriWhen my friend Kanji sent me a beautifully decorated canister from Japan, I was most impressedand intrigued. You can imagine my dismay when I removed the cover and found seaweed. Mydismay was only temporary, however. I reluctantly opened one of the cellophane envelopes andpulled out a tissue-thin slice. My first nibble was quite a surprise—it was delicious. Whenconsumed in small amounts, I found, it had virtually no effect upon blood sugar. Once addicted, Icombed the health food stores searching for more. Most of the seaweed I tried tasted like saltypaper. Eventually, a patient explained to me that Kanji's seaweed is a special kind called toastednori. It contains small amounts of additional ingredients that include soybeans, rice, barley, andred pepper. It is available at most health food stores, and is a very tasty snack. Five or six piecesat a time have had no effect upon my blood sugar. The Clinistix/Diastix test showed no glucoseafter chewing. A standard slice usually measures 11/4 x 3 1/2 inches and weighs about 0.3 gram.Since the product contains about 40 percent carbohydrate, each strip will have only 0.12 gramcarbohydrate. Larger sheets of toasted nori should be weighed in order to estimate theircarbohydrate content.

Sweeteners: Saccharin, Aspartame, Stevia, and CyclamateI carry a package of Equal (aspartame) tablets with me, particularly when I go out to eat.Cyclamate is not currently available in the United States, but may be returning. Aspartame isdestroyed by cooking and is much more costly than saccharin, which has a bitter aftertaste, but itwill work for sweetening hot coffee or tea. I find that using one Equal tablet for every saccharintablet rather than two saccharin tablets or two Equal tablets eliminates saccharin's aftertaste andkeeps costs down. Equal tablets are available in most pharmacies and many supermarkets.Acesulfame-K is a new artificial sweetener being marketed in tablet form outside the UnitedStates by Hoechst, AG, of Germany. It is not degraded by cooking. It is added to some "sugar-free" foods in the United States under the brand name Sunette, and is combined with glucose inthe packaged powder called The Sweet One, which you should avoid for obvious reasons. Othernoncaloric tablet sweeteners will be appearing on grocery shelves in the United States in thefuture. Stevia, an herbal sweetener, has been available in health food stores for many years. It isnot degraded by cooking and is packaged in powder and liquid forms.

No-Cal Brand SyrupsThese artificially sweetened liquid flavors are sold by many supermarkets in the New Yorkmetropolitan area. (They are distributed by H. Fox and Co., Inc., Brooklyn, NY 11212.) Theavailable flavors include strawberry, raspberry, black cherry, chocolate, and pancake/waffletopping. This product contains no calories, no carbohydrate, no protein, and no fat. It takes a bitof imagination to put it to good use. For example, I sometimes spike my coffee with thechocolate flavor, or my tea with fruit flavors. I put the pancake/waffle topping on my eggs in themorning after heating it in a skillet.

Flavor ExtractsThere are numerous flavor extracts often used in baking that you can use to make your foodmore exciting. They usually can be found in small brown bottles in the baking supply aisles ofsupermarkets. Read carbohydrate content from the label. Usually it's zero and therefore won'taffect your blood sugar.

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Mustard, Pepper, Salt, Spices, HerbsMost commercial mustards are made without sugar and contain essentially no carbohydrate. Thiscan readily be determined for a given brand by reading the label or by using the Clinistix/Diastixtest. Pepper and salt have no effect upon blood sugar. Hypertensive individuals with proven saltsensitivity should, of course, avoid salt and highly salted foods (see page 318).Most herbs and spices have very low carbohydrate content and are used in such small amountsthat the amount of ingested carbohydrate would be insignificant. Watch out, however, for certaincombinations such as powdered cinnamon with sugar. Just read the labels.

Low-Carbohydrate Salad DressingsMost salad dressings are loaded with sugars and other carbohydrates. The ideal dressing forsomeone who desires normal blood sugars would therefore be oil and vinegar, perhaps withadded spices, mustard, grated cheese, or even bacon bits. There are now available somecommercial salad dressings with only 1 gram carbohydrate per 2-tablespoon serving. This is lowenough that such a product can be worked into our meal plans. Be careful with mayonnaise.Most brands are labeled "carbohydrate—0 grams," but may contain up to 0.4 grams pertablespoon. This is not a lot, but it adds up if you eat large amounts. Some imitation mayonnaiseproducts have 5 grams of carbohydrate per 2-tablespoon serving.

NutsAlthough all nuts contain carbohydrate (as well as protein and fat), they usually raise blood sugarslowly and can therefore be worked into meal plans. As with most other foods, you will want tolook up your favorite nuts in one of the books listed in Chapter 3 in order to obtain theircarbohydrate content. By way of example, 10 (small, not jumbo) pistachio nuts contain only 1gram carbohydrate, versus 10 cashew nuts, which contain 5 grams of carbohydrate. Although afew nuts may contain little carbohydrate, the catch is in the word "few." Very few of us can eatonly a few nuts. In fact, I don't have a single patient who can count out a preplanned number ofnuts, eat them, and then stop. So unless you have unusual will power, beware. Also beware ofpeanut butter—another deceptive addiction. One tablespoon of natural, unsweetened peanutbutter contains only 3 grams of carbohydrate, but imagine the effect on blood sugar of downingthe contents of a jar.

