In September 2015, The Johnson & Johnson Diabetes Institute, in partnership with The Diabetes Influencers Network (DiabetesInfluencers.com, @DiabetesINFL), hosted a Twitter chat for healthcare professionals about nutrition and diabetes. The chat was facilitated by Mary Ann Hodorowicz, RD, MBA, CDE, CEC, @mahodorowicz  and Amy P. Campbell, RD, MS, CDE, @amypcampbell.

Here are some common questions asked by people with diabetes, followed by answers from our hosts and participants.

Do I have to give up sugar or sugary foods and drinks completely?

It’s  not  realistic  to  think  that  people  will  give  up  sugar  completely, so help them manage their  intake. “Use  in  moderation  and  be  accountable  for  what you eat”  is  much  more  acceptable.  Educate to count portion size, calories and carbs.

Sugary  food  can  be  substituted  for  other  carbs, but it is  low in nutrients and  fiber  and  high in  kcal.  Diet soda is best to prevent high blood glucose.  Some sugary foods can be surprisingly low in carbs.  Educate your patients to read labels!

Patients  need  to  find  what  amount  of  sugar  they  can  tolerate  and  what  foods  with  sugar  they can have.  They can have sugary foods for a treat or special occasion.  But  don’t  forget  to  count  them  as  carb  choices!

Food and drink  considerations  are  a  part  of  an overall  Lifestyle  Change  and  should  be  considered  on  a  case  by  case  basis. Frequent  blood glucose  checks  can  help  a  person  know  how  to  best  fit  treats  into  eating  plan.

Can I use artificial sweeteners?

Yes, but wisely.  They are usually found in non-nutrient dense foods.  “Diet” foods  can  be  a  trap, so its important  to  remind  patients that  sugar-free  foods  aren’t  always  carb  or  calorie-free.  Carb  and  calorie  free  sweeteners  are ok, but  foods  containing  them,   like sugar  free  cookies, usually  have  carbs  that  must  be  counted.

Beware also that artificial  sweeteners  can  induce  glucose  intolerance:  the  body  doesn’t  know  it’s  an  artificial  sweetener  until  it’s  too  late,  so insulin  may  still  be  stimulated.  Consider natural no- or low-cal sweeteners if your patient has this reaction.

Can I eat foods made with sugar alcohols?

Some people mistake sugar alcohol for true alcohol.

Sugar  alcohols  don’t  contain  sugar  or  alcohol:  they  are  a  carb,  and not  necessarily  low  cal.  Mannitol,  maltitol,  lactitol,  xylitol,  sorbitol,  hydrogenated  starch  hydrolysate,  and  isomalt  are all sugar  alcohols.

Sugar  alcohols  have  some  serious  side  effects – patients  must  use  in  moderation.  Read labels!!

Foods  with  sugar  alcohol  (carb),  are  OK  but  often  have  other  carbs  that  must  be  counted.  Sugar  alcohols  are  NOT  low  in  calories, and sugar-free  may  not  mean  carb  free.

Not all sugar alcohols are created equal.  Sugar  alcohols  can  have  a  laxative  effect,  causing  gas,  bloating,  and  diarrhea.  Erythritol has the fewest GI effects as it does not ferment in the colon.

If  counting  carbs  on  insulin-carb  ratio, if a  food  has  5  or  more  gm  SA,  subtract  1/2  of  from the total  carb count. Sugar alcohols have 2 calories per gram.

Should I eat more high fiber foods?

High  fiber  foods  are  sensible  all  around,  not  just  for  diabetes.  A  high  fiber  diet  can  reduce  the risk  of  diabetes mellitus and  help  control  blood  sugar and promote good  colon  health.

High  fiber  foods  help  moderate  the  rise  in  blood glucose, control  blood  cholesterol  and  can  help  slow  glucose  absorption.  Its bulk helps people feel full.  A good goal is 20-35 grams daily

Viscous fiber is best. Viscous fiber gels in fluid and can best reduce blood glucose and blood cholesterol!  Fibers  that  do  not  “gel”  are not  as  effective  in  blood glucose  and  blood  cholesterol  reduction.  The Academy  of  Nutrition  and  Dietetics  diabetes  evidence-based  guideline recommends  7  to  13  gms  viscous fiber  per  day.

Can I drink alcohol?

If diabetes is under control, an occasional drink is probably ok. As with so many foods, moderation is best. The AHA’s recommendation is 1 drink/day for women, 2 for men.

Alcohol can cause a low blood glucose episode. With  alcohol,  the liver  will  kick  in  to  detox  and  then  cannot  release  stored  glucose  quick  enough.  Low  blood glucose  can  occur  quickly  with  ETOH  and  activate  insulin  in  the system  So check  blood glucose  more  often  when  drinking  alcohol.

