Carbohydrate is one of the body’s main sources of energy.

Carbohydrate is broken down into glucose relatively quickly and therefore has a more pronounced effect on blood sugar levels than either fat or protein.

This makes awareness of carbohydrate a particular important factor in management of diabetes.

Which foods contain carbohydrate?

Carbohydrate is found, to varying degrees in a wide variety of food, notably in starchy foods such as rice, pasta and flour (therefore including pastry, bread and other dough based foods).

Sugar
is also a form of carbohydrate.

Carbohydrate is generally found in all

fruits and vegetables, however, the amounts of carbohydrate can vary substantially.

Carbohydrate is generally found, at least to some degreen, in all

fruits and vegetables

However, the amounts of carbohydrate can vary substantially with vegetables such as celery having almost negligible carbohydrate whilst potatoes and citrus fruits typically have a higher amount of carbs.

Fruit and vegetables with relatively high carbohydrate content include:

• Potatoes
• Root vegetables (such as parsnips and beetroot)
• Mangoes
• Bananas
• Pears

How much carbohydrate is recommended for diabetics?

The optimum level of carbohydrate consumption for people with diabetes has been one of the hottest diabetic debates in the last few decades.

The recommendation of the Scientific Advisory Committee on Nutrition (SACN) for carbohydrate intake for people with diabetes is

no different

to people without diabetes.

The SACN recommend that 50% of our daily energy comes from carbohydrates. This amounts to about 225 to 300g of carbohydrates for people on a diet of



2,000 to 2,500 calories

The recommendations are typically passed down to patients through the NHS.

However, the

NHS carbohydrate advice
has come under a lot of criticism from those who feel that for people with type 2 diabetes, in particular, the level of carbohydrate intake is too high for many people with diabetes to maintain good blood glucose levels without progressing onto stronger diabetes medication.

Carbohydrate and blood glucose levels

Because carbohydrate directly influences

blood sugar levels, it is important to be aware of how much carbohydrate you are having at each meal.

It is often easy to underestimate exactly how much carbohydrate you’re having, particularly when eating starchy foods such as pasta, rice and potatoes.

Referring to the nutrition information and weighing out certain foods will help you to see how much carbohydrate you are having.

Types of carbohydrate

There are different types of carbohydrate which are broken down quickly or less quickly because of their chemical structure.

• Simple carbohydrates are sugars and are broken down quickly by the body and therefore raise blood sugar levels quickly
• Complex carbohydrates are starches and broken down more slowly than simple carbs and will raise sugar levels more slowly.

Note that eating highly refined starches such as white bread will usually result in a sharp rise in blood sugar levels.

Whole grain foods, which have a greater level of fibre, are a much better choice of starches as the fibre helps to slow down how quickly the food affects your blood sugar levels.

• Read more:
  
  Simple and complex carbs

Carbohydrate and type 1 diabetes

In type 1 diabetes, the amount of insulin you will produce is likely to be either a small or negligible amount. As a result, people with

type 1 diabetes
will need to inject insulin and pay close attention to matching the dosage with the amount of carbohydrate eaten.

To match the insulin dosage with carbohydrate intake as closely as possible, people with type 1 diabetes will need to learn to estimate and count the amount of carbohydrates in each meal.

Correctly estimating carbohydrate content can be a difficult skill to pick up; as a result, a number of carbohydrate counting courses, such as the

DAFNE course, have been developed to assist with carbohydrate counting as well as other key aspects of insulin dosing decisions.

Carbohydrate and type 2 diabetes

People with type 2 diabetes are able to produce their own insulin but are not able to respond to insulin as effectively as people without the condition. This is called

insulin resistance
The body’s natural response is to produce more insulin to help get glucose from the blood into the cells that need it.

Generally, the higher the amount of carbohydrate eaten, the more likely it is that the body will struggle to produce enough insulin. As a result, people with type 2 diabetes on a relatively high carbohydrate diet are more likely either to have too

high blood glucose levels
or to need larger doses of stronger diabetes medication.

There are two main ways to combat and cope with insulin resistance. The primary way is to reduce your body’s need to produce insulin by lowering your calorie intake, including the amount of carbohydrate eaten, and by exercising.

Some people will also require the additional measure of taking

diabetes medication
to ensure sugar levels stay at healthy levels.

Note that the greater your dependence on medication, the greater the extent of medication side effects therefore it’s important to make sure you’re working hard in meeting the first option.

As noted above, the NHS does not generally advise people with type 2 diabetes to go onto a

low carb diet, however, many patients have opted to go for this approach of their own accord.

Carbohydrate and weight gain

When carbohydrates are broken down into glucose within the blood, the body will:

1. Use
   
   insulin
   to help fuel the body’s cells
2. Use insulin to turn any remaining excess of glucose in the blood into fat for storage

Carbohydrates provide energy and therefore if you have too high a level of carbohydrate in your diet this can lead to weight gain.

It is important therefore to ensure you are having an appropriate level of carbohydrate and overall calorie intake to ensure weight gain is prevented.

The amount of calories you need varies from person to person and your doctor and dietitian can help with setting an appropriate level for you personally.

Carbohydrate and high cholesterol

Whilst it is often high fat diets that are most commonly mentioned as being associated with unhealthy

cholesterol
levels, the true cause of blame for high cholesterol is any form of excessively high calorie diet.

Having a high calorie diet, whether that comes from too many carbohydrates or too much fat, will lead to the storageof excess

body fat
as well as the development of high triglyceride and cholesterol levels.

Nutrition is a critical part of diabetes care. Balancing the right amount of carbohydrates, fat, protein along with fibre, vitamins and minerals helps us to maintain a healthy diet and a healthy lifestyle.

Getting the balance right can help the body to stay in prime condition, but what is the right balance of nutrients? People have been arguing over the ideal mix for generations and the discussion still rages today.

For people with diabetes, there is at least one extra consideration for our nutritional needs and that is the question of how our blood sugar levels will respond to different diets.

