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We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. METRO photo
Soy puts less stress on the kidneys than animal protein

By David Dunaief, M.D.

Dr. David Dunaief

There are many myths about managing type 2 diabetes that circulate. Fortunately, our understanding of diabetes management is continually advancing, and some older guidance deserves to be retired. Let’s review a few common myths and the research that debunks them.

Should fruit be limited or avoided?

Fruit in any form, whether whole, juiced, or dried, has been long considered taboo for diabetes patients. This is only partly true.

Yes, fruit juice and dried fruit should be avoided, because they do raise or spike glucose (sugar) levels. This includes dates, raisins, and apple juice, which are often added to “no sugar” foods to sweeten them. The same does not hold true for whole fresh or frozen fruit. Studies have demonstrated that patients with diabetes don’t experience sugar level spikes, whether they limit whole fruits or consume an abundance (1). In a different study, whole fruit was shown to actually reduce the risk of type 2 diabetes (2).

In yet another study, researchers looked at the impacts of different types of whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load, actually lowered these levels. The only fruit tested that seemed to have a mildly negative impact on sugars was cantaloupe.

Whole fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the fruits’ flavonoids, or plant micronutrients, but another is their fiber.

Do all carbohydrates raise your sugars?

Fiber is one type of carbohydrate that has distinct benefits. We know fiber is important for reducing risk for a host of diseases and for managing their outcomes. This is also true for type 2 diabetes. 

In the Nurses’ Health Study (NHS) and NHS II, two very large prospective observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. So, the more they ate, and the more metabolites in their urine, the lower the risk. The authors encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include cruciferous vegetables, such as broccoli and cauliflower; an assortment of fruits and whole grains; flaxseed; and sesame seeds (5). The researchers could not determine which plants contributed the greatest benefit. They wrote that they believe antioxidant activity drives this effect.

Should you avoid soy when you have diabetes?

In diabetes patients with nephropathy (kidney damage or disease), soy consumption showed kidney function improvements (6). There were significant reductions in urinary creatinine levels and proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.

This was a small, randomized control trial over a four-year period with 41 participants. The control group’s diet consisted of 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s diet consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is very important, since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism and low iodine levels should be cautious about soy consumption, since some studies suggest it might interfere with synthetic thyroid medications’ effectiveness (8).

Is bariatric surgery a good alternative to changing my diet?

Bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of 16 randomized control trials and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (9). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, even with bariatric surgery, altering diet and exercise are critical to maintaining long-term benefits.

We still have a lot to learn with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. Emphasizing a plant-based diet focused on whole fruits, vegetables, beans and legumes can improve your outcomes. If you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery in order to sustain its benefits.

References:

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Thyroid. 2006 Mar;16(3):249-58. (9) Obes Surg. 2014;24:437-455.

Dr. David Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Tofu

By Leah S. Dunaief

Leah Dunaief

In the middle of the last century, which is when I was growing up, no one I knew had ever heard of tofu. In fact, restaurants where we might have encountered tofu were few and limited to university campus neighborhoods like the sole Japanese restaurant near Columbia University on the City’s upper west side.

But of course, in addition to all the other revolutions in the intervening years, we have eateries offering unending ethnic foods. Dining out has become a gastronomic visit to every corner of the globe. And I, and my family, have discovered tofu.

I love tofu.

Now for a long while, tofu got a bad rap. Tofu is, of course, soy, and soy has relatively high levels of isoflavones, which are similar to the hormone estrogen. This hormone has been linked to cancer, and further there was the concern that soy might affect fertility and even cause men to develop feminine characteristics.

In fact, after many years of trials and study, soy has not only been declared safe but also to be of possible benefit to good heart and metabolic health. Tofu offers considerable protein and all nine essential amino acids, B vitamins, healthy unsaturated fatty acids and assorted minerals, including calcium, magnesium, zinc and iron. And according to a recent article in The New York Times, while isoflavones can “weakly mimic estrogens, they also seem to have anticancer, anti-inflammatory and antioxidant properties.”

Not only does soy seem not to promote breast cancer, studies have shown it may even lower such risk for women compared to those who ate little or no soy. It may even protect against prostate and lung cancers. Further studies have largely disproven any association of soy with diminished fertility or sperm count. And in a more than 30-year study of nearly 120,000 health care professionals in the United States, “those who consumed at least one serving of tofu or soy milk per week were 15 to 16% less likely to die than those who ate less than one serving per month.” There you have it, encouragement to eat tofu for our health.

What about taste?

Tofu is definitely more than a blob in a square package. It can be smoked, made into noodles, baked, shredded and flavored in unlimited ways. Tofu was invented some 2000 years ago in China and consumed throughout Asia. So now that 9% of United States households use tofu in multiple ways, we can helpfully categorize it as presented in three types: basic, chewy and intensely flavored. Like eggs and chicken, basic tofu’s flavor is neutral, which allows it to incorporate profitably any additional ingredients. It can serve in stir-fries or even crisped in an air fryer and presented with a dipping sauce, for example.

