public health.

Fighting Type 2 Diabetes means finding flexible places to dine

 

[dropcap]Ready-to-wear fashion season is always a bit stressful around here. I’m up at 2:00 in the morning trying to catch early runway shows in Europe and trying desperately to keep up with trends and issues. I can get a wee bit irritable by the time it’s all over.[/dropcap]

This past February, though, was worse than usual. I was fussy before New York even started. There were other issues as well. I was constantly running to the bathroom. I was always eating something. If I wasn’t in the middle of a show or writing a review, I was napping. The slightest little deviation from expectations was upsetting. Worst of all, my blood pressure was at dangerous levels despite medication. Something had to be done and Kat gave me little choice but to make an appointment with my doctor.

After the appropriate blood tests, my doctor determined that I have Type 2 diabetes and, oh yeah, that puts me at high risk for a whole slew of other things, of which high blood pressure is only the beginning. Liver disease. Kidney failure. Heart disease. Every time the doctor mentioned something else, he wrote another prescription. The instructions were to take them all or bad things, very bad things, could happen.

I left the doctor’s office that morning feeling devastated. My father had Type 2 diabetes. Unfortunately, he didn’t find out until his retinas detached, leaving him blind. I remember far too vividly the adjustments he had to make to his entire lifestyle. Mother was incredibly strict not only about what he ate (and didn’t eat), but also making sure he ate at exactly the same time, or as close to it as possible, every day. Poppa confided to me on more than one occasion that his menu had become so dull and tasteless as to take all the joy out of eating. Is this what the rest of my life would become?

Then, as though the universe wanted to emphasize the point, an acquaintance who had ignored her diabetes until she lost a leg, unexpectedly passed away. The entire time I knew her, she subsisted on pizza, fried chicken, and mac-and-cheese. On top of that, she smoked two to three packs of cigarettes a day. The only nod she made to her diabetes was drinking Diet Coke. Granted, the diabetes wasn’t the direct cause of her death, but it most certainly contributed to it.

The message I was received was clear: a lot had to change, and that change had to be made immediately without compromise. My A1C, which is a three-month average of blood sugar, was at 10.5. Anything above 6.5 is diabetes territory. At 10, one is in danger of everything from eye problems to nerve disease. I needed to get that number down and get it down quickly.

Following what I knew from Poppa’s regimen, everything with sugar in it went away immediately. No chocolate. No pie. No cake when anyone celebrated a birthday (and we had three within a month). No barbecue sauce. In fact, since most sauces have fat as a base (either in the form of meat drippings or butter/dairy), almost every sauce I’ve ever used is off the menu. Nothing fried, at least not in the traditional sense. At my next check-up, a month later, I had gotten my A1C down to 8. Still high, but low enough for one month that the doctor was impressed. We were doing the right things. All we had to do was keep it up. Easy enough, right?

Hardly.

I need to eat now

[dropcap]At my doctor’s insistence, we met with a dietician who specializes in counseling diabetics. She was encouraging in telling us that we were doing all the right things, and, if anything, could ease up a little on how strict we were being. She explained that current science shows that a complete elimination of fats and sugars isn’t necessary, but a severe limit on certain foods while emphasizing others. Her recommendations were similar to the American Diabetes Association’s Create Your Plate program: 25% protein, 25% grains & starchy foods, and 50% non-starchy vegetables. She also emphasized getting 130 grams of carbohydrates in each day, which isn’t as easy as it sounds.[/dropcap]

We set out some dietary goals that I could track easily enough. I shoot for 2000 calories a day, though I seldom actually eat that much. When we’re talking steamed veggies and fruit, 2000 calories is a lot of food! We try to keep the total amount of sugars under 50 grams. This includes naturally-occurring sugars, mind you. Most days I’m able to keep that under 20 grams, though, which is helpful. My limit on saturated fat is more of a challenge some days. 22 grams is the limit. I’ve had to change much of the way I cook to stay under that number.