Macronutrients

The macronutrients referred to in human diets are the three food groups that provide us with energy, namely: carbohydrates, fat and protein. The three major nutrients are more than simply providers of fuel for our bodies.

Fats and protein are both vital for building cells and helping the cells carry out their duties. Each of the macronutrients are versatile allowing the body to break them down into a number of uses.

Carbohydrate can be stored as fat and fat and protein can both be converted into glucose for example.

Read more on macronutrients and their relevance to diabetes:

• 
  Carbohydrates
• 
  Fat
• 
  Fibre
• 
  Protein
• 
  Salt

In addition, we have guides on the differences between carbohydrate types and sugar and fat.

• 
  Simple carbs vs complex carbs
• 
  Sugar vs fat

Read more about

trans fats
and their relation to fats as well as guides to vitamins and supplements:

• 
  Dietary supplements
• 
  Vitamins and minerals
• 
  Vitamin D
• 
  
  Chromium

Micronutrients

Micro may mean small, but micronutrients are far from insignificant. Without a regular supply of micronutrients, our bodies would literally starve.

Micronutrients include all vitamins and minerals we take it i, often without realising, and are an essential part of a diabetic diet.

As an example, celery contains well over a dozen different micronutrients including a number of vitamins, potassium, calcium, iron and more.

If you feel you may be missing out on any particular nutrients, you can arrange to speak with a dietitian who will be happy to discuss your dietary needs.

Don’t forget dietary fibre

Last but not least, there’s also fibre which helps to move food through our digestive system, can help to delay the absorption of carbohydrate and also help us to feel full.

Carbohydrates are sugars that come in 2 main forms – simple and complex. This is also referred to as simple sugars and starches.

The difference between a simple and complex carb is in how quickly it is digested and absorbed – as well as it’s chemical structure.

Most carbohydrates can be broken down by digestion into glucose and these are the carbohydrates we shall look at in this article.

For examples of carbohydrates that do not get fully broken down into glucose, see

insoluble fibre
and

sugar alcohols

Simple carbohydrates

Simple carbohydrates are called simple sugars. Sugars are found in a variety of natural food sources including fruit, vegetables and milk, and give food a sweet taste. But they also

raise blood glucose levels quickly

Sugars can be categorised as single sugars (monosaccharides), which include glucose, fructose and galactose, or double sugars (disaccharides), which include sucrose (table sugar), lactose and maltose.

Many processed foods contain added sugars but currently there is

no UK law that requires manufacturers to state how much sugar has been added in processing

The

NHS advises
adults to consume

less than 70g a day of sugar for men

and

under 50g of sugar a day for women

However, people with diabetes will benefit from better blood glucose levels if sugar intake can be limited to lower levels.

Because sugars provide no nutrition aside from energy (hence why they are often referred to as empty calories), people looking to lose weight will also benefit from eliminating sources of added sugar from their diet.

Note that if you are at

risk of hypoglycemia, never worry about

taking sugar if it is to avoid or treat a hypo

Complex carbohydrates

Complex carbohydrates, also known as polysaccharides, are starches formed by longer saccharide chains, which means they take longer to break down.

Chemically, they usually comprise of three or more linked sugars.

Strictly speaking, the term complex carbohydrate refers to any starches, including the highly refined starches found in:

• White bread
• Cakes
• Most pastries and
• Many other food sources

When dietitians and nutritionists advise having complex carbohydrates, however, they are usually referring to whole grain foods and

starchy vegetables which are more slowly absorbed
than refined carbohydrate.

Whole grain foods

Whole grain starches
include the wheat grain and kernel which provide the majority of fibre and nutrients to be found in starchy foods.

When it comes to picking starchy foods, such as rice, bread and any other products made from flour, it’s best to opt for whole grain versions of these products.

Whilst whole grain foods impact upon blood glucose levels more slowly than other forms of carbohydrate, higher levels of carbohydrate can still raise blood sugar levels substantially.

Blood glucose testing before and meals
is a good way to assess how much carbohydrate your body can adequately cope with.

Refined carbohydrates

Refined carbohydrates refer to carbohydrates that have been processed.

In grain products, the bran and kernel are stripped out, leaving just the starch.

With much of the fibre removed in this way, the carbohydrate is broken down by the body more quickly and can sometimes raise blood glucose levels as quickly as simple sugars.

Simple sugars can also be refined. A prominent example of a processed sugar is glucose-fructose syrup, also known as high fructose corn syrup. Glucose-fructose syrup is corn syrup which has been treated with enzymes to turn a proportion of the syrup’s glucose into fructose.

Sugar and fat are two of the most widely talked about dietary topics, with one of the most commonly asked questions by people with (and without) diabetes being ‘how much sugar or fat can I have in my diet?’

Sugar

Limiting the amount of sugar we take in should be a priority for all people, not just individuals with diabetes.

Sucrose (table sugar) is a major part of some of our favourite daytime snacks like cakes and biscuits, but what many people fail to remember is that sugar is also present in a wide range of other foods.

These include:

• Cereals
• Fruit drinks and smoothies
• Fruit yoghurts
• Ready meals
• Soups

Aside from energy (calories), sugar provides no nutrition which is why it is often referred to as ’empty calories’.

It also increases blood glucose levels quickly, which is one of the reasons why people with diabetes are advised to limit their daily intake of sugar (the NHS recommends consuming less than 70g a day of sugar for men and under 50g of sugar a day for women).

In fact, limiting sugar intake is a good way to start getting your blood glucose levels under control.

Cutting back on the amount of processed foods you eat is also recommended as the majority contain added sugars and in the UK,
manufacturers are currently not required to state how much sugar has been added in processing.

But saying no to sugary foods in an effort to restrict your sugar intake can be difficult, especially if those around you (friends, work colleagues, relatives, etc) often indulge in sweet food and drink.

Sugary snacks such as energy drinks (lucozade) and glucose tablets are used to prevent or treat hypoglycemia, so don’t worry about taking these if you are at risk of hypos.

Fat

For decades, fat has been labelled the ‘bad guy’ in diet and nutrition. However in recent years, a number of research studies have shown that fat is no worse for us than carbohydrate.

