Glycemic Index Applied to a Vegetarian Diet
Q. My elderly sister has brittle type 1 diabetes, is an ovo-lacto vegetarian, and has had dozens of hospital admissions for low blood sugar episodes. She is recovering from a several month hospitalization following a broken hip and bypass surgery. Her home health nurse is trying to make her follow a diet with no grains, legumes, and only limited fruit, which doesn't leave my sister many options. The nurse is telling her to eat meat to get her protein, which she chooses not to do. As I have reviewed the glycemic index, it appears there are certain grains/legumes with acceptable, low glycemic indexes. I live in another state and cannot "do battle" with this nurse. Do you have a professional opinion as to how the glycemic index is to be applied to a vegetarian diet?
A. Yes, with a grain of salt. I typically defer to the expert dietitians to handle nutrition-related questions. Since I am an ovo-lacto vegetarian nurse, and have heard many diabetes education leaders speak about Glycemic index, I feel qualified to respond to the well-intentioned, misguided recommendations made by your sister's home health nurse.
First, let's address the glycemic index and then cover specific issues relating to your sister's situation.
The Glycemic Index
The glycemic index gets a lot of press, but what is the science behind how it applies to the real world? Technically speaking, the glycemic index is the area under the post meal glucose curve that compares how the same person in a fasting state (no food or caloric drinks for 8 hours) responds to the same 50 grams of digestible carbohydrate from a standard food (usually white bread or glucose).
Let's visualize this. You wake up with nothing in your system. You take 50 grams of sugar. The glycemic index measures how long the sugar stays in your system, not how rapidly glucose values peak. You do this a few other days to see the consistency with which the body responds. Research shows a significant variability between individuals and food types. For example, rice has a standard deviation of plus or minus 38, meaning, the same person having the same 50 grams of rice will have a wide range of glucose values. When was the last time you only ate 50 grams of one type of food? We normally eat foods with other foods.
The glycemic index can be very misleading. Regular sodas have a low glycemic index! Potatoes have a higher glycemic index than pizza. Pizza has many more carbohydrates per serving than do potatoes. The end result is a glycemic load (or overall glucose effect) that is much lower for potatoes than pizza. Evidence shows no significant positive effect of eating low glycemic index foods. Over 20 studies show the benefits of choosing a variety of carbohydrates and keeping them consistent. Whether a person is a vegetarian or a carnivore, the key is to focus on total carbs. Glycemic index by itself has limited value and application.
Now onto my concerns and considerations for your sister's situation.
Telling a vegetarian they need meat is like telling a Catholic to become Muslim or vice-a-versa. Many vegetarians do not eat animals because of religious or spiritual beliefs. There are many ways to get enough protein sources without meat (tofu, legumes, nuts, wheat gluten, and dairy products).
There are no forbidden foods or fruits for someone with diabetes. It is a quantity and quality issue. Whole grains are better than refined; fruits are better than juice. Everyone with diabetes deserves to eat healthily and enjoy food. To cut out grains, legumes and limit fruit for a vegetarian is unnecessary and in your sister's case, potentially dangerous as it can lead to more lows. Grains and fruit are an important part of a well-rounded diet.
Have you considered finding a registered dietitian and certified diabetes educator (RD, CDE) who will make a home visit? Many RDs have private practices. You might even find one who would charge for a "virtual" meal plan. That way, you are not doing battle with the nurse; you are providing an expert's diet plan. You can also use the Find a Recipe feature of this website. When I clicked on this link http://www.dlife.com/diabetes/diabetic-recipes/ and typed in tofu, many delicious recipes surfaced.
Why is your sister going so low? Does she have a continuous glucose monitor? It would alarm to warm her she is about to go low (do an Internet search for DexCom or Navigator). If going high tech isn't a possibility, what about a four-legged friend who can detect lows? Dogs for Diabetics is a non-profit organization that has trained dogs who "smell" lows and save peoples lives. Check out www.dogs4diabetics.com for more information.
As a former home health nurse, I can appreciate the limited resources and challenges of that field, with access to a registered dietitian being one of them. This is where nurses can get into trouble by stepping outside of their scope of practice (except in the case of certified diabetes educators where professional scopes overlap between nurses and dietitians).
Consider involving a medical social worker to find ways to keep your sister safe at home. Most home health agencies have them. Also, how often does she see an endocrinologist? It is hard to find a certified diabetes educator in homecare, but they do exist. Once she is no longer homebound, she could benefit from their expertise. Check out the Diabetes Locator function on dLife to search for experts in your area.
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NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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