At one time, diabetes was a rare disease—an obscure term whose meaning was relegated to the dictionary. But this is no longer the case, as studies paint a very disturbing picture of a condition that is fast taking on epidemic proportions. According to a new report by the U.S. Centers for Disease Control and Prevention, the number of American adults with diabetes could double or triple by 2050 if current trends continue. This means that as many as one in three people could have the disease, primarily type 2 diabetes, compared to one in 10 with the condition now.
Diabetes remains the leading cause of new cases of blindness under age 75, kidney failure, and preventable leg and foot amputation among adults in the U.S, as well as being a contributor to heart attacks, strokes, and possibly some forms of cancer and dementia. And the costs to treat these complications can be very expensive. The CDC report, published in Population Health Metrics, notes that people diagnosed with diabetes have medical costs that are more than twice of those without the disease. The total costs of diabetes in the U.S. are an estimated $174 billion annually—$116 billion of which is direct medical costs. Previous research has suggested that the “financial burden” may easily double in the next 20 years.
And this epidemic is a global one. About 285 million people worldwide had diabetes in 2010, and that number could swell to as many as 438 million by 2030, claims the International Diabetes Federation.
In type 2 diabetes, either the body does not produce enough insulin or the cells ignore the insulin, explains the American Diabetes Association. Insulin is necessary for the body to be able to use glucose for energy. When you eat food, the body breaks down all of the sugars and starches into the basic fuel for the cells of the body. Insulin takes the sugar from the blood into the cells. When glucose builds up in the blood instead of going into cells, it can lead to diabetes and its serious complications.
One major factor fueling CDC’s bleak prediction is an increasing number of overweight or obese individuals. In fact, because diabetes is so strongly associated with obesity, a new term, “diabesity” has been coined by researchers. Strategies utilizing ingredient solutions need to be developed to effectively address diabesity and improve metabolic syndrome biomarkers. Metabolic syndrome refers to a collection of risk factors for type 2 diabetes and heart disease that includes abdominal obesity, high blood pressure, elevated blood sugar, low HDL cholesterol, and high triglycerides. Not too surprisingly, this precursor to diabetes has been rising. Researchers estimate that about 50 million U.S. adults had metabolic syndrome in 1990; 64 million had it in 2000, and 68 million had it between 1999 and 2006.
How do you eat to beat diabetes? Ingredients such as sweeteners, resistant starch, whole grains, and proteins can help manage blood glucose levels, promote weight loss, and ultimately control a condition that is reaching epidemic proportions. This article will look at a number of these ingredient strategies and how they can help create a healthy diet that can improve blood sugar control, reduce weight gain, and ideally minimize long-term complications.
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These ingredient strategies, especially when used in combination with each other, may prove effective in the development of foods that are friendly for individuals with diabetes. Furthermore, it is important that these ingredients, which may act independently or synergistically, be used in food and beverage products that consumers are comfortable with so that they can be part of a consistent diet. This is why reformulating popular foods such as pasta or pizza to make them compatible (when eaten in proper portion size) in a diabetic diet can be such an important step.
The CDC’s prediction is certainly a bleak one. It may even be more somber when you consider the number of people who have diabetes but haven’t been diagnosed yet. And the growing number of children (not even out of puberty yet) who already have the condition, once described as adult onset diabetes but whose name may have to be changed to reflect the new reality. But it is precisely because of this dark prediction and its implications that it is essential that we take the necessary first steps to try to manage this problem before it is too late for our species. Despite its seriousness, type 2 diabetes can be controlled through a proper diet, medication, and other lifestyle changes.
Sweeteners and Diabetes
Consumption of sugar-sweetened beverages, which include soft drinks, fruit drinks, iced tea, and energy and vitamin-enhanced water drinks, has risen across the globe. Regular consumption of these beverages has been associated with weight gain and risk of overweight and obesity, but their role in the development of related chronic metabolic diseases, such as metabolic syndrome and type 2 diabetes, has not been quantitatively reviewed.
