Nutrition Insights for People with Diabetes

[Music] tonight's discussion is going to be on diabetes management and the nutrition implications for the many things that people with diabetes deal with I did put my email up there if there was some burning question that didn't get answered tonight feel free I wanted to put some phone numbers up here as well the diabetes teaching center does offer workshops for people with type 2 diabetes and type 1 diabetes the diabetes and pregnancy program for anyone with gestational diabetes or type ones or type tools for planning pregnancies and then if you have any children that you need to direct to the Madison and pediatric diabetes clinic those are the phone numbers so diabetes as you know is largely self-managed and diet and exercise are foundations to the care of diabetes there are many people that have not only diabetes but they're also juggling things like managing their lipids their blood pressure their weight trying to learn things about exercise and how alcohol impacts them so I think you've probably got these statistics but just to put it in print again 30 million Americans currently have diabetes and about 90 to 95 percent of them have type 2 and 86 million people have pre-diabetes which is an alarming number in fact it's about one third of adults ages 20 and above and it's almost 50% of adults who are 65 and over and diabetes can be diagnosed with a fasting blood sugar a glucose challenge test or the hemoglobin a1c and I just put the numbers up in terms of what represents normal pre-diabetes or diabetes so metabolic syndrome is something that many type-2 people have and it's a constellation of things in terms of the weight that's carried it's found that if you carry weight in the center of your body in the abdomen that you have more risk of type 2 diabetes it causes more insulin resistance when the weight is in the center part of the body versus larger hips and thighs people with diabetes also have lipid problems many people not everybody but the ones that you see with type 2 diabetes tend to be elevated triglycerides and a low HDL and later in the talk we'll talk about lipids and what those mean often people have a high LDL which is considered the bad kind of cholesterol and hypertension is very common high blood pressure so I'm going to talk about nutrition considerations for these sorts of things as well so when you're looking at weight and when it becomes a risk for diabetes there are tables such as these where they classify its height to weight and it's not really a perfect measure but these are the grades that they put based on BMI and that can be calculated I think the easiest way to calculate it is go on an app or go online and look up EMI if you wanted to do the math it's kilograms of weight divided by height and meter squares but there's there's apps everywhere for that obesity itself causes insulin resistance and when you look at people with diabetes three out of four do you have extra weight to shed and it doesn't mean people have to lose weight to what the textbook says and I think that's what becomes frustrating is when somebody's told okay for your height the textbook says you should weigh 120 pounds and you think well gee I weighed that in high school the fact of the matter is you don't have to weigh 120 pounds if you're 5 foot 4 or whatever in fact losing part of the weight which we're going to talk about later can make a big impact in decreasing insulin resistance improving blood glucose control improving improving blood pressure and lipids and the diabetes prevention program DPP supports the idea that weight control and exercise reduce the incidence of type 2 diabetes when they studied people with pre-diabetes those that went on to lose about 7% of their starting weight and exercised about 30 minutes a day had a tremendous decrease in progressing from pre-diabetes to diabetes so weight loss diets you know there are many out there and there's no perfect weight loss diet but no matter how you dice it women tend to lose weight when they get their calorie intake down to about 1,200 to 1,500 and that of course depends on the woman interactivity and and her age men tend to lose weight on 1,500 to 1,800 calories a day and when people are restricting calories to lose weight it's a good thing to look at are you shy of any nutrients do you need a calcium supplement or there vitamins that you might be lacking so people can lose weight on various diets some of them aren't that healthy and there's a lot of fad diets that come and go so people will find what feels right for them but the bottom line is you have to burn more calories than you eat so the best diets are those that you can stick with long term because I think a lot of people realize with crash dieting and getting weight off rapidly that oftentimes that weight comes right back and that's the yo-yo syndrome so the best diets would be things that are nutritionally sound and are sustainable and enjoyable long-term one pound of body fat is a storage of about 3500 calories and so usually when someone's talking about a weight loss calorie level they will calculate somebody's estimated caloric needs and then subtract about 500 calories because a 500 calorie deficit per day and you multiply by seven days in a week that would be about 3,500 calories less than a week and so that's oftentimes what people are striving for so managing meals when it comes to diabetes it's not only what you eat the amounts you eat but it's when you eat that affect blood glucose levels so I want to look at all of those things but it does not work very well to get all of your calories and one or two big meals in the day it's best to distribute what you eat throughout the day and generally people can aim for 3 meals but other people are happy four or five smaller meals and that's fine too you know roughly four to six hours apart for those main meals and something that people don't often realize is you don't want to eat and go right to bed because blood glucose levels will fluctuate and they'll be highest maybe one or two hours after you eat and if you eat dinner at 8 o'clock and go to bed at 10 o'clock you're going to bed when your blood sugar is at its highest and it's harder for it to come down so moving the dinner meal a little bit earlier having it at least three hours before bed can be a strategy that helps in terms of you know what is your number when you wake up the next day that fasting blood sugar it's also important to look at snacks you know a lot of people are unaware of the afternoon snacking that goes on and they roll into dinner time and their numbers are already high before they have dinner so controlling portion sizes and snacks is important sweets and refined grains you know limiting those makes sense it also makes sense not to skip meals because when people skip meals they often are so hungry by the time the next meal rolls around that that it's hard not to overeat and for people who are on insulin and certain oral agent certain pills for diabetes going long periods of time can lead to hypoglycemia so when you look at this