In fact,
diets that are low in carbohydrate and high in fat are now widely regarded as being healthier,  particularly in terms of blood glucose control and
weight loss, than low fat, higher carb diet plans.

Fat is the most energy dense nutrient and carries twice as many calories as the
same weight of pure carbohydrate.

While this doesn’t mean you should avoid fat altogether, you do need to be
reasonably aware of how many calories you are taking in when eating high-fat (or fatty) foods such as butter, cheese and cream.

It’s also important to remember that some fats are a lot worse than others. The worst fats are those typically found in processed foods such as ready meals, crisps, pies, cakes and biscuits, so it’s best to limit these foods in your diet.

• For more in-depth information, see our guide on
  Fat and Diabetes

Fat and blood glucose levels

Unlike sugar, fat has little immediate effect on blood glucose levels and this a key reason why
low carb, higher fat diets tend to produce better blood glucose control.

However, it’s important to note that taking in excessive fat, if it leads to an excessive calorie intake, will result in
increased insulin resistance and therefore higher blood glucose levels.

What about low fat products?

Low fat products are a popular option amongst consumers as they tend to have less calories, but it’s not always the case.

Some low fat foods, such as yoghurts, contain significantly more sugar so being ‘low fat’ doesn’t necessarily make it healthier.

Deciding on low fat products also depends on the rest of your diet.

For example, if you tend to eat quite a lot of dairy produce then it may be better to go for low fat dairy options.

Insoluble fibre is the type of fibre that adds bulk to our stools helping to pass solids out more easily.

Insoluble fibres found in our diet include cellulose, hemicellulose and lignins.

Insoluble fibre is important for maintaining good gut health. Good sources of this form of fibre are vegetables, fruit and whole grains.

Health benefits

Insoluble fibre is helpful for the health of our gut in the following ways:

• Promotes movement in the bowel
• Prevents constipation
• May help to reduce the risk of haemorrhoids (piles) and diverticulosis
• Helps good gut bacteria to grow

Which foods contain insoluble fibre?

Good sources of insoluble fibre include:

• Wholegrain foods such wheat bran, brown rice and couscous
• Root vegetables, such as carrots, parsnips and potatoes
• Celery, cucumbers and courgettes
• Fruit with edible seeds
• Beans, pulses and lentils
• Nuts and seeds

In terms of fruits and vegetables, the skins are a particularly good source of insoluble fibre.

Insoluble fibre, bowel movements and constipation

The bowel is a muscular organ that contracts to move contents through.

Insoluble fibre helps by adding bulk and moisture to stools which makes it easier for the bowel to steadily push its contents through and therefore helps to prevent constipation.

Because insoluble fibre helps to give stools moisture, it is important to drink the recommended intake of fluids, which in the UK is 6 to 8 cups, or around 1.2 litres, of non-alcoholic fluid.

Insoluble fibre, haemorrhoids and diverticulosis

Haemorrhoids, also known as piles, is a swelling of tissue in the rectum or anus which can be caused by persistent constipation.

Having to regularly strain to pass solids can put excess pressure on the blood vessels close to the anus, causing the area to become swelled.

Diverticulosis is when bulges form on the inside of the colon (large intestine) and cause bacteria to get trapped and can result in symptoms such as feeling sick, having a high temperature and rectal bleeding.

Having a diet with an adequate source of insoluble fibre can reduce problems associated with diverticular disease.

Insoluble fibre and gut bacteria

Our gut contains helpful bacteria which are essential for the health of our digestive system.

Helpful gut bacteria play a key role in helping to digest food for energy and promoting immune health.

• Gut inflammation: Blastocystis ST7 metabolism can trigger gut disease
• Microbiome: small changes in sleep patterns linked to harmful gut bacteria
• Weight gain triggered by toxic substances from gut

Gut bacteria feed off insoluble fibre and so this form of fibre is needed to help maintain a healthy level of helpful gut bacteria.

Insoluble fibre and blood glucose levels

People with diabetes will want to strike a balance between having food with a good source of insoluble fibre and keeping blood glucose levels stable.

Some good sources of insoluble fibre such as potatoes and whole grain foods are relatively high in carbohydrate so should be eaten in moderation, particularly if after meal blood glucose levels are consistently too high.

Generally speaking, non-starchy vegetables and fruits with lower carbohydrate content are a good way of getting insoluble as well as soluble fibre into your diet whilst not raising blood sugar levels too high.

Non-starchy vegetables are particularly good for people looking to lose weight.

A Nutrition Facts label will appear on most packaged foods, allowing shoppers to make healthy food choices when purchasing items.

However, knowing what to look out for is important in enabling you to select the right foods that offer the most health benefits.

Daily Value percentages

If a food has a Daily Value of 20 per cent for vitamin A, for example, this has 20 per cent of the amount of vitamin A you should consume in a day.

When comparing foods, you should aim for foods that have certain nutrients, while limiting others.

Carbohydrate and calorie values are of particular importance to gauge how much different foods are likely to affect our blood sugar levels.

Take the

carbohydrate value
into account rather than the sugar value, however, as if a product does have a high sugar value, that’s a good indication that the product is likely not purchased.

When picking starchy products, compare different products and aim to pick those with a lower carbohydrate value and higher fibre value.

Serving sizes

Nutrition labels will show nutrition either per 100g or, if fluid, per 100ml. Some nutrition labels may also give values per serving, in which case you make sure to check though how large each portion size is.

Some packaging may list a smaller serving size than you intend to have.

Some labels may require some calculation to work out how many carbs and calories are in a portion but you can use the ‘per 100g’ figure to compare similar products to see how the carbohydrates vary.

Be wary, when assessing a nutrition label, to ensure you know how much of the food product is being referenced when totalling values such as carbohydrates or calories.

Reduce your calories

Everyone should look to reduce their calorie intake when eating, but this is especially important if you are looking to
reduce your BMI reading

The calories section of a Nutrition label can help you manage your weight by displaying calorie content.