A study published in Diabetes Care shows that regular consumption of soda and other sugar-sweetened beverages is associated with a greater risk of metabolic syndrome and type 2 diabetes. According to the lead researcher, affiliated with the Dept. of Nutrition at the Harvard School of Public Health, findings from a meta-analysis of 11 published studies show a clear and consistent link between the consumption of sugar-sweetened beverages and the risk of metabolic syndrome and type 2 diabetes.
The researchers conducted an in-depth literature search for prospective cohort studies of sugar-sweetened beverage intake and risk of metabolic syndrome and type 2 diabetes. They identified 11 studies (three for metabolic syndrome and eight for type 2 diabetes), which provided data from almost 350,000 people, for inclusion in a meta-analysis comparing sugar-sweetened beverage intake to risk of metabolic syndrome and type 2 diabetes.
People with high intakes of sugar-sweetened beverages (consuming between one and two servings per day) were found to have a 20% greater risk of developing metabolic syndrome than those in the lowest category of intake (none or less than one serving per month). And people in the highest category of intake had a 26% greater risk of developing type 2 diabetes than those in the lowest category of intake.
The researchers concluded: “In addition to weight gain, higher consumption of sugar-sweetened beverages is associated with development of metabolic syndrome and type 2 diabetes. These data provide empirical evidence that intake of sugar-sweetened beverages should be limited to reduce obesity-related risk of chronic metabolic diseases.”
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Today there are a variety of sweeteners available that can help reduce the amount of sugar—and calories—in a formulation without compromising its sweetness and functionality properties. Stevia-based sweeteners would be one example.
According to Robyn Webb, Scientific Advisory Board Member for the Global Stevia Institute, which is sponsored by PureCircle USA, Oak Brook, Ill. (phone 630-361-0374, www.purecircle.com), controlling blood sugar scores and dropping excess pounds play a major part in the management of diabetes. Not too long ago, this was largely done by completely avoiding sugar and severely restricting carbohydrates and fats. “Today, we have learned that eating for diabetes can include a wide variety of foods all put together into a plan, which when practiced consistently, can give you the results you need,” she noted. “And here is where stevia, a natural, no-calorie, no-carbohydrate sweetener, can play a role in helping food manufacturers develop diabetic-friendly foods.”
Carbohydrates have the most impact on your blood sugar levels, Webb explained. One of the simplest ways to control blood sugar is to limit refined sugar from the diet. “But who doesn’t love the taste of sweet?” she pointed out. “Deprivation of any foods completely from a diet is not a great strategy for health or success. One solution is to reduce the amount of sugars consumed by using stevia. With zero effect on the blood sugar since it does not contain calories or carbohydrates when used by itself, stevia is a natural solution for formulating foods for consumers with a sweet tooth.”
Stevia, unlike many low or no-calorie sweeteners, is shelf and heat stable. It can also be used in conjunction with some sugar in formula development. PureCircle offers a variety of all-natural stevia products that provide functional options for food manufacturers interested in reducing calories and carbohydrates. Potential applications may include soy milk, flavored beverages, salad dressings, breads, yogurts, and fruit juice drinks.
Erythritol may be another attractive sweetening alternative. Clinical studies have shown the polyol does not raise blood glucose or insulin levels and is therefore a suitable replacement for sucrose in products formulated specifically for diabetic diets. Erythritol, under the brand name Erysta®, is offered by Corn Products International Inc., Westchester, Ill. (phone 877-379-7631, www.cornproducts.com). With a caloric value of 0.2 calories per gram, the white crystalline powder is approximately 70% as sweet as sucrose with a clean, sweet taste similar to sucrose. The synergistic effects created when combining the benefits of erythritol with other sweetening ingredients make it a versatile solution for reduced-calorie, reduced-sugar, and sugar-free product development.
Sucralose, under the brand name Splenda, is another way for people with diabetes to decrease their carbohydrate intake. The ingredient, manufactured by Tate & Lyle, Decatur, Ill. (phone 217-423-4411, www.sucralose.com), may be used to sweeten a variety of foods and beverages. Since it has no effect on blood glucose or insulin levels in people with diabetes, it is safe for them to consume.
