SO WHAT’S LEFT TO EAT?
It’s a good question, and the same one I asked myself more than thirty years ago as I discovered that more and more of the things that the American Diabetes Association had been telling me were perfectly fine to eat made blood sugar control impossible. In the following pages, I’ll give you a broad overview of the kinds of food my patients and I usually eat. Please remember that with the exception of the no-calorie beverages (including seltzer water and mineral water with no added carbohydrate) and moderate portions of sugar-free Jell-O without maltodextrin, there are no “freebies.” Virtually everything we eat will have some effect upon blood sugar if enough is consumed. You may discover things I’ve never heard of that have almost no effect on your blood sugar. If so, feel free to include them in your meal plan, but check your blood sugar every half hour for a few hours before assuming that they are benign.
Vegetables
Most vegetables, other than those listed in the No-No section, are acceptable. Acceptable vegetables include asparagus, avocado, broccoli, brussels sprouts, cabbage and sauerkraut, cauliflower, eggplant, onions (in small amounts), peppers (any color except yellow), mushrooms, spinach, string beans, summer squash, and zucchini. As a rule of thumb, 2/3 cup of whole cooked vegetables, 1/2 cup of diced or sliced cooked vegetable, 1/4 cup mashed cooked vegetable, or 1 cup of mixed salad acts upon blood sugar as if it contains about 6 grams of carbohydrate. Remember that cooked vegetables tend to raise blood sugar more rapidly than raw vegetables because the heat makes them more digestible and converts some of the cellulose to sugar. Generally, more cooked vegetables by weight will occupy less volume in a measuring cup, so ? cup cooked spinach will weigh considerably more than ? cup uncooked. On your self-measurements, note how your favorite vegetables affect your blood sugar. Raw vegetables can present digestive problems to people with gastroparesis.
Of the following vegetables, each acts upon blood sugar as if it contains about 6 grams of carbohydrate in 2/3 cup (all cooked except as noted):
artichoke hearts
asparagus
bamboo shoots
beet greens
bell peppers (green and red only, no yellow) (cooked or raw)
bok choy (Chinese cabbage)
broccoli
brussels sprouts
cabbage
celery
celery root (celeriac)
collard greens
daikon radish
dandelion greens
eggplant
endive
escarole
hearts of palm
kohlrabi
mushrooms
mustard greens
okra
patty pan squash
pumpkin
radicchio
rhubarb
sauerkraut
scallions
snow peas
spaghetti squash
spinach
string beans
summer squash
turnip greens
turnips
water chestnuts
watercress
zucchini
zucchini flowers
In addition to the above, you should keep the following in mind:
• Onions are high in carbohydrate and should only be used in small amounts for flavoring—small amounts of chives or shallots can pack a lot of flavor.
• One-half small avocado contains about 6 grams of carbohydrate.
• One cup mixed green salad without carrots and with a single slice of tomato or onion has about the same impact on blood sugars as 6 grams of carbohydrate.
• One-quarter cup mashed pumpkin contains about 6 grams of carbohydrate. My own opinion is that without some flavoring, pumpkin tastes about as appetizing as Kleenex. Therefore I flavor it with much stevia and spice (cinnamon) and warm it to make it a bit like pumpkin pie filling. (For other vegetables from this list, such as turnips, assume that ¼ cup of the mashed product contains 6 grams of carbohydrate.)
Meat, Fish, Fowl, Seafood, and Eggs
These are usually the major sources of calories in the meal plans of my patients. The popular press is currently down on meat and eggs, but my personal observations and recent research implicate carbohydrates rather than dietary fat in the heart disease and abnormal blood lipid profiles of diabetics and even of nondiabetics. If you are frightened of these foods, you can restrict them, but depriving yourself will be unlikely to buy you anything. Appendix A details the current controversy and the shaky science behind the present, faddish high-carbohydrate dietary recommendations, and lays out my concerns and opinions. Egg yolks, by the way, are a major source of the nutrient lutein, which is beneficial to the retina of the eye. Organic eggs contain large amounts of omega-3 fatty acids, which are good for your arteries.
Tofu, and Soybean Substitutes for Bacon, Sausage, Hamburger, Fish, Chicken, and Steak
About half the calories in these products come from benevolent vegetable fats, and the balance from varying amounts of protein and slow-acting carbohydrate. They are easy to cook in a skillet or microwave. Protein and carbohydrate content should be read from the labels and counted in your meal plan. Their principal value is for
people who are vegetarian or want to avoid red meat. Health food stores stock many of these products. For the purpose of our meal plans, as described in the next chapter, remember to divide the grams of protein listed on the package by 6 in order to get “ounces”of protein (see page 167).