As a general guide, a low calorie meal is considered as one with 500 calories or less when all parts of the meal are accounted for.

Soluble fibre is a form of water soluble carbohydrate that can’t be digested by the body.

Soluble fibre dissolves in water which can have beneficial effects on digestion,

metabolism

and longer term health.

Soluble fibres in our diet include pecti, psyllium, beta-glucans and gums such as guar gum.

Which foods contain soluble fibre?

Good sources of soluble fibre include:

• Oats
• Fruits and berries, particularly apples, strawberries and blueberries
• Nuts and seeds
• Beans, pulses and lentils
• Vegetables

Health benefits

When soluble fibre interacts with water it forms a gel. In this gel form, the emptying of the stomach, the passage of digestion and the absorption of glucose are slowed.

• Delays emptying of the stomach
• Slow down digestion
• Helps you feel fuller
• Reduces
  
  visceral fat
  
• Improves blood
  
  cholesterol levels
  
  and heart health
• Improvement in
  
  blood glucose levels
  

Soluble fibre and blood glucose levels

Research studies have found that even modest increases in soluble fibre intake helps to lower blood glucose levels.

The fact that soluble fibre could help improve blood glucose in two ways.

The slowing down of passage through the digestive gives digestive hormones more time to act and by forming a gel with water, soluble fibre prevents carbohydrate from being so quickly absorbed by the

small intestine

Research published in the New England Journal of Medicine in 2000 compared a moderate fibre diet (24g of total fibre including 8g of soluble fibre) with a high fibre diet (50g of total fibre including 25g of soluble fibre) over 6 weeks.

The high fibre diet saw a reduction in pre-meal blood glucose levels by 0.7 mmol/l compared to the moderate fibre diet as well as reducing triglyceride levels and post meal blood glucose levels.

Soluble fibre and cholesterol

Soluble fibre also helps to reduce levels of LDL cholesterol, the so-called bad

cholesterol

Research has found that soluble fibre in the diet results in bile being excreted from the body. Bile is produced from cholesterol and bile acids.

When more bile is excreted and therefore less bile is reabsorbed by the body, it can therefore help to regulate cholesterol as the body uses cholesterol from the blood to synthesise more bile.

Studies have that people with type 2 diabetes taking a 14g a day of psyllium for 6 weeks had reduced their LDL (bad) cholesterol by 9% and their total cholesterol by 7%.

Soluble fibre, appetite and weight loss

Soluble fibre has been shown to delay emptying of the stomach and slowing down the absorption of energy from foods. These digestion slowing effects also significantly delay the release of the appetite stimulating hormone ghrelin.

All of these effects help you to feel full and satisfied for longer which can help towards

weight loss

and weight management.

Soluble fibre and type 2 diabetes prevention

In addition to suppressing appetite and helping to lose weight, soluble fibre could help to decrease the likelihood of insulin resistance.

Insulin resistance

is when the body no longer responds effectively to its own insulin and if this is persistent, type 2 diabetes can develop.

Insulin resistance is known to develop in people that have higher than normal levels of fat around the abdominal organs such as the liver,

pancreas

and the gut. This form of fat is known as visceral fat and has different properties to subcutaneous fat, the fat under our skin.

A

study published in 2011

and carried out by researchers at Wake Forest Baptist Medical Center, showed that higher intakes of soluble fibre resulted in decreased accumulation of in visceral fat.

Protein is one of the three main energy providing macronutrients, along with carbohydrate and fat. It helps the body to grow new tissue, therefore helping to build muscle and repair damage to the body.

Protein is also a constituent part of each cell of our bodies and makes up approximately a sixth of our body weight.

Protein and blood glucose

In addition to helping the body grow, protein can also be broken down by the body into

glucose
and used for energy (a process known as gluconeogenesis).

Protein can be broken down into glucose by the body and the effects are more likely to be noticed if you are having meals with less carbohydrate.

Protein is broken down into glucose less efficiently than

carbohydrate
and, as a result, any effects of protein on blood glucose levels tend to occur any where between a few hours and several hours after eating.

People with

type 1 diabetes, or

type 2 diabetes
on insulin, may need to bear the effects of protein in mind if having a largely protein based meal. It’s best to learn how your sugar levels react to such meals so that you can judge the right insulin requirements.

How much protein should I be eating?

The UK Food Standards Agency has a sliding scale for recommended protein intake, varying by age:

• 
  1 to 3 years:
  
  15g
• 
  4 to 6 years:
  
  20g
• 
  7 to 10 years:
  
  28g
• 
  11 to 14 years:
  
  42g
• 
  15 to 18 years:
  
  55g
• 
  19 to 50 years:
  
  55g
• 
  Over 50 years:
  
  53g

Some diets, such as the Zone diet, advocate eating an amount of protein in proportion to your lean body mass (body weight minus body fat).

Can protein be bad for you?

A number of studies have found there to be correlations between intake of red meat and the development of

type 2 diabetes
and cancers (including lung cancer liver cancer and notably bowel cancer).

The studies found that if people were consuming processed red meat the chances of developing these illnesses were significantly higher.

Having a particular excess of protein in the diet, particularly in combination with

alcohol, could potentially lead to problems such as gout.

Although red meat has been linked with health problems, the increase in risk is not so great to advise people to avoid it altogether.

However, looking for good quality, fresh red meat rather than processed meat is recommended.

Protein and kidney damage

Kidney damage (

diabetic nephropathy
) is a complication that can affect as many as 40% people with diabetes. Kidney damage in diabetes can be diagnosed by

testing for ketones
– the presence of protein in the patient’s urine.

People with diabetes who have, or are at risk of, kidney damage may be advised to lower their consumption of protein.

Which foods containing protein are best to eat?

Oily fish and lean meats, such as skinless chicken and turkey, are often recommended for a

diabetic diet

As noted above, with red meat, it’s best to look for fresh and unprocessed cuts where possible. Another good source of protein is vegetable protein as found in beans and other legumes. Nuts are another good source of protein.