just sort of cartoon image it's showing the blue line the blood glucose levels going up and down throughout the day and it's going to go up and down according to the amount of carbohydrate but also the type of carbohydrate and every time people eat some of that carbohydrate is going to be stored in the liver so we break down our foods our carbohydrate foods into individual sugar molecules which enter the bloodstream and the blood first flows to the liver so after you absorb all the nutrients from your meal the first pass goes through the liver it's called portal circulation and the liver will grab some of the glucose and store it for later and so every time you eat some of that glucose is getting packed away in the liver the liver storage form is called glycogen and the glycogen becomes your food source while you sleep and so all night long the glucose is coming out of the liver for the brain the heart the lungs the kidneys the body is not using as many calories while you sleep but it's certainly using glucose to sustain life that's called glycogen so what happens if the liver runs out of glycogen okay imagine those boys in Thailand that got stuck in the cave you saw on the news not long ago and they didn't eat for nine days what happens is the body turns to itself for calories and for nutrition and for energy and the amino acids from the muscles can break down and supply themselves to the liver so the amino acids are the building blocks of protein all proteins are made out of amino acids including our muscles and so if the muscles were to break down and supply those amino acids to the liver the liver can dismantle it into its chemistry of carbon hydrogen and oxygen kind of gets rid of the nitrogen and it reassembles it as glucose and so those boys use their muscles to produce glucose so their hearts would keep beating okay so that's where the glucose comes from you break down fat and that turns to ketones so the ketones come from fat breakdown so I want to talk about carbohydrate foods because they have the main impact on the blood sugar and so all of these foods shown here are going to be digested and turned into glucose and other individual sugars that enter the bloodstream foods that have little or no carbohydrate would be flesh so meat chicken fish certain dairy products have carbs milk and yogurt have carbs but cheese cream cheese and cottage cheese have little to none cream in half-and-half also very low in carbs eggs tofu seeds nuts nut butters avocados all of the fats oils butter margarine and then some of the vegetables are so minimal and carbohydrate lettuce for example I think there's two grams of carbohydrate and a cup of lettuce one of which is fiber so that leaves you with one gram I think you burn more than that you and the lettuce so I wouldn't count the lettuce limes or lemons so why are carbohydrates important so first of all the main user of glucose is your brain the brain uses more than any other part of your body except you know if you're out exercising the muscles are sucking it up as well but not only that the foods the carbohydrate food groups carry specific nutrients and plant foods like beans whole grains fruits and vegetables are rich in fibers and we'll talk about the benefit of soluble and insoluble fiber later but each food group has its unique you know often are rich in certain vitamins and minerals and they don't always cross over that that you know not not exactly the same so a balanced diet is a is a way to get the complement of nutrients that we need carbohydrates are also naturally low in saturated fat and as you know saturated fat is linked to heart disease so I wanted to point out that you have at your fingertips if you go online this journal called diabetes care and every January they come out with a supplement called standards of medical care and diabetes and you can access that by going to diabetes org and click on the professional section there's lots of great information on type 1 type 2 gestational diabetes in their regular body of their website but there's a tab that says professional and if you click on that you're going to see this journal and this journal is filled with information that is science-based reputable information and it will often touch on the the common things that came up that year so there is a section on nutrition and lifestyle management in there but there's also a section on medications and and treating hypertension and lipids and so forth they now have an app which is shown on the bottom there you can download the ad a standards of care app as well so when you ask you know well how much of the diet should be carbohydrate and this is where there's going to be debate forever into the future because not everybody's going to agree on this and so I'll look at a couple of the things are our standards so the 2015 to 2020 Dietary Guidelines are set by the Institutes of Medicine and in the left column what they're showing is their guideline for the breakdown of carbohydrate protein and fat in the diet this isn't specifically for diabetes this is the general guidelines for healthy Americans and they're saying and it's a wide wide range 45 to 65% of calories should be carbs now having done diabetes management for 28 years I'll say 60 65 percent is a lot and I don't think most people with diabetes are going to tolerate that unless they're riding their bike to Utah this weekend so you might you know you might not want to go on the upper ends the protein 10 to 35% is what they recommend as as part of the diet and the fad 20 to 35% now the diabetes care Journal that I just pointed out has done observational studies and looked at what the average intake is for people with diabetes and the average intake Falls around 45% of the calories coming from carbs some people hire some people lower but that's the average and their protein was noted at 15 to 20 percent and fat at 35 to 40 so they're most people fall pretty close to what would be generally a you know guideline for a healthy balanced diet anyway in this case the fat content was higher a little bit higher but provided that that's healthy fat you know heart healthy monounsaturated polyunsaturated fats that doesn't mean that's a bad thing we're going to talk about the different types of fats in a bit so you know I'm throwing numbers out there and then people are you know anyway what does that really mean for me and so what I did was I crunched numbers just to give you a table that you could look at and I did calorie and takes from 1,200 to 3,000 I don't know that anybody in the room needs 3,000 calories but I've done you know diabetes management for 18 year old football players who do and so that's why there's such a big table there but I made four columns remember that they said 45 to 65% carbs I did 45 to 55 and I add forty on my own because plenty of people can get by on less carbs and still have a healthy balanced diet and a lot of people with diabetes strive to be somewhat on the lighter side of carbs I'm just suggesting without going too low this might be a way of looking at it now also there's a little guide up in