Certain Commercially Prepared and Homemade Soups
Although most commercial and homemade soups contain large amounts of simple sugars, you can learn how to buy or prepare lowor zero-carbohydrate soups.Many but not all packaged bouillon preparations have no added sugar and only small amounts of carbohydrate. Check the labels or use the Clinistix/Diastix test, observing the special technique described on page 136. Plain consommé or broth in some 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 by barely covering the meat or chicken with water while cooking, rather than filling the entire pot with water, as is the customary procedure. Alternatively, let the stock cook down (reduce) so you get a more concentrated, flavorful soup. You can also use herbs and spices, all of which have negligible amounts of carbohydrates, to enhance flavor. See “Mustard, Pepper, Salt, Spices, Herbs,” below. Clam broth (not chowder) is usually very low in carbohydrate. In the United States you can also buy clam juices (not Clamato), which contain only about 2 grams of carbohydrate in 3 fluid ounces. Campbell’s canned beef bouillon and consommé contain only 1 gram carbohydrate per serving. College Inn brand canned chicken broth contains no carbohydrate.Most bouillon cubes are also low in carbohydrate; read the labels.
Cheese, Butter, Margarine, and Cream
Most cheeses (other than cottage cheese) contain approximately equal amounts of protein and fat and small amounts of carbohydrate. The carbohydrate and the protein must be figured into the meal plan, as I will explain in Chapter 11. For people who want (unwisely) to avoid animal fats, there are some special soybean cheeses (not very tasty). There’s also hemp cheese, which I know nothing about. Cheese is anexcellent source of calcium. Every ounce of whole milk cheese contains approximately 1 gram carbohydrate, except cottage cheese, which contains more. Generally speaking, where dairy products are concerned, the lower the fat, the higher the sugar lactose, with skim milk cheeses containing the most lactose and the least fat, and butter containing no lactose and the most fat.
Neither butter nor magarine in my experience will affect your blood sugar significantly, and they shouldn’t be a problem as far as weight is concerned if you’re not consuming a lot of carbohydrate along with them. One tablespoon of cream has only 0.5 gram carbohydrate—it would take 8 tablespoons to raise my blood sugar 20 mg/dl. The cheese puffs I describe in the next chapter (page 174) are low in carbohydrate and can be used instead of bread to make sandwiches.
Yogurt
Although personally I don’t enjoy yogurt, many of my patients feel they cannot survive without it. For our purposes the plain whole milk yogurt, unflavored, unsweetened, and without fruit, is a reasonable food. A full 8-ounce container of plain, Erivan brand, unflavored whole milk yogurt contains only 11 grams of carbohydrate and 2 ounces of protein. You can even throw in some chopped vegetables and not exceed the 12 grams of carbohydrate limit we suggest for
lunch. Do not use nonfat yogurt. The carbohydrate goes up to 17 grams per 8-ounce container. Yogurt can be flavored with cinnamon, with Da Vinci brand syrups, with baking flavor extracts, or with the powder from sugar-free Jell-O brand gelatin (if the package doesn’t list maltodextrin as an ingredient) without affecting the carbohydrate content. It can be sweetened with stevia liquid or powder or with Equal or Splenda tablets that have been dissolved in a small amount of hot water. Erivan brand yogurt is available at health food stores throughout the United States. If you read labels, you may find brands similarly low in carbohydrate in your supermarket; two such brands are Stonyfield Farm and Brown Cow Farm.
Soymilk
There are many soy products that can be used in our diet plan, and soymilk is no exception. It’s a satisfactory lightener for coffee and tea, and one of my patients adds a small amount to diet sodas. Others drink it as a beverage, either straight or with added flavoring such as those mentioned for yogurt. Personally, I find the taste too bland to drink without flavoring, and I much prefer cream diluted with water.
When used in small amounts (up to 2 tablespoons/1 ounce), soymilk need not be figured into the meal plan. It will curdle if you put it into very hot drinks.
As noted in the No-No foods section, of the many brands of soymilk on the market,WestSoy offers the only unsweetened ones I’ve been able to find, although other unsweetened brands are available in various parts of the country.
Soybean Flour
If you or someone in your home is willing to try baking with soybean flour, you will find a neat solution to the pastry restriction. One ounce of full-fat soybean flour (about ¼ cup) contains about 7.5 grams of slow-acting carbohydrate. You could make chicken pies, tuna pies, and even sugar-free Jell-O pies or pumpkin pies. Just remember to include the carbohydrate and protein contents in your meal plan.
