kris ulland

Your Nutrition Partner

People with underlying medical conditions such as diabetes might be at higher risk of severe illness from COVID-19.

Symptoms of COVID-19 can appear 2–14 days after exposure and typically include:

  • fever
  • a cough
  • shortness of breath

In general, infectious diseases such as COVID-19 are more serious in people with diabetes.

One reason for this is that the immune system does not work as well in people with diabetes, which makes it harder for their body to fight the virus. According to the CDC, the novel coronavirus “may thrive in an environment of elevated blood glucose.”

Diabetes also keeps the body in a low-level state of inflammation, which makes its healing response to any infection slower.

High blood sugar levels combined with a persistent state of inflammation makes it much more difficult for people with diabetes to recover from illnesses such as COVID-19.

Anyone with diabetes who notices symptoms of COVID-19 should speak to their doctor as soon as possible.

In the US, one in eight adults have diabetes (mostly type 2). Another one in three have pre-diabetes. Among people 65 or older, a quarter have diabetes and half have pre-diabetes.

Data, which spans 188 countries, shows a 45 percent increase in diabetes prevalence between 1990 and 2013, with some countries faring worse than others. In the U.S., diabetes rates rose by 71 percent.

At least 20 percent of the population in every U.S. state is also obesea condition that severely predisposes you to diabetes. That said, being skinny is not a blanket assurance of healthy insulin sensitivity. Research suggests one-third of normal-weight adults may also be pre-diabetic without knowing it.

  • Diabetes can cause blurry vision, spots, or other symptoms, and can lead to blindness.
  • The risk of heart attack or stroke is roughly twice as high in people with diabetes.
  • About half the people with diabetes have nerve damage the can cause problems like numbness, tingling, weakness, and pain in the feet or hands.
  • People with diabetes and pre-diabetes are more likely to be diagnoses with dementia.
  • Diabetes is the leading cause of kidney failure.
  • Diabetes causes about 60 percent of foot and leg amputations that are not caused by accidents.

The good news is that research now shows that for some people both pre-diabetes and type 2 diabetes can be reversed.

Reversing diabetes “is a new way of thinking,” reported Roy Taylor, professor of medicine and metabolism at Newcastle University in England in 2018. Taylor is one of the principle investigators of the Diabetes Remission Clinical Trial (DiRECT). He went on to say, “Until now, we’ve regarded type 2 diabetes as inevitably downhill – it’s only going to get worse.”

But, the DiRECT turned that idea upside down.

The trial randomly assigned 49 doctors’ practices in the UK to treat overweight or obese patients who had been diagnosed with type 2 diabetes within the previous six years. The patients were divided into two groups. One group received a very low calorie diet (the intervention group) and the other carried on with the usual care (the control group).

The intervention group got about 850 calories a day for 12-20 weeks. The diet consisted of a liquid formula and salads and other veggie dishes. Then, the intervention group slowly added back foods for two to eight weeks. After that, they met with a dietitian or nurse monthly to help them maintain their weight for two years.

If someone’s weight went up by more than ten pounds, the doctors intervened and provided the liquid diet again. All the diabetes medicines were stopped on day one of the liquid diet and were only restarted if necessary.

“In the intervention arm of the study at one year, 46 percent of the people were free from diabetes, off all their tablets. At two years, 36 percent were still free of diabetes, off all their tablets.” said Taylor. “We demonstrated that, yes, type 2 diabetes can be made to go away.”

In contrast, only 3 percent of the control group were free from diabetes and off meds after two years.

Weight loss plays a key role in type 2 diabetes. Of the 272 people in the two groups, 64 percent of those who lost at least 22 pounds were free of diabetes. Taylor explained, ” It goes up in prevalence if a population is overfed. If a population is short of food, it disappears.”

Weight loss matters because excess fat in the liver makes the body resistant to its own insulin. Excess fat in the pancreas makes it produce less insulin.

Insulin is like a key that allows blood sugar to enter cells. When it stops working well, blood sugar levels stay high, which makes the pancreas secrete more and more insulin until its beta cells eventually give out and produce little or none. Taylor notes that in a study performed in 2011, 11 people who had type 2 diabetes were put on a very low calorie diet. “Within seven days the fat had disappeared sufficiently for the liver insulin resistance completely to vanish. Fasting blood glucose went back to normal.” And, after eight weeks, “We demonstrated that the fat disappeared out of the liver,” and the fat in the pancreases gradually went down. In other words, the diabetes was reversed!