the right corner calorie king calm and what they have at calorie king calm is a little button that says how many calories should I eat and you plug in your height weight gender your exercise level and it will crunch those numbers and say hey you probably need about 1800 calories a day if you want to lose weight 1300 it gives you the buttons for do you want to lose or stay the same or gain weight and then you come up with a basic calorie level and then you could use this table to get an idea of how many carbs that might be I do want to point out that the food and nutrition board Institutes of Medicine National Academies of science have a minimum recommended amount of carbohydrate and that's called the Dietary Reference intake and that number is a hundred and thirty grams so that's their studied number of the amount of carbohydrate suggested for the basic functioning needs that doesn't include exercise it doesn't include the fact that some people are six foot tall and you have more muscle so they're still suggesting calculating it based on somebody's personal needs but they're giving a minimum of 130 and the funny thing is is when you look at the table it says if your age is one to three a hundred and thirty grams if your age is four to eight 130 grams all ages were 130 grams until you got to pregnancy as 175 so that would be where that number comes from so if you wanted to just bypass all of those tables and all that math you could just say well what sort of a ballpark amount of carbohydrate people might want to aim for and I broke it out into women and men and I gave three sections maybe somebody who wanted to be on a lower carb intake or somebody who is older more sedentary a woman might be thirty to sixty grams at a meal and a man might be 45 to 75 then you have younger people who are more fit and more active and and you know more muscular and they have lower metabolism sorry higher metabolisms and they can burn more calories and so you can see that there's a variety of things to choose from here okay so I wanted to talk about insulin and type 1 diabetes because when you're thinking about insulin for type 1 diabetes that mealtime dose needs to be based on three things really at least three things carbohydrate content of the meal is a huge part of what drives that dose and then the current blood sugar level as well you know if somebody's blood glucose is above where they want to be they're going to add a corrective unit or two or whatever it is that they need to do but there has to be a reflection on the physical activity you know have you been active all day did you just finish going to the gym or are you going to go play tennis afterwards and so people with type 1 diabetes often use insulin to carbohydrate ratios where their team helps them figure out that one unit of insulin covers a certain amount of carbohydrate well whereas in the past there was just sort of sliding scale insulin where the doctor said if your blood sugar is 100 250 take four units and if it's 150 to 200 take five units something like that we're just sort of ramped up based on the blood glucose level but what I want to point out is that had no way possible of covering all meals so just taking a dose based on a starting blood glucose level doesn't look forward at the food that's about to be eaten so in this case on the left you've got an omelet sausages and a piece of toast with coffee and it turns out to be 15 grams of carbohydrate the toast is the only thing they're offering any carbohydrate and if somebody was following their sliding scale and taking 4 units 4 units might be way too much and on the next day they might have an equal amount of food that turns out to be much carbohydrate so the bagel 60 banana 30 juice 30 120 grams of carbohydrate and four units probably can't touch that and so people would follow these you know sliding scale insulin plans and get frustrated because they were checking their blood glucose they were following their scale they were taking their insulin and the blood sugar did all kinds of things so that is something that we work with people on is as trying to help them develop an insulin to carbohydrate ratio so they have the flexibility of eating a smaller meal one day a larger meal the next day and adjusting their own dose it's where I come back to saying diabetes lark is largely self-managed for many people but I do know that there are people that take 70/30 insulin in you know people with type 2 diabetes not so many with type 1 but I did want to mention something about that and the impact of understanding carbohydrates even when you're not doing insulin to carbohydrate ratios and what this diagram is showing is if the person was taking 70/30 that's two kinds of insulin mixed together 70 percent NPH for example in 30 percent regular and the blue represents the regular so if somebody got a shot here an injection at breakfast the blue represents the regular insulin covering breakfast and the green represents the slow onset and coverage of NPH which Peaks over the lunch hour and lasts all afternoon so that's sort of the image of what the insulins timing is and again they would take it at dinner so that the pitfalls of that is if you're taking a shot in the morning of seven to thirty you have to eat lunch on time that insulin is going to work and you have to eat lunch four to five hours after that injection or the insulin is cranking your blood sugar down and there's nothing to go with it meal times have to be fixed you can't decide you only want a Caesar salad if you took something like NPH or seventy thirty in the morning you're having the same amount of carbs and the NPH lasts all afternoon and then people might be driven to eat snacks when they're not especially hungry sometimes people get low when both insulins are sort of acting at the same time the regular hasn't worn off here where the arrow is the NPH is really cranking up into gather the synergistic effect as the insulin is very strong before lunch there are other varieties of blended insulin their 70/30 made with a Humalog and a 7525 made with novalog and those actually probably would cover breakfast and dinner better but you'd still need to eat lunch on time because of this biphasic insulin this insulin that comes on later a really good website that you could go to for nutrition information for your kids for you know planning how do you get more vegetables in your diet how do you choose leaner proteins is called choosemyplate.gov and so no longer does the food pyramid exist that's kind of ancient history now and kids are learning about the plate model in schools and so the basic concept is that about a quarter of the plate slightly less goes to fruit about a quarter of a plate slightly more goes to vegetables and you can see the grains on a quarter and a protein on a quarter with you know dairy source if if interested on the side and so this is the concept the very simple concept of saying eat you know healthy foods a balanced diet and joy food use some method of controlling portions because portion control is so important for weight control and blood sugar