Soybean flour usually must be blended with egg to form a batter suitable for breads, cakes, and the like. Creating a blend that works requires either experience or experimentation. Some recipes using soy flour appear in Part Three, “Your Diabetic Cookbook.”
Bran Crackers
Of the dozens of different crackers that I have seen in health food stores and supermarkets, I have found only three 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, SC 29901, phone [843] 525- 1437). Each 9-gram slice contains about 3 grams of digestible carbohydrate. If this product is not available locally, you can order it directly from the importer. One case contains thirty 4- ounce packages. They are also available from Trotta’s Pharmacy (877) 987-6882.
• Bran-a-Crisp, produced by Saetre A/S, N1411, Kolbotn, Norway (distributed in the United States by Interbrands, Inc., 3300 N.E. 164th Street, FF3, Ridgefield,WA 98642). Each 8.3-gram cracker contains about 4 grams of digestible carbohydrate. Bran-a-Crisp may be ordered directly from Interbrands, Inc., by phone or e-mail if you cannot find it locally. Phone (877) 679-3552; e-mail: pstbac@hotmail.com. A number ofWeb sites sell these crackers— just search for Bran-a-Crisp if you want to order that way, or order from Trotta’s Pharmacy.
• Wasa Fiber Rye. These crackers are available in most supermarkets in the United States and in some other countries. One cracker contains about 5 grams of digestible carbohydrate. Many of my patients feel that this is the tastiest of these three products. Although some people eat these without a spread, to me they taste
like cardboard. My preference is to enjoy them with chive-flavored cream cheese or butter. Crumbling two G/G crispbreads into a bowl and covering them with cream or cream diluted with water can create bran cracker cereal. Add some Equal or Splenda tablets (dissolved in a bit of hot water) or some liquid stevia sweetener and perhaps a baking flavor extract (banana flavor, butter flavor, et cetera), or one of the Da Vinci syrups.
If eaten in excessive amounts, bran crackers can cause diarrhea. They should be eaten with liquid. They are not recommended for people with gastroparesis (delayed stomach-emptying), since the bran fibers can form a plug that blocks the outlet of the stomach. The carbohydrate in these crackers is very slow to raise blood sugar. They are great for people who need a substitute for toast at breakfast.
Note: In the United States, labeling regulations require that fiber be listed as carbohydrate. There are many different kinds of fiber, soluble and insoluble, digestible and undigestible, and so, because there is no requirement to distinguish in labeling between them, these listings can complicate computation of carbohydrate content. Use the carbohydrate amounts that I have listed above instead of those listed on the package labels.
Toasted Noria
When my friend Kanji sent me a beautifully decorated canister from Japan, I was most impressed and intrigued. You can imagine my dismay when I removed the cover and found seaweed. My dismay was only temporary, however. I reluctantly opened one of the cellophane envelopes and pulled out a tissue-thin slice. My first nibble was quite a surprise—it was delicious. When consumed in small amounts, I found, it had virtually no effect upon blood sugar. Once addicted, I combed the health food stores searching for more. Most of the seaweed I tried tasted like salty paper. Eventually, a patient explained to me that Kanji’s seaweed is a special kind called toasted nori. It contains small amounts of additional ingredients that include soybeans, rice, barley, and red pepper. It is available at most health food stores, and is a very tasty snack. Five or six pieces at a time have had no effect upon my blood sugar. The Clinistix/Diastix test showed no glucose after chewing. A standard slice usually measures 1¼x 3½inches and weighs about 0.3 gram. Since the product contains about 40 percent carbohydrate, each strip will have only 0.12 gram carbohydrate. Larger sheets of toasted nori should be weighed in order to estimate their carbohydrate content.
Sweeteners: Saccharin, Aspartame, Stevia, Splenda, and Cyclamate
I 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 is destroyed by cooking and is much more costly than saccharin, which has a bitter aftertaste, but it will work for sweetening hot coffee or tea. I find that using one ½- grain saccharin tablet for every Equal tablet rather than two saccharin tablets or two Equal tablets eliminates saccharin’s aftertaste and keeps costs down. Equal tablets are available in most pharmacies and many supermarkets. Although Equal tablets contain lactose, the amount is too small to affect blood sugar.
