A Lifestyle Tool for Preventing Diabetes

Nancy Bennett, MS, RD, CDE

The number of Americans with diabetes or pre-diabetes is staggering. There are currently 20.8 million persons with diabetes, 18.7 of whom have type II diabetes. According to a National Institutes of Health estimate, there are another 54 million Americans with pre-diabetes, defined by impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Some 20% to 34% of those with IFG will go on to develop Type II diabetes in five to six years; those with both IFG and IGT have a 38% to 65% chance of developing diabetes in the same time interval.

The NIH paints a dire picture for the health of future generations in this country. They predict that one-third of all those born in the year 2000 will develop diabetes in their lifetimes. As diabetes is the leading cause of blindness, amputations, and kidney failure, it is imperative that health-promoting interventions begin early and continue throughout the patient’s lifetime if untold levels of suffering are be averted.

As this threat to America’s public health is fueled by the obesity epidemic, these interventions need to be directed at stemming the tidal wave of obesity. Eighty percent of type II diabetes is caused by obesity and, according to the National Health and Nutrition Survey of 2003–2004, currently one-third of Americans are obese and another one-third are overweight.

Though these facts are grim, there is a sliver of hope on the horizon. Researchers have shown that small losses in weight, coupled with activity, can reverse these escalating trends in diabetes and profoundly impact the future of America’s health.

The Diabetes Prevention Trial (DPP), completed in 2001, demonstrated that a loss of 7% to 10% body weight and an increase of 150 minutes of weekly activity decreases the risk for developing diabetes by 58%. The Finnish Diabetes Prevention Program duplicated these results and found that such lifestyle intervention programs can produce lasting results. Those who received lifestyle intervention were shown to have maintained a 58% lower risk for developing diabetes four years after the study interval.

Researchers at the University of Colorado Health Sciences Center analyzed the DPP results and the relative contributions of changes in diet, physical activity, and weight loss to the reduction in diabetes incidence. They found that weight loss was most strongly associated with lower diabetes incidence, compared to diet and/or physical activity. On average, there was a 16% reduction in diabetes risk per kilogram weight loss (Hamman 2006).

Though this research is indeed promising as far as averting this looming epidemic, losing weight—and maintaining that loss—is no easy matter. Simply eating fewer calories than one burns is easier said than done. Many a health professional has struggled right alongside their patients in this arena.

It might be helpful to focus interventions on those behaviors that lead to leanness. After all, the above studies focus on lifestyle interventions, not dietary restrictions; and, to this author’s knowledge, no one ever successfully “thought” their way to leanness, though their actions have lead them there.

Therefore, focusing interventions on those key, simple, actionable steps that lead to leanness is helpful in directing our patients’ efforts to lose weight and maintain a leaner weight.

One very realistic and practical approach to helping our patients lower their calorie intake and lose weight is to give them specific examples of how small substitutions in food choices can lead to large losses of weight over time. For example, sprinkling a tablespoon of toasted almonds on sautéed green beans instead of a one tablespoon of melted butter saves seventy calories a day. Not only does this daily action translate into a seven-pound weight loss per year, it lowers the patient’s saturated fat intake as well. As many of these clients are at a higher risk for heart disease, small tips like this can help them translate the message “eat less saturated fat” into realistic, practical actions they can take on a consistent basis. In other words, the behavior becomes a lifestyle change rather than a “diet.” The sidebar (see TK) lists other practical substitutions for common food choices that help to lower the intake of calories, refined carbohydrates, and saturated fat.

America is the land of plenty, and our growing waistlines are the consequence of eating large portions. Feeling satiated with smaller portions is a challenge for many. Fortunately, certain food choices have been proven to promote the feeling of fullness while lowering the caloric density of the meal.

Barbara Rolls, a professor of nutrition at Penn State University, has shown that those who begin meals with salads and/or broth-based soups eat fewer calories per meal, and, more importantly, they do not compensate by eating more later on in the day. Suggesting soup is a well-received message for those who complain that they cannot feel full with smaller portions of food.

Another action step that promotes satiety with smaller portions is to choose foods that require chewing, such as fruits and vegetables. Though research tells us it takes twenty minutes for gastric hormones to signal satiety in the brain, most find eating slowly a difficult behavior to develop. Choosing foods that demand a lot of chewing aids in slowing down the speed in which people eat. Whole-grain breads for sandwiches at lunch and apples for dessert (in lieu of softer foods such as sandwich rolls and raisins) not only help boost satiety but increase your patient’s soluble fiber intake as well. Soluble fiber from whole grains, fruits, and vegetables slows gastric emptying, which promotes satiety. Soluble fiber has also been shown to flatten postprandial glucose curves, lower insulin levels, and decrease low-density lipoproteins.