Sugar-Free Jell-O GelatinThis is one of the few foods that in reasonable amounts will have no effect upon blood sugar. Itis fine for snacks and desserts. A 1/2-cup serving contains no carbohydrate, no fat, and only 1gram of protein. Just remember not to eat so much that you feel stuffed (see "The ChineseRestaurant Effect" in Chapter 6). You can enhance the taste by pouring a little heavy cream overyour portion. One of my patients discovered that it becomes even tastier if you whip it in ablender with cream when it has cooled, just before it sets. If you add No-Cal chocolate syrup orchocolate-flavored baking extract and some stevia before whipping, you will have a deliciouschocolate mousse. Of the many flavors of sugar-free Jell-O that are available, I like apple,Hawaiian pineapple, and watermelon. Unfortunately, very few supermarkets seem to carry theapple flavor, and I wonder if it still exists.

Sugar-Free Jell-O PuddingsAvailable in chocolate, vanilla, pistachio, and butterscotch flavors, these make a nice dessert

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treat. Unlike Jell-O gelatin, they contain a small amount of carbohydrate (about 6 grams perserving), which should be counted in your meal plan. Instead of mixing the powder with milk,use water or cream diluted with water.

Chewing GumGum chewing can be a good substitute for snacking. The carbohydrate content of one stick ofchewing gum varies from about 1 gram in a stick of sugar-free Trident to about 7 grams perpiece for some liquid-filled chewing gums. The 7-gram gum will rapidly raise my blood sugar byabout 35 mg/dl. The carbohydrate content of a stick of chewing gum can usually be found on thepackage label. "Sugar-free" gums all contain small amounts of sugar—the primary ingredient ofTrident "sugarless" gum is sorbitol, a corn-based sugar alcohol. It also includes mannitol andaspartame.

Frozen Diet Soda PopsMany supermarkets and toy stores in the United States sell plastic molds for making your ownice pops. If these are filled with sugar-free sodas, you can create a tasty snack that has no effectupon blood sugar. Do not use the commercially made "sugar-free" or "diet" ice pops that aredisplayed in supermarket freezers. They contain fruit juices and other sources of carbohydrate.

Very Low Carbohydrate DessertsAppendix D of this book consists of low carbohydrate recipes, prepared and tested by chefs. Itincludes easy recipes for some low-carbohydrate desserts that are truly delicious.

Coffee, Tea, Seltzer, Mineral Water, Club Soda, Diet SodasNone of these products should have significant effect upon blood sugar. The coffee and tea maybe sweetened with liquid or powdered stevia, or with tablet sweeteners such as saccharin,cyclamate, and aspartame (Equal tablets). Remember to avoid the use of more than 2 teaspoonsof cow's milk as a lightener. Try to use cream (which has much less carbohydrate). Read thelabels of "diet" sodas, as a few brands contain sugar in the form of fruit juices. Many flavoredmineral waters, bottled "diet" teas, and seltzers also contain added carbohydrate or sugar, as domany powdered beverages. Again, read the labels.

Alcohol, in Limited AmountsEthyl alcohol (distilled spirits), as we discussed in Chapter 9, has no direct effect upon bloodsugar. Moderate amounts, however, can have a rapid effect upon the liver, preventing theconversion of dietary protein to glucose. If you are following a regimen that includes insulin or apancreas-stimulating oral hypoglycemic agent, you're dependent upon conversion of protein toglucose in order to maintain blood sugar at safe levels. The effects of small amounts of alcohol(i.e., 1 1/2 ounces of spirits for a typical adult) are usually negligible. Most "light" beers containonly about 3 grams of carbohydrate per can or bottle. (See Chapter 9.)

Increase Your Awareness of Food Contents

Read LabelsVirtually all packaged foods bear labels that reveal something about the contents. The FDA nowrequires that labels of packaged foods list the amount of carbohydrate, protein, fat, and fiber in a

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serving. Be sure, however, to note the size of the "serving." Sometimes the serving size is sosmall that you wouldn't want to be bothered eating it.Beware of labels that say "lite," "light," "sugar-free," "dietetic," "diet," "reduced-calorie," "low-calorie," et cetera. "Fat-free" desserts may be the most dangerous of all. Even if you're losingweight, carbohydrate intake will impede your efforts much more than fat (see Chapter 9). Thesefoods frequently but not always contain more carbohydrate than the foods they replace. The onlyway you can determine the carbohydrate content is to read the amount stated on the label. Buteven this can be deceptive. For example, one popular brand of "sugar-free" strawberry preserveshas a label that states "carbohydrate—0." Yet anyone can see the strawberries in the jar, andcommon sense would tell you strawberries contain carbohydrate. So deceptive labeling occurs,and, in my experience, is fairly prevalent in the "diet" food industry.