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Isomaltulose (Palatinose™) from the Beneo Group, Morris Plains, N.J. (phone 973-539-6644, www.beneo.com), is a low-glycemic carbohydrate that may help in the control of diabetes. It is digested slowly, supplying the body with the full energy of the available carbohydrate but in a more balanced way and over a longer period of time than with conventional carbohydrates. In a study at Freiburg University conducted on overweight individuals with insulin resistance, the consumption of meals containing Palatinose, in comparison to conventional readily available carbohydrates, proved to result in lower rises in blood sugar and a lower daily insulin level as well as an increase in fat burning by up to 28%. These findings may be particularly important because there have been discussions on whether a high insulin level over a long period of time is involved in the development of obesity and diabetes.
And, of course, there is a wide variety of artificial high-intensity sweeteners available that can be used in the formulation of foods for people with diabetes. In recent years especially, these sweeteners are being combined with nutritive sweeteners to help bring down the levels of sugar in the formulation. This gradual reduction of sugar can be particularly important for younger consumers and can help delay—or even eliminate—the onset of diabetes.
Resistant Starch/Fiber and Diabetes
Resistant starch and different ways to incorporate it into the diet have been the subject of several new diet books, including The Skinny Carbs Diet and The Carb Lovers Diet. With its ability to not only lower glycemic and insulin response but also to sustain energy release, this carbohydrate may offer therapeutic effects for individuals with diabetes. Reducing weight and balancing blood sugar levels are two very important considerations when developing foods for individuals with diabetes.
A resistant starch from high-amylose corn, the Hi-maize brand was developed by National Starch Food Innovation, Bridgewater, N.J. (phone 908-685-5555, www.foodinnovation.com). Because of its low digestibility, the ingredient causes a lower rise in blood sugar than high-glycemic carbohydrates such as flour, starch, and most maltodextrins. This trait is common to all types of dietary fiber, which similarly pass to the large intestine, but unlike other types of dietary fiber, it has been shown to positively impact major metabolic pathways underlying blood sugar (glycemic) management. These metabolic pathways involve not only insulin, which controls the movement of glucose from the blood into the muscles and tissues, but other hormones as well. “The positive health benefits of resistant starch occur at a biochemical level rather than simply mimicking fiber by increasing bulking and transit time through the digestive tract,” noted the author of The Skinny Carbs Diet.
According to Rhonda Witwer, the company’s Senior Business Development Manager of Nutrition, clinical studies have shown that the dietary consumption of Hi-maize resistant starch does not cause high spikes in blood sugar levels, but rather actively helps to maintain healthy blood sugar levels in increasing insulin sensitivity. For example, in 2009, preliminary results from a University of Surrey clinical study found that the consumption of Hi-maize significantly increased insulin sensitivity in individuals with insulin resistance and metabolic syndrome. Reversing this insulin resistance may reduce the risk of developing type 2 diabetes, as well as cardiovascular disease.
Improving insulin sensitivity means that the body needs to produce less insulin to effectively manage blood sugar. The body’s muscles and tissues are more sensitive to insulin and respond faster to transport glucose out of the bloodstream. Furthermore, Hi-maize’s fermentation in the large intestine also increases the production of additional hormones, glucagon-like peptide (GLP-1) and peptide YY (PYY), which are involved in satiety and glycemic management.
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The potential role that resistant starch can play in lessening the “dawn phenomenon” was discussed in one of my recent IngredienTalk blog posts, which can be read on pp. 55-57.
Also in the November 2010 Ingredients section, I looked at how Hi-maize resistant starch can be used in the reformulating of pasta products. These better-for-you pastas are one example of foods being developed that can provide advantages for people with diabetes, and may help set the stage for future product development in this area.
When developing foods for people with diabetes, other fibers also show noteworthy promise. For example, digestion-resistant maltodextrin, Fibersol-2® from Matsutani America Inc., Itasca, Ill. (phone 630-250-8720, www.fibersol-2), reportedly can help lower blood glucose after meals. Studies have shown that this soluble dietary fiber can moderate postprandial rise in blood glucose levels, preventing rapid rises that may lead to conditions such as diabetes. In bakery applications such as cookies, the ingredient may also be used to replace some of the sugar and corn syrup that are used in a typical formulation.
