One morning last week, I three patients each “brag” about how all they ate for the dinner the night before was a plate of vegetables. I have had patients do this before, but three in one morning was a big surprise. It makes me wonder if there was something recently on TV promoting the vegetable-only diet. I know when Dr. Oz said to eat a slice of whole wheat bread dipped in olive oil before dinner, I had a slew of patients doing just that and completely ignoring their meal plan. Likewise, when Oprah said not to eat “even a grape after 7 pm,” I had people skipping dinner.

I’m wondering if you all have had the same experiences. I praised these three for seeking out healthful foods and explained the need for balance – all in a non-threatening way so no one felt ridiculed. I try to be only as simplistic as I need to be, depending on the patient’s knowledge, enthusiasm and ability to take on new material. The Plate Method has been very valuable in explaining balance or defining a meal, but one of the three patients found this too complicated. I ended up just writing out a list of about 8 dinner menus for him that included only foods he would eat and could prepare. I’m going to see him again in a few weeks and would like to hear your suggestions for helping him define a meal.

I  haven't seen anything specific on TV or in the news that would lead to people eating only vegetables for dinner. However, sometimes I see this happen in my practice when I encourage my clients to increase their vegetable intake, and they decide that means eating only veggies for a meal or two. It's always interesting to see what clients take away from our meetings! I try to end each meeting by asking them what one or two specific goals they want to focus on until we meet again, and that's usually very helpful.

I've had some success asking people to think about what type of meal they would serve for guests, or the foods that were included in family meals when they were children. Most of the time, they zero right in on protein, grains, veggies. Sometimes we go through their food records, and place all the foods they've eaten into food groups. I use paper pictures or rubber food models to give them additional visual feedback. I often find that people are trying to make meal planning too complicated, and zeroing in on familiar food groups makes it easier.

      Even i have experienced the same with my patients especially when we say weight reducing diet.  patient usauly skip thier breakfast or just have a serving of fruit or a cup of vegetable salads. they really don't understand the importance of balanced meal in their diet.  
   I define my patient about balanced diet using food pyramid and pie chart showing the serving size of various food groups. I explain them the importance of various food groups in diet and what each food group contains and their function. you can also use real food models and complete meal displayed in a plate which includes all food groups in recmmended quantity. So that it will easy for them to understand.  usauly we prepare a day's menu starting from early morning to bed time milk, and display it during time community shows and explain them about balanced diet. Instead we can use model for the same.

   thanks,
  uma 
       

Uma, this is really interesting to  me. Are you currently working in India? If so, it seems that we have similar problems with explaining balanced meals, no matter where we live!

 Jill and Lynn, an interesting discussion. I usually do use a 10 inch plate with 3 sections to demonstrate food portion sizes and the types of foods patients can benefit from nutritionally.... taking into account their food preferences. Sometimes, when patients tell me(especially with Type 2 DM) that they will only eat, for example... cold cereals and toast for breakfast- I teach them about insulin resistance in detail and the need to adjust their carb intake based on their fasting bg  levels. The cause and effect relationship between the spiked up blood sugars and increased carb intake usually gets the patients thinking and many a time leads them to a change in an eating behavior. One specific patient and his attachment to instant oatmeal comes to mind. This patient used to eat 2 packets of instant oatmeal(44 g of carbs in total)+ 1 glass of 1% milk(12-15 g of carbs) each am with a resultant 2h pp hyperglycemia of >200 mg/dl.
He is obese and on Salfonyluria/metformin regimen bid.  After replacing the instant oatmeal with  2/3 cup of  an oldfashioned /rolled oats prepared in a tiny slow-cooker overnight, with the same amount of milk - his 2h pp bg level went down to about 150 mg/dl, without any change in the meds or their dosages. This experiment clearly demonstrated to the patient that specific types of foods, wholesomeness of the products and portions have a direct effect on his sugar metabolism. The change in the kind of oatmeal he utilized resulted not only in better sugar control, but "addressed satiety better as well"/per pt.  Bottom line- individualized patient education regarding specific foods is sometimes  key to a positive change in eating behavior . Thank you. Isabella, RN/CDE

I love this example! You worked together with the patient to identify something he wanted to accomplish - lower BG after breakfast. He found a similar breakfast that he could enjoy while at the same time achieve his goal of improved BG control. This is exactly how I strive to work with patients, empowering them to set goals, figure out how to achieve those goals, and then celebrate their success. Thanks for sharing!