Use Food Value ManualsIn Chapter 3 a number of books are listed that show the carbohydrate contents of various foods.These manuals are recommended but not essential tools for creating your meal plan. Theguidelines and advice set forth in Chapters 9–11 of this book, plus perhaps the recipes inAppendix D, are all you really need to get started.If you want the potential for considerable variety in your meals, get all the books listed inChapter 3. Food Values of Portions Commonly Used has been the dietitian's bible for over fiftyyears. It is updated every few years. Be sure to use the index at the back to locate the foods ofinterest. Note that on every page in the main section, carbohydrate and fat content are listed inthe same column. The carbohydrate content of food always appears below the fat content. Do notget the two confused. Also, be sure to note the portion size in all these books. Another book onthe list, Kosher Calories, is not just for people whose diets are restricted to kosher foods. Over10,000 common brand-name foods available in the United States are listed.

Vitamin and Mineral Supplements

It is common practice to prescribe supplementary vitamins and minerals for diabetics. This isprimarily because most diabetics have chronically high blood sugars and therefore urinate a lot.Excessive urination causes a loss of water-soluble vitamins and minerals. If you can keep yourblood sugars low enough to avoid spilling glucose into the urine (you can test it withClinistix/Diastix), and if you eat a variety of vegetables, and red meat once or twice a week, youshould not require supplements. Note, however, that major dietary sources of B-complexvitamins include breads and grains. If you're following a low-carbohydrate diet and excludethese from your meal plan, you should eat some bran crackers, bean sprouts, spinach, broccoli,brussels sprouts, or cauliflower each day. If you do not like vegetables or bran crackers, youmight take a B-complex capsule or a multivitamin/mineral capsule each day. See pages 153–154for a discussion of calcium supplementation for certain people who follow high-fiber or high-protein diets.Supplemental vitamins and minerals should not ordinarily be used in excess of the FDA'srecommended daily requirements. Large doses can inhibit the body's synthesis of some vitaminsand intestinal absorption of certain minerals. Large doses are also potentially toxic. Doses ofvitamin C in excess of 500 mg daily appear in the blood and may interfere with the chemicalreaction on your blood sugar strips. As a result, your blood sugar readings can appearerroneously low. Vitamin E has been shown to reduce one of the destructive effects of high

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blood sugars (glycosylation of the body's proteins), in a dose-dependent fashion—up to 1,200 IU(international units) per day. It has recently been shown to lower insulin resistance. I thereforerecommend 400–1,200 IU per day to a number of my patients.

Changes in Bowel Movements

A new diet often brings about changes in frequency and consistency of bowel movements. Thisis perfectly natural and should not cause concern unless you experience discomfort. Increasingthe fiber content of meals, as with salads, bran crackers, and soybean products, can cause softerand more frequent stools. More dietary protein can cause less frequent and harder stools. Normalfrequency of bowel movements can range from 3 times per day to 3 times per week. If younotice any changes in your bowel habits other than these, discuss them with your physician.

How Do People React To The New Diet?

Most of my patients initially feel somewhat deprived, but also grateful because they feel morealert and healthier. I fall into this category myself: my mouth waters whenever I pass a bakeryshop and sniff the aroma of fresh bread, but I am also grateful simply to be alive and sniffing.

No-No's in a Nutshell

Below is a concise list of foods to avoid that are discussed in this chapter. You may want tomemorize it or copy it, as it is worth learning.

Sweets and Sweeteners

• Powdered sweetners (other than stevia)• Candies, including so-called sugar-free types• Honey and fructose• Most "diet" and "sugar-free" foods (except sugar-free Jell-O gelatin and diet sodas that do

not contain fruit juices• Desserts (except Jell-O) and pastries: cakes, cookies, pies, tarts, et cetera• Foods containing, as a significant ingredient, products whose names end in -ol or -ose

(dextrose, glucose, lactose, mannitol, mannose, sorbitol, sucrose, xylitol, xylose, etcetera); also, corn syrup, molasses, et cetera

Sweet or Starchy Vegetables

• Beans (chili beans, chickpeas, lima beans, lentils, sweet peas, et cetera; string beans areokay, as are many soybean products)

• Beets• Carrots• Corn• Onions, except in small amounts• Packaged creamed spinach containing flour

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• Parsnips• Potatoes• Tomatoes, tomato paste, tomato sauce, and raw tomatoes except in small amounts• Winter squash

Fruit and Juices

• All fruits (except avocados)• All juices (including tomato and vegetable juices)

Certain Dairy Products

• Milk• Sweetened and low-fat yogurts• Cottage cheese (except in very small amounts)• Powdered "milk substitutes" and "coffee lighteners"

Grains and Grain Products

• Wheat, rye, barley, corn• White, brown, or wild rice• Pasta• Breakfast cereal• Pancakes and waffles• Bread, crackers, and flour products

Prepared Foods

• Most commercially prepared soups• Most packaged "health foods"• Snack foods (virtually anything that comes wrapped in cellophane)• Balsamic vinegar (compared to wine vinegar, white vinegar, or cider vinegar, balsamic

contains considerable sugar)