Fiber from oats, especially oat beta glucan, may be used as a slowly digested ingredient in foods formulated for people with diabetes. For example, GTC Nutrition, a business unit of Corn Products International Inc., offers an oat bran concentrate, OatVantage™, that can help preserve healthy blood sugar levels by preventing the glucose concentration from rising sharply after meals.
Whole grains, which will be next looked at for their potential value in developing foods for people with diabetes, also provide an important source of fiber.
Nuts and Diabetes
Nuts are high in polyunsaturated and monounsaturated fat and other nutrients that may improve glucose and insulin stability. Consequently, they can play a role not only in a healthy diet, but in food products developed for individuals who are at high risk for diabetes or who have the condition. Studies have shown that the consumption of nuts may be linked with lesser risk of diabetes. Research from the Yale-Griffith Prevention Research Center, published in the February 2010 issue of Diabetes Care, demonstrated that consumption of a diet enriched with 56 g (approximately two ounces or ½ cup) of walnuts per day for eight weeks significantly improved endothelial function in 24 adult participants with type 2 diabetes. The researchers compared the effects of typical diets and walnut-enriched diets on endothelial function—a measure of how well blood vessels are able to dilate and increase flow, and a powerful predictor of overall cardiovascular risk. The researchers concluded these findings may be attributed to the favorable fatty acid and nutritional profile of walnuts providing the plant-based omega-3 fatty acid alpha-linolenic acid (ALA), along with numerous bioactive compounds, including dietary fiber, folate, and antioxidants. More information can be obtained from California Walnut Board, Folsom, Calif. (phone 916-932-7070, www.walnuts.org).
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A growing body of research also indicates that including almonds in a healthy diet might help decrease the risk of type 2 diabetes and heart disease. In a new study released this summer, 65 prediabetic adults were randomly assigned to follow an American Diabetes Association (ADA) diet containing approximately 2 ounces of almonds per day or a nut-free ADA diet for 16 weeks. By the end of the study, those consuming almonds had experienced significant decreases in LDL cholesterol and also saw improvements in insulin sensitivity. Another study, Chen 2009, concluded that replacing 20% of the caloric intake of the NCEP Step II Diet with almonds led to a significant decrease in body fat by 1%, total cholesterol by 8%, blood sugar by 6.7%, and insulin by 7.9%. The Almond Board of California, Modesta, Calif. (phone 209-549- 8262, www.almondboard.com), can provide further details.
Better-for-You Flours and Diabetes
A “noodle” made with yam flour and water reportedly contains zero calories, fats, sugar, starch, soy, gluten, or preservatives. An alternative to the traditional noodle, this product, aptly called NoOodle (pronounced No-Oodle), is particularly beneficial for individuals with type 2 diabetes.
Yam-based noodles have been eaten for many years in Japan (yam flour is said to be an ancient Japanese ingredient). A restaurant owner and chef, Terri Rogers, heard of the ingredient and created the new brand of noodle, which she served at her suburban Chicago restaurant, Lincolnshire Gourmet. Because of its success with her patrons, she founded the NoOodle Company to manufacture and distribute these noodles as packaged meals to restaurants and retailers throughout the United States. The product is available at select foodservice establishments and retail outlets, and can be purchased online at www.nooodle.com).
The yam-based product contains glucomannan, a water-soluble dietary fiber that slows digestion and helps avoid spikes in glucose levels. The fiber traps cholesterol and fat and helps prevent it from being absorbed by the body. These properties make this product helpful in developing foods for people with diabetes. Furthermore, the product is versatile, and its neutral flavor allows it to take on the taste of whatever it is prepared in. It can be eaten plain, topped with sauces, soaked in soup, or added to salad for extra fiber. Rogers is using the noodle to create a new line of heat-and-eat meals. Flavors include marinara and primavera, with chicken teriyaki and macaroni and cheese rolling out soon.