Perhaps the most challenging, though, is watching my sodium intake. High blood pressure is one of the most common problems associated with diabetes. Watching sodium intake is critical to controlling both diseases, but it’s not easy. Everything one buys at the store has sodium, even if it’s labeled organic. My limit is 2300 milligrams, which may sound like a lot, but consider that just ONE Big Mac contains 950 mg of sodium. If you want to get really crazy, a Dave’s Single at Wendy’s contains 1250 mg of sodium! Add fries and a soft drink to either, and one can pretty much exceed the sodium limit in just one meal. Even something that sounds as healthy as boneless, skinless chicken breast comes packed in a solution that contains, you guessed it, sodium.

We discovered that keeping to most of the dietary limits was easy enough, though I still have issues with cholesterol. The more unexpected issue was that once the prescriptions kicked in and my blood sugar began dropping and my blood pressure evened out, I was more aware of severe drops in my blood sugar when they happened. Yes, most of the time I was feeling better, but when my blood sugar drops there is an instant weakness, dizziness, and often a sense of confusion. The solution is to eat something immediately, such as sucking on a piece of hard candy.

If Kat is with me, which she is a large portion of the time, there’s no problem. She keeps Jolly Ranchers in the bottom of her purse for just such emergencies, and then we get something healthier to eat as soon as possible. When she’s not with me, though, the situation can get scary, quickly.

This first became critical one Thursday in April when I was out by myself, sitting at the Starbucks on 46th and Illinois, doing some writing. After a few hours of working and sipping coffee, I began to feel the early signs that a sugar drop was happening. I had wisely brought some candy with me and fished a piece from my sweater pocket. Disaster averted, so it would seem. But I needed something real to eat. I looked at the Starbucks menu and there was nothing safe. While sugar counts might be low on some items, everything was loaded with sodium!

I looked across the street at one of my favorite places to eat: The Illinois Street Emporium. If nothing else, I figured, I could get a salad there. Even that, though, came with a challenge. At 11:30, there was already a line out the door and down the sidewalk. I knew there was no way I could stand in line for several minutes. I popped another Jolly Rancher and waited for the line to go down.

Once I could get inside, about 30 minutes later, I looked at the menu board. I was starving by this point and really wanted more than just a salad. The fragrances of all the homemade breads and fresh food were intoxicating. There’s a damn good reason people go out of their way to eat here. Examining the menu was a bit disheartening, though. Many of the sandwiches contained sauces or were cooked in a sauce that was either high in fat, contained a lot of sugar, or loaded with sodium. For some, the portion size alone was too much. I finally found a spinach and tomato sandwich on 100% whole wheat bread (a critical factor) that, with a couple of minor adjustments, wouldn’t cause any problems and would meet my dietary requirements.

That experience drove home something I had rather known all along but had yet to experience first hand: eating out diabetic is difficult!

A larger problem

[dropcap]If I were the only person on the planet with this unique dietary problem then we might say that it’s my fault for having eaten poorly, and there are still some who might say such a thing. We frequently hear Republicans refer to diabetes as a “lifestyle” disease, implying that we bring it upon ourselves. That’s not the case, though. I’m far from being alone. Over 30 million people in the US alone have diabetes and that number grows dramatically every year. Does diet play a part in that? To some degree, yes, but it does not cause the disease. In fact, scientists have yet to figure out exactly what predisposes someone to be a candidate for contracting Type 2 Diabetes. Hereditation seems to play a factor. Ancestry seems to be a contributor. Diet is a participant but not necessarily a determining factor.[/dropcap]

Adding fuel to the fire is the fact that as much as a third of the people who have Type 2 Diabetes don’t realize they have it and of those who do know and are receiving treatment only about 20% are getting appropriate treatment. Like my recently-deceased friend, many people who have diabetes think they can either wish it away or that it’s not a real disease. They couldn’t be more wrong.

When we spoke with our dietician, she explained her amazement with my early results. “Here we are talking about little ways you can improve how you eat and that’s unusual for me. With the majority of patients, I struggle to get them to just cut back just one can of soda a day. They don’t understand how everything they put in their mouth is killing them.”

Because of that sense of lack of urgency, diabetes doesn’t get as much public attention as it should. Not since the late Wilford Brimley, whose diabetes-related commercials have been widely parodied, has the disease had a spokesperson widely associated with Type 2 Diabetes. Because the issue is rarely in our faces, we don’t think about it. Its symptoms are similar enough to other more “popular” diseases, such as depression, we are more likely to investigate those remedies than we are to ask our physician for a blood test.