Thank you all for your comments and stories about how you have helped your patients learn about balance. This is quite a difficult topic for some because they have become so focused on carbohydrates only from listening to neighbors, friends, the media etc. I continue to struggle to teach balance to some of my patients, but really emphasizing the need to select at least one fiber-rich food and one protein-rich food at every meal has seemed to help the ones who have had the most trouble.

The reason I love the PLATE is that it does show the balanced meal; we talk about hypertension being such an issue with all the clients we see that focusing on the CARBS without addressing the need for the carbs to come from FRUITS AND VEGGIES is a true disservice!

Those TV professionals really do a disservice to a lot of people. There is no one right answer. No standard plate, no do this, that works for everyone.

But I know a lot of people are overwhelmed by having to learn about something they gave very little thought to before.

Just about any relatively healthful plan will be a good start. But a tailored plan for that individual needs to be done for the long term. Moving the lines on the "plate" to take account the individual needs.

I think the plate method needs to be thought of as the plate of the day.  While you don't want a meal to be almost all of one type, it may be better to see the whole days diet and work the plate from there

I love the plate method because it is simple.  I have a tear-off pad that our CCS rep gives out that shows a big picture of a meal using the plate method.  It is designed for diabetes but works for everyone.  I teach my patients to look at their plate and ask themselves if half their plate is half full of non-starchy vegetables.  Then ask themselves to look to see if the other half of the plate is divided between lean protein and high fiber starch.  These are excellent questions to ask at home as well as when eating out for a quick healthy eating gauge. 
I think I have shared this before but I love it.  I had one woman who would not eat breakfast or lunch.  She cared for her grandchild through out the day.  I asked her if she would allow her grandson to go without eating breakfast or lunch.  "No way!"  was her reply.  We then talked about "taking care of herself" the way she takes care of her grandson.  She returned for f/u and said it really helped her.
I also like to refer my patients back to how their mother or grandmother used to feed them.  I first ask them how they fed them of course.  But usually people were brought up to eat balanced meals.  Especially the older generation.  The sad truth is that the current working generation and their children may not have ever been taught what healthy eating is so we are essentially starting from the beginning.
I saw a 20 something about 10 years ago who reported she had never eaten any vegetables but corn and potatoes!  And macaroni and cheese...she considered that a vegetable as well. 

I love the plate when working with families.  Getting the message across that calcium foods are just as important as the fruits for other reasons than CARBS is critical to good health....

I do also use the PCRM plate too....that is good for those with vegan palate!

Hi Joan
Thank you for referring to the PCRM plate.  I had never heard of PCRM before. I just went to the PCRM website and found a wealth of information!

For me this means having a sufficient balance of protein, for energy and health, fats and a well planned selection of vegetables, such as broccoli, cauliflower and other low carb. greens for salads.  In a third World country where I live and work it is not easy to get the food items we do when I am in the U.S. during the summers.  So my proteins are tuna, sardines, chicken, ground beef, cheeses and fats are free,

An average week I now consume ± 5 lbs of ground meat, 3-4 pounds of hard cheeses like cheddar, 2-3 cans of tuna, 5-6 cans of sardines (calcium rich) and about 2 dozen eggs.  Chicken is interspersed as well.

On the low carb diet  I initially lost a lot of weight and dropped from near ±188 lbs to 148 lbs.   At 6’ that was too low so I increased the protein portion of my diet and gradually started putting back lean mass and now stable at 160 lbs.

We are lucky in the tropics as cold pressed coconut oil is cheap and used to cook eggs etc.

NO soy based oils as that belongs in paint not food LOL.

I make mayonnaise at least once a week.  No preservatives or additives just olive oil, canola oil, salt, pepper, cider  vinegar and fresh eggs.  I have the mayo as a free fat with a lot of my food.  Some weeks if I am very active with our field research along with running 3 times per week I consume well over a pint of this mayonnaise as well.

The balance is aimed at good energy levels and maintaining tight BG levels .

Below is a link to the Metabolism Society. On May 8^th there is a series of research papers being presented on the value of low carbohydrate diets and current research and thinking.

http://metabolismsociety.org/AboutFat.aspx

In my zeal to highlight my low carb, high protein diet, I missed the rest of the story...

the rest of the household likely needs to eat as well ;-).