Better-for-you flour can also be developed from pulses or legumes. Peas, beans, lentils, and chickpeas are pulses, the edible seeds of plants belonging to the legume family. Pulses have a low glycemic index, which can be beneficial for people with diabetes. When eaten on their own or as part of a high-fiber diet, pulses can lower fasting blood glucose levels. Pulses were also found to improve glycosylated hemoglobin, an indicator of long-term blood sugar control. In the November 2010 Ingredients section, I discussed how using precooked pulse flours in pasta manufacturing can be one innovative way to formulate new products that can have advantages for diabetics. Pulses can also be paired with other better-for-you ingredients such as whole grains, flaxseed, and fiber ingredients. More information about their health potential can be obtained from the Northern Pulse Growers Association, Bismarck, N.D. (phone 701-222-0128, www.northernpulse.com).
Flours developed from whole grains can provide benefits for individuals with diabetes. Whole grains are low-glycemic carbohydrates, which means they are less likely to cause spikes in blood glucose levels. Studies have shown that whole grains may help reduce the risk of developing heart disease, high cholesterol, and obesity—serious concerns for those with diabetes. Eating a variety of whole grain foods such as breads, cereals, brown rice, slow-cooking oatmeal, and even popcorn can help better control blood glucose levels and therefore can play an important role in the diet of people—whether they have diabetes or not.
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In fact, a new study published in The American Journal of Clinical Nutrition shows that people who consume several servings of whole grains per day while limiting daily intake of refined grains may have less of a type of fat tissue thought to play a key role in triggering cardiovascular disease and type 2 diabetes. Researchers at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University observed lower volumes of visceral adipose tissue (VAT) in people who chose to eat mostly whole grains instead of refined grains.
The researchers found that VAT volume was approximately 10% lower in adults who reported eating three or more daily servings of whole grains and who limited their intake of refined grains to less than one serving per day. Additionally, the researchers observed that participants who consumed, on average, three daily servings of whole grains but continued to eat many refined grains did not demonstrate lower VAT volume.
A wide range of ingredients based on whole grains is available from ConAgra Mills, Omaha, Neb. (phone 402-240-5153, www.conagramills.com). One of these flours is Sustagrain barley, a proprietary, identity-preserved barley variety that offers flexibility, functionality, and nutritional properties that are ideal for developing foods for people with diabetes. With two to three times the fiber of most cereal grains, the consumption of this ingredient is important for digestive health, blood sugar management, and increased satiety that can help in weight management. In terms of glycemic index, the high-fiber, low-starch ingredient is said to rank among the lowest of commercially available grains, smoothing out spikes in blood glucose and insulin responses that may play a role in the development of type 2 diabetes. Standard in vivo testing procedures have shown that Sustagrain barley is effective in lowering postprandial blood glucose response in a variety of food applications, and when eaten as part of breakfast, can extend between-meal fasting and can improve glucose tolerance at the lunch meal.
Fruits and Diabetes
A breakthrough research study has found that including regular servings of blueberries in one’s diet can have a positive impact on people at risk for type 2 diabetes, notes the Wild Blueberry Association of North America, Portland, Maine (www.wildblueberries.com). The study, led by researchers April Stull and William T. Cefalu of the Pennington Biomedical Research Center (PBRC) at Louisiana State University, adds new information to the body of research supporting the benefits of making blueberries a regular part of a healthy diet.
The new research findings, published in the October issue of The Journal of Nutrition, reveal that blueberries have properties that can help to improve factors related to prediabetes and decrease inflammation in obese men and women. Chronic low-grade inflammation related to obesity contributes to insulin resistance, a major factor in the development of type 2 diabetes.
The study was conducted over a six-week period with 36 obese subjects diagnosed with insulin resistance, but who had no evidence of type 2 diabetes. The participants were assigned randomly either a blueberry-rich or nutritionally equivalent blueberry-free smoothie twice daily over the 42-day period. It was found that participants who consumed the blueberry smoothies had improved insulin sensitivity compared to those consuming smoothies with no blueberries. The improved insulin sensitivity was observed in both men and women.