Salt has a rich history, having been frequently regarded as a much valued mineral. Salt in the diet is needed but research indicates that the UK population’s average reliance on

processed foods
may have increased our salt intake to excessive amounts.

We take a look at which foods are high in salt, what the health benefits and risks associated with salt are and how you can help to control how much salt you consume from day to day.

Health benefits of salt

Intake of salt is vital for the human body and helps with the following:

• Regulating water levels in the body
• Maintaining normal pH of blood
• Transmission of
  
  nerve signals

The body requires a regular intake of salt and many foods provide a source of salt. The mineral cannot be produced by the body but it does get excreted, meaning we do need to consume some salt each day.

There is debate as to how damaging high levels of added salt are but it is generally recommended to be aware of levels of salt in the food you eat and to use table salt in moderation. See below for some of the health risks associated with salt.

Recommended intake of salt

The Department of Health recommends we eat

no more than 6g

of salt a day, which is equivalent to one teaspoon of salt across the day.

Some foods will state how much sodium is in food rather than saying how much salt. If the packaging quotes the amount of sodium, this needs to be multiplied by 2.5 to get the equivalent amount of salt.

Currently, the average person in the UK consumes around 9g of salt per day.

Which foods are high in salt?

Processed foods, which includes

store bought bread
, are particularly rich sources of salt. Foods which are high in salt include:

• Ready meals
• Soup
• Bread
• Breakfast cereal
• Pre-made sauces – such as pasta sauces
• Pizza
• Pies and pastries
• Cheese
• Gravy granules
• Baco, ham and salami
• Prawns and salted fish

Salt and high blood pressure

Salt has been linked with raised blood pressure levels.

The

DASH diet
study, published in 2011, was a 30 day trial that showed that a low sodium diet decreased average blood pressure levels.

High blood pressure
is linked with a 3 times higher risk of heart disease and stroke. Blood pressure is particularly important for those of us with diabetes as high blood pressure also increases the risk of microvascular complications such as retinopathy, nephropathy (kidney disease) and neuropathy (nerve damage).

Salt and stomach cancer

The World Cancer Research Fund states that research indicates a link between diets high in salt and an increased risk of stomach

cancer, with salt accounting for 14% of UK stomach cancer cases.

How can I reduce the amount of salt in my diet?

The World Cancer Research Fund reports that 75% of the average person’s salt intake comes from processed foods. Reducing any reliance on

processed foods
is therefore the best way to reduce your salt intake.

Cooking at home tends to be the best way to control how much salt you take in and has additional health advantages as the nutritional value of home cooked meals is usually significantly higher than from pre-prepared foods.

Is table salt or sea salt best?

Advantages of table salt include:

• Fine
• Free flowing
• Usually cheaper

Advantages of sea salt include:

• Less processed
• May not include any anti-caking agents (check the packaging)

Sodium ferrocyanide and potassium ferrocyanide are frequently used as anti-caking agents in table salt in the UK. Sodium and potassium ferrocyanide are stable compounds. Research into the effects of sodium ferrocyanide on rats has shown that it can cause

kidney damage, albeit it at significantly higher doses than would be found in human diets.

In March 2016 the government announced that a tax on

sugary soft drinks
would be introduced in the UK from 2018. Long-time campaigners rejoiced at the news as former chancellor George Osborne declared the government was committed to tackling rising rates of

obesity
and

type 2 diabetes

The levy will

tax the soft drinks industry
for total sugar content over 5g per 100ml and apply to drinks such as Coke, Red Bull and Irn Bru. It is estimated to raise around £520 million a year, which will be spent on increasing funding sport in primary schools.

But the road to the 2018 UK sugar tax was not easy. Doctors, campaigners and scientists had remained frustrated for years that their calls for a sugar tax were ignored by the government, and before Mr Osborne’s announcement in March 2016 it appeared that their pleas were going unheard.

Doctors and scientists unite

In July 2015 the British Medical Association (BMA)

urged the government
to introduce a 20 per cent tax on sugar, saying it would combat escalating rates of obesity and type 2 diabetes. The report was well received by sugar tax campaigners such as Action on Sugar and celebrity chef Jamie Oliver.

Just two weeks later a University of Cambridge study highlighted why a sugar tax could be so beneficial. Their researchers discovered that 8,000 cases of type 2 diabetes a year were

linked to sugary drinks consumption

We then investigated

how a proposed sugar tax would work
in the UK and whether, politically, it would be justifiable in implementing.

At this point, Mexico was having great success with its sugar tax: sales of sugary soft drinks had been reduced by six per cent in its first year.


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But in late-2015 it didn’t seem that the UK government had any intention of introducing anything similar.

David Cameron responded to a Public Health England (PHE) report calling for measures to tackle obesity by saying there were ”

more effective ways of tackling obesity
” than a sugar tax.

But the concept kept generating more support, with more and more global organisations getting involved. In November 2015 the International Diabetes Federation (IDF) added their backing

for world leaders to use sugar taxes
in fighting obesity and type 2 diabetes.

The turn of 2016 further put pressure on the government. Queen Mary University scientists in London concluded that

reducing sugar in soft drinks by 40 per cent over
five years could prevent 300,000 cases of type 2 diabetes and 1.5m cases of obesity in the UK.

While the studies came thick and fast, the government backtracked,

delaying its childhood obesity strategy
and tentatively suggested that a sugar tax was unlikely to be included.

The delay was described by “unacceptable” by campaigners as the government rescheduled its long-awaited strategy for the summer of 2016.

The sugar tax is announced

It came as a surprise to many when Mr Osborne included a planned sugar tax as part of the 2016 Budget in March.

Speaking at the House of Commons, Mr Osborne said: “I am not prepared to look back at my time here in this Parliament, doing this job and say to my children’s generation ‘I’m sorry. We knew there was a problem with sugary drinks. We knew it caused disease. But we ducked the difficult decisions and we did nothing’.”

It was revealed that manufacturers of soft drinks will be taxed on the volume they produce or import. Drinks will fall into two bands: one for total sugar content over 5g per 100ml, and a second band for drinks with more than 8g per 100ml.

