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Nutrition for Type 2 Diabetes: What To Focus On

Female holding blood glucose monitor

Type II diabetes mellitus (most often referred to as type II diabetes) is a disease in which your pancreas does not produce enough insulin (a hormone that helps your body maintain healthy blood sugar levels), and/or your body does not properly use the insulin it makes. As a result, glucose (sugar) builds up in your blood instead of being used for energy. ‘Blood sugar’ and ‘blood glucose’ are often used interchangeably.

Your body gets glucose from foods that contain carbohydrates, such as bread, potatoes, rice, pasta, milk and fruit. Your body breaks down these carbs into glucose. To use this glucose, your body needs insulin.

If left untreated or improperly managed, diabetes can result in a variety of complications, including heart attack, stroke, kidney failure, blindness, problems with erection (impotence) and amputation.

What Causes Type II Diabetes?

In a healthy person, the pancreas (an organ behind the stomach) releases insulin to help the body store and use the sugar from the food you eat. Diabetes happens when one or more of the following occurs:

• When the pancreas does not produce any insulin.
• When the pancreas produces very little insulin.
• When the body does not respond appropriately to insulin, a condition called “insulin resistance.”

Unlike people with type 1 diabetes, people with type 2 diabetes produce insulin; however, the insulin their pancreas secretes is either not enough or the body is unable to recognise the insulin and use it properly (insulin resistance).

When there isn’t enough insulin or the insulin is not used as it should be, glucose (sugar) can’t get into the body’s cells and builds up in the bloodstream instead. When glucose builds up in the blood instead of going into cells, it causes damage in multiple areas of the body. Also, since cells aren’t getting the glucose they need, they can’t function properly.

To understand why insulin is important, it helps to know more about how the body uses food for energy. Your body is made up of millions of cells. To make energy, these cells need food in a very simple form.

When you eat or drink, much of the food is broken down into a simple sugar called “glucose.” Then, glucose is transported through the bloodstream to these cells where it can be used to provide the energy the body needs for daily activities.

While not everyone with type 2 diabetes is overweight, obesity and lack of physical activity/a sedentary lifestyle are two of the most common causes of this form of diabetes.

Type II Diabetes Is Also Believed to Have a Strong Genetic Link, Meaning That It Tends to Run in Families

Other risk factors include the following:
• High blood pressure
• High blood triglyceride (fat) levels
• Gestational diabetes or giving birth to a baby weighing more than 9 pounds
• A diet that contains a high amount of refined sugars and carbs
• High alcohol intake
• Ethnicity: Certain groups, such as African Americans, Native Americans, Hispanic Americans, and Asian Americans, have a greater risk of developing type II diabetes.
• Ageing: The risk of developing type II diabetes begins to rise significantly at about age 45, and rises considerably after age 65.

With a proper diabetes diet and healthy lifestyle habits, along with diabetes medication, if necessary, you can manage type II diabetes just like you manage other areas of your life

What Are Healthy Blood Sugar Levels for People With Diabetes?

If you have diabetes, you should try to keep your blood glucose (sugar) as close to the target range as possible. This will help to delay or prevent complications of diabetes.
The following are the typical target ranges for those with diabetes:

Fasting blood glucose/ blood glucose before meals (mmol/L) – 6.0 to 8.0

Blood glucose two hours after eating (mmol/L) – 6.0 to 10.0

Risk of hypoglycaemia (low blood sugar) (mmol/L) – Less than 4.0

While these are the typical ranges, it is important to work with your doctor in an individualised fashion.

Common Medications

Diabetes Medications

Type 2 diabetes is managed through physical activity and meal planning and may require medications and/or insulin to assist your body in controlling blood glucose more effectively.

If you are unable to keep your blood sugars within the target ranges, your doctor will typically prescribe medications to help keep blood sugar levels in check.