Making matters all the more difficult is the fact that Type 2 Diabetes is a lifetime disease. Yes, one can get it under control to the point that medication is no longer necessary. However, if at any point one decides to abandon the diet, the problems and dangers of the disease are coming right back, and likely even stronger and more troubling than before.

Type 2 Diabetes requires individualized treatment to be effective. Not everyone needs to take insulin shots. A significant number of people, myself included, are able to control their diabetes with Metformin, a biguanide that decreases blood sugar levels. Some, like my late father, need other stronger medications. Some need very little. There’s no one-fix-cures-all approach to controlling the disease. One needs to see their doctor on a regular basis and carefully follow the instructions provided.

Then, there are the associated diseases to which we’ve referred. Diabetes can contribute to any of the following:

• Glaucoma
• Retina detachment
• Nerve disease
• Stroke
• High blood pressure
• Kidney disease
• Liver disease
• Bronchospasm
• Insulin Autoimmune Syndrome
• Low Blood Sugar
• Confused
• Depression
• Easily Angered Or Annoyed
• Feel Like Throwing Up
• Gas
• Itching
• Loss Of Appetite
• Not Feeling Well
• Over Excitement
• Rash
• Redness Of Skin
• Sleep Disorder
• Swelling Of The Abdomen
• Taste Problems

On top of all that, as if those weren’t enough, diabetes can sap your stamina and cause severe sexual dysfunction! Even when the disease is being reasonably well managed, many of those problems can still affect one’s health. So, instead of just taking one or two medications, most people with diabetes end up taking several others as well in order to avoid the problems for which they’re most at risk. Again, every situation is different, so consulting a doctor is absolutely critical.

So, where do we eat?

[dropcap]I enjoy cooking, so for me, the best and easiest solution for controlling my diet is to eat at home, which is what we do a very large percentage of the time. There are days, however, where eating at home is either not practical, possible, or pleasurable. Those are the times when eating out becomes a challenge. Convenience certainly goes out the window because there is practically nothing on fast food menus that keeps both fat and sodium below my allowable limits. Most devastating from the convenience food category is pizza. From the dough to the sauce to the processed meats, there is no standard pizza place that makes a pizza I can eat.[/dropcap]

Sit-down dining offers more and better options, but even there one can find plenty of challenges, even if all you want is a salad. House dressings are almost always loaded with sodium, especially if they are low- or no-fat. Pre-packaged salads are frequently covered in cheese, which is a high-fat food. Chain restaurants buy much of their meat in bulk and freeze it, which inherently means a higher salt content. Plates are frequently loaded with starchy vegetables, such as potatoes, corn, and peas. One has to be careful.

One’s best, and safest, approach is to dine at locally-owned restaurants. The food here is likely to be fresher, contain less fat and sodium, and depending on the time of day and the item, more easily customized to one’s particular needs. We asked restaurateur Ed Rudisell, owner and investor at several Indianapolis-area restaurants, including Rook, Black Market, and Siam Square, how his restaurants respond to requests for special orders. We weren’t surprised by his response:

“We get occasional requests for substitutions and happily do what we can when preparing the food. Of course, some dishes are easier than other to make adjustments to, but we always try our hardest to accommodate.”

While we’ve only eaten out a few times since being declared diabetic, I have found Ed’s response is typical for locally-owned eateries. Generally speaking, local restaurants are more responsive and sensitive to unique customer needs. There are times, though, when even a locally-owned restaurant can’t adjust a menu item to order. Rob Koeller, Owner/Executive Chef at Culinary Concepts & Hospitality Consultants and former dean at The Chefs Academy at Harrison College, went into a bit more detail:

“The whole “trick” to the restaurant business regarding the food is that you “prep” or pre-prepare as much of the food as possible without jeopardizing the quality so that you can get the food out to the customer in a timely fashion.  Depending on the dish that is offered, many (if not all) of the ingredients are already fully cooked and simply needing a reheat.  An example would be Veal Osso Buco or any braised dish.  Of course, soups and stocks are not being “made-to-order” so being able to keep your food quality up is a struggle and daily challenge.  In these types of dishes, it is hard to make any substitutions due to the nature of the recipe.

