As the recession deepens and the unemployment rate hovers at 10%, (1) diabetes clinicians often find themselves caring for individuals with serious financial concerns. Comments such as "Healthy food is too expensive," "I can't afford to follow a diabetes diet," and "Diabetic food costs too much" are now commonly heard during patient care encounters. It is not surprising that individuals with diabetes have financial issues because those with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than those without diabetes. (2) According to the American Diabetes Association, the per capita annual cost of health care for people with diabetes is $11,744, of which $6,649 (57%) is attributed to diabetes. (2) The recent economic downturn has added further financial pressure. The current Consumer Price Index Inflation Calculator estimates that what $100 would buy 5 years ago now costs $114.52, (3) an amount that will vary with changes in the economy.
Although some individuals with diabetes may not disclose financial anxieties to their clinicians, health care professionals should be aware that the inability to pay for food, medications, and other aspects of diabetes care can pose a barrier to optimal self-management. Health care professionals should be prepared to assist individuals with diabetes by providing guidance on pennywise meal planning, smart shopping, and cost-effective cooking to help patients reduce their food costs without sacrificing important aspects of their care.
Planning Pennywise Meals
Planning pennywise meals is the first step toward taking a big bite out of food expenses. Sharing information such as "Saving just $5 a week on food--about the cost of one fast-food value meal--adds up to more than $250 a year" with patients can open a discussion about the effectiveness of making small behavior changes to move toward the bigger goal of healthy eating on a budget.
Because today's diabetes nutrition guidelines parallel the dietary guidelines for all Americans, meal planning for individuals with diabetes incorporates the same foods recommended for the entire family to promote good health. Whether by counting carbohydrates, using the Exchanges Lists from Choose Your Foods: Exchange Lists for Diabetes, following a plate method, or implementing another diabetes nutrition approach, planning meals is the first step that individuals with diabetes should take when making the transition from diabetes nutrition theory to actually sitting down and enjoying a great-tasting, good-for-you meal. It may be helpful to suggest to patients that meeting with a registered dietitian or diabetes educator can be a good use of both money and time when starting the meal-planning process.
Meal Planning Pays Off
Diabetes care professionals can help patients see the multiple benefits of planning their meals.
Saving time. With practice, planning five evening meals for a week such as those shown in Table 1 takes only about 5 minutes--time that can be found while waiting for a doctor's appointment, waiting for a pot of water to boil, or sitting in traffic. That initial 5-minute time investment will then pay off by simplifying the process of making a shopping list and going to the grocery store. Following a quickly written list of ingredients needed to prepare the planned meals, individuals can make their way through the grocery store more efficiently, eliminating the need to spend time later making extra trips to buy forgotten items. Further, when the menu is planned in advance and the pantry and refrigerator are well stocked, healthy meals are only minutes away.
Saving money. Planning meals and shopping from a list also translates into cost savings at the checkout. According to a CNN report, shoppers spend between 50 cents and $1 for every minute over one-half hour they are in the supermarket. (4) Getting through the store faster by following a shopping list means spending less money.
Planning ahead and shopping with a list can also help ensure that the shopping cart will be filled with only foods that are needed, in the proper package size, resulting in less wasted food and fewer impulse purchases. Just one or two impulse purchases can add $5.00-10.00 at the checkout, and if those items are snack foods, they can also challenge efforts to follow a healthy diet.
Although favorite family recipes, with nutrition-boosting modifications as needed, are the heart of the menu plan, incorporating at least one meatless meal each week will mean lower food costs (as well as less saturated fat and cholesterol) because meat typically makes up the largest part of the food budget.
With advance planning, it is possible to feed a family of four at home for ~$120-140 per week. Health care professionals can direct patients with diabetes to the U.S. Department of Agriculture Web sites for healthy food plans and simple recipes.
Saving energy. Planning meals ahead and buying all the necessary ingredients at one time saves not only the shopper's personal energy by reducing the need for multiple quick trips to the store, but it also saves environmental energy and mental energy. There's no more wondering, "What's for dinner?"
Planning for "Planned Overs" No one wants to eat the same foods day after day, but "planned overs" are a smart cook's best friend. Planned overs are planned leftovers--key ingredients deliberately prepared in larger quantities with the plan to use them in several different ways. For example, by grilling a few extra chicken breasts while preparing tonight's chicken dinner, you can then use some of the extra chicken for a green salad with chicken strips in tomorrow's lunch and put extra diced chicken in the freezer for use in a future chicken and broccoli casserole.
Using planned overs means more than just eating tonight's leftovers for lunch tomorrow. Deliberately cooking and baking in larger quantities and using planned overs for additional meals makes the most of a cook's time, energy, and ingredients.
Savvy supermarket shopping is one sure way for individuals with diabetes to spend less and eat more healthfully. With food prices rising at a pace not seen in almost 20 years, people are adjusting their shopping habits and frequenting a combination of stores to stretch their food dollars.
Smart shoppers may want to consider visiting a warehouse club once a month to stock up on nonperishable staples in bulk (Table 2), a super center type store for best everyday prices, and a regular supermarket to save time or pick up low-fat milk or fresh produce as needed. No-frills discount groceries and bakery outlets boast a 40-50% savings and are growing in popularity. New to the grocery shopping scene are "dollar stores," many of which are expanding their food offerings to meet the needs of penny-pinching consumers.