The tax will not directly affect consumers, but some people with diabetes were left wondering if it meant hypo treatments such as Lucozade would become more expensive. We looked at the

maths behind the tax
and sought to assuage the diabetes community regarding the levy’s cost implications.

Launch of the childhood obesity strategy

Theresa May’s appointment as the new prime minister in July, which made her the

first ever world leader with type 1 diabetes, saw the childhood obesity strategy sped up.

It was finally launched in August, but received vitriol from critics who called the strategy

“weak” and “embarrassing”
A major criticism was the introduction of a voluntary target for the food and drink industry to reduce sugar in products by 20 per cent, which was deemed “pointless”.

“Although the government proposes targets for food companies to reduce the level of sugar in their products, the fact that these are voluntary and not backed up by regulation renders them pointless,” said Professor Parveen Kumar, the BMA board of science chair.

The strategy was also censured for failing to include a ban of junk food promotions in supermarkets and restricting junk advertising to children through television – two measures previously recommended by PHE.

Later in 2016, the Committee on Advertising Practice (CAP) eventually announced that a ban for online junk food adverts targeting children would be

introduced in July 2017

Looking ahead to 2018

The soft drinks industry already seems to be mobilising towards 2018 preparations, with PepsiCo announcing in October 2016

that their most sugary drinks
will have reduced sugar by 2025.

The potential approaches of the soft drink industry formed the core of a study published by University of Oxford researchers in December 2016 that

predicted the effects of the 2018 sugar tax

The research team assessed realistic better and worse scenarios using modelling of three possible levy reactions: reformulating drinks to lower sugar content, raising the price of sugary drinks and encouraging consumers to switch to lower sugar drinks.

They theorised that all possible reactions would significantly reduce the number of people who become obese and improve the health of children, resulting in fewer cases of type 2 diabetes and less incidences of tooth decay.

As 2016 came to an end, the World Health Organisation (WHO)

released a report
further stressing the importance of sugar taxes in improving worldwide health.

Along with protein and carbohydrates, fat is one of the main macronutrients. Unlike carbohydrate, and to a small extent protein, the fat we eat does not directly raise our

blood sugar levels, whether we have diabetes or not.

Fat is needed by the body for providing energy, keeping hair and skin healthy, helping our cells to function properly and for protecting our body and organs.

Which food is fat found in?

Fats are found in a range of foods which include nuts, avocados, beans, fish, meat, milk, cheese and other dairy products.

Fat is also used in the frying of foods and within processed foods including crisps, cakes, pastries and other bakery foods.

What are good and bad fats?

Good fat has typically been used to describe unsaturated fats that are found in nuts, avocados, oily fish, and oils such as sunflower and olive oil.

Saturated fats
are often referred to as ‘bad fats’. Saturated fat is frequently found in less healthy foods such as crisps, chips and muffins but they are also found in meats, butter and other dairy.

The terms good and bad fats are a crude simplification and there is significant debate within nutrition research about which fats deserve to be termed ‘bad fats’.

In 2014, research from the University of Cambridge showed that the saturated fats found in dairy conveyed a lower risk of insulin resistance and type 2 diabetes than starchy foods.

What are trans fats?

Trans fats can be naturally occurring (in relatively tiny quantities) but generally refers to ‘man made’ fats that have been hydrogenated to chemically change the structure of the fat molecules.

Trans fats have been around for decades but in recent years they have come under scrutiny as they can be dangerous to health if consumed in too high quantities.

• Read more on
  
  trans fats

Diabetes and low fat diets

The

advice of the NHS
is for people to reduce the amount of fat, and particularly saturated fat, in their diet.

The low fat approach has been strongly recommended for people with diabetes.

However, low fat diets have come under a certain amount of criticism in that low fats diets often require a relatively high amount of carbohydrate in the diet which can lead to

overproduction of insulin
and could therefore lead to increased hunger through the day, weight gain and increased health problems.

Deficiencies of vitamins
A and D in low fat diets, which help to prevent the development of osteoporosis, has also been a criticism of the diet.

Fat and cholesterol

When discussing the fat we eat and cholesterol, it is important to recognise the different types of fat as well as the

different types of cholesterol

There are two different forms of cholesterol, LDL (low density lipoproteins) and HDL (high density lipoproteins). Whilst both forms are essential for the body, having either high levels of LDL or low levels of HDL is associated with higher risks of heart disease. For this reason, LDL is often referred to as bad cholesterol and HDL as good cholesterol.

An additional form of blood fats are triglycerides. High triglyceride levels are linked with higher rates of heart disease and other complications so any lowering of triglyceride levels is beneficial.

Saturated fats

Saturated fat can raise levels of both LDL and HDL. The type of foods you consume can make a difference though.

A low carb, high fat diet with a strong intake of vegetables is usually associated with beneficial effects on cholesterol, such as raised HDL levels and lower triglyceride levels.

Diets with a

high amount of saturated fat
coming from processed food such as chips, cakes and biscuits, however, are linked with poorer cholesterol levels and higher triglyceride levels.

Unsaturated fats

Unsaturated fat from nuts and avocados (the fats termed good fats) help to increase levels of HDL (good cholesterol).

HDL has a key role in helping to remove LDL from

healed artery walls
and back to the liver. HDL (good cholesterol) can therefore help to prevent LDL cholesterol from blocking arteries.

For this reason, it is believed to be beneficial to include foods with unsaturated fats, such as nuts, avocados and oily fish within one’s diet.

Dietary fibre, also known as roughage, is the general term for a range of different carbohydrates found in the diet which are not digested by the body.

The

2 main types of fibre

are.

• 
  Soluble fibre
  – fibres which dissolve in warm water
• 
  Insoluble fibre
  – fibres which don’t dissolve in warm water.

Plant foods usually contain both soluble and insoluble fibre, albeit the proportions can vary quite significantly between different plant foods.

For example,

whole grain foods
are particularly high in insoluble fibre, whereas say

fruits
such as apples tend to be higher in soluble fibre.