On the other hand, many dishes are not that way when it comes to preparation.  Sandwiches, salads, sautéed items, etc. all can be actually “made-to-order” and quickly reach the customer.  With these types of dishes, it is easy to make substitutions or leave allergens out, etc.

My basic approach to any special requests from customers is that if their request is possible/doable, then the answer is “yes” as to whether or not a substitution or alternative can be executed.  The customer, in my regards, is always right so if their request is something that can be done at the moment then it will be done.  Of course, there are requests that simply can’t be fulfilled.  (i.e. a gluten free customer wants sorghum flour used in their pasta but there is no sorghum flour in the establishment).”

One of the things I appreciate about Chef Koeller is his ability to adjust to requests on the fly, something that is aided by the depth of his experience. Experience and education such as his typically aren’t found in most chain or fast-oriented restaurants. Many chain restaurants don’t require any formal education for their kitchen staff at all and turnover is frequently high, making the development of those skills difficult. Asking a line cook at iHop to make adjustments in how your chicken is cooked might be more challenging than making a similar request at a restaurant such as Black Market.

Again, Chef Koeller explains:

One of many points that are taught to a culinary student is that he/she are not cooking for themselves anymore; they are cooking for others.  In today’s world of increasing food allergies, diabetes, and compromised immunities, it is critical for a chef to be aware of the various challenges such as you speak.  Truth in advertising is heavily stressed because of these obvious reasons.  A menu item that contains 40% sodium enriched ingredient(s) should state something to that fact on the menu. With the high turnover in hospitality employees, it has been increasingly difficult to rely on the server to relay important dietary information to the customer.

When I first started looking at places that were safe to eat, I instinctively looked online for nutrition information. What I saw tended to scare me. There are several websites that specialize in providing nutrition information for common dishes at chain restaurants. Pulling from the website nutritionix.com, we looked at some dishes one might think would be safe. Here’s what we found. Percent Daily Values are based on a 2000 calorie diet.

From Applebee’s:

From Panera Bread:

From Red Lobster:

Any of those menu choices might be one which a conscientious person would reasonably think safe for the average diabetic, and for some diabetics, they might very well fit the bill. However, there are caution points to each one. Look at the fat values, especially saturated fat. Fat turns into sugar and is often more dangerous than the actual sugar content of the food. Anything that represents more than 10% of my total allowable fat intake for the day is something I tend to avoid. Pay attention, also, to sodium. The Applebee’s menu item, as healthy as it sounds, is already over my limit of 2300 mg for the day. For anyone with concerns about heart disease, cholesterol levels are important as well. None of these menu items are as safe as we would like for them to be.

There’s a danger, though, of relying on nutrition information. There are different ways of calculating those numbers and percentages. While the differences are typically not severe, when one is watching each and every gram, such as I do, those differences can matter a lot.

Diabetics also need to understand that certain foods inherently come with certain risks. One large egg, for example, represents 50% of my daily cholesterol limit. I don’t have to ask, I know that anything prepared with egg is going to have a higher cholesterol and a slightly higher fat level. Knowing these things is important when dining at locally-owned restaurants that are not likely to have nutrition information available and for very good reason. Ed Rudisell explains:

“For small restaurants, it is nearly impossible to provide nutritional information. Our menu items change too frequently, the lab costs for testing are insanely high – making it the territory of chain restaurants, and preparations of a dish can change daily with the availability of ingredients/produce meats.”

What may be the biggest challenge to diabetics, however, is portion size. We, as Americans, are preconditioned to think that more is better and that, especially when it comes to food, we need to make sure we are getting our money’s worth. This is one of the primary reasons that America has an obesity issue and contributes in no small amount to the rise in Type 2 Diabetes. We are, in a word, gluttons, and that is a huge problem. Moreover, the fault for that problem doesn’t lie with the restaurants, but with the consumer. We demand more, so restaurants feel obligated to provide more.