Another behavior that promotes satiety with meals is the inclusion of lean protein with every meal or snack. Protein and fat delay gastric emptying and give meals or snacks “staying power.” Two such foods that are perfect for quick meals on the go are walnuts and dry-roasted edamame. These foods are also good sources of omega-3 fatty acids, which have been shown to reduce chronic inflammation. However, though these foods are delicious and healthy choices, they can be a concentrated source of calories. Experience has shown that handing patients a quarter-cup container can help them limit their portions to a level that does not interfere with weight loss efforts.

Finally, encourage your patients to surround themselves with healthy foods. Those who are hungry will eat foods that are available. We live in a sea of fast-food chains and convenience markets filled with high-fat, high-fructose foods, so suggest to your patients that they carry some healthy snacks with them to work or school. Set them up for success by suggesting a few of the snack and meal ideas in the sidebar (see below).

Last, but not least, promote activity. Simply adding two thousand steps a day can lead to a ten-pound weight loss in a year. A pedometer is an inexpensive tool in helping patients monitor and increase their activity levels. Increased activity not only helps patients burn more calories, it also helps decrease the insulin resistance that is at the very core of this disease.

Health professionals play a pivotal role in shaping the health of future generations. We have an opportunity to show that simple, realistic actions can help people lose weight and lower their risk of developing diabetes. If we share our perception of diabetes as preventable, we will begin to help our patients live in the solution and, perhaps, stem the tide of this wretched disease.

“Let history be the final judge of our deeds.”—John F. Kennedy

Nancy Bennett, MS, RD, CDE is a consulting nutritionist and the principal author of Enlightening Choices. Her company provides nutrition consultations for a number of health care agencies, medical clinics, private physicians, corporations, and individuals within the San Francisco  Bay Area. She earned her bachelor's of science degree in nutrition from University of California at Berkeley in 1976, her master's in nutritional science from the University of Bridgeport in 1992, and her certificate of diabetes education in 2000.

Choices for Losing Weight

Substituting one food for another is a great way to subtract fat and calories from your diet without feeling the deprivation and suffering commonly associated with the famous four-letter word diet.

Consider this: Every ten calories you subtract each day from your normal fare results in one pound of weight loss per year. Subtracting one hundred calories per day results in ten pounds per year and 250 calories per day results in twenty-five pounds lost per year. Imagine, losing two pounds every month just by choosing one food over another!

The foods below list their calorie content in parentheses; see if aren’t a few ideas you can realistically incorporate into your daily life. Who knows, you just may choose your way to leanness and drop your risk for diabetes too!

Substitute These Foods…                 

Breakfast:
2 oz. whole-milk cheese (220)                 
4 oz. sausage (432)                            
¼ C. raisins (120)               
¾ C. granola (375)                             

Lunch:
Quarter-pounder (530)                                   
3 oz. hamburger (244)                        
3 oz. bologna (270)                            
1 large croissant (231)                                   
1 C. cream of broccoli soup (234)      

Snacks:
1 C. fruit-flavored yogurt (232)                      
Flour tortilla (115)                             
3 oz. potato chips (330)                                                          
Dove ice cream bar (260)                   
15 Triscuits (280)                               

Dinner:
4 Tbsp. blue cheese dressing (308)     
6 oz. steak (344)                                 
1 C. rice (266)                                    
4 Tbsp. butter (400)                            
2 Tbsp. hollandaise sauce (200)                     

With These Foods…

2 oz. Laughing Cow reduced-fat cheese (70)
4 oz. Canadian bacon (180)
½ C. grapes (57)
1 C. Kashi Go Lean cereal (140)

Grilled chicken sandwich (310)
3 oz. grilled chicken (140)
3 oz. ham (90)
2 slices rye bread (140)
1 C. minestrone (82)

1 C. sugar-free yogurt (90)
Corn tortilla (67)
3 C. popcorn, air-popped (90)
2 Dove Miniature bars (100)
16 Wheat Thins (140)

4 Tbsp. light balsamic vinaigrette (200)
6 oz. chicken breast (200)
1 medium potato (140)
4 Tbsp. sour cream (120)
2 Tbsp. parmesan cheese (50)