The Challenges of Healthy Eating: An Interview with Hope Warshaw

Hope Warshaw portrait

Thanks to Glu for the opportunity to talk about balancing the challenges of healthy eating and diabetes management. It’s one heck of a tough job, day in and day out. Hopefully in responding to the questions posed by Glu below I’ve offered you a few thoughts to ponder as you strive to eat healthier and achieve glycemic control in 2014!

1. With the New Year many people are starting new diets or healthy eating initiatives as part of a New Year’s resolution. Is this a good time to try something new?

HW: I struggle with the concept of New Year’s resolutions regarding weight loss and healthy eating for the general public, and even more so for people with diabetes. Here’s why. Making significant changes in calorie intake (for weight loss) or food choices clearly impact insulin needs and glucose control. It’s been proven that people have a hard time maintaining lofty New Year’s resolutions much beyond Valentine’s Day, if that long.

Why not try a different and more potentially long-lasting approach this year?

Reality is diets—that’s rigid, food choice limiting plans—don’t survive long-term for most people. Research shows people have a difficult time achieving the goals of a diet that aren’t in accord with their usual way of eating. People slowly but surely gravitate back to their usual way of eating over time. Our eating habits are deep rooted. In addition, research in behavior change, which is what achieving a healthy eating plan and lifestyle are all about, shows that the best way to change behaviors forever is to achieve these with small steps vs. wholesale changes.

So this year, rather than contemplating a laundry list of New Year’s resolutions or attempting to fit the latest, greatest “diet” into your life; how about taking the approach of making tweaks towards healthier eating. Start by setting a few goals. Tops on my list are: eat more greens, whole grains, and legumes (beans) and make and pour homemade salad dressing.

What tweaks towards healthier eating do you want to (and are able to) make?

2. What’s the best way to start a healthy eating routine?

HW: This answer builds on the answer above and details the four steps to make most any behavior change:

  • Step 1: Honestly assess your current eating habits (or any habit).
  • Step 2: Choose a few easy-to-do actions you are willing and able to take to tweak your current habits.
  • Step 3: Set a SMART goal related to each of the actions/changes you chose to make.
  • Step 4: Go! Then evaluate. Revise as needed. Repeat.

Set yourself up to achieve success early. Success breeds success! In the words of B.J. Fogg, PhD, director of the Stanford University Behavior Design Lab and keynote speaker (my favorite!) at the AADE 2013 annual meeting, Build ‘success momentum’—that’s when you successfully change one tiny habit after another. Fogg noted, “We can’t break bad habits, but we can, overtime, untangle them.”

3. There seems to be tension with for T1Ds between eating healthy and eating for glycemic control? What is the difference, and is there a happy medium?

HW: Yes, I believe there is tension and it’s understandable. It goes without saying that a key goal of diabetes management is glycemic control. Research shows that it’s wise to broaden that out to factor in metabolic control—control of glucose, lipids, and blood pressure. What research has shown over and over is treating these measures to the targets you and your healthcare provider think is best for you at your particular age and stage, is what will keep you (most anyone with diabetes) healthy over time and maximizing the prevention of complications.

Let’s layer on the challenge of choosing foods and the timing of meals and snacks onto controlling glucose. It’s tempting and understandable to want to severely limit intake of carbohydrates. Yes, research shows it is the carbohydrate in foods that is the macronutrient (in comparison to protein and fat) which most impacts glucose levels after eating.1 However, nutrition research also demonstrates and eating guidelines recommend1,2 that for optimal health and disease prevention an intake of carbohydrate should be at least 45% and up to 65% of calories. It should include ample amounts of vegetables, fruit, whole grains, legumes, and low-fat dairy foods.1

In addition, research to date on the use of low carbohydrate diets in diabetes (for purposes of evaluating the research moderately low carbohydrate is defined 30 or less than 40% of calories3) is mixed and inconclusive.1,3 What is conclusive is that monitoring carbohydrate intake is of value in improving after meal glucose levels. And if one can improve after meal glucose levels (which encompasses many hours of the day when you add them up), then it may help improve overall glycemic control. When it comes to balancing carbohydrate and insulin to achieve glucose control, research shows the focus should not be on limiting carbohydrate as a means to limit insulin doses, but on adjusting insulin based on carbohydrate consumption.1 This includes findings from the Diabetes Control and Complications Trial (DCCT) and others.

A popular notion seems to be that the less insulin one needs to take the better. To date, however, there’s no research to substantiate this notion. What is most important for glycemic control is to match carbohydrate intake and glycemic rise from food with available insulin.1 Paying attention to timing rapid-acting insulin in sync with food intake is also important.

4. There seem to be diets aplenty, from low carbohydrate, anti-wheat, to Paleo to gluten-free promoted to people with diabetes as being the latest, greatest solution for glycemic control. What is your opinion on these types of diets for people living with diabetes?

HW: Generally speaking these are fad diets for which there’s essentially no existing research discussing their benefits for the general population or people with diabetes. (The exception here is the use of a gluten-free eating plan for people diagnosed with celiac disease which has an increased occurrence among people with T1D.) It’s common, especially in today’s world, to see this or that diet gain popularity through the publication of books, websites, blogs and/or anecdotal reports of success.

In conclusion, let me come back around to the points I made above—diets don’t work long-term, tweaks to your eating plan that you can confidently put into action can.


  1. Evert A, Boucher J, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36(11):3821-3842.
  2. Report of the Dietary Guidelines Advisory Committee, Chapter 3 Translating and Integrating the Evidence on the Dietary Guidelines for Americans, 2010
  3. Wheeler et al. Macronutrients, Food Groups, and Eating Patterns in Management of Diabetes. Diabetes Care. 2012; 35:434-445.

Hope Warshaw, MMSc, RD, CDE, is a dietitian, diabetes educator, consultant, and freelance writer. She is the author of numerous books published by the American Diabetes Association including Complete Guide to Carbohydrate Counting and Diabetes Meal Planning Made Easy. To learn more check out her website and blog at Follow her on Twitter @hopewarshaw.

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