We have found (when int he U.S. and supplies are available) that the book:

Leanne Ely's book Saving Dinner the Low-Carb Way: Healthy Menus, Recipes, and the Shopping Lists has an entire year of menu plans that are seasonally adjusted for what is available (in the U.S.).

We found that these meals are great and easily expandable with potatoes or other veg items for the rest of the family who have normal physiological responses to carbs.

The weekly shopping list was also wonderful and removed all the stress of What are we going to cook tonight?

Personally, I'm a bit dubious of the PCRM.  The appears to be an alliance of key personnel behind the PCRM with primarily an animal rights (PETA) agenda.    Type "PCRM scam" into google and you will get a wealth of hits.  Other elements of this group include the new age guru Gabriel Cousens and Neal Barnard with his "Reversing Diabetes" book.  Excuse me for being a bit skeptical.  I have no problem with vegan diets.  But don't expect a diabetic to sacrifice their health to save animals.

Thanks for the reference, Bruce.  I just ordered the book

Hi Brian:
I do agree that the PCRM are a group associate with PETA, but they happen to have some great eduational tools to help folks adopt a vegan lifestyle: should they choose.  My experienc with teaching many people about the benefits of a plant based diet is that many don't know how to prepare foods from plants....so they have great tools. As for their political message, I'm able to work my way through that....and am not distracted by it at all.

I have no disagreement with a vegan choice, my daughter is a vegetarian.  What I object to is the suggestion that fat elimination or raw food diets can "cure" diabetes.  In particular, such claims as made in the movie "Simply Raw" that one can cure type 1 are irresponsible.  There are many resources for vegetarian and vegan recipes and dietary suggestions, and it is imperative that sound advice be available to patients who are at severe risk of nutrition deficiencies.  I work very hard to see that my daughter has sources of sufficient fats and protein as well as working with her to get enough calories.  We have many resource at home dating back many years from the early works of Mollie Katzen to more modern and varied cuisines.  But personally, my red flags have gone up with PCRM and I am inclined to distrust the advice from this group and associated people and efforts.

We can then agree to disagree...

Of course.  Without new and contrasting ideas we might as well be cavemen.

I am with you Brian. Although I am a proud meat eater, I do enjoy a lot of vegitarian dishes. some are great on there on and most are even better when you add  meat to them.

A lot of meat based cuisine does not celebrate the "sides". I think making the most of everything a good idea. So I borrow from those that have no choice.

A vegitarian diabetic is hard, a vegan is 10x harder.  I admire those that do it on principle, distain for those that do it for weight loss or the in thing to do

I think we often define "balanced" with a very narrow view.  I think every individual has different things that are important to them and these considerations affect what is an appropriate balanced meal.  For instance:

1. What is healthy for me? - such as macronutrients
2. What is is appropriate for my ethics?  - such as not wanting to eat animals
3. Is it free of contamimants/toxins? - should you choose organic?
4. Does it support agribusiness? - should you eat to support large american business, wheat, soy, corn, feedlot meat
5. Should it be sustainable/green? - such as local grown foods that are sustainably farmed
6. Should it be fresh/whole or processed? - such as packaged foods versus home prepared

In my case.

I choose a very low carb, high protein and high fat diet as healthy for my diabetic condition.  I have elminated trans and hydrogenated fats.

I have no problem eating meat, dairy or seafood

I'll sometimes select organic, but only for items where I think it makes a difference and it does not cost too much or compromise the product too much.  I avoid HFCS and artificial sweeteners.

I won't make selections to support agribusiness.  I eat very little wheat, soy or corn.  I'll eat feedlot meat, but prefer grassfed.

I will often try to buy from local/farmers markets.

I buy as much whole foods as possible and cook my own food, choosing to carry premade and leftover food in preferance to ready to eat/prepared foods.

Now everyone has their own considerations.  If someone feels strongly enough about not harming any animals or fish and is willing to compromise their own health, that is their choice.  We can argue with them about their considerations, choices and priorities, but when they fill their plate according to that balance, it does not make their choice unbalanced.  In the same way, when I choose to eat a meal like I did last night, cooked outside on my grill; grass fed steak, seafood, roast veggies and salad, almost all procured locally and made by me from whole foods, it is balanced in my eyes.  For somebody else, it may not be balanced, but then again, they have different considerations, concerns and priorities.