Recommended fibre intake

The Department of Health recommends that most of us should have 18g of fibre a day.

The NHS notes that in the UK, the average person only has

14g of fibre

daily, meaning that most of us fail to meet the recommended intake of fibre.

The increased demand for

processed and ready-made foods
in place of home cooked meals, in recent decades, offers an explanation for the lower than recommended intakes of fibre amongst the UK population.

How is soluble and insoluble fibre different?

Soluble fibre binds with water to form a gel and this has been shown to have beneficial properties in slowing down digestion and the absorption of energy from the food.

The way soluble fibre behaves has benefits for lowering cholesterol,

improving blood glucose levels, reducing appetite and improving heart health.

Insoluble fibre, which does not dissolve in water, also plays a necessary role in helping matter to move through the gut efficiently, helping to reduce bowel problems such as

constipation, haemorrhoids and diverticulosis.

Low fibre intake and type 2 diabetes risk

Research has found that low intake of fibre has been linked with higher rates of

type 2 diabetes
A Harvard study of healthcare professionals found that diets with a higher intake of cereal fibre was associated with a lower incidence of type 2 diabetes.

Whilst fibre intake is just one of many factors that has been linked with the risk of developing type 2 diabetes, the benefits of dietary fibre show it to be an important part of diet that can help to improve overall health in a multitude of ways.

How can I increase my fibre intake?

Eat plenty of vegetables. The Department of Health advises us to eat least 5 portions of vegetables and fruit each day. Generally speaking, beating rather than meeting the daily target is recommended. Note that in terms of meeting vegetable targets, potatoes do not count towards the targets.

If you’re buying starchy foods such as rice, bread or pasta, look for those with higher amounts of fibre per 100g. Foods listed as

whole grain
should usually be good picks but checking the nutritional value per 100g tends to be the most reliable way of ensuring you pick a high fibre option.

The NHS recommends increasing fibre gradually as sudden increases in fibre could lead to stomach cramps and bloating in the short term. If increasing your daily fibre intake, ensure you

keep yourself hydrated
It is recommended to have around 1.2 litres of fluid a day, which is about 6-8 mugs or glasses a day.

Fibre supplements

Generally speaking, it’s best to meet the fibre intake recommendations with a combination of vegetables and whole grains, as these will provide a range of nutritional benefits in addition to the fibre they contain.

However, some people with specific dietary needs may wish to or need to take fibre supplements. Fibre supplements may be soluble fibre based, insoluble fibre based or a combination of the two.

Fibre supplements may be based on one or more the following fibres:

• Psyllium
• Inulin
• Guar gum
• Flax
• Cellulose

If you are

taking supplements, it is recommended to drink adequate fluid and you may find you need to drink slightly more than the recommendation of 1.2 litres of fluid a day.

Common side effects of fibre supplements include bloating and flatulence and it may be advisable to introduce fibre supplements gradually to reduce such side effects.

Sugar has become perhaps the most discussed dietary issue in recent years with more and more research studies linking the effects of sugar to greater risks of obesity and

type 2 diabetes.

Statistics show that most of us in the UK are consuming more sugar than is good for our health.

Many of us are unaware that starchy foods like bread, rice or potatoes are broken down by digestion into surprisingly large amounts of sugar; a small slice of wholemeal bread is equivalent to three spoonful’s of sugar. It’s important therefore that your diet does not contain too much carbohydrate either.

A major cause of this has come from the high amounts of sugars added to a wide range of

processed foods.

Sugar has extra relevance to people with diabetes as sugar has a formidable effect in raising blood sugar levels.

Sources of sugar

Sugar in the diet can be found in 3 forms. Sugar can be:

• 
  Natural
  
  – as found in fruit and honey
• 
  Added
  
  – as found in biscuits or cereals
• 
  The product of the digestion
  
  
  of more complex carbohydrates
  
  (e.g. bread)

There are natural sugars found in

fruit, milk based products and vegetables.

Added sugars, also called free sugars, refer to the sugars that are added to a whole range of processed foods and drinks, including microwave meals, pasta sauces, breakfast cereals, sweetened drinks and desserts.

Sugar and type 2 diabetes

Sugar is a form of carbohydrate that will quickly affect your blood sugar levels if you have diabetes. All

carbohydrate
raises blood glucose levels and sugar has a very quick effect.

It is therefore important not to have too much sugar in your daily diet.

‘Sugar diabetes’

Type 2 diabetes was once referred to as

sugar diabetes

– because sugar is at the heart of the problem.

For somebody with diabetes, it is the total

sugar burden

from any of the three sources (natural, added or as a product of the digestion of complex carbohydrate) which need taking into account to keep blood glucose levels low.

Don’t worry, reducing sugar intake

reduces

the likelihood of needing medication and diabetes-related complications.

Research has shown a close association between sugar intake and development of type 2 diabetes. The more sugar in the

diet, the higher the risk of type 2 diabetes.

This doesn’t mean that your type 2 diabetes has necessarily been caused by eating too much sugar although sugar intake is one of the most important factors.

Others include

stress,

lack of exercise
and a

genetic predisposition.

Added sugar – why is it a worry?

All age groups are currently consuming more added sugar than the recommendations according to the National Diet and Nutrition Survey which is carried out by Public Health England.

Added sugars have become a real problem because most of us aren’t aware of just how much sugar we are taking in when having what many of us consider everyday foods.

Is there a recommended maximum added sugar intake?

The Scientific Advisory Committee on Nutrition (SACN), which advises the government on nutrition guidelines, recommends the following limit for added sugars in the diet.

For reference

: 4 grams of sugar is equal to a teaspoon of sugar.

Sugars are being added to a huge range of foods from bread and hams to more obvious foods such as cakes and biscuits.

The sugar makes food designed to have a long shelf life more palatable but this is having a negative effect on health of those of us that are living off these foods.

Most of us will be aware of more obvious sugary, such as

sugary fizzy drinks, cakes and biscuits but there are also other foods which contain a lot of sugar that may not be immediately obvious.