The Most Common Medications Include:

Metformin (Glucophage, Glumetza, etc.) – most commonly the first medication prescribed these work by improving insulin sensitivity and helping your body use insulin more effectively.
Sulfonylureas – help your body to secrete more insulin.
DPP-4 inhibitors – help reduce blood sugar levels, but tend to have a modest effect.
GLP-1 receptor agonists – slow digestion and help lower blood sugar levels

Some people who have type 2 diabetes need insulin therapy as well. In the past, insulin therapy was used as a last resort, but today it’s often prescribed sooner because of its benefits.

Because normal digestion interferes with insulin taken by mouth, insulin must be injected. Depending on your needs, your doctor may prescribe a mixture of insulin types to use throughout the day and night. Often, people with type 2 diabetes start insulin use with one long-acting shot at night.

Insulin injections involve using a fine needle and syringe or an insulin pen injector — a device that looks similar to an ink pen, except the cartridge is filled with insulin.

There are many types of insulin, and they each work differently.

Options include:

Types of Insulin and How They Work 
Insulin typeHow fast it starts to work (onset)When it peaksHow long it lasts (duration)
Rapid-actingAbout 15 minutes after injection1 hour2 to 4 hours
Short-acting, also called regularWithin 30 minutes after injection2 to 3 hours3 to 6 hours
Intermediate-acting2 to 4 hours after injection4 to 12 hours12 to 18 hours
Long-actingSeveral hours after injectionDoes not peak24 hours; some last longer

Discuss the pros and cons of all medications with your doctor.

Nutritional Management of Type II Diabetes

Heart healthy foods

Adopting a healthier lifestyle and managing blood glucose levels can help prevent or control type II diabetes, and can significantly reduce complications such as heart disease, stroke, kidney disease, etc.

Traditional Nutritional Management

Traditionally, diabetes is managed by a diet that gives a certain amount of carbs in grams per meal and snack. This is typically referred to as carb counting.

High carbohydrate foods

*The general guidelines are:
Women: Up to 45 grams of carbs per meal and 15 grams of carbs per snack
Men: Up to 60 grams of carbs per meal and 30 grams of carbs per snack

*These guidelines are flexible depending on factors such as the age, weight, height, and activity level of the person following the plan.

Given with this diet, is a list of carb-containing foods, and how much of that food would give you 15 grams of carbs. This is referred to as the carb exchange list, which makes it easier for people to ensure that they are getting the recommended amount of carbs per meal and snack.

Examples of ‘Carb Exchange’ Foods That Contain 15g of Carbs:

• ½ cup of cooked beans, peas or lentils
• ½ cup cereal
• ½ a bagel
• 1 slice of bread
• 3 cups of plain popcorn
• 5 crackers
• ½ cup fresh fruit
• 1 cup of milk
• ¾ cup yoghurt

Additional Nutrition Recommendations for Blood Sugar Management:

• Consider having a variety of carbs per meal. For example, have one carb choice that is a grain or complex carb, one that is a fruit, and one that is dairy; rather than having all 45g come from bread or grain products.
• Choose mostly low glycaemic index or ‘complex’ carbs that are higher in fibre (such as whole grains, quinoa, beans, sweet potato, etc.)
• Include a protein source with each meal and snack.
• Not go longer than 4-6 hours between meals (blood sugar can drop too low if on insulin), but also not eat meals too close together (blood sugar can build up and get too high).
• Monitor blood sugar levels and work with your healthcare team to identify how your body responds to food and to ensure that your blood sugar levels stay at healthy levels.

The above diet and recommendations have been traditionally used to maintain optimal blood glucose levels for someone with diabetes.

Also, for those with higher body weight, the diet should promote weight loss. This helps to improve insulin sensitivity and maintain healthy blood sugar levels.