control eat less sodium and their big push is to drink water instead of sugary soft drinks another alternative plate model would be this one where you give half the plate to vegetables because really you can't eat too many vegetables there's nothing high you know they're high in vitamins they're high in fiber but they're low in calories they're low in carbs and they're rich in nutrition and they help people fill up so if people are trying to lose weight the belly wants to be full you put in more salads and vegetables but you still include a healthy lean protein and a serving of starch and preferably those starches and grains are whole grains at least half the time and then having a fruit on the side is fine having milk or yogurt on the side is fine I think a very simple method of portioning because you know it's really easy to go out and get served a very large portion you start eating it it's delicious and you you know maybe eat until the plates gone a reference point might be if your starch is the size of your own fist that's probably a reasonable portion so my fist is about a cup a cup of quinoa is about forty five grams of carb you know a cup of beans is about thirty like that's reasonable palm of your hand for your protein so about the thickness and the size of the palm of your hand for your protein and if you're choosing a lean protein that's a very adequate amount of protein at that meal fruit something you could cup in your hand really that image here thanks to my teenage daughter who was my hand model there is no limit on vegetables eat as many vegetables and salads as you'd like and and watch the added fat so this is just one way of referencing things and it does give you sort of a consistent amount of carbohydrate if you are on medications that require a consistent amount of carbohydrate using the hand method as a way of eyeballing it when you're out at a restaurant I mean we don't leave home without these appendages so there are carb counting options so if you want to be really more accurate you can go back to what we began talking about which is carbohydrate counting and we're gonna look at labels but you can also get food composition lists carbohydrate counting books any chain restaurant now has their information online and it's generally the name of the restaurant com so be Subway comm PF Changs comm any of those restaurants comm and they'll have their Chipotle comm they'll have all of their items so you can look at the calories and the carbs and the sodium and try to make better choices website such as calorie king.com our databases where you can look up things like tamales and pizza and mixed dishes something like an Indian doll soup you'll find those things online and you can also use apps like My Fitness Pal King fit is an app with four diabetes experts with videos 5 to 10 minutes long doctor a nurse exercise physiologist and dietician they all have 18 to 20 videos I'm one of them I'll just say but miss carneros the other one one of the other ones but those are reputable videos that you could watch in five to ten minute increments to learn more about diabetes management so let's look at a food label the FDA updated the food label in July of this last summer so in 2018 that's when all new packaging was supposed to start using the new label but they do have a grace period to get there you know printing up to date but we're gonna still be seeing the older food labels for some time because I'm sure you have freezers and pantries that have canned and frozen items that have an expiration date of 2021 and so this is a look at on the left the the food labels that we've been using for years and on the right the new one and what they're what they're trying to do is make the calories so much more obvious because so many people are struggling with weight and they've standardized serving sizes and they've made that bold and a little bit bigger so it's to make it clearer of what you're getting they also now show how much of the total sugar has been added that's a new thing the total carbohydrates are listed and underneath that it used to just say the sugars now it tells you how much is added versus naturally occurring because in the sugars column that includes the sugar and milk lactose the sugar and fruit fructose and the added sugars but now it breaks it out for you and I also appreciate at the bottom that it tells us the milligrams of calcium the old labels used to say 20% that didn't tell people much 20% well I know that the Dietary Reference intake is a thousand so 20% is 200 but most people wouldn't know that and that's not something people should be expected to know so the new labels tell you the milligrams of iron and calcium and so forth so I think it's an improvement so when you're looking for carb counting you're going to want to check the servings they're the number in parentheses is the weight you're going to want to look at the total carbohydrate grams it's really easy to get confused and look over here on the right column because it's bold and it's all lined up but that's the percent daily value and the percent daily value is based on the reference diet 2000 calories that's not everybody and so they're saying that it provides 10 percent of your estimated carbohydrate needs but again I would look at the grams of carbohydrate now in terms of fiber fiber does not digest it's a non digestible carbohydrate and so when you look at labels we're going to compare to here on the left you see a tortilla the serving size is one tortilla the total carbohydrate is 13 grams and the fiber is 1 gram so the 1 gram of fiber doesn't digest now if you're counting carbs do you want to count it as 13 or 12 it really doesn't matter it's not a big difference but if you look at the label on the right the tortilla says the carbohydrate is 10 and the fiber is 7 which means when you subtract that you're only getting three grams of digestible carbohydrate because fiber doesn't digest so now if somebody was taking insulin this is a critical point you need to subtract if you're counting carbs and adjusting your own insulin you need to subtract the fiber when it's significant or you're getting too big of a dose I know some a teenager who had three of these tortillas and didn't subtract the fiber and took way too much insulin so it's something for the insulin users to be aware of especially now carbohydrate counting list this is just a sampling but everything on this list has about 15 grams of carbohydrate in the serving size listed so an 8 ounce cup of milk 1/2 a cup of starchy vegetables or beans third of a cup of cooked rice pasta quinoa slice of bread small apple all of these are 15 grams of carbs so when people are carb counting they get used to the foods they eat over and over and you know they can have these on an app they can have them as a paper now I wanted to mention non starchy vegetables things like asparagus beets broccoli cauliflower all of those things green beans they do have a little bit of carbohydrate and for people with type 2 diabetes I would I would generally say eat as much as you want don't worry about it don't