People taking  insulin  or  certain  types  of  diabetes  pills  should always  eat  a  carb  food  when  drinking  alcohol  to  prevent  lows.

Look out for alcohol mixers, however, like soda and juice. Consider diet versions or seltzer water instead.

What kind of fats can a person with diabetes eat?  How much is ok?

Good  fats  are  important  for  heart  health  and  help  to  slow  the digestion  of  carbs.  Avocado,  extra virgin olive oil,  nuts,  canola  and  peanut  oils,  fatty  fish  like  salmon,  seeds  and  avocado are recommended. Also avoid the obvious trans fats.

If  carbs  raise  blood  sugar,  should  I  avoid  all  carbs?

NO,  NO,  NO!  Avoid all carbs only if you want sub-optimal brain function.  The brain needs glucose.  The human body needs carbohydrate to function properly.  Carbs are the bodies preferred fuel source. But plant-based, whole-food carb are the healthiest choices.

A daily meal plan should include healthy carbs.  Low quality, empty calorie carbs are the downfall of healthy eating. The best  carbs  are  from  plants – veggies,  fruit,  whole  grains,  nuts,  seeds and  beans – and  low-fat  milk  and  yogurt.

Educate patients to eat  less  saturated  and  trans  fats, and  more  mono  and  polyunsaturated  fats  plus  omega-3s. If weight loss is desired, use less fat in cooking and at the table.

Do I need to lose a lot of excess weight?

Excess weight affects much more than just diabetes. To lose excess weight, recommend a balanced,  calorie  controlled meal plan under the guidance of a medical professional.

Slow, steady weight loss is best to avoid complications. Make  small,  gradual  changes  to  food  and  physical  activity  –  it helps  weight  come  off  and  stay  off!

Losing  as  little  as  5%  of  excess  weight  can  greatly  help  control  blood glucose,  blood pressure,  blood  lipids  and  increase  energy.

Gastric bypass is a last resort, but can have amazing improvements. It almost instantly returns blood glucose to normal levels.  For  some  people,  gastric  bypass  surgery  can  lead  to  diabetes  remission.  But it’s not for everyone! Many people still need long term counseling to maintain weight loss

Do I have to eat 3 meals a day, every day?

There  is  not  a  single  “perfect”  meal  pattern,  but  3  meals  a  day  is  great.  3  meals  and  2  healthy  snacks  is good,  too!

Basically, every body is different, and your patients need a meal plan that fits their lifestyle.  Some people eat 6 (smaller) meals per day.  Smaller  meals  eaten  more  often  will  likely  promote  satiety  and  help  keep  blood  sugars  steady, especially  if  they  contain  protein.

Have  patients  do  a  food/activity  log  to  track the  number of  calories  they consume over  a day  and  see  where  adjustments or additional  foods  are  needed.

Should  I  take  my  diabetes  medications  if  I  skip  a  meal?

It depends on the medications and the meal.

Some  diabetes  medications  trigger  the pancreas  to  release  insulin  all  day, so  foods  need  to  be  eaten  to  prevent  low  blood glucose.  Know which medications cause low blood glucose.

Skipping  meals  is  the  quickest  way  to  feel  lousy  both  from  hunger  and  blood sugar  dips.  A  regular  “meal  skipper”  should  talk  with  their healthcare provider  – they might  need  a  different  type  of  diabetes  medication.

Skipping  meals  also  sets  people  up  to  overeat  at  the  next  occasion  (or  choose  less  healthy  foods).  The brain and central nervous system can only burn blood glucose to survive.  The rest of the body can burn fat and muscle.

Should I take vitamins/minerals or other supplements?

It depends  on  the  quality  of  the  diet  and  other  medical  conditions.  Some dietary supplements can affect blood glucose levels.  Specific questions should be addressed to a doctor or dietitian.

People  should  carry  full  list  of  every  over-the-counter  and  herbal  supplement  they  are  taking,  in  addition  to  their prescriptions.

No  matter  what,  remember,  “supplements”  are  not  “substitutes”  for  a  healthy  diet!

Do  I  have  to  cut  back  on  salt  and  salty  foods?

Reducing  intake  to  less  than  2.4 g  sodium/day  should  have  clinically  important  effects  on  blood  pressure.

Most  sodium  comes  from  packaged and restaurant  foods,  not  the  salt  shaker.

Also look  out  for  salt  substitutes  which  often  contain  potassium.  Check with a healthcare provider before using.

The recommended daily allowance is 2300mg sodium, 1500mg for those over 50, or who have hypertension or related conditions.  These are difficult but doable numbers.

Salt raises blood pressure, which raises the risk of heart attack and stroke.  Read labels and use salt substitutes, like herbs, spices, garlic, etc.

Remember  that  meal  planning, medications  and  exercise  all  work  together  to  control  blood glucose  and  cardio-vascular disease  risk.