Sample Carb Counting/Carb Exchange Meal Plan:

Oats with nuts and berries

(This is an example of a plan that has 45 grams of carbs per meal)

Breakfast Options:

1) ½ cup cooked porridge, with 1 tbsp sultanas, with ½ cup of milk and one boiled egg on the side (or scramble the egg into the oatmeal)
2) ½ an English muffin with 1 tbsp peanut butter and ½ a banana, with three slices of turkey bacon
3) ¾ cup plain yoghurt with ½ cup berries, 1 tbsp raisins and 1 tbsp of sliced almonds
4) 1 slice of whole-grain toast with ½ an avocado and a fried egg, 1 cup of milk and one ½ cup fruit

Lunch and Dinner Options:

1) 2 slices whole-grain bread or 1 whole-grain wrap with 120g sliced turkey or chicken breast, lettuce, spinach, sliced tomato, 1 tbsp light mayo, and 1 small apple (for vegetarian, omit apple and have ½ cup black beans or chickpeas instead of meat)
2) 2/3 cup cooked wild rice, 1 cup of milk, 1 cup cooked broccoli with chicken or fish or tofu and a small serve of fruit on the side
3) Green salad with a handful of lettuce or spinach, chicken, ½ cup cooked quinoa, ½ cup berries, ¼ an avocado and a glass of milk
4) 2 small corn tortillas, ½ cup refried beans, 2 tbsp guacamole, shredded lettuce, 2 tbsp salsa and 2 tbsp plain Greek yoghurt or sour cream

Snack Options: (15 grams carbs per snack)

1) 3 cups plain popcorn with 2 tbsp unsalted nuts
2) 1 small apple with 2 tbsp nut butter
3) 1 slice of whole-grain bread with nut butter
4) 5 whole-grain crackers with cheese
5) ¾ cup yoghurt with 2 tbsp unsalted nuts

Hypo Management

Having a “hypo” is when blood glucose levels drop so low that hypoglycaemia (<4mmol/L) occurs and symptoms are present.

How to manage a hypo

Symptoms of a hypo include:

  • Weakness, trembling or shaking
  • Sweating
  • Lightheadedness/dizziness
  • Headache
  • Difficulty focusing
  • Irritability
  • Hunger
  • Numbness of lips and fingers
  • Increased heart rate
  • Blurred vision

If a hypo occurs, the protocol is as follows:

STEP 1 –

Have some easily absorbed carbohydrates such as one of the below options:

  • Glucose tablets equal to 15 grams of
  • 6–7 regular jellybeans or 4 large glucose
  • 1 tube of oral glucose gel (equal to
    15 grams of carbohydrate)
  • 1/2 a can (150mL) of regular (not ‘diet’)
    soft drink
  • 3 teaspoons of sugar or honey
  • 1/2 a glass (125mL) of fruit juice

After 10–15 minutes, re-check your blood glucose level to make sure it has risen above 4mmol/L. If it hasn’t, repeat step 1.

Step 2

Once your blood glucose level is above 4mmol/L, you will need to eat some extra carbohydrates. If your next meal is more than 20 minutes away, eat  some carbohydrate food such as:

  • 1 slice of bread
  • 1 glass (250mL) of milk or soy milk
  • 1 piece of fruit
  • 4 dried apricots
  • 1 tablespoon sultanas
  • 1 small tub (100g) fruit yoghurt

These are general guidelines and are not individualised advice. Some people will have higher needs, while others will have lower needs.

Low Carb Diets and Type II Diabetes

Low carb meal with chicken and salad

There has been emerging support over the past several years for a low carb diet (LCD) or a very low carb diet (VLCD) in the nutritional management and sometimes complete reversal of type II diabetes.

Again, carbs are broken down by the body into sugar, directly leading to high blood sugars. Eat fewer carbohydrates and you will typically end up with less sugar in your blood.

Before you start a low-carbohydrate diet, talk with your healthcare provider. If you are taking blood-sugar-lowering medications, or type I diabetes, then eating fewer carbohydrates without lowering your medication dosage may cause dangerously low blood sugars.

A low-carb diet limits foods that are high in carbohydrates such as grains (bread, pasta, rice, tortillas) and sweets (cookies, cakes, sugary drinks, fruits) and starchy vegetables (potatoes, carrots, beets).

There is no one way to follow a low-carb diet. Generally, people try different amounts of carbohydrates until they reach an amount per day that works for their energy, taste preferences and blood sugar levels. Some people with diabetes on a low-carb diet eat as few as 20 grams of carbohydrates per day while others may eat up to 100 grams.

Many people on a low-carb diet eat a wide variety of foods and simply replace or limit grains or starchy vegetables and fruits to small portions once or twice a day. They fill up on non-starchy vegetables, healthy fats, and protein sources instead.