count them it's fine but for people with type 1 diabetes who are adjusting their own insulin it's something to think about so they have less carbs a half a cup has 5 grams of carb whereas a half a cup of potatoes has 15 a half a cup of these has 5 let's look at two different individuals this is an example of Liz who has type 1 diabetes and her insulin the carbohydrate ratio is one unit for every 5 grams of carbohydrate that's what she takes she counts all her carbs and does the math she eats 2 cups of vegetables so 1/2 a cup is 5 grams 2 cups of 20 grams on a 1 to 5 ratio she needs 4 units of insulin and sometimes I meet people with type 1 diabetes that are struggling with why can't I just get my a1c down that last point and it's things like this just missing this one little subtlety that sheets enough vegetables that she's been missing her insulin for her vegetables but then you have ed who has type 1 diabetes and his insulin des carbohydrate ratio is 1 to 20 C not everybody's the same don't change your insulin based on these examples of slides everyone's very different and you should get that information from your from your doctor your your health care provider but he eats only 1/2 a cup of vegetables so 1/2 a cup of vegetables is 5 grams of carb he takes a unit for every 20 grams of carb he only needs a quarter unit he doesn't need to count his vegetables you see so whether or not you should count your vegetables has to do really about insulin use now let's talk about the variables that affect digestion normally blood glucose would peak roughly 1 to 2 hours after you eat a meal so often people are checking their blood glucose levels and they tell me yeah I check every day when I wake up so they only know one time of the day when they wake up that's a pretty data and if you're only going to check one time a day why not mix it up in check sometimes an hour or two after breakfast an hour or two after lunch an hour or two after dinner and if you're checking twice a day why not rotate it and do before breakfast and after breakfast one day and the next day before lunch and after lunch so that you gather data about the different times of day so you can see how different foods affect you so blood sugar does not always peak one to two hours after the meal liquids go right in so on an empty stomach liquids don't really stop it's like a sink gravity they're down into the intestine and absorb very rapidly within ten minutes probably for juice if you have highly refined grains white rice white bread they digest fast also whereas a high fiber food digests more slowly so the benefit of slowing down the digestion is that the blood glucose doesn't peak is high fat definitely has an impact on your digestion so fat affects the bottom of the stomach here where the arrows showing the pyloric sphincter fat causes it to tighten up so when you have a fatty meal it needs to stay in the stomach longer mixing and churning getting more acid squirted on it needs to prepare for digestion and the pyloric sphincter is keeping that food up in your stomach longer and that's going to delay the digestion of everything so that you know if you had a big fatty meal and felt full forever it's because you are you're full much longer and that can sort of mess things up with your insulin too sometimes but as I said liquids are the fastest and don't underestimate the impact of these drinks on your blood glucose level a Red Bull has six teaspoons of sugar whereas a regular soda and I'm not trying to pick on any brands they're all about the same okay nine teaspoons per can a soda usually and a big kind of drink you know I'm not trying to point out any brands I should have probably put mass black lines over them all but but you know those for Apple wonderful things or fourteen teaspoons of sugar and even what we consider a natural healthy thing like juice isn't necessarily a healthy thing for people who are struggling to control their blood sugar because that size juice doesn't matter the brand is probably equivalent to 15 teaspoons of sugar the American Diabetes Association doesn't give much concrete firm firm diet advice they give you know some general guidelines but they say avoid sugar sweetened beverages quite firmly now the difference that I was saying between refined and whole grains has to do with the digestion timing and so these two different-colored curves are to illustrate that the first one this rise is more steep the blood glucose goes up maybe more sharply after white rice white bread refined breakfast cereals sweets some sweets and then the lower curve would be something more like your quinoa your beans black beans and brown rice meals things like that so they might have an equal amount of carbohydrate and a different effect on your blood glucose level so you might eat 45 grams of carb with one meal and 45 grams of carb with a different meal and have entirely different blood glucose results and that's where you can start to find benefit in some of these healthy whole grains and beans now when you're using insulin it's important to realize that the timing of the insulin needs to be peaking over the timing of the digestion of the meal so this relative concentration look is showing you in blue the insulin timing of our rapid-acting insulins like Humalog and Novolog and when you inject those insulins they really do work their strongest within 30 60 90 an hour two hours there they're strong right away for the first couple of hours by the third hour they're kind of waning and by four hours that's pretty much their duration but when you have a really fatty meal like I'm talking cheeseburger and fries fish and chips where everything's ride or a cheesy meal like a quesadilla with sour cream and guacamole and chips like everything's fatty I mean most meals have fat that's fine but I'm talking over the top fatty then your foods going to digest so much slower that this black line is showing you by the time the food is digesting the insulins already on its way down and the first issue would be that the insulins been crank and Anja for the last 90 minutes and your blood sugar could be dropping you could be getting a low blood sugar with a belly full of pizza and it's a timing thing it's not that you counted the carbs wrong it's just that they didn't show up in the same place at the same time and then later when the food finally digests the insulin is not strong enough to do much for it and then at 10 o'clock you check your blood glucose before bed and it's like darn I'm 210 again you know it's the it's the word of the high number come from and that's the mismatching of the digestion and the insulin so it's really important to understand what kind of insulin you're on and when it works so the same can be looked at in the opposite you know kind of situation here's the insulin action of those rapid-acting insulins and what about the person who says but i am going to have this big smoothie and i'll just count the carbs you know it's 90 carbs and I'll take 10 units or whatever they take this whopping dose but the thing is the juice is all in in 10 to 15 minutes from