Diabetic Mediterranean Diet

I’m astounded by how many people with diabetes I meet who pretty much eat whatever they want. Others, when I ask if they’re on a particular diet, say, “I watch what I eat.” Which usually just means avoiding obvious sugar bombs.

The American Diabetes Association in 2019 hosted a conference on nutrition therapy for diabetes. I assume the ADA endorses the panel’s recommendations. The big news is continued movement toward carb-restricted eating. Some excerpts:

Today, there is strong evidence to support both the efficacy and cost-effectiveness of nutrition therapy as a key component of integrated management of individuals with diabetes. This is increasingly relevant as it is evident that “one-size-fits-all” eating plan is not suitable for prevention or management of diabetes, also considering diverse cultural backgrounds, personal preferences, comorbidities, and socioeconomic settings. The American Diabetes Association (ADA) is now emphasizing that medical nutrition therapy (MNT) is fundamental for optimal diabetes management, and the new report also includes information on prediabetes.

***

One of the key recommendations is to refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT [medical nutrition therapy] at diagnosis and as needed throughout the life span, particularly during times of changing health status to achieve treatment goals.

           ***

The new consensus recommendations consider that a variety of eating patterns are acceptable for the management of diabetes.

In the absence of additional strong evidence on the comparative benefits of different eating patterns in specific individuals, healthcare providers should focus on the key factors that are common among the patterns, including emphasizing non-starchy vegetables, minimizing added sugars and refined grains, and preferring whole foods over highly processed foods.

Reducing overall carbohydrate intake for individuals with diabetes is associated with the most evidence for improving glycemia and may be applied in a variety of eating patterns.

For selected adults with type 2 diabetes who are not meeting glycemic targets or where reducing anti-glycemic medications is a priority, reducing overall carbohydrate intake with low or very low carbohydrate eating plans is also a viable approach.

***

Regarding weight loss in overweight or obese folks with diabetes or prediabetes:

…a low carbohydrate diet is now recognized as a safe, viable, and important option for patients with diabetes, and the other is that greater emphasis is now placed on weight loss in patients who are overweight/obese for the prevention of diabetes and its treatment.

Indeed, in type 2 diabetes, 5% weight loss is recommended to achieve clinical benefits, with a goal of 15%, when feasible and safe, in order to achieve optimal outcomes.

In prediabetes, the goal is 7–10% for preventing progression to type 2 diabetes.

“Metabolic surgery,” better known as bariatric surgery, and medication-assisted weight loss (aka weight-loss drugs) should be considered in some cases.

***

Best approach for optimizing blood sugars:

For macronutrients, the available evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.

[Self-monitoring of carbohydrate consumption is important.]

People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general population; increasing fiber intake, preferably through food (vegetables, pulses (beans, peas, and lentils), fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering HbA_1C.

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What about sugar-sweetened beverages?

Firstly, sugar-sweetened beverages should be replaced with water as often as possible.

Secondly, if sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources.

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Is alcohol forbidden? No.

…educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended.

To reduce hypoglycemia risk, the importance of glucose monitoring after drinking alcohol beverages should be emphasized.

Steve Parker, M.D.

PS: I note that William Yancy, M.D., was on the expert panel.

PPS: Bold emphasis above is mine.

This is a topic I’d never run across online until recently. In the anal hygeine department, it looks like the Europeans and Japanese—with their bidets—are ahead of us in North America.

From Insider:

To keep your backside happy, Goldstein [a rectal surgeon] recommended using a patting motion rather than a wiping motion and being as gentle as possible. Ideally, he added, you should use a bidet to clean yourself and then pat the excess water dry with a bit of toilet paper if need be.

From MF (Mental Floss):

Asbury [a dermatologist] is an advocate of the standalone or add-on toilet accessory that squirts a spray of water between your cheeks to flush out residual fecal matter. While bidets are common in Europe and Japan, the West has been slower to adopt this superior method of post-poop clean-up; others might be wary of tapping into existing home plumbing to supply fresh water, even though DIY installation is quite easy. For those patients, Asbury has developed an alternative method.

TRY PAPER TOWELS AND WATER

“What I tell people to use is Viva, a really soft, thick paper towel made by Kleenex,” he says. “You get a squirt bottle and you leave it near the toilet and moisten the paper towel.” Regular toilet paper is usually too flimsy to stand up to a soaking, while normal paper towels are too harsh for rectal purposes. Viva is apparently just right. (And no, Asbury is not a brand ambassador, nor does Kleenex endorse this alternative use.)

This advice does come with a major caveat: Viva wipes are not flushable and might very well clog your pipes if you try to send them down the drain.

From Shape:

When it comes to wiping, less is more and not just because it keeps you from replacing the toilet paper roll every other day. “Overwiping can irritate the perianal skin and lead to small abrasions that trigger inflammation and itching,” Sheth [a gastroenterologist] says. One or two wipes are all it takes, he says. If you need to wipe more than that you may not have completely emptied your system or you could be constipated (in which case, up your fiber and water intake like you would to prevent hemorrhoids). If you still require more than a few wipes, consider switching to wet toilet paper or unscented baby wipes. “Moist wipes decrease the friction of wiping and cause less irritation,” Sheth says.

The first two links recommend against baby wipes.

From Sussex Surgery:

Many people cannot bear the thought of a dirty anus and they go to great lengths to keep their anus spotlessly clean using large amounts of toilet paper and vigorously washing the area, especially after defaecation.  Unfortunately this breaks down the fragile anal skin and then this usually effective barrier to bacteria lets in microbes to the surrounding tissues.  This is very irritating to local nerves and people then get in to a viscious cycle because they get itchy, feeling the need to clean the anus even more, which breaks down the anal skin barrier even further.  Therefore it is ironically and usually the cleanest people that end up in my specialist bowel surgery clinic rather than the dirtiest!

The first thing to do is to break the vicious cycle and I recommend that people tone down their anal cleaning routine.  Fingernails and abrasive materials such as rough toilet paper should be kept away from the anus.  Non-scented baby wipes or luxury toilet tissue are usually the kindest and most effective ways of wiping the bottom after opening the bowels.  Running water is the best way to wash the anal surfaces.

Often people think that they must keep on wiping their bottom with toilet paper until they do not see any more brown smears on the toilet paper but this can cause significant damage.  Instead people should stop wiping when the brown smears have lessened but before they rub their fragile anal skin raw.

From Atlas Obscura:

All of this provides a mixed view on the ideal material for wiping. Water is very good, because it’s gentle and won’t cause tears, but you want to stay away from residual moistness. Toilet paper isn’t bad, because it easily soaks up any moisture, but it also can be a little rough, which is bad. The ideal method would probably be a water bath followed by careful, gentle, and immediate drying, whether that’s with toilet paper or a jet of warm air.

For a history of anal hygeine and a tour of various cultures, visit Toilet Guru.

Steve Parker, M.D.