Three different sources of sugars that make up our total dietary ‘sugar burden’; shown as 4g teaspoon of table sugar equivalents:

Note:

as each food would effect blood glucose, from the International tables of

glycaemic index
and glycaemic load (Atkinso, Foster-Powell et al. 2008) as per the calculations in a paper submitted to The British Journal of Obesity ‘It’s the glycaemic response to, not the carbohydrate content of food that matters in diabetes and obesity: The glycaemic index revisited.’ D J Unwin et al.

What is not so well known is that starchy carbohydrates such as bread, rice potatoes or pasta are broken down by digestion into surprising amounts of sugar. This means that just avoiding sugar itself may not always be enough. This is why recent government (NICE) guidelines ‘encourage high-fibre, low glycaemic index sources of carbohydrate in the diet’.

Why is sugar bad for us?

Sugar provides energy but has no other nutritional value. Sugar is therefore often referred to as empty calories.

Sugar raises blood glucose levels quickly and requires insulin to be produced (or taken by injection) as high blood glucose levels over time cause damage. Insulin causes the cells of your body to take up the free glucose in your bloodstream. So having too much sugar means having or needing

more insulin

As many of the cells taking up glucose are fat cells, insulin itself can give rise to weight gain and the development of

insulin resistance, the hallmark of type 2 diabetes.
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Many people find that sugar has addictive qualities meaning that we may crave sugary foods even if we know they’re not good for us.
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Health problems connected with sugar

Sugars, and particularly the problem of added sugars, have been linked with increased risks of the following health problems:
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• 
  Weight gain
  and
  
  obesity
• 
  Type 2 diabetes
• 
  Tooth decay
• 
  Heart disease

How to cut down on sugar

The good news is that reducing sugar intake reduces the likelihood of needing medication and diabetes-related complications.

Cutting back on all sources of sugar is a great strategy to stay healthy.

• Cut down on sugary drinks – non-diet versions of cola, lemonade, tonic water
• Swap
  
  fruit juices
  for water and whole fruit
• Replace sugary cereals with plain porridge, whole grain cereals or
  
  lower carb breakfasts
• Avoid having ready meals, tinned meals on a regular basis
• Make your own pasta or curry sauce – you can make larger portions and freeze what you don’t need for a future meal
• Get into the practice of having fruit instead of sugary snacks or desserts
• Don’t have takeaways more than once a fortnight

Dietary supplements are products that can help us get the right balance of important nutrients in our diets.

Some dietary supplements may perform another function such as helping with digestion.

They are designed to supplement a

diet, and should not be used as a replacement for

healthy foods
which provide a rich, natural source of essential nutrients.

Currently there is insufficient scientific evidence to suggest that any dietary supplements can help prevent or manage diabetes unless there is a known deficiency.


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It’s best to consult your doctor before taking a supplement to ensure it will be appropriate and to prevent side effects from occurring or any interactions with medication you are currently taking.

What are dietary supplements?

A dietary supplement, also known as a food supplement or nutritional supplement, is intended to provide nutrients which may include:

• Vitamins
• Minerals
• Amino acids
• Omega-3 fatty acids
• Fibre
• Digestive enzymes

They are available in various forms, including tablet, capsule, powder and liquid.

Dietary supplements are appropriate for people who have a clinical need for them This may include nutrient deficiencies or if people have a condition that requires supplements to compensate.

Supplements and diabetes

There are currently no supplements that have been shown to directly benefit diabetes.

Several studies have assessed the benefits of dietary supplements for diabetes management but none have conferred strong benefits.


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It is therefore recommended that supplements are only taken if there is a clinical need for them such as a nutrient deficiency.

In some cases, supplements may lead to side effects or drug interactions.

There has also been research into several herbs, spices and other plant-based supplements to see if they can help people with diabetes. These include:

• 
  Aloe vera
• 
  Bitter melon
• 
  Cinnamon
• 
  Fenugreek
• 
  Ginger

Whilst some studies have shown benefits, the evidence to date is lacking in reliability and more studies will be required to confirm benefits.

For more information on plant-based therapies take a look at our guides on

vitamins and minerals
and

herbal remedies for diabetes

Are there any precautions I should take before using supplements?

Many dietary supplements contain active ingredients that can make them unsafe and harmful in some situations. Not all supplements have proven health benefits and even ‘natural’ supplements can be risky, particularly if you have an existing medical condition such as diabetes.

So before using any supplement you must first check with your GP to ensure it is safe to take alongside any prescribed medication you’re on.

You should also:

• Read trustworthy information about supplements
• Be wary of supplements which sound too good to be true – e.g. those which claim they can “treat or cure diseases”
• Avoid substituting prescription medicines for supplements
• Avoid taking a bigger dose than the label recommends
• Stop taking a supplement if you experience side effects

Diabetic neuropathy

Certain supplements, such as vitamin B12, have been investigated as a potential treatment for diabetic neuropathy (nerve damage), a common complication among people with diabetes.

This is because neuropathy is often associated with a vitamin B12 deficiency.

However, researchers have not found any significant evidence that vitamin B12 supplementation can lessen the symptoms of neuropathy.


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Safety precautions and supplements

Some dietary supplements contain active ingredients which can make them unsafe and harmful for some people.

Certain supplements can be particularly risky if you have an existing medical condition such as diabetes.

You should check with your GP to ensure it is safe to take supplements alongside any prescribed medication you are receiving.

• Never substitute prescription medicines for supplements
• Never take a bigger dose than the label recommends
• Read up on the side effects of supplements
• Stop taking a supplement if you experience side effects
• Be wary of supplements which sound too good to be true – e.g. those which claim they can “treat or cure diseases”

Supplements and hypoglycemia

If you have diabetes and take medication that can cause

hypoglycemia
(low blood sugar), such as insulin, glinides or sulphonylureas, then some supplements might not be suitable for you.

These include

fenugreek, a supplement that may lower blood sugar levels by slowing down digestion and absorption of carbohydrates.

Your diabetes healthcare team will be able to advise you on the safety/risks of a particular dietary supplement.