from your lips to your fingertips where you can test it I call it lips 2 tips 10 to 15 minutes and the insulin is not going to be strong enough at that point to cover it all so you could really escape and have this high number but my concern is also that the insulin is gonna last for hours and the juice isn't so I don't know what's going to happen so sometimes people end up getting low a few hours later because their meal was all liquid so I wanted to touch on sweeteners it's a question that often comes up when we're talking about carbohydrate none of these have carbohydrate but there's still something that we should look at they're not all the same there is a lot of information and a lot of misinformation out there on the sweetener so I just wanted to touch on them briefly they're all fda-approved I'll start at the bottom because that's the the most recent one on the market stevia Truvia that that's made from a leaf of a plant it's extracted from a stevia plant and it's been chewed on in South America for centuries sucralose is Splenda that's the yellow packet it's made from sugar cane there's nothing else added it's just processed differently you can go to their website and you can see a little video clip on it a cell fame KK is in chemistry potassium so it's a potassium derivative sweetener aspartame remember we are talking about amino acids are the building blocks of proteins aspartame is made out of two amino acids specifically phenylalanine and aspartic acid so it's not actually a chemical sweetener I'm not trying to convince anybody to choose to use these if they don't want I'm just telling you what they're made out of saccharin is made in a lab so saccharin is a manufactured sweetener and it's the one that's been around since the 1800s so it's been around more than a hundred years it did have a warning on the label for about thirty years and that's because when they originally did some studies on saccharin which well they were here before the FDA so they'd been in the market for a long time then they said why don't you guys study it and of the hundred rats that were given saccharin for got tumors and their bladders and in the hundred rats and the placebo group to got tumors so it was four versus two but the warning went on and it stayed on for about thirty years and then they never saw those specific tumors show up in human bladders so after about thirty years people were questioning what will why aren't humans getting that specific tumor and so they studied it again and they realized the physiology of the rat was so different than the bladder of the human that humans didn't stand that same so that's why they took the warning off so there's a little background on some of the sweeteners but I would direct you to the links on the bottom the one on the very bottom well actually the one the first one position paper on sweeteners from the Academy of Nutrition and Dietetics I put the URL there it's an excellent like seven or eight page document you can learn all about sweeteners I do want to point out sugar alcohol is something different sugar alcohol is still a carbohydrate so I'm sure you see you know sugar free cough drops and sugar free chocolates and sugar free ice cream and syrups and things like that cookies so what does that really mean so sugar alcohol is a modified sugar so what's represented in this image down here this little six-sided hexose that's that's what glucose is drawn like in a chemistry book it's a six-sided structure and when you turn a sugar into a sugar alcohol what you're adding is an oxygen and a hydrogen molecule so in in chemistry that's called an alcohol group it's not alcohol like bourbon or anything it's it's a chemistry term so this is how they name sugar alcohols you can turn fructose into sugar alcohol sucrose lactose you know lactose becomes lacked at all maltose becomes maltitol so those are the sugar alcohols and the issue with them that can be misleading is they are still a carbohydrate and people do digest them and it does contribute some glucose into the blood but they're hard to digest so a lot of people get gas cramps bloating some people diarrhea so if you're a user of those products it's not like a danger to you it's not going to hurt you but it's not like their calorie free when you look side by side in those candies the calories are the same the fats the same the carbs are the same ones made with sugar ones made with sugar alcohol so just be aware of what you're getting and if you're getting gassy just get the regular one I mean I'm all for a really good chocolate but it's just all in moderation so labeling just to point out what sugar free candy label would look like on the left you can see on the front of the package that said sugar-free and on the back the consumer looks sugars zero and they get all excited that they found a sugar-free candy and the sugars were zero the problem is is it's just listed in the next line down sugar alcohol 21 grams didn't go away it just is one line down and so many people don't notice that but the calories and the carbs are are the same as the other product now when you look at something that's called no sugar added what that means is they can't say sugar free because there's natural sugar in it so if you've got a yogurt or an ice cream that's got lactose which is a natural sugar so they shouldn't be saying sugar free but they can say no sugar added so when you look at that label you can see that this has four grams of natural sugar 11 grams of sugar alcohol so when you are looking at labels be a label detective and make sure make sure you're seeing the information you're looking for so I wanted to just talk about in general a lot of people that I've seen in the past with diabetes will react to their blood glucose levels being elevated by making a change to what they're about to eat and sometimes that's really a good thing to do but I've also seen it to the extent where a parent will check the child's blood glucose and it's elevated so they skipped the milk they skipped the fruit and they get a diet soda with dinner and pretty soon that's happening over and over and over and that kids not getting the nutrients the kid needs and we're all like that well need nutrients and so if it's a repeated issue that keeps happening you need to look at the medications to correct the issue upfront so that you are able to eat a healthy balanced diet you know but on a day to day basis you want to be able to eat a healthy balanced diet but there will be days when the glucose levels are elevated and yeah it would be better to have a low carb lunch and get that blood glucose out of the 300s or whatever but I've also seen people who want a snack in the afternoon and they don't want to take another injection so they're snacking on salami and Bologna and cheese all of those things and those are specifically high in saturated fat and a hundred calories and every ounce that they eat and so I see that sometimes backfire in terms of cardiac health or weight so the other thing is is some people just have it in their head that insulin is bad and someone's a hormone and