Jolene Ketzenberger, editor, and the host of WFYI’s Eat, Drink, Indy, among a number of other food-related qualifications, places the responsibility for portion sizes squarely on the consumer:

Consumer demand drives dining trends. As more people wanted vegetarian or gluten-free dishes, for example, more restaurants began offering them. And now we have some strictly vegetarian restaurants. If there is a demand for a specific type of food, the market will comply, and someone will offer it. I think some restaurants, particularly the locally focused, farm-to-fork restaurants, do offer smaller portions; in fact, many of them get criticized about it. And the “small plates” trend makes it easy to enjoy a few bites of a dish rather than an entree-sized portion. So diners do have more options these days to eat lighter, healthier fare.

Mr. Rudisell adds:

As far as portion control is concerned, we try to keep everything reasonable. But I will say this: A LOT of Hoosiers’ definition of value is based on quantity over quality. We encounter this all the time. If you read the reviews of some of the best restaurants in the city, you’ll very often find “portions are too small for the price”. Again, quality is hardly taken into consideration, if at all. A lot of people only focus on the size of the plate and not the quality of the food/preparation. I’ve seen this time and again in my 25 years managing restaurants.

I cannot help but think that this is why it can so often be difficult to find menu items that are safe for diabetics without modification. We don’t say anything. Some are too embarrassed. Some don’t want to be a bother. The worst, though, is that the majority of people with Type 2 Diabetes aren’t even trying. Again, going back to the case of my deceased friend, even among people who know they are diabetic, roughly 70% are not following any kind of doctor-prescribed plan for addressing the disease! They prefer to endure the ever-growing list of consequences rather than watching and tracking what they eat, taking a handful of medicines every day, and getting a reasonable amount of exercise. Such ignorance speeds one’s encounter with death and ultimately reduces the amount of pleasure one can have in their life.

Solving The Problem

[dropcap]Since that first day when I was caught out and needing food, I have had other situations come up where I needed to make a quick decision about where to eat. While I may not be able to indulge in my favorite fat-ladened pizza, I found several places that I can eat safely and still enjoy something with more culinary expression than kale. The onus is on me, however, not the restaurants and not the chef, to know what my body needs and what fits within my dietary allowances. [/dropcap]

Can diabetics eat out and enjoy the experience? Absolutely! Here are some simple steps for making your dining out just as much fun as it has always been.

1. Know your dietary limits. Talk to your doctor. Consult a dietician. Follow their advice. Everyone’s dietary needs are going to be different based on their specific risk levels. There’s no way to control diabetes with your diet if you’re just making guesses at what your body does/doesn’t need.
2. Choose a dining location carefully. Avoid fast food unless there is simply no other reasonable option. Locally-owned, smaller restaurants are far more likely to have delicious fresh food and typically can be more responsive to requests for changes.
3. Be considerate when requesting changes, but do ask for them. Things prepared in advance, such as soups and sauces, often cannot be modified. Understand that there are limits to what a chef can do and avoid being unreasonable in your requests.
4. Eat smaller portions. This just needs to be a regular part of your dining habit. Stop eating so damn much unless your doctor specifically tells you otherwise (and they rarely do). There’s no shame in asking for a half-portion if necessary.
5. Leave good reviews. In today’s socially-aware environment, restaurants and patrons alike rely heavily on reviews. If you have a good experience with a restaurant that made adjustments to accommodate your needs, then let people know! There are other diabetics who would love to see that kind of information in a restaurant review and it helps the restaurant out as well.

Let’s get real before we end this thing. Being diabetic is anything but fun. The problems can be severe and it has severely curtailed my activities. Even if I get my A1C level down below 5, diabetes never goes away. The dangers associated with the disease never goes away. Diabetes is a life sentence and the best one can do is learn how to deal with it effectively.

I am distressed by the number of people who do nothing to control their diabetes. If all 30 million diabetics started paying attention to controlling the disease, eating better, taking their medicine, and exercising, we could have a dramatic impact on the entire country. We would likely see more restaurants with menu items appropriate for diabetics without modification. We might even see changes to how fast food is stored and prepared. Who knows, we might even start seeing pizzas with whole wheat crusts and non-processed toppings!

We, as diabetics, have to shoulder the responsibility, though. Nothing changes if all we do is sit on our ever-expanding asses and ignore the issues plaguing our health.

Yes, you can eat out. Take some responsibility and find places that work for you. Everyone will be better for it.