Smart Shopping Tips to Share Diabetes care professionals can help their patients in their quest for low-cost healthful food by sharing the following shopping tips.
* Shop alone, and don't head in to the store hungry. Having extra people along (especially kids!) or a growling stomach means extra food in the cart and extra money spent at checkout.
* Be a list lover; don't leave home without it. Shopping lists help shoppers stay focused and resist high-price, low-nutrition impulse buys. Advise your patients to organize their lists aisle by aisle to realize additional cost and time savings.
* Grab a basket, not a cart. To control purchases, suggest that patients grab a handheld basket rather than a cart when heading into the store to pick up a few items. When the basket gets heavy, shoppers should be ready for checkout. A cart makes it easier to continue buying impulse items.
* Stick to the perimeter. Foods with the most nutritional value are typically found on the store's perimeter. That's where produce, fresh meats, dairy, and breads can be found. High-traffic areas are typically located in the back of the store, so shoppers are more likely to pass through the inner aisles where processed and convenience foods are found, encouraging impulse buys.
* Look high and low for the best buys. Point out to patients that the more expensive brands and impulse buys are at eye level, whereas store brands and betters buys are often located on the top and bottom shelves.
* Take advantage of store specials. If blueberries are on the shopping list but the store circular shows grapes to be a better buy, encourage patients to consider making a switch to save money.
* Buy store brands. More consumers are switching to store brands or generics to save 20-30% on their food bill.
* Skip "special" foods. Special "dietetic" and "diabetic" food items are not necessarily lower in carbohydrates and typically are higher priced than regular versions of the same foods. For example, a piece of regular red and white peppermint hard candy costs 2 cents, whereas a piece of sugar-flee red and white peppermint hard candy costs 8 cents (based on January 2010 prices in Lexington, Ky.). Both contain 5 g of carbohydrate.
* Cut costs with coupons. Coupons can save individuals with diabetes money on routine purchases and add extra savings if double or triple coupon days are available in their area stores. Using just five 50-cents-off coupons per week can create a savings of $130 each year. Coupons have gone high tech, so it is no longer necessary to hassle with clipping them. Coupons can be printed from popular coupon Web sites such as www.coupons.com or received via text messages and downloaded to supermarket rewards cards for scanning at checkout.
* Fresh isn't always best. Fruits and vegetables that are "in season" are a best buy. Consumers may want to buy extras and freeze them to use throughout the year. Economical and nutritious choices in the winter months include apples, cabbage, carrots, oranges, tangerines, and turnips.
Although many think that "fresh is best" when it comes to fruits and vegetables, canned and frozen versions often cost less and require less preparation. Furthermore, the nutrient value is as good as or better than fresh food and less food is wasted during preparation. Canned and frozen fruits and vegetables are picked at their peak ripeness, whereas produce sold fresh is often harvested before it is fully ripe, which may compromise its nutritional value.
Patients who are concerned about the syrups in canned fruits can easily drain and rinse them to reduce the carbohydrate content. Some canned vegetables are available in "no salt added" versions. Those that are not can be drained and rinsed to remove a significant amount of sodium.
Relearning the lost art of cooking is key for individuals with diabetes who want to get the most from less costly and more healthful meals. Traditional meals have become a casualty of our time-obsessed society. Today, the average American spends a mere 31 minutes per day on food preparation and cleanup. (6)
Expensive and often nutrient-poor convenience and ready-to-eat foods have taken on a central role in meals prepared at home. Consumers pay premium prices for foods that have been grated, chopped, precooked, pre-sliced, or individually packaged. For example, shredded carrots by the pound cost more than three times more than whole carrots, which can be shredded in moments in the kitchen. Individuals with diabetes who are willing to invest time in food preparation will reap savings, both by using fewer of these convenience products and by cutting down on pricy fast-food drive-through fare, home-delivered meals, and restaurant splurges.
It is not necessary for patients to cook at the level of Julia Child or be a "Top Chef" to save money. A good basic cookbook is the place to start, with recipes that are quick to assemble, feature few ingredients, and emphasize simple cooking techniques. The American Diabetes Association publishes several budget-friendly cookbooks, such as Diabetes Meals on $7 a Day-- or Less! and The 4-Ingredient Diabetes Cookbook. (7)
Clever, cost-conscious cooks can also save time and money by using techniques such as batch cooking, which means cooking and baking in large quantities and freezing portions for future use. For example, a person can cook a large batch of waffles on a Sunday morning, serve a few for that day's breakfast, and then freeze the rest to pop into the toaster on busy weekday mornings, saving both time and money.
Handle With Care
Economical eating does require special attention to food safety, particularly when storing large amounts of food or using "planned overs" or batch cooking. For people with diabetes, food-borne illness is not only unpleasant, but its accompanying nausea, diarrhea, and vomiting can have serious effects on blood glucose control. Resources available from the U.S. Department of Health and Human Services (8) provide patients with tips on proper food storage, cooking, and handling.