Although researchers have discovered that certain foods have both blood glucose-lowering and anti-inflammatory effects in experimental animals, few studies have been done in humans, according to the journal article. “We now know that compounds in blueberries may help obese, non-diabetic individuals maintain healthy blood glucose levels,” said Stull. PBRC is urging additional research to determine whether the same effects would be found in people with type 2 diabetes.
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According to the U.S. Highbush Blueberry Council, Folsom, Calif. (phone 650-824-6395, www.blueberry.org), the use of blueberries can mean reductions of sugar, high fructose corn syrup, and other sweeteners in products ranging from baked goods to snack foods. This is because of blueberries’ similar distribution of sugars, fructose and glucose. While providing sweetening properties, blueberries can help deliver dietary fiber, vitamins, minerals, and antioxidants and thus provide individuals with diabetes a food that is nutritionally dense.
Clinical studies have shown that Citrus Bergamot (the common name of the fruit Citrus bergamia Risso which grows in the Calabrian region of Italy) can reduce blood sugar levels, a benefit for individuals with diabetes. These human clinical studies reported a 22% decrease in blood sugar levels, along with a significant reduction in total cholesterol, LDL, and triglycerides, as well as an increase in HDL cholesterol. Citrus Bergamot contains high levels of naringin, neoeriocitrin, and neohesperidin—the active ingredients responsible for these benefits. HP Ingredients, Bradenton, Fla. (phone 877-437-2234, www.hpingredients.com), touts that the use of Citrus Bergamot can provide healthy cholesterol, weight loss, and blood sugar support, and may even be successful in reversing metabolic syndrome. The company offers Citrus Bergamot in a polyphenolic extract powder and a juice concentrate.
Trends and Diabetes
Taking into consideration a number of today’s flavor and ingredient trends and how they can relate to—or even impact—the development of foods for individuals with diabetes can prove to be especially beneficial. For example, the growing interest in different ethnic cuisines and the ingredients they use can lead to the creation of a variety of flavorful and healthy foods. Thai food, for instance, is a wonderful combination of meat and vegetable proteins. Furthermore, certain spices may have therapeutic benefits.
Umami continues to be in the news, but I never see the concept associated with diabetic foods. In my opinion, understanding umami and applying the savory taste of proteins could prove to be very rewarding when developing foods for people with diabetes. Proteins play a very important part in the diet of people with this condition.
The wide variety of flavors being developed for yogurt makes this food even more of an attractive option for people with diabetes. Yogurt provides protein, a low source of fat, and other important benefits. It can be eaten as a breakfast food, a snack after lunch, and even as nighttime repast to help balance out blood sugar scores, negating the effects of the dawn phenomenon.
Popcorn makes for an ideal whole-grain snack, providing dietary fiber, balancing out spikes in blood sugar, and improving sensitivity to insulin. New ingredient developments are also helping to enhance this snack, making it even more of a viable option. Popcorn can be made with a heart-healthy canola oil solution. Or perhaps it can be flavored with vanilla and other flavors to create a different kind of taste or as an alternative to popcorn made with salt or butter. Perhaps popcorn can be used as a topping for salads for an extra fiber punch.
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And as interest in whole grain grows, imagine whole-grain pizza bread with a light coating of low-fat cheese as an alternative to a large pizza. Or consider the possibilities of a number of whole-grain pasta formulations that were mentioned in the November 2010 Ingredients section. Or perhaps some of the breads that we will be discussing in next month’s Ingredients article.
And no salad has to be boring with the combinations of ingredients available today that can be diabetic friendly. Imagine trendy salads such as the one shown in the photo on this page. Perhaps a line of salads can be developed promoted specifically for individuals with this condition.