Acesulfame-K is a new artificial sweetener being marketed in tablet form outside the United States 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 in the packaged powder called The Sweet One, which you obviously should avoid. There are, however, some questions about its causing cancer, so there may be better choices. Other noncaloric tablet sweeteners will be appearing on grocery shelves in the United States in the future. Stevia, mentioned earlier, is an herbal sweetener and has been available in health food stores for many years. It is not degraded by cooking and is packaged in powder and liquid forms. The liquid must be refrigerated to prevent spoiling. Stevia has not yet been approved in the European Union because of fears that it may cause cancer. Studies of this “possibility” are under way.
Splenda (sucralose) tablets are available now in some parts of the United States, overseas, and on the Internet. They are benign in spite of containing minute amounts of lactose. In powdered form, Splenda, like the others except stevia, is principally a mixture of sugars to provide bulk and should be avoided.
No-Cal Brand Syrups
These artificially sweetened liquid flavors are sold by many supermarkets in the northeast United States. (They are distributed by Cadbury Beverages, Inc., Stamford, CT 06905-0800, and are stocked by Trotta’s Pharmacy.) The available flavors include strawberry, raspberry, black cherry, chocolate, and pancake/waffle topping. This product contains no calories, no carbohydrate, no protein, and no fat. It takes a bit of imagination to put it to good use. For example, I used to spike my coffee with the chocolate flavor, or my tea with fruit flavors. I put the pancake/waffle topping on my eggs in the morning after heating it in a skillet. In recent years, however, to my taste, the chocolate flavor has deteriorated, so I no longer use it.
Da Vinci Gourmet Syrups
Similar in concept to No-Cal syrups but in my opinion much tastier, this product is available from several Web distributors, including www.netrition.com and www.davincigourmet.com, and from Trotta’s Pharmacy. Da Vinci currently produces more than forty flavors. Internet prices range from $7.49 to $8.95 for a 750 ml bottle. Flavors include banana, blueberry, caramel, cherry, chocolate, coconut, cookie dough, pancake, peanut butter, and watermelon. I like to sometimes mix the toasted marshmallow syrup into my morning omelet. For a list of distributors, phone Da Vinci Gourmet, Ltd., at (800) 640-6779. The product is certified kosher.
Flavor Extracts
There are numerous flavor extracts often used in baking that you can use to make your food more exciting. They usually can be found in small brown bottles in the baking supply aisles of supermarkets. Read carbohydrate content from the label. Usually it’s zero and therefore won’t affect your blood sugar.
Mustard, Pepper, Salt, Spices, Herbs
Most commercial mustards are made without sugar and contain essentially no carbohydrate. This can readily be determined for a given brand by reading the label or by using the Clinistix/Diastix test. Pepper and salt have no effect upon blood sugar. Hypertensive individuals with proven salt sensitivity should, of course, avoid salt and highly salted foods (see page 439).
Most herbs and spices have very low carbohydrate content and are used in such small amounts that the amount of ingested carbohydrate will be insignificant. Watch out, however, for certain combinations such as powdered cinnamon with sugar. Just read the labels.
Low-Carbohydrate Salad Dressings
Most salad dressings are loaded with sugars and other carbohydrates. The ideal dressing for someone who desires normal blood sugars would therefore be oil and vinegar, perhaps with added spices, mustard, and followed by grated cheese or even real or soy bacon bits. There are now available some commercial salad dressings with only 1 gram carbohydrate per 2-tablespoon serving. This is low enough 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 per tablespoon. This is not a lot, but it adds up if you eat large amounts. Some imitation mayonnaise product shave 5 grams of carbohydrate per 2-tablespoon serving.
Nuts
Although all nuts contain carbohydrate (as well as protein and fat), they usually raise blood sugar slowly and can in small amounts be worked into meal plans. As with most other foods, you will want to look up your favorite nuts in one of the books listed in Chapter 3 in order to obtain their carbohydrate content. By way of example, 10 pistachio nuts (small, not jumbo) contain only 1 gram carbohydrate, while 10 cashew nuts contain 5 grams of carbohydrate. Although a few nuts may contain little carbohydrate, the catch is in the word “few.” Very few of us can eat only a few nuts. In fact, I don’t have a single patient who can count out a preplanned number of nuts, eat them, and then stop. So unless you have unusual will power, beware. Just avoid them altogether. Also beware of peanut butter, another deceptive addiction. One tablespoon of natural, unsweetened peanut butter contains 3 grams of carbohydrate, and will raise my blood sugar 15 mg/dl. Imagine, however, the effect on blood sugar of downing 10 tablespoons.