Low Carb Diet Strategies

A simple way to start getting the hang of low-carb eating is to learn how to build your plate.

First, make sure you have some kind of source of protein like grilled chicken, fish, tofu, or red meat. Then add a serving of low-carb vegetables like broccoli or add a leafy green salad. Then depending on how few carbs you plan on eating, add one more serving of something else:
• Very low-carb eaters may add something like a serving of nuts or olives–something that contains fat and very few carbs.
• Other low-carb eaters may avoid grains but add in a portion of a root vegetable like carrots or sweet potato, or they may add tomatoes, some lower-carb fruit, or some legumes.
• Still other low-carb eaters may choose to add a serving of whole grains. The best types are unprocessed like brown rice, quinoa, bulgar, barley, millet and sorghum. It helps to omit or limit processed or refined grains like white pasta, wheat bread, wheat or corn tortillas, and oatmeal.

The key is to try different quantities of different foods and check your blood sugar to see how it responds to the way you are eating. You also want to have enough energy and be satiated after a meal. Filling your plate with plenty of protein, healthy fat and fibre tend to make a very satisfying meal.

Sample Low Carb Meal Plan:

Low carb meal

Breakfast Options:
1) Chia seed pudding with 2 tbsp unsalted almonds and a handful of berries
2) Two egg muffin cups with three slices of turkey bacon
3) Omelet with various vegetables, fried in butter or coconut oil
4) Bacon and eggs scrambled with a handful of spinach

Lunch/Dinner Options:
1) Smoothie with coconut milk, berries, almonds and protein powder
2) Green salad with chicken or fish, 2 tbsp nuts and/or seeds and olive oil dressing
3) A hamburger without the bun with a green salad and olive oil dressing
4) Steak or grilled chicken or fish with 1-2 cups steamed veggies (or sautéed in olive or coconut oil)

Snack Options
1) Plain Greek or Icelandic (lower carb) yoghurt with ½ cup berries and 2 tbsp unsalted nuts
2) A boiled egg and a handful of nuts
3) A piece of fruit with 2 tbsp nut butter
4) Deli meats with 1-2 oz cheese
5) Tuna mixed with avocado, lemon juice, salt and pepper wrapped in a lettuce leaf

Diabetes & Weight Loss

A lot of people consider type II diabetes a naturally progressive disease that you were unable to reverse.

Even if you were able to lose weight and reduce the fat around the pancreas, you would not be able to repair the damage that had been done to the beta cells. Well, at least not effectively.

The only management strategies available typically centred around managing carbohydrate intake to keep blood glucose levels within a moderate range. These are still the most common management strategies. 

However, there is consistent evidence that even a modest amount of weight loss between 5-10% can have a significant impact on blood glucose levels without the specific management of carbohydrate intake.

Beyond just the pancreas aspect, reducing levels of body fat typically improves insulin sensitivity significantly. This means the total amount of insulin needed to get the job done would be lower. Regardless of whether it is produced naturally or with the aid of medication.

The Direct Trial

The DIRECT trial took this one step further to investigate the effects of rapid weight loss and its ability to put diabetes into remission. 

During this trial, participants were on a very low energy diet of 825-853 calories per day for 12-20 weeks.  This diet was provided in the form of pre-packaged shakes and soups. 

Following this, there was a structured reintroduction of food over 2-8 weeks for a longer-term weight loss maintenance program. 

Participants were also offered ‘rescue packages’ for relapse management if they gained >2kgs or their diabetes had returned. These packages were 2-4 week programs. 

Researchers found that 46% of participants undergoing this intervention had reversed their diabetes with the best results found in participants that had lost 15 or more kilos in that time. 

Even more surprisingly, 36% of participants were in remission at the two-year follow-up. Although, people were more likely to stay in remission if their weight loss had been maintained. 

Diabetes remission was defined as a HbA1c under 6.5 and/or fasting blood glucose levels under 7.

Can Rapid Weight Loss Be Used To Put T2DM Into Remission?