a hormone that's needed for life and so if you need insulin you need insulin and if you need four units or you need eight units or you need ten units it's what you need to be able to have a healthy balanced diet so what are the long term implications of just going year after year after year cutting out healthy foods is the question so let's look for leaner proteins that's one way to help keep the heart healthy and leaner proteins are defined by the amount of fat they have the lean meats have between zero to three grams of fat per ounce and I've listed some examples sirloin tenderloin skinless poultry fish shellfish also they do have certain low fat hot dogs and low fat cheese's but you would look at the label and check the grams of fat low fat is zero to three grams of fat per ounce medium fat items like corn beef ground beef poultry with the skin on those have between four to seven grams of fat per ounce and there are cheeses that fall in that category like the two percent reduced fat cheese's mozzarella and ricotta are naturally in the in the medium fat range and then there's the high fat group and the high fat group has at least eight grams of fat per ounce bacon sausage hotdog salami bratwurst things like cheddar Jack brie all of the regular cheese's and so it can add up if your portion sizes of protein are large you know so watch how often you choose from which group in terms of how it adds up looking at a six ounce portion of lean protein another definition of lean is it's about 45 calories per ounce so if you had a six ounce portion you're getting about 270 calories so in terms of what does that look like a deck of cards is about three ounces so B two decks of cards it's similar to the palm of my hand twice similar and if that was a high-fat protein like sausage bacon salami Bologna or cheese six ounces of 600 calories and that's a pretty significant difference 270 versus 600 and if that happens once in a while it's not a problem but if it's happening once a day or twice a day then all those extra calories are adding up and if that's adding up to an increased weight year by year then it's having a negative impact back to that comment in the very beginning about the Institutes of Medicine saying that our diets could be about 20 to 35 percent fat and still be healthy and that is true if you choose healthy types of fat to show you what that would be in grams again I've got different calorie levels on the Left twelve hundred sixteen eighteen hundred and so forth and on the right I've done the math to show you how many grams of fat that would be so if you had somebody on a sixteen hundred calorie diet that person would be you know somewhere between 35 and 62 grams of fat a day or eighteen hundred maybe forty to seventy the standard u.s. diet the labels are based on 2,000 calories which is way too much for most women unless they're young women 44 to 278 grams of fat well look at this one meal a deluxe cheeseburger a large order of fries in a 16-ounce shake has a hundred grams of fat okay so it blows it beyond one meal and they've had twice as much fat as they should have for the day and this is where people get into trouble I don't know the statistic but a large number of people they eat at fast food restaurants every day so it's not that you can't you know we all end up in Bakersfield sometimes and so if you're traveling and you find yourself taking that exit you can still do better you can get the grilled chicken sandwich side salad the fruit you know if you're gonna get a soda get a diet soda or something like that so if you're trying to trim calories limit how often you hit the fast-food restaurants or know what you're getting go to their websites and look at the choices use leaner proteins now the dairy products this is you know this is debatable it says use lower fat dairy products that's a personal decision and it depends on how much you have so I put half in half of my coffee the real stuff and I have one cup and I don't feel bad about it but if people are drinking a half a gallon of milk or even a quart of milk every day in its whole milk that's a lot of extra calories so you're looking at it in terms of calories and the butter fat is why you get the same amount of calcium whether you're getting 2% milk or whatever added fats and moderation it doesn't mean you have to be on a low-fat diet but you know they add up quickly so pay attention and cook in a lower fat method that's really important a small order of french fries 3 ounces a french fries is about pretty close to 300 calories and if it's just a 3 ounce boiled potato its 80 calories so the difference between 80 and 300 is how much fat soaks into the frying process so when you deep fry foods you get a lot more calories you know once in a while is fine again but you know just watch how often everything is fried opt for a lower calorie beverage alcohol is especially high in calories and then you can use methods of portioning such as the plate method that I showed you earlier or the hand method as a way of keeping portion sizes controlled so as promised I said we'd touch on lipids and I think it's important to know what the targets are the serum lipid targets for cholesterol less than 200 I generally don't even look at the total cholesterol I look at the the individual things like the triglycerides LDL and HDL the goal for triglycerides is less than 150 the goal for LDL depends on a few it's generally for people with diabetes to be less than a hundred but if you have multiple risk factors and remember many people with type 2 diabetes have multiple risk factors because it's this metabolic syndrome or they have hypertension they are struggling with weight they do have dyslipidemia well when you have multiple risk factors they want the LDL cholesterol under 70 to be safest the HDL is the good cholesterol it's good because it cleans out your blood vessels and for a minute should be above 40 and women it should be above 50 and many people struggle with having low HDL it's part of the metabolic syndrome of having an HDL of 30 or something it's too low you don't have enough of the boyscout cleanup crew out there lipid management so what do you do about it well when people lose weight their lipids shift somewhat and that's in a positive direction so weight loss does have that benefit of crossing over and helping with heart health exercise helps lipids and in fact exercises one of the ways that people raise their HDL but the key dietary strategy when you have high LDL is to limit saturated fats which are predominantly in animal fats limit hydrogenated fats and trans fats now they've gone a long ways in the last decade to get trans fats out of our diet which is great another thing that I'll show you in a minute with a different slide is increasing soluble fiber helps if you do have elevated triglycerides then there's several things that people are going to focus on which is optimizing your glucose control because when your blood your a1c is elevated then the triglycerides tend to be worse and cutting down on the sweets the white greens and alcohol are always to help