Thank you all for your great comments. I find it very interesting that so many people who come to see me feel that eating healthfully means choosing a single nutritious food. The idea of balance simply escapes them.

Thank you Jill; I thoroughly enjoyed the comments from everyone. I could not believe that one of our diabetes telephonic operators did not know what to eat one evening for supper so she chose a can of peas thinking that she was eating a green vegetable until I discussed the concept of a starchy vegetable with her.  Bruce, I am curious as to what Third World Country you live in  where you cook your eggs in coconut oil and use soy in your paints..very interesting. Isabella, your comments regarding the oatmeal are quite practical and this is the approach that I use with my clients when they tell me about a craving for a particular food that they have been told by someone in the past to avoid i.e. sugar.  Thus, I tell them to have a small portion of the food they are craving (telling them that if eaten at a meal its effect may be somewhat blunted and not as great as when eaten at a snack time) and see what effect it has on the blood glucose. Brian, I applaud your deep thinking and awareness of even agribusiness when considering meal planning and what balance means to you. I wish you could have expounded more. As usual, all of  you have stretched my mind and thinking regarding a balanced diet. Thank you, Diane Black.

Hi Diane et al.,

I am in Belize, Central America. I think my profile correctly reflects this now.  When I initially signed in here I used our temporary U.S. address where we head for a short while every summer.

This is a bit off-topic to a degree... and I am not intending to start a fire storm of comments…

We were ± 80% vegetarian with some chicken and a bit of fish, before health issues became a dictating factor in what I could eat (now virtually no carbs).

Having been working for more the 40 years (last 24 here in BZ) in research and applied conservation, protecting wildlife and habitats I think far too many vegetarians that are basing there choice on “moral” or “ethical” grounds are more than a bit naïve.

The number of domestic, AKA food animals that are killed and enter the human food web is not the real issue. IF vegetarians are morally really against animals being killed or suffering they need to be aware of the big picture and the ecological web that is now very tenuous these days, replete with global climate change etc.

The myriads of species i.e. individual animals and entire populations, that suffer and are wiped out- killed -  Meaning - EXTINCT - gone forever from planet earth -  and are not renewable resources like domestic farm animals is horrendous.  99% due to big agro-industry and removing habitat from the face of the earth for yet more grain related crops.

Just because one eats mainly vegetables does not mean animals DID not die to get them on ones plate.  The number of species currently under threat due to grain agriculture is mind boggling, if not downright depressing for someone who more or less gave up “gainful” employment 25 years ago to live and work in conservatin science and live in the tropics to save species and their habitats.

There is an excellent book recently released that does the best job I have seen, summarizing all of these issues, written by a long time vegan (some 20 year or so I think) who had to finally give it up for health reasons, protein deficiencies, toxic build up from soy products etc. It is extremely well referenced which was a surprise in this day of TV one-size fits all diet and medical claims based on whim and opinions but no supporting science.

The Vegetarian Myth: Food, Justice, and Sustainability by Lierre Keith

With our research on bats (me) & cats (my wife studies jaguars – the cats not cars) we are both very keen to make sure no animals wild or domestic, suffer.  We also support humane societies and animal shelters.

While as a scientist and following tons of peer reviewed literature (now including diabetes research) on a weekly basis I assumed I was well versed in the many impacts of the “human food chain” production.  this is critical to helping to understand and assist with protected area management with surrounding subsistence communities.

When my wife finished reading the book above and she strongly suggested I read it.

I was not only blown away by the impacts these big corporation have on all of our lives but many aspects I was unaware of, like the enormous amount of petroleum products used in order to produce fertilizers to grow the grain crops.

Off my soap box on that topic.

Cheers all from the jungels of Belize,

Bruce

All -

It's interesting to read this string of thoughts and recall a few items about a patient I saw today. He is a man with > 15 years of T2. He's now on max dose metformin, max Byetta, Levemir BID. His eating habits are fairly eratic often not eating until 1 - 2 in the afternoon and then not eating again until late in the evening. He is limiting healthy sources of carbohydrate. To be honest it was difficult to figure out what he was eating.