The Center for Disease Control (CDC) reports that “without weight loss and moderate physical activity, 15-30 percent of people with pre-diabetes will develop type 2 diabetes within five years”

Recent research shows life expectancy has declined in the U.S. for the first time in two decades. A follow-up study suggests type 2 diabetes is a factor in this declining life expectancy. This is a tragedy when you consider that type 2 diabetes is entirely preventable and treatable with a low-net-carb diet and other healthy lifestyle changes, such as avoiding sitting all day and getting healthy sun exposure. Most of these strategies are inexpensive or free.

Meanwhile, the cost of conventional diabetes treatment keeps going up. In fact, diabetes is now one of the most expensive diseases in the U.S. Of 155 chronic conditions, diabetes topped the list at $101.4 billion in personal health care spending in 2013.

In the last 20 years, the cost of insulin has shot up by more than 450 percent. A single months’ supply of insulin can now cost nearly $275, compared to less than $21 in 1996.

To that, you have to add the cost for other medications, syringes, pumps and blood sugar sensors and monitors, plus health care costs associated with comorbidities. It’s not surprising then that diabetics spend an average of 230 percent more on medical expenditures than non-diabetics.

Most of the food people eat these days skews metabolism toward insulin resistance, metabolic syndrome and type 2 diabetes. This is because most Americans are burning glucose as their primary fuel, which elevates blood sugar and promotes insulin resistance and inhibits your body’s ability to access and burn body fat. This is the connection between obesity and diabetes. Healthy fat, meanwhile, is a far preferable sort of fuel, as it burns far more efficiently than carbs.

One of the most important dietary recommendations is to limit net carbs (total carbohydrates minus fiber) and protein, replacing them with higher amounts of high quality healthy fats. A key way of preventing diabetes is to keep your net carbs below 50 grams per day. Read labels to get a ballpark idea or use an online nutrition tracker.

Be sure to avoid trans fats and processed foods of all kinds, and boost your fiber intake. Research shows that people with high intakes of dietary fiber have a significantly lower risk of obesity and diabetes. Aim for about 50 grams of fiber per 1,000 calories consumed. Also replace sugary beverages with plain water.

Exercise is one of the fastest and most powerful ways to lower your insulin and leptin resistance. Excessive sitting and general sedentary behavior is equally, if not more, harmful than forgoing an exercise regimen, so make the effort to stand up and move around more throughout the day.

Recent research shows low vitamin D is a predictor of type 2 diabetes mortality due to heart disease. This is important because the risk of cardio vascular disease is generally high in people with type 2 diabetes.

Other nutrients of importance include magnesium and vitamins B12, K2 and C. Vitamins D and B12 are particularly important during pregnancy, as maternal vitamin D deficiency may increase your child’s risk for both type 1 and type 2 diabetes, and B12 deficiency may increase your child’s risk of type 2 diabetes.

Multiple studies have shown that obese people have different intestinal bacteria than lean people. The more beneficial bacteria you have, the stronger your immune system will be and the better your body will function overall. You can reseed your body with good bacteria by eating fermented foods (such as fermented vegetables and natto) or by taking a high quality probiotic supplement. Remember, do not buy your supplements at a drugstore like Walgreen’s or CVS. Go to Whole Foods or a local co-op to get the best products.

Recent research suggests reducing exposure to phthalates, DDT, polychlorinated biphenyls (PCBs) and perfluoroalkyl by 25 percent could lower diabetes rates by 13 percent. Check your cleaning and personal care supplies.

Tofu

Tofu is a food made of condensed soy milk that is pressed into solid white blocks in a process quite similar to cheesemaking. It is also know as bean curd. It originated in China.  A cook discovered tofu more than 2,000 years ago by accidentally mixing a batch of fresh soy milk with nigari. Nigari is what remains when salt is extracted from seawater. It is a mineral-rich coagulant used to help tofu solidify and keep its form.

Most of the world’s soybeans are currently grown in the US, and a very large proportion is genetically modified (GMO). Be sure you verify that the tofu you buy is non-GMO and organic.

