The number of persons with diabetes — estimated at 20 million with nearly a third undiagnosed — is growing at an accelerated rate. The number of “prediabetics” (persons with elevated glucose levels not yet to the level of active diabetes) is estimated at 5 to 7 million and also increasing. These numbers are expected to double by mid-century.
If the numbers are correct, and most experts agree they are, the population of persons with diabetes will continue to increase exponentially. Manufacturers of food products for this important demographic, although long aware of this, still find themselves working full speed to keep up.
Taken together with the population of persons having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), this is a market segment food manufacturers ignore to their peril.
Discussions of diabetes focus on carbohydrate metabolism. Carbohydrates exist in a few basic forms — simple and complex — but infinite variety. Simple carbohydrates consist of one or two sugar units. Glucose is the sugar in blood.
Two glucose units linked together compose maltose, the sugar of sprouted grain. Glucose linked to fructose is sucrose, the sugar in sugar cane that we extract and refine for table sugar. Complex carbohydrates, the starches of grains, beans, and potatoes, are chains of glucose links, either straight or branched.
The difficulty is that these chains, which break up during digestion, may be changed by processing before consumption. When starch granules are heated in a moist environment, the granules swell and break apart.
When starches are processed under the high temperatures and dry conditions characteristic of baking and frying, they break down into smaller chains and are handled by the body more as sugar. The addition of acids and enzymes further trigger the breakdown of starch to sugars, either when processed into syrups and sweeteners, or during digestion.
Foods containing complex carbohydrates are best prepared by steaming or boiling (where temperatures don’t exceed 212˚F). This keeps the complex carbohydrates from breaking into small chains before being consumed.
Fiber, also a carbohydrate, is associated with reduced diabetic symptoms (when fiber content of the diet is high). Kathleen Ellwood, of the Center for Food Safety and Applied Nutrition, confirmed the FDA is studying petitions recommending nondigestible fiber be removed from the carbohydrate portion of the nutritional label, making it clearer for persons with diabetes that fiber does not raise blood sugar levels.
Sugars require insulin to aid their entrance into muscle or fat cells. Normally the insulin is produced by specialized pancreatic cells. In type I diabetes, these cells are damaged and insulin must be taken either orally, by injection or through a small automatic pump. Measuring the proper amount of insulin needed makes the difference between regulated and uncontrolled diabetes with all its dangerous side effects, including kidney failure, blindness, and amputation.
In type II diabetes, the muscle and fat cells are resistant to the effects of insulin. This form of diabetes can generally be controlled by diet and exercise, without the necessity of added insulin.
Persons with diabetes must be able to accurately gauge their food intake to keep their blood glucose regulated. Those who successfully manage their condition with diet and exercise are must be aware of the content, component amounts and types of foods they eat. This demands accuracy in label statements.
Controlling Blood Glucose
Controlling blood sugar in diabetes involves monitoring the types and amounts of food eaten. This holds true even for persons taking insulin on a regular schedule or via automatic pump. Monitoring the glycemic index of foods is another system used by persons with diabetes to control blood glucose. Glycemic index is a rating system based on the concept that different carbohydrates raise blood glucose by different amounts.
The GI system was developed by Jennie Brand-Miller, PhD, of the University of Sydney, Australia. According to Brand-Miller, GI helps consumers tell how a food will affect blood sugar. Foods with a high index are believed to raise blood sugar and should be eaten in small amounts. A GI of 70 or greater is high, a GI of 56 to 69 intermediate and a GI of 55 or less low. (To learn more about the glycemic index, check out “GI Blues” on the Wellness Foods web channel at www.foodprocessing.com.)
During deliberations, the 2005 Dietary Guidelines Advisory Committee (DGAC) evaluated the utility of the glycemic index, which they defined as the overall health significance of glycemic response to carbohydrates and the contribution of “added sugars” to human health.
The committee did not find GI to be a useful tool for the average American, primarily because it is only one factor among many describing the nutritional value of a food and may eclipse other values such as fat, fiber or energy content.
Another system of monitoring is Glycemic Load, which adds the information about the quantity of carbohydrate to information about the response to a specific carb. If a food has a high GI, but there isn’t a lot of that particular food in a mix, the glycemic load is relatively low. A GL of 20 or more is high, a GL of 11 to 19 is intermediate, and a GL of 10 or less is low.
Carb counting is another, more basic method of monitoring carb intake. Based on the total amount of carbohydrates consumed in a meal, grams of carbs are converted to insulin units using a relatively simple algorithm. Because most U.S. foods are labeled for total carbs, using the carb counting method is fairly simple.
Foods That Count
While nutritionists debate the best way to manage blood glucose, the market is stirring. The current trend is toward GI- and glycemic load-oriented products, according to Lynn Dornblaser, director of consulting services for the Mintel Group, Chicago.