For people with diabetes, you’re only as good as your last blood glucose reading. If your reading is normal, you try for the same score the next day. If too high (or low), you work to adjust it. I keep wondering if food formulators and manufacturers can learn something from this approach. For those developers who are conscious of the epidemic we face—and the fact that the clock is ticking—you’re only as good as your last ingredient development. Achieve it and you take a step forward. Don’t achieve it (rely on traditional approaches and perceptions) and you may be taking a step backwards. And even though you still have tomorrow to do something about it, that—sadly enough—may not always be the case.
Next month’s Ingredients section will look at breads and beyond, and how ingredients such as prebiotics, whole grains, gluten replacers, and others are transforming this category.
IngredienTalk:
The Dawn Phenomenon refers to abnormally high blood glucose readings in the morning, not caused by food consumed the previous evening or night. In my 25th blog post, I describe how this happens and ingredient solutions that may help address this particularly frustrating problem for individuals with diabetes. If you have thoughts on lowering these morning “highs,” (and you’re an IFT member), visit www.ift.org, type in your name and password, click on the IFT Community button, and go to the blog section. Hopefully, more formulators will wake up to the challenge of addressing this problem.
Waking up to the Dawn Phenomenon
What is “the Dawn Phenomenon?” If you said that it has something to do with that music group of the seventies, Tony Orlando and Dawn, making a comeback, you would be wrong. Although it would be a good guess, considering that this particular term has not really reached mainstream status yet and is probably quite unfamiliar to most people. This may change though as understanding this term—and its implications—can be especially important for individuals with type 2 diabetes, as well as individuals who are at high risk for this disease or those who are concerned about their blood sugar levels in general.
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To put it simply, hormones are released during the night or early morning hours that cause glucose production. Most likely this happens to prepare the body for daytime activity (sort of like a wakeup call, you might say) after a period of fasting. Unfortunately, for people with type 2 diabetes, their bodies may not respond well enough to insulin to stop the glucose production, and their blood glucose levels subsequently rise between 4 a.m. and 8 a.m. even though they might not have eaten anything the previous evening to have caused this reaction. Because of this, the dawn phenomenon, named after the time of day it occurs, is one area that can be particularly troublesome for people with diabetes and can be very frustrating as well. Some individuals who have diabetes may feel like an innocent person caught with a bloody knife at the scene of a crime. “But I didn’t do anything,” cries the person, protesting genuine innocence. “Why is my glucose reading so high?”
To learn more about the dawn phenomenon, I recently read an article, “How to lower morning highs,” published in the Fall 2010 issue of Diabetic Living. The article was written by Hope Warshaw, Registered Dietitian, Certified Diabetes Educator, and co-author of the book, Real Life Guide to Diabetes. Hopefully, I will have the opportunity to read the book someday, but in the meantime this article helps to explain succinctly why blood glucose results might be higher in the morning than any other time of day. The article can be found on Warshaw’s website, www.hopewarshaw.com, and I recommend reading it to gain a better understanding of the dawn phenomenon.
According to Warshaw, “the dawn phenomenon describes high blood sugar in the morning, when most people expected low blood sugar from not eating overnight. Essentially, the circadian rhythm of the body produces hormones (including cortisol and growth hormone) to help wake you up and start moving. These hormones trigger the release of glucose that is not tied to food consumption. Under normal conditions, the body responds to this morning effect by putting out more of the hormones that keep your blood glucose in control. In type 1 or type 2 diabetics, this doesn’t happen.”
In Warshaw’s article, she explains that during the years (up to a decade) that type 2 diabetes develops, the hormonal control of blood glucose breaks down. There are four hormones involved in glucose control. Insulin, made in the beta cells of the pancreas, helps the body use glucose from food by helping it to move into the body’s cells. People with type 2 diabetes have slowly dwindling insulin production and reserves and increasing insulin resistance, a condition in which the body’s cells do not use insulin properly. Amylin, secreted from the beta cells, slows the release of glucose into the bloodstream after eating by slowing stomach-emptying and increasing the feeling of fullness. People with type 1 and type 2 diabetes are amylin-deficient. Incretins, a group of hormones secreted from the intestines that includes glucagon- like peptide 1 (GLP-1), enhance the body’s release of insulin after eating. This in turn slows stomach-emptying, promotes fullness, delays the release of glucose into the bloodstream, and prevents the pancreas from releasing glucagon, putting less glucose into the blood. The fourth hormone, glucagon, made in the alpha cells of the pancreas, breaks down glucose stored in the liver and muscles and releases it to provide energy when glucose from food isn’t available. When diabetes is not present, the body handles the changing supply of and demand for glucose (the energy from food) 24 hours a day using a system that involves the four hormones mentioned above. But for people with diabetes, because the hormonal control of blood glucose has broken down, the end result can be abnormally high blood sugar in the morning.