One 3.5-ounce serving of tofu has:

  • Protein: 8 grams
  • Carbs: 2 grams
  • Fiber: 1 gram
  • Fat: 4 grams
  • Manganese: 31% of the RDI
  • Calcium: 20% of the RDI
  • Selenium: 14% of the RDI
  • Phosphorus: 12% of the RDI
  • Copper: 11% of the RDI
  • Magnesium: 9% of the RDI
  • Iron: 9% of the RDI
  • Zinc: 6% of the RDI

In this serving size, there are 70 total calories, which makes tofu a highly nutrient-dense food. The micronutrient content of tofu can vary depending on the coagulant used. Nigari adds more magnesium while precipitated calcium increases the calcium content.

Like most plant foods, tofu contains several anti-nutrients.

  • Trypsin inhibitors: These compounds block trypsin, an enzyme needed to properly digest protein.
  • Phytates: Phytates can reduce the absorption of minerals, such as calcium, zinc, and iron.

Soaking or cooking soybeans can inactivate or eliminate some of these antinutrients. Sprouting soybeans before making tofu reduces phytates by up to 56% and trypsin inhibitors by up to 81% while also increasing protein content by up to 13%.

Fermentation can also reduce antinutrients. For this reason, fermented, probiotic soy foods, such as miso, tempeh, tamari, or natto, are low in anti-nutrients.

Soybeans contain natural plant compounds called isoflavones. These function as phytoestrogens, meaning that they can attach to and activate estrogen receptors in your body. This produces effects similar but weaker to the hormone estrogen. Tofu contains 20.2–24.7 mg of isoflavones per 3.5-ounce serving.

Scientists have also discovered that soy isoflavones can reduce blood vessel inflammation and improve their elasticity. One study found that supplementing with 80 mg of isoflavones per day for 12 weeks improved blood flow by 68% in people who were at risk of stroke.

Taking 50 grams of soy protein per day is also associated with improved blood fats and an estimated 10% lower risk of heart disease. In postmenopausal women, high soy isoflavone intake is linked to several heart-protective factors, including improvements to body mass index, waist circumference, fasting insulin, and HDL cholesterol.

Research shows that women who eat soy products at least once a week have a 48–56% lower risk of breast cancer. This protective effect is thought to come from isoflavones, which have also been shown to positively influence the menstrual cycle and blood estrogen levels.

Tofu contains saponins, compounds thought to have protective effects on heart health. Animal studies show that saponins improve blood cholesterol and increase the disposal of bile acids, both of which can help lower heart disease risk.

In fact, research shows that women who ate soy products at least once a week throughout adolescence and adulthood had a 24% lower risk of breast cancer, compared to those who ate soy during adolescence alone.

One frequent criticism of tofu and other soy products is that they may increase breast cancer risk. However, a two-year study in postmenopausal women who consumed two servings of soy per day failed to find an increased risk. Other studies report similar findings, including a review of 174 studies, which found no link between soy isoflavones and increased breast cancer risk.

One study observed that higher intakes of tofu were linked to a 61% lower risk of stomach cancer in men. A second study reported a 59% lower risk in women. A recent review of several studies in 633,476 people linked higher soy intake to a 7% lower risk of cancers of the digestive system.

Several recent test-tube and animal studies show that soy isoflavones may boost blood sugar control. In one study of healthy postmenopausal women, 100 mg of soy isoflavones per day reduced blood sugar levels by 15% and insulin levels by 23%  For postmenopausal women with diabetes, supplementing with 30 grams of isolated soy protein lowered fasting insulin levels by 8.1%, insulin resistance by 6.5%,  LDL cholesterol by 7.1%, and total cholesterol by 4.1%.

In another study, taking isoflavones each day for a year improved insulin sensitivity and blood fats while reducing heart disease risk.

  • Bone health: Scientific data suggests that 80 mg of soy isoflavones per day may reduce bone loss, especially in early menopause
  • Brain function: Soy isoflavones may have a positive influence on memory and brain function, especially for women over 65.
  • Menopause symptoms: Soy isoflavones may help reduce hot flashes. However, not all studies agree.
  • Skin elasticity: Taking 40 mg of soy isoflavones per day significantly reduced wrinkles and improved skin elasticity after 8–12 weeks.
  • Weight loss: In one study, taking soy isoflavones for 8–52 weeks resulted in an average weight loss of 10 pounds (4.5 kg) more than a control group.

Eating tofu and other soy foods every day is generally considered safe. That said, you may want to moderate your intake if you have:

  • Breast tumors: Due to tofu’s weak hormonal effects, some doctors tell women with estrogen-sensitive breast tumors to limit their soy intake.
  • Thyroid issues: Some professionals also advise individuals with poor thyroid function to avoid tofu due to its goitrogen content.