One noteworthy product line, from Russell Stover, includes DiabetX candy and snack bars. They’re fortified for people with diabetes and labeled as having low glycemic index (23), glycemic load (3), fortified with chromium, zinc and magnesium. “These products are a logical extension of Russell Stover’s original low-carb candies,” says Dornblaser.
Another meal/snack bar brand, Solo GI Nutrition, is being retailed with GI listed on the label. Many other products are also opting to list GI on their labels. These aren’t medical foods, although they may be sold in the nutrition section of the grocery store or drugstore.
ProImmune Co., an immunity technology company and maker of supplements and nutraceuticals, developed two formulations of the antioxidant glutathione. Research suggests glutathione helps via its antioxidant effects on elements key to blood glucose control. The formulations can be used as additives in ice cream, yogurt and other dairy products, sports drinks, fruit juices, nutrition bars and cereals.
National Starch Food Innovation’s (formerly National Starch & Chemical Co.) Novation Hi-maize resistant starch was shown in human clinical trials to reduce the glycemic and insulin response of persons with diabetes as well as in healthy individuals. Research also suggests Hi-maize increases insulin sensitivity.
Following the popularity of the low-carbohydrate trend, a number of products were introduced with higher levels of fiber, including whole grains and carbohydrate polymers that resist digestion because of their specific shape.
Digestion uses enzymes to cleave portions of the carbohydrate chain, and these are geared toward specific carbs. If the body doesn’t make an enzyme that reduces a particular carbohydrate, it isn’t broken down by digestion. It simply goes through the digestive tract, providing neither sugars nor calories.
One fiber product with about a third of the sweetness of sugar but no calories (GI is zero) is inulin, a polymer of fructose units (see “Inulin: The 'In' Fiber,” April 2005). Raftilose P95 inulin, marketed by Orafti, Malvern, Pa., is highly soluble, and synergistic with high-intensity sweeteners.
Hilary Hursh, Orafti’s food and nutrition scientist, notes inulin grew quite popular during the low-carb era, and consumers are aware of the differences between digestible and undigestible carbohydrates. “Consumers know fiber is a good thing,” says Hursh. “They’re learning about the functions of nondigestible carbohydrates. But they may not know inulin is a fiber or identify it from an ingredient statement as a fiber source. We think low-carb products will be around for a long time, but changed somewhat for the diabetic market.”
Hursh also notices a growing interest in GI among food companies, although she doesn’t believe GI will be common on food labels, at least for some time. “We use whatever measure our customers do — in this country, most persons with diabetes are still using the carbohydrate exchanges introduced years back by the American Diabetes Association. And most foods thought of as diabetic foods are sugar-free, although it’s not always as simple as that.”
Palatinose, made by Palatinit, Mannheim, Germany, is a slowly released carbohydrate with a natural, mild sweet taste. Made from sucrose, it is fully digested. Unlike sugar, however, it is noncariogenic and slowly digested, which leads to a low glycemic response and prolonged glucose supply for optimized energy. Palatinose is a viable component for foods and beverages.
Fat Intake and Diabetes
Persons with diabetes are at greater risk for elevated blood cholesterol and cardiovascular disease than nondiabetics. For that reason, doctors specializing in diabetes, obesity, and cardiac problems signed on to the National Institutes of Health initiative on cholesterol and triglycerides. They encourage persons with diabetes keep cholesterol under control with diet and exercise.
Because diabetes — especially Type II — is one aspect of a cascade of disease conditions that frequently includes obesity, other metabolism irregularities, kidney and cardiovascular disease, managing carbohydrates but letting fat consumption increase does not constitute proper diabetes management.
Some new fats were introduced recently. Two are Nextra and Nextra Gold, produced by Source Food Technology in Durham, NC. Nextra is a tallow-based, second-generation healthy fat with the cholesterol removed and plant sterols added, which reduce absorption of dietary cholesterol. The oil tastes similar to tallow, making it favored for French fries. Nextra Gold is vegetable-based (no cholesterol). Both are free of trans fats.
“Diabetic” foods are whatever foods a diabetic can eat and manage the total disease. There are a lot of holes in nutritional knowledge about diabetes, and until they are understood, keeping consumers with diabetes informed about nutrient content, and creating products particularly suited for them, is the sensible course.
What’s In a Label?
Persons with diabetes who successfully manage their condition with diet and exercise are must be made aware of the content, component amounts and types of foods they eat. This demands accuracy in label statements. Even those regulating their diabetes with insulin pumps must know the components of the foods they eat in order to adjust pump output accordingly. (To learn more about diabetes management and exchanges, check out the ADA Web site at www.diabetes.org.)
The American Diabetes Association recommends an exchange scheme that provides a balance between carbohydrates, fats, and proteins. This program is currently used by many persons with diabetes, so foods that are designed to appeal to persons with diabetes should provide information about exchanges so those on that program can select foods easily.