Health care providers can share the following safety tips with patients.
* Buy cold food last, and refrigerate fast. Bacteria that cause foodborne illnesses grow rapidly at room temperature.
* Start clean, and keep it clean. Wash hands, utensils, and cutting boards before and after contact with raw meat, poultry, seafood, and eggs.
* Separate, don't cross-contaminate. Keep raw meat, poultry, and seafood apart from foods that will not be cooked.
* Cook safely. Use a food thermometer to ensure that food is thoroughly and appropriately cooked.
* Remember the cool rules. Chill leftovers and takeout foods within 2 hours in a refrigerator that is [less than or equal to] 40[degrees]F.
As incomes drop and food budgets shrink, strategies for eating right when money is tight are a necessity for individuals with diabetes. Diabetes clinicians should be aware of their patients' financial concerns and help them make the changes they need in terms of meal planning, shopping, and cooking to enjoy healthy eating even on a lean budget. Offering practical strategies such as grocery shopping tours, cost-conscious cooking classes, and label-reading lessons is another way to help patients make the most of their available options. Healthy diabetes nutrition need not be sacrificed in an unhealthy economy.
(1) U.S. Department of Labor: Labor force statistics from the current population survey [article online]. Available from www.bls.gov/ cps. Accessed on 12 January 2010
(2) American Diabetes Association: Economic costs of diabetes in the U.S. in 2007. Diabetes Care 31:596-615, 2008
(3) U.S. Department of Labor: CPI inflation calculator [article online]. Available from www.bls.gov/data/inflation_calculator.htm. Accessed 10 January 2010
(4) CNN: Is the grocery store ripping you off? [article online]. Available from www.cnn. com/2008/LIVING/personal/07/09/food.bill/ index.html. Accessed 2 March 2010
(5) U.S. Department of Agriculture. Recipes and tips for healthy, thrifty meals [article online] Available from http://www. cnpp.usda.gov/Publications/FoodPlans/ MiscPubs/FoodPlansRecipeBook. pdf#xml=http://188.8.131.52/texis/search/ pdfhi.txt?query=recipes+and+tips+for+healt hy+thrifty+meals&pr=CNPP&prox=page& rorder=500&rprox=500&rdfreq=500&rwf req=500&rlead=500&rdepth=0&sufs=2& order=r&cq=&id=4b8442007. Accessed 10 January 2010
(6) U.S. Department of Labor: American time use survey, 2008 [article online]. Available from http://www.bls.gov/news.release/pdf/ atus.pdf. Accessed 10 January 2010
(7) American Diabetes Association: Books for healthy living. Available online from http:// store.diabetes.org/products/product_details. jsp?PRODUCT%3C%3Eprd_id=84552444 1764104&FOLDER%3C%3Efolder_id=253 4374302024139&bmUID=1267292492395. Accessed 10 January 2010.
(8) U.S. Department of Health and Human Services: Food Safety.gov: your gateway to federal food safety information [Web site]. www.foodsafety.gov. Accessed 10 January 2010
Tami A. Ross, RD, LD, CDE, provides diabetes education for a large internal medicine practice, and Patti Geil, MS, RD, FADA, CDE, is the president of Geil Nutrition Communications in Lexington, Ky. They are co-authors of Diabetes Meals on $7 a Day--or Less! 2nd ed. Alexandria, Va., American Diabetes Association, 2007
Tami A. Ross, RD, LD, CDE, and Patti Geil, MS, RD, FADA, CDE
Table 1.5-Day Meal Plan for Dinner * Day 1 3 oz oven-fried chicken 1/2 cup broccoli 1 medium ear corn on the cob 1 tsp. light margarine 1/2 cup rainbow sherbet 12 oz iced tea Day 2 3 oz roasted turkey breast 1 cup roasted carrots, onions, and potatoes 1/2 cup green beans 1 whole-grain roll 1 tsp. light margarine 1 cup skim milk Day 3 1 cup homemade turkey pot pie (incorporating "planned over" roasted turkey from Day 2) 2 cups salad of lettuce, tomatoes, cucumbers, and carrots 2 Tbsp. oil and vinegar dressing 1/2 cup mandarin oranges with light whipped topping 8 oz sugar-free lemonade Day 4 2 cups crockpot vegetable soup (incorporating leftover vegetables from previous meals) 6 whole-grain crackers 1/2 medium banana 1 cup skim milk Day 5 Fast food: 1 small (8-oz) chili with 6 crackers 1 side salad with 1 packet light dressing 1 small diet soda * Each menu includes ~55-60 g of carbohydrate and costs < $1.80 per person, except for the fast-food meal, which is < $3.25 (based on January 2010 prices in Lexington, Ky.). Menus adapted from Geil PB, Ross TA: Diabetes Meals on $7 a Day-or Less! 2nd ed. Alexandria, Va., American Diabetes Association, 2007 Table 2. Sample Staples That Can Be Purchased in Bulk * Baking powder * Baking soda * Bouillon cubes * Cocoa * Cooking spray * Corn starch * Cornmeal * Extracts * Evaporated milk * Flour * Oil * Powdered milk * Sugar * Sugar substitute