I have 2 vegan vegetarian patients (eating no animal products: meat, milk, cheese, eggs, etc), a 6 year old with type 1 and a 60 year old with type 2. How can I advise them on eating habits when they are already eating so well? Both want to maintain a vegan lifestyle. The 60 year old patient (100 pounds) wants to manage through diet alone without medication. She eats 72% carbs. Do you know of any good books, resources, cookbooks, web sites, etc., for vegan diabetics?

My best suggestion for both of your clients is the same one that I would give to omnivores and others. Consume a healthy diet composed of the foods you normally enjoy and have available in your family and surroundings. Test blood glucose daily to confirm that the total amount of carbohydrate being consumed is in balance with the insulin available to metabolize it.

For the Type�1 child, this insulin would have to be provided by injected insulin — preferably mealtime boluses of Humalog insulin (or perhaps Regular since a vegan diet is likely to be quite high in fiber, producing a blunted glucose response after meals). Meal bolus therapy (together with a source of background insulin — perhaps NPH twice a day or Ultralente) will give the child and her family greater flexibility to respond to variations in appetite without getting in to food-related battles. I hope someone (preferably a pediatric endocrinologist) is monitoring this child’s growth and development because both the vegan diet (because of low calorie density and low digestibility by kids) and the diabetes place her at some risk for maintaining optimal growth patterns.

As for your older patient, a lean person who develops diabetes — even at this late age — is more likely to eventually require insulin than someone diagnosed when overweight. Some researchers are now investigating the possibility that lean persons who develop diabetes in their later years may actually have a slowly developing form of type 1 diabetes. If that is the case with your patient, she may not be able to maintain diet control of her blood glucose values for a very extended period. For diet management to work, she must still be producing an adequate amount of her own insulin to metabolize the amount of calories and carbohydrate in an adequate diet. Post-meal testing (with a goal of maintaining values less than 180 mg/dl) will reveal whether your patient’s insulin producing capacity can handle the high carbohydrate diet she is currently consuming. If it is high in fiber, she may be doing fine. However, if she finds the post-meal values elevated, reducing carbohydrate (and replacing it with more vegetarian protein and monounsaturated fats) may help her restore glucose control. However, if she cannot keep blood sugars under control eating a healthy and reasonable diet, I hope you will speak with her about her other options for therapy. Given her leanness, insulin may be in her future and I hope you can position that possibility to her as a positive option for her health, not a failure or a burden.

BB