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This interview provided courtesy of The Diet Channel. The Diet Channel is an award winning web site that provides a wealth of authoritative information and support for dieters and health conscious individuals. Founded in the mid-90’s, it has twice garnered a Forbes “Best of the Web” award as one of the web's most trusted, useful, and interesting sites. The Diet Channel has hundreds of current, professionally researched and written articles, including a series on diabetes and diet.
Q: Please describe your background.
Morey Haymond: A pediatric endocrinologist by training, I have been involved in metabolic studies of kids, infants, and adults for 35 years. I work with children who have disorders of carbohydrate metabolism, including diabetes and hypoglycemia. Understanding the regulation of those processes has been a focus of my research, and I have looked at amino acid and fat metabolism as well.
Close to 70% of my patients have the autoimmune variety of diabetes, type 1, wherein their body rejects the insulin-making beta cells, leaving them insulin insufficient. About 30% to 35% of our newly diagnosed kids have adult onset type 2 diabetes, usually associated with obesity, family history of obesity, and African-American or Hispanic-American ethnicity.
Q: When you have diabetes, isn’t it important to follow a dietary regimen designed to control your blood sugar?
Morey Haymond: If you are a type 2 diabetic, that is correct. We try to get people on a lower caloric diet so that they lose weight and increase their insulin sensitivity. People with type 2 diabetes make insulin, sometimes a lot of insulin, but their bodies are resistant to it. If they lose weight, they become more insulin sensitive. We generally manage these patients with diet and oral hypoglycemic agents. For type 1 diabetes, we try to match the insulin that we give with the carbohydrate that they consume. As long as the kids are not overweight, we can give them a wide variety of carbohydrates as long as we cover them with insulin, and we monitor and manage their blood sugar. We don’t try to control the Type 1 diabetics with diet per se; instead, we match the carbohydrate consumed to the insulin administered.
This gives the kids a lot more freedom in their diet selections, allowing them to participate in parties and eat high carbohydrate meals as long as they calculate the carbohydrates and give the amount of insulin necessary. Now, that’s assuming that they are monitoring their blood sugars regularly and that they are in reasonable control to start with.
If they are not monitoring their blood sugars, then they are probably not going to be in good control. It is the high blood sugar itself that causes the long-term micro-vascular complications in type 1 diabetes. And, there is some evidence that perhaps in the type 2 patients, it’s the high fat content that is causing the long-term damage. In either case you are pushing the oxidative metabolic pathways beyond their capacity, and you end up with oxidative damage to tissues that occurs over time.
Problems with micro-vascular circulation in the capillaries, in both type 1 and type 2, lead to poor circulation in predominantly peripheral vessels like those in the feet. Micro-vascular problems also cause peripheral nerve damage and the kidney damage that can ultimately lead to kidney failure. In type 2 diabetes, you can get macro-vascular disease, which is that the large blood vessels clot occasionally. As a result, when you walk, you get pain in your legs. But, we primarily focus on the small vessel damage that is the real killer in diabetes.
Q: What are some of the specific dietary measures to take in the case of type 2 diabetes?
Morey Haymond: The big issue we focus on is weight. If you are overweight, you are consuming more calories than you are burning. The body is very efficient in storing fat for lean times that never come in our societies today.
With our type 2 diabetic children, we reduce their caloric intake in any way we can that’s reasonably acceptable to them and to their families. It’s really a family and cultural problem. In many homes, the children are ingesting very high amounts of carbohydrate in the forms of soft drinks or juices, which are really just flavored water with sugar added to them in many cases. Getting the child to convert from a regular Coke or Pepsi, to one that has no sugar will often reduce caloric intake by 500 to 1500 calories a day.
We try to help the children reduce their number of high carbohydrate feedings. Note that there is nothing inherently wrong with sugar; it’s a nice metabolic fuel. It’s only a problem when it is consumed in excess of the calories that you need. We also try to get children to lower their fat intake, because fat calories are the densest. You can easily make small adjustments in diet by moving from high fat foods such as whole milk to skim milk, by eliminating butter, and by staying away from fried foods. They taste wonderful, admittedly, which makes it very difficult to change behaviors. But we do whatever we can to help children first to reduce caloric intake, and second, to increase energy expenditure by walking, joining exercise programs, and getting into sports.
Q: You mentioned fruit juices earlier, and noted that some of these are mostly water and sugar, with just a little bit of fruit in it. Aren’t there also categories of fruit juices that are unsweetened and produced purely from fruit?