To prepare tofu, “high-protein food grade soybeans are soaked, made into soy milk and coagulated with a salt or edible organic acid or both. The resulting semisolid curds and clear whey are manipulated for different kinds of tofu,” according to The New York Times.”Texture is determined by whether and how the curds are pressed. Basic tofu options include silken, medium, medium-firm, firm, extra-firm and superfirm. Many dishes involve slicing, cubing and mashing tofu, but depending on its density, it can be scooped, crumbled and even grated.” 

You may have to visit Chinese or Vietnamese markets  to go beyond silken and firm. Pressed (baked) tofu, tofu sheets and fried tofu are all made with chewy tofu. They can look like pasta if cut up into thin strips for a salad. White and red fermented  tofu are deeply flavored and sold in jars at Asian markets in the condiments section. They can be fragrant, rich from sesame oil or spicy from chile.

Tofu can be used in place of animal protein, as a substitute for ricotta in lasagna or mozzarella in a caprese, or as a replacement for high carbs. Since it is already cooked, tofu can go anywhere without fuss.

See why I like it?

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The final chapter for WholeSoy & Co.

Stonyfield Organic O'Soy yogurt at Wild By Nature is one option to fill the hole left by WholeSoy.

It’s been a month and a half since my stash of Trader Joe’s organic soy yogurt ran out, and I still haven’t found anything equally as satisfying to fill the void in the lunchbox. Though it’s never been confirmed, I’ve always believed that family-owned WholeSoy & Co. made Trader Joe’s soy yogurt, since both brands always seemed to disappear from stores at the same time.

Now, after two years of following WholeSoy’s battle to keep its yogurt on the shelves, I bring you the anti-climactic conclusion. The 16-year-old company shuttered in March.

This premature end was particularly surprising, since things seemed to be looking up back in January when Maryland-based Nutroganics licensed the WholeSoy & Co. name for the production and sale of soy milk. Whether this marriage will remain intact, or even extend to soy yogurt, remains to be seen.  The company, which owns three other “healthy lifestyle” labels, did not return calls for comment.

This is not the way epics and stories about underdogs are supposed to end.

WholeSoy, based in Modesto, Calif., fought valiantly to pick itself up after its factory — known as a co-packing plant — closed in 2013. I tracked the progress as the company moved to a new facility, and then, because the facility couldn’t meet its huge production needs, put together funds to build and operate its own dairy-free yogurt-making facility. Then we all waited yogurt-less, month after month, as deadlines came and went and the yogurt we yearned for didn’t return to store shelves. Finally, after almost a year, it was back in April 2014, and all, it seemed, was right with the world.

Not quite a year later — in March — I noted the dwindling supply of yogurt at Wild by Nature and knew something was up. A visit to the WholeSoy website confirmed it. A letter to customers explained that the company simply could not afford to both run the business and cover the debt it incurred while off the shelves and from building a new facility.

At that point, I did the only thing I could do. I went to Trader Joe’s and cleared the shelf — actually, I think I left about four containers behind. If this was the end, we were going down with a boatload of soy yogurt.

While WholeSoy stood out for making organic soy yogurt with ingredients that had no genetic modifications, it was also notable for its transparency. In an effort to be “honest and forthright” it tried to keep its customers in the loop through regular posts to its website and social media. At one point, the executives even apologized for promising and then delaying (several times) the yogurt’s comeback “and not taking into account consideration of all of the potential pitfalls.”

It was also no secret that executives had poured their own money into the business along with a $400,000 loan from Whole Foods. Yet, in the end, it wasn’t enough.

“[W]e have exhausted all possible sources of additional funding and can no longer continue to operate,” the bare-all message said.

And yet, aren’t these precisely the companies we want to see thrive?  It’s sad, really —and not just for vegans and people with dairy allergies — that an independently owned, environmentally and socially conscious company was unable to survive despite the high demand for its product. According to them, they were the number one selling soy yogurt, and based on all of the love notes customers have left as recently as this month on their page, it’s clear that they had quite the following.

Certainly, there are other soy yogurts on the planet, but even my own little soy yogurt connoisseur votes with a spoon and declares that the others do not taste the same. Besides, after watching our protagonist face and overcome so many obstacles, this denouement is less than satisfying.

I can only hope for a sequel in which the WholeSoy founders are able to rise from the ashes to build a stronger, even more successful business.

Until then, I’ll echo their final words to customers back to them.

“Thank you from the bottom of our hearts and farewell.”

 

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Stonyfield Organic's O'Soy yogurt tries to fill the void left by WholeSoy's absence.

Stonyfield Organic O'Soy yogurt at Wild By Nature is one option to fill the hole left by WholeSoy.