Sugar-Free Jell-O Brand Gelatin
This is one of the few foods that in reasonable amounts will have no effect upon blood sugar if you get the kind that is indeed sugar-free. I have been informed by some of my patients and found it to be true that in some areas “sugar-free” actually contains some maltodextrin, which is a mixture of sugars and will raise your blood sugar. The ready-to-eat variety in plastic cups does not thus far contain maltodextrin— or at least that which I’ve found on my grocery’s shelves.
Check the labels. Truly sugar-free Jell-O or other truly sugar-free brands of gelatin are fine for snacks and desserts. A ½-cup serving contains no carbohydrate, no fat, and only 1 gram of protein. Just remember not to eat so much that you feel stuffed (see “The Chinese Restaurant Effect,” in Chapter 6). You can enhance the taste by pouring a little heavy cream over your portion. One of my patients discovered that it becomes even tastier if you whip it in a blender with cream when it has cooled, just before it sets. 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 the apple and Hawaiian pineapple flavors, and I wonder if they still exist. If the only “sugar-free” Jell-O you can find contains maltodextrin, try adding some liquid stevia and Da Vinci syrup to Knox unflavored gelatin as a tasty substitute.
Sugar-Free Jell-O Puddings
Available in chocolate, vanilla, pistachio, and butterscotch flavors, these make a nice dessert treat. Unlike Jell-O gelatin, they contain a small amount of carbohydrate (about 6 grams per serving), which should be counted in your meal plan. Instead of mixing the powder with milk, use water or water plus cream. Every 2 tablespoons of cream will add 1 gram of carbohydrate.
Chewing Gum
Gum chewing can be a good substitute for snacking and can be of value to people with gastroparesis because it stimulates salivation and saliva contains substances that facilitate stomach-emptying. The carbohydrate content of one stick of chewing gum varies from about 1 gram in a stick of sugar-free Trident or Orbit (tastes better) to about 7 grams per piece for some liquid-filled chewing gums. The 7-gram gum will rapidly raise my blood sugar by about 35 mg/dl. The carbohydrate content of a stick of chewing gum can usually be found on the package label. “Sugar-free” gums all contain small amounts of sugar—the primary ingredient of Trident “sugarless” gum is sorbitol, a corn-based sugar alcohol. It also includes mannitol and aspartame. I personally use a chewing gum called XlearDent. It contains 0.72 grams of the sugar xylitol per piece. Xylitol is an antimetabolite (metabolic poison) for bacteria and prevents tooth decay when chewed regularly. It may be obtained by phoning (877) 599-5327 or on the Internet at www.xlear.com.
Very Low Carbohydrate Desserts
Part Three of this book consists of low-carbohydrate recipes, prepared and tested by chefs. It includes easy recipes for some low-carbohydrate desserts that are truly delicious.
Coffee, Tea, Seltzer, Mineral Water, Club Soda, Diet Sodas
None of these products should have significant effect upon blood sugar. The coffee and tea may be sweetened with liquid or powdered stevia, or with tablet sweeteners such as saccharin, cyclamate, sucralose (Splenda tablets), and aspartame (Equal tablets).Remember to avoid the use of more than 2 teaspoons of cow’s milk as a lightener. Try to use cream (which has much less carbohydrate, tastes better, and goes much further). Read the labels of “diet” sodas, as a few brands contain sugar in the form of fruit juices. Many flavored mineral waters, bottled “diet” teas, and seltzers also contain added carbohydrate or sugar, as do many powdered beverages. Again, read the labels.
Frozen Diet Soda Pops
Many supermarkets and toy stores in the United States sell plastic molds for making your own ice pops. If these are filled with sugar-free sodas, you can create a tasty snack that has no effect upon blood sugar. Do not use the commercially made “sugar-free” or “diet” ice pops that are displayed in supermarket freezers. They contain fruit juices and other sources of carbohydrate.
Alcohol, in Limited Amounts
Ethyl alcohol (distilled spirits), as we discussed in Chapter 9, has no direct effect upon blood sugar. Moderate amounts, however, can have a rapid effect upon the liver, preventing the conversion of dietary protein to glucose. If you are following a regimen that includes insulin or a pancreas-stimulating oral hypoglycemic agent, you’re dependent upon conversion of protein to glucose in order to maintain blood sugar at safe levels. The effects of small amounts of alcohol (i.e., 1½ ounces of spirits for a typical adult) are usually negligible. Most beers, in spite of their carbohydrate content, don’t seem to affect blood sugar when only one can or bottle is consumed.