Morey Haymond: There are; they are usually more expensive. From a nutritional standpoint they have a distinct advantage over the other type of juice. But they do have high amounts of their own glucose, and fructose, and sucrose in some cases. The sugar that’s found in natural fruit juices is the same sugar that may be added to fruit juices that are simply fruit flavored and then supplemented with carbohydrates, and the body handles them the same way.
Q: Isn’t it true that the body takes sucrose or fructose and converts it into glucose?
Morey Haymond: That’s partly correct and partly not correct. Sucrose is made up of fructose and glucose. If you consume fructose, very little of the fructose ever appears in the systemic circulation. Most of the fructose is metabolized in the liver, and comes out as lactate; it doesn’t come out as glucose on the first pass. Glucose generally passes through the liver and appears in the systemic circulation just as if you are eating pure glucose.
If you look at milk sugar, it is made up of galactose and glucose. Most of the galactose portion is taken up by the liver, and a lot of it can be converted to glucose. When you co-consume it with glucose, however, your blood sugar goes up; insulin goes up, and a lot of that carbohydrate that’s made from the galactose ends up in storage form, as glycogen in the liver.
Q: What about Exchange Lists? Are these still in use today?
Morey Haymond: We don’t use exchange lists, at least in our practice, for kids with type 2 diabetes. We just try to get their caloric intake down and exercise up. We do use exchange lists sometimes with type 1 patients. An exchange is roughly fifteen grams of carbohydrate. We are moving away from exchange lists and to carbohydrate counting, but for some people calculating the carbohydrate content of food is a complex issue. Exchange lists are basically known amounts of food that all contain the same number of grams of carbohydrate, so that we are able to pattern what the patient can eat from day-to-day. There are exchanges for meats and for fats that we used to use a lot more than we currently do.
Q: There are also some foods that you can think of as free foods. Can you discuss those a bit?
Morey Haymond: There are some foods that are free of carbohydrates, and some that are calorie free. There are also foods that are free of both. Examples of these include celery, carrots, pickles, diet drinks containing aspartame or another artificial sweetener, and water. Examples of carbohydrate-free foods that still have calories are cheeses and meats. However, those also have a fair amount of fat in them, and if weight is a concern, then they should be avoided.
Q: If you are pre-diabetic or have a family history of diabetes, are there classes of foods that help to reduce the chance of developing diabetes - for example, foods with polyunsaturated fats and fiber?
Morey Haymond: My professional opinion is that, if you continue to gain weight and you are prone to type 2 diabetes, you are going to get type 2 diabetes. And, if you are in a family in which type 1 autoimmune diabetes occurs and you have antibodies, there is probably very little that we can do from a dietary standpoint to alter that process.
There are tests that show some benefits in mice and rats, but it is very difficult to expand this to the human environment, for which there is frequently no meaningful data in controlled trials. A lot of things are advocated as being preventive or preserving beta cell function, but they are by and large unproven, with the exception of a very few. One of these is weight loss, and the second is using some of the insulin-sensitizing drug if you are already a type 2 diabetic. And, if you are a new onset type 1 diabetic, getting your blood sugars in very tight control may prolong what we call the honeymoon phase. But for type 1, ultimately there is very little that one can do.
Q: Assuming that you have your weight under control and exercise regularly, are there any foods that are known to increase the risk of bringing on diabetes?
Morey Haymond: Not that I am aware of. There is a myth that children get type 1 diabetes because they ate too much sugar, but that’s totally a myth. Often parents feel very guilty when their child is diagnosed with diabetes, thinking that they did something that caused this to happen. It’s in the genes. We have no control over it at the present time.
Q: With the exception, of course, of managing weight, right?
Morey Haymond: Absolutely. Children now develop type 1 diabetes two to three years younger than used to be the case. I think the reason is that they are higher in body fat now than they used to be, so they are more insulin resistant. A defect in insulin secretory ability will show up sooner rather than later in the obese child who is prone to type 1 diabetes. Although that’s the primary explanation that a number of us have, there is no proof for it. But I think you can make correlations and then come up with logical explanations with no proofs.
Q: Are there any other myths that you would like to take the opportunity to bust right now?
Morey Haymond: People get mega-vitamins, macronutrients, and supplements that they find in the stores, but there is only so much vitamin that you can use. I often caution families that these are very expensive; people are spending $50-80 a month on supplements.
Q: Are you saying that there is no use for supplements, or that they just need to be used judiciously?
Morey Haymond: We focus first on getting people on normal, well-balanced diets. Supplements may help if you have a deficiency of some sort, but for most people it’s enough to buy a once-a-day multivitamin and mineral supplement from a reputable company.