However, a recent report from the European Food Safety Authority (EFSA) concluded that soy and soy isoflavones pose no concerns for thyroid function or breast and uterine cancers. Nevertheless, researchers agree that infants should not be exposed to soy isoflavones, which may disrupt the development of reproductive organs.

Although this has not been studied well in humans, some animal studies suggest that high amounts of soy may interfere with fertility.

If you have concerns, discuss soy consumption with your doctor.

How to Buy

Tofu can be purchased in bulk or individual packages, refrigerated or not.

You can also find it dehydrated, freeze-dried, jarred, or canned

Heavy processing is unnecessary to make tofu, so choose varieties that have short ingredients lists.  You can expect to see ingredients like soybeans, water, coagulants (such as calcium sulfate, magnesium chloride, or delta gluconolactone) and maybe some seasoning.

How to Store

Once opened, tofu blocks need to be rinsed prior to use.

Leftovers can be kept in the refrigerator for up to one week by covering with water, as long as you change the water often. It is best to use filtered water.

If you will have to store it longer than a week, tofu can also be frozen and will last for up to three months. Cut it into chunks and freeze on a parchment-lined baking sheet until solid, then transfer to an airtight freezer container or bag. Defrost in the refrigerator and squeeze out any excess liquid before cooking. Tofu that has been previously frozen will have a sturdier, spongier texture that many cooks prefer, especially if you plan on marinating it.

How to Cook

The most common methods for cooking extra-firm and firm tofu are pan-frying, stir-frying, baking, grilling, and scrambling it.
  1. Crispy Tofu – Pan-frying is the easiest, least fussy way to cook tofu
  2. Stir-Fried Tofu – add it to veggies
  3. Baked Tofu – use a marinade
  4. Grilled Tofu – with herbs
  5. Scrambled Tofu – treat it like an egg

Maple-Roasted Tofu with Butternut Squash

Melissa Clark Image: Linda Xiao for The New York Times. Food Stylist: Monica Pierini.

4 Servings

Ingredients

  • 1 (14- to 16-ounce) package extra-firm tofu, drained and patted dry
  • ¼ cup maple syrup
  • 2 teaspoons peeled and grated fresh ginger
  • ¼ teaspoon red-pepper flakes
  • ¼ cup extra-virgin olive oil, plus more for drizzling
  • 12 ounces butternut squash (1 small to medium squash), peeled, trimmed, seeded and cut into 1/2-inch cubes
  • 1 pound brussels sprouts, trimmed, small ones left whole, large ones halved
  • 1 medium red onion, cut into 1/2-inch wedges
  • Kosher salt and freshly ground black pepper
  • ¾ teaspoon ground coriander
  • 1 tablespoon finely chopped fresh sage leaves
  • 1/2 teaspoon smoked paprika
  • 1 ½ tablespoons tamari
  • 3 teaspoons fresh lime juice, plus more for drizzling
  • 1 teaspoon vegan fish sauce – 1/2 t tamari and 1/2 t rice vinegar (any vinegar will do)
  • ½ cup sliced scallions (white and green parts), for garnish

Instructions

  1. Heat oven to 400 degrees.  Rinse tofu and slice into 1-inch-thick slabs. Pat them dry with paper towels and arrange in single layer on a plate. Cover tofu slabs with more paper towels and set aside.
  2. In a small saucepan, combine maple syrup, smoked paprika, ginger and red-pepper flakes. Simmer until syrup thickens slightly, about 1 minute, then stir in 1/4 cup olive oil.
  3. Place squash, brussels sprouts and onion in a bowl. Toss with salt, pepper, coriander, sage and half of the maple syrup mixture. Spread vegetables in an even layer on a rimmed baking sheet.
  4. Add tamari and 2 teaspoons lime juice to remaining maple mixture.
  5. Remove paper towels from over tofu, and sprinkle salt on tofu slabs. Tuck tofu onto the baking sheet with squash and brush half of the soy-maple mixture over the slabs. Roast for 40 minutes, tossing the vegetables occasionally. Halfway through roasting, flip the tofu slabs, and brush with remaining soy-maple mixture. Turn oven off and heat broiler.
  6. Broil tofu and vegetables for 1 to 2 minutes to crisp the edges of the tofu. When vegetables are still hot, toss with remaining 1 teaspoon lime juice and the vegan fish sauce. Garnish with sliced scallions and drizzle with more olive oil and a little more lime juice if you like.

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