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Key takeaways:

• Avoiding carbohydrates is misguided advice for people with diabetes.
• Holistic diabetes care includes a plant-based, individualized nutrition plan paired with “optimistic coaching.”

DENVER — People living with diabetes have the same nutrient needs as all well-nourished people, yet food is often a main source of stress or even disordered eating, according to a speaker at the Lifestyle Medicine Conference.

A diabetes diagnosis can be the reason a person becomes the healthiest they have ever been in their life; yet conflicting recommendations on carbohydrate intake and the ideal eating plan can lead to insulin resistance, increased hypoglycemia, a preoccupation with food and dieting and diabetes distress, Lauren Plunkett, RDN, LD, CDCES, a registered dietitian nutritionist, certified diabetes care and education specialist and founder of LP Nutrition Consulting in St. Paul, Minnesota, said during a presentation.

“People with diabetes benefit from whole, person-centered nutrition,” said Plunkett, who was diagnosed with type 1 diabetes in 1993. “We are not just a blood glucose value. We are a lot of things. What we need to remember in diabetes is that the collective goal is to improve nutritional quality, nourish adequately and eat to improve insulin sensitivity while reducing insulin resistance.”

How people with diabetes think and feel about food directly shapes quality of life, Plunkett said. For someone with diabetes, nutrition can feel confusing, complicated, restricting and stressful. Those feelings can be overwhelming when diabetes is already tied to feelings of distress, isolation, distrust, depression and anxiety, perfectionism and self-worth, Plunkett said.

“I can tell you that inside every single one of your exam rooms — even if it’s a virtual exam room — the emotions of a person with diabetes are in there with you,” Plunkett said. “We can feel all of these things at the same time. … Sometimes we feel that we are our HbA1c, and we are never good enough because of it.”

Addressing ‘diet culture,’ carb fears in diabetes

The idea of carbohydrates as problematic in diabetes goes back to the earliest literature on how to treat the disease, Plunkett said. Early medical documents from the late 1700s from military surgeon John Rollo highlight eliminating vegetable starch and increasing animal fat and protein to induce anorexia in “diabetics” as a treatment, Plunkett said. Before the discovery of insulin, Frederick Allen’s starvation diet for people with diabetes in the 1910s included restricting calories and carbohydrates until death.

Today, diet culture further fuels “carb-phobia” and so can the clinic, Plunkett said. The relationship between diabetes and carbohydrates is complicated; carb counting and an overall emphasis on a low-carb lifestyle often begins at diabetes diagnosis, Plunkett said. That thinking can fuel resentment toward foods that can raise blood glucose, sometimes leading to disordered eating.

“Can you imagine analyzing every single thing that you eat?” Plunkett said. “Having to count it, think, ‘What is this food going to do to me?’ Diabetes can take all: mind, body and spirit if we cave in.”

As new published research demonstrated that people with diabetes should reduce fat intake and increase mostly complex carbohydrates with a nutrition plan and insulin regimen that considers individual lifestyle, many clinicians balked at the changes, Plunkett said. The role of the diabetes or lifestyle educator is critical in reframing nutrition education from an approach that is often perceived as oppressive into a progressive strategy.

“We can see HbA1c reductions pretty quickly with people who are eating low carb, but there is no consensus on the amount of carb permitted,” Plunkett said. “We also know that high-fat diets are not conducive to long-term preventive health because there is no glycemic advantage of reducing those carbohydrates super low. Why? Because over time, if you are not eating the carbohydrates, you are eating the fat, and that is what causes insulin resistance in the long term.”

Go above and beyond food

Clinicians and educators should embrace helping people with diabetes build their nutrient knowledge, learning the vital roles of carbs protein, fat, fiber and water. To do this, educators should reframe macronutrient language: Instead of “eat low carb” or “eat more protein,” say “eat more plants” and “eat more fiber,” Plunkett said. Patients should focus on increasing food variety and nutrient value, using food as “energetic nourishment” to support prevention and biodiversity. Decrease insulin resistance with healthy fats such as nuts, seeds or avocado; meet daily recommended fiber needs with beans, vegetables, whole grains and fruits; stay hydrated to move and absorb nutrients.

“Eating more protein just ends up increasing the inflammatory foods that can hurt the rest of the body, including the cardiovascular system,” Plunkett said. “Protein is complicated; none of us have the exact same protein needs. Saying, ‘Eat more protein?’ We can do better than that.”

“High fiber” does not equal “high carb,” Plunkett said.

“If I am eating 40 g of fiber per day, which exceeds the daily minimum, I am eating a lot more carbohydrates,” Plunkett said. “But if I am meeting my nutrient needs and eating enough fiber to fulfill my daily intake, it doesn’t mean I am eating high carb. It means I am eating an appropriate amount of food. High carb is language we can do away with. The same with low carb. High carb or low carb doesn’t matter if it is specific to who we are, and that is exactly what dietitians excel at finding out for people.”

When discussing a plant-based eating plan with a person with diabetes, listen for negative self-talk that can hinder making positive changes, Plunkett said, noting that these are the moments to tie in optimistic coaching.

“Get to the root, and then provide individualized advice,” Plunkett said. “It really challenges care-team skill sets to do this. This is not just motivational interviewing. This is human interaction and it is holistic thinking and listening.

“A person with diabetes is so much more than diabetic,” Plunkett said. “They are the holistic presence of a human being, and we can support all of them.”

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