When I asked him his goal for our session, it was to get a list from me of green, yellow, red foods. (Problem is I don't do good food/bad food lists.) Yet after all of these years with diabetes he couldn't tell me the food groups containing carbohydrate, how much carbohydrate he needs to eat, etc. And he is a very bright and able man.

Several other things bothered me with this man's knowledge/information and I see this alot...messages from doctors to eat this food, don't eat that - for example, don't eat strawberries or bananas, but eat grapes and peaches, etc. Where do they come up with this information? I encouraged this man to use an online nutrient database and look up the carb counts of foods he eats. He needs to learn...it's never too late.

And one more common thread that I saw with this man as well ...hearing from his physician over and over, if you can just lose some weight you'll get your blood glucose into control. People like this man berate and chatise themselves for not losing weight and controlling their blood glucose. Reality is after all of these years with diabetes, he (as many others) is insulin deficient and likely needs to add meal time rapid acting insulin.

This man needs to focus on eating healthy...balanced meals at least a couple of times a day. Then assess his control and, if need be, progress his medications.

Hope Warshaw, MMSc, RD, CDE

Nutrition Section Editor, PRESENTdiabetes.com

Hello Hope,
I appreciate your comments relating to the abilities and intelligence of a client with Type 2 DM who has an inability to perform at his best due to a knowledge deficit in addition to receiving the old black and white good meal bad meal concept.  It is a wonder that this man even attemps to comply with meal planning and carbohydrate counting. Kudos for the client!

I read an article today in "Arthritis Today" regarding balance in the diet.  The article suggested 70-74% cocoa solids for a daily antioxidant fix;something we have probably all read about but something that we may not think  to incorporate into a balanced diet.. Likewise, when we lived on Bainbridge Island  in Seattle, my neighbor and her husband considered a  1-2 drink glass of red wine( Two Buck Chuck) from Trader Joe's as part of their balanced meal plan.  They grow a garden yearly living a therapeutic lifestyle.  Both the cocoa solids and the red wine reflect the fact that balance and the pleasure of eating does not mean bad foods or deprivation but should mean inclusion of what the client considers to be a blanced diet.  Both sound like healthy viable options that I want in my balanced diet.  

I want to thank Bruce for posting his thought-provoking comments from Belize. This serves to remind me not only of the larger, global effect that our individual food choices play but also that there is a huge variation in people's ability to obtain and choose healthy foods.

Balance and moderation are two words that seem to get lost in conversation. For some reason, they have little meaning to those looking for right and wrong or good and bad. Hope, the patient you describe is all too familiar. And probably not just to me. I'm sure we all have patients like this on a regular basis. I try to remind both my students and my patients that no single food makes you healthy or unhealthy. The entire diet and lifestyle are key. I also remind them that no one gets skinny or fat in a single day. Again it’s the entire diet and lifestyle. When I ask them if someone could become obese by overeating on Thanksgiving only, they show some signs of getting it. Red light and green light, good and bad and all the rest are hard to fight, but it sure makes work interesting. And Diane, I’m with you on the wine and chocolate. Throw some peanut butter and coffee in there and I’m mighty happy.

Jill,

Chocolate is the base of the food pyramid right?

Everything else comes after that LOL.

+++++++++++++++++++++

One young woman I was discussing her mother's diabetes with, did not grasp the carb connection at all.

Her mother has been in and out of the "local" hosptial (a 3 hour drive) for foot problems and serious complications with kidneys etc. as a result of continued high BG levels.

The daughter was not aware of any medication her mother was on, but she was told by the nurse when she consulted her that if her mother would just to eat normal meals (here that is rice and beans and corn tortillas etc.) "moderately." and she would be fine.

A fad diet that swept through our local community last year was the "Brown Rice Cleansing Diet."

All one ate for 7 days straight was boiled "healthy" brown rice. This young woman had her mother on that diet for 3 meals per day 7 days and when her mother complained that she was feeling bad she continued her on this for a total of 10 days.  Only water was used to supplement boiled brown rice.

This was going to "cleanse" her mother's system.

About a week later her mother was re-admitted to the hospital for about a week... unrelated the young woman thought, but was likely due the the "toxins" being purged from her mother's system.

I am not sure if working on becoming a CDE and currently a volunteer DE will be worth the effort in a Third World country butting up against the odds with ignorance and distrust of medical knowledge.

I am sure most of you have similar horror stories, but you all keep at it.