What is interesting about this study is that it shows that not only is remission from diabetes possible and that beta cells of the pancreas can recover, but also that people are capable of maintaining a regime for rapid weight loss. 

Rapid weight loss often gets laughed off as an intervention not worth trying. This is for a few reasons but the main reason is that people would not be able to stick to this type of dietary approach. Not to mention keep the weight off long term. 

However, Professor Roy Taylor of the DiRECT trial stated in a Sigma Nutrition podcast, that when you remove the burden of making decisions and provide someone with a protocol as simple as having several shakes per day, that their compliance is likely to go up. 

He also reported that only 1 out of 15 of his participants dealt with ongoing hunger and most found that hunger significantly reduced after the diet had been established. 

Thoughts on Rapid Weight Loss for T2DM

I think that this type of approach might be useful for a person with an all or nothing kind of personality. 

For some, it is hard to commit to small lifestyle changes that can take years to have a significant impact. Whilst committing to 12-20 weeks of aggressive treatment followed by a more long term maintenance phase sounds much more doable.  

There is also the issue that the longer the duration of diabetes before the weight loss, the lower the chances of the beta-cell function returning to normal.

So there could definitely be an argument for aggressive treatment at the onset of diabetes or pre-diabetes as opposed to a more long term management plan from the get-go.

Another factor to consider is that in the DiRECT trial, participants were required to adjust their medications, mainly through discontinuing the use of hypertension and diabetes medication, right off the bat. This was to prevent hypos and low blood pressure. So if you were to go down this route, it would be strongly encouraged to have medical advice on how to manage your medications.

Obviously, individualized care is important and whether or not aggressive dieting is the most optimal approach will differ from person to person. But it is something to potentially consider. 

Vegan Diets & Type II Diabetes

Another interesting area of research in diabetes management is the effects of a plant based or vegan diet on type II diabetes management. 

In a study published in 2009, researchers took free-living individuals with type 2 diabetes and they were randomly assigned to a low-fat vegan diet or a diet following 2003 American Diabetes Association guidelines. 

Both diets were calorically matched and designed to aid in weight loss.

The principal diet change in the conventional diet group was a reduction in energy intake rather than changes in macronutrient balance.

However, the vegan diet also contained a higher carbohydrate and lower fat content in addition to an overall reduction in caloric intake. 

Weight loss was significant within each diet group but not significantly different between groups (24.4 kg in the vegan group and 23.0 kg in the conventional diet group).  

However, changes in blood lipid profiles were significant between groups. The vegan diet group had a much greater reduction in both total cholesterol and LDL (“bad”) cholesterol. 

In relation to diabetes management, both groups saw a significant reduction in participants HbA1c. The mean change was slightly but not significantly greater in the vegan group. Meaning that it was likely the weight loss that contributed most to the reduction. 

This is interesting because the vegan diet was high in carbohydrates. So despite participants often having high carb meals and snacks throughout the day, they were still able to bring down their HbA1c levels even slightly more than that seen in the conventional diet group.

The results of this study challenge our idea that moderating carbohydrate intake is the solution to diabetes management. 

What Diet Should You Try?

Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes because different diets work for different people.

There are studies that show that people with diabetes can achieve success with both low-carbohydrate and high-carbohydrate diets. Those pursuing high-carb diets are often recommended to follow a more vegetarian or vegan diet or the Mediterranean diet that are high in complex carbohydrates, protein and fibre.

By Felicia Newell

Felicia is a Registered Dietitian, Sport Nutritionist, and Health Coach. She is also the owner of Sustain Nutrition. She specializes in: sport nutrition, weight loss, chronic disease management, food allergies and intolerances, and digestive health. Felicia is passionate in helping others fight through the massive amounts of nutrition misinformation in the online world, and to navigate life and health, but most importantly, to enjoy it while doing it. She has over 11 years of education and experience in Nutritional Sciences. Between completing her Bachelor and Masters in Nutritional Sciences, working at a research centre, teaching university courses, years of nutrition counselling helping people crush their goals, and being a busy mom of 4 young boys, she has the passion, skills, education, and experience to help people achieve their health goals.