So what can be done about this? Warshaw makes several suggestions in her article. First, a blood-glucose-lowering drug at diagnosis can help fight the insulin resistance and the hormonal imbalance. Second, weight loss, especially soon after diagnosis of type 2 diabetes, can help the hormonal disturbances, increase insulin sensitivity, and lower blood glucose levels. Third, physical activity can enhance the body’s response to insulin. And fourth, a small bedtime snack containing no more than 20 g of carbohydrates can help you wake up with better fasting blood glucose. A snack shortens the time span that the liver is in overdrive producing glucose.
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While surfing the web, I came across several observations by diabetic individuals who claim that they have had good luck controlling the dawn phenomenon by consuming before-bedtime foods that contain resistant starch. Curious about this, I contacted Rhonda Witwer, Senior Business Development Manager—Nutrition, for National Starch Food Innovation, a producer of Hi-maize resistant starch, to see if there was a connection. Witwer explained that Hi-maize from high-amylose corn, can help with the dawn phenomenon. By improving insulin sensitivity, it helps the body to transport glucose into the muscles faster and can help manage high blood sugar during the morning hours.
Hi-maize reportedly improves insulin sensitivity, which means that the body needs to produce less insulin to effectively manage blood sugar. In other words, the body’s muscles and tissues are more sensitive to insulin and respond faster to transport glucose out of the bloodstream.Hi-maize’s fermentation in the large intestine also increases the production of additional hormones, glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) which are involved in satiety and glycemic management. Witwer noted that researchers do not yet understand the interrelated connections between these chemical signals, but natural resistant starch from high-amylase corn appears to trigger improvements in several of these metabolic pathways.
(See the section of the accompanying feature titled “Resistant Starch/Fiber and Diabetes” beginning on p. 58 for more on the potential benefits of resistant starch.)
Before closing, I should point out there can be other reasons for morning highs (other than the dawn phenomenon.) Some of the more obvious possibilities can be a lack of medication, a failure in the medication currently being used, an improper diet, and late-night eating. Another possibility is the so-called “Somogyi effect,” which according to Warshaw, “is very high fasting blood glucose thought to be caused by the liver making a lot of excess glucose in response to hypoglycemia (low blood glucose) during the night. Somogyi effect is uncommon in type 2 diabetes.” She also points out that there’s controversy as to whether it even exists with the rapid- and long-acting insulins available today.
And (I’m basing this on some of the observations that I have seen while surfing the internet) there doesn’t seem to be complete agreement as to the existence of the dawn phenomenon. Some individuals, including doctors, attribute high morning scores to other factors already mentioned, especially improper eating during the evening, as opposed to hormonal imbalances. Also, if the dawn phenomenon does exist, it may not affect all individuals with diabetes. More research probably has to be done on this phenomenon.
In any case, if you have high morning readings, it would still be wise to try to control them, regardless of the reason. (For example, the consumption of breakfast if nothing else can help interrupt the dawn phenomenon, making it briefer in nature.) The consumption of certain ingredients such as resistant starch or small amounts of foods containing fat and protein before bedtime may help provide a solution to this frustrating problem. But also keep in mind that you’re only as good as your last reading. Over time, your readings may change and new solutions, especially dietary ones, will have to be tried to address high morning readings.
If morning highs are making you feel low, or if you have other thoughts and observations regarding the dawn phenomenon and how food developers can help provide solutions to this problem, let’s IngredienTalk.
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Donald E. Pszczola,
Senior Editor
[email protected]