lower triglycerides and then sometimes your doctor might be recommending fish oil capsules omega-3 fats now the labels do give us the information so the total fat is listed on the labels and they're required to tell you the saturated fat and the trans fat that's a requirement sometimes they'll give you extra information and tell you about the mono ins treated healthy fats and so forth but that's required and the goal for trans fat is zero okay this should be zero the only thing is is they can say zero if it's anything less than 0.5 so if it's 0.49 they can still say zero and so in order to figure out which foods are going to have those hidden trans fats you're going to want to read the ingredients list and in the ingredients list you can identify the risk by the word hydrogenated so if it's got hydrogenated oils or partially hydrogenated oils then that carries the risk of having some trans fats now if you're having one portion that's one thing but if you're having multiple portions that that adds up a quick tip in identifying the healthy fats versus the not so healthy fats the healthy fats are liquid at room temperature if you take something out of your cupboard and it's liquid it is not going to clog your arteries it is not going to raise your LDL whether it's canola oil olive oil peanut oil sesame oil corn oil they're not going to clog your arteries none of them are low fat they're all pure fat but those are considered heart-healthy fats they typically come from plant foods which would include things like your nuts and your nut butters and your avocados and all your plant oils the not so heart-healthy ones tend to be sludgy thick fats the fat the white fat in the in the meat that thick white fat is a saturated fat the fat in in dairy products cheeses Brie tends to be a saturated fat here's a little table that separates them the monounsaturated fats are very heart healthy olive oil is not the only one canola and peanut oil are rich in monounsaturated fats as well as avocados and some of the nuts the polyunsaturated fats are a lot of the other vegetable and nut oils but one of the healthiest fats you can have are the omega-3 fats found in things like salmon but it's not just fish you find some in walnuts and tofu and soy products and flax seeds and so forth those fats help reduce your risk of heart attack they do help prevent clogging and little platelet aggregation the saturated fats on the right side doesn't mean you can't butter your toast I butter my corn on the cob it's just don't put half a stick of butter in the big baked potato you know use moderation and the fats that aren't as healthy for you include soluble fiber so I have two slides on this the next one's the visual so we'll walk through a whole visual scenario but I wanted to just say soluble fiber is a kind of fiber that helps lower cholesterol and I want to explain how because you've all seen that oatmeal is good for your heart but nobody's ever told you what I'm gonna tell you because but basically soluble fiber is the kind of fiber that swells up and out swell up and get gooey and lentils and kidney beans and black beans swell up and they absorb things that's the soluble fiber absorbing that water the other kind of fiber insoluble fiber is sort of the roughage stuff like bran flakes you pour it in water it floats all day doesn't absorb anything that's insoluble fiber so the soluble fiber helps us and it has to do with bile so I'm gonna give you a few sources of soluble fiber here the cereal grains oatmeal especially high in in things like legumes beans black beans in some fruits papaya citrus fruit strawberries I want to fast forward to the next slide because it's a little bit easier to follow we're going to start at the top right corner so bile is a digestive juice and cholesterol is the precursor so you make bile out of cholesterol and that happens in the liver and then the the bile will travel to the upper intestine bile is a digestive juice for fats so it helps to break up dietary fats and helps to transport those fats into the bloodstream okay so that's the first thing to know is cholesterol turns into bile bile comes into the upper intestine to digest fats now back to the soluble fiber here's the soluble fiber here soluble fiber travels through the intestine it's absorbing things it absorbs that's what soluble fiber does it absorbs the bile so the bile can't be reused normally what you see here is that bile is normally transported back to the liver and used again in fact it in one meal it's reused it's circulated oh it's recycled so the bile comes in the upper intestine and in the lower intestine it's reabsorbed okay but not if it gets stuck in the bile the bile sorry not if it gets stuck in the in the soluble fiber it goes down the toilet because we don't digest fiber so the take-off on that is you have to make more bile if you lose your bile in your fiber you have to make more what do you make it out of back to the top right you make it out of cholesterol so you're lowering your cholesterol by eating soluble fiber okay so it's a really nice thing to do have your hummus have your split pea and lentil soups and your doll and and your you know your bean beans and brown rice okay back to those triglycerides when people have elevated triglycerides they do have to watch their overall intake of fat it's not just the saturated fat it's all of the fats if you have a fatty diet I tend to have higher triglycerides but you have to limit the sweets and the refined grains and I have a slide to show you why on that as well and then you have to limit alcohol alcohol does raise triglycerides weight control helps blood glucose control helps when you're managing your triglycerides and again those omega-3 fats but I wanted to show you this slide so let's talk about high fructose sweeteners and sodas that have 12 spoons of sugar and all of those soft and soft drinks that we were talking about earlier so this diagram here on the left these little house shaped things are called pentoses so in chemistry fructose is a pentose shaped sugar it's not ready to be used by the body so the first place it goes is the liver several things can happen as fructose enters the liver the liver can sort of take it apart and reassemble it as glucose and so it could store it right here as glucose and the storage form of glucose is called glycogen so again fructose goes to the liver can be converted to glucose and just stay there for later and feed you at night while you're sleeping or fructose can come in get converted to glucose and go into the bloodstream so people who have too much are gonna still see a high blood glucose from it but it can also turn to fat so this is the the problem with having too much high fructose corn syrup and sugars is that fructose can be converted to fat in the liver and if it stays in the liver it contributes to fatty liver which is a common problem people are dealing with it can also be converted to fat and come out into the bloodstream and raise your triglycerides so there's a lot of different pathways but if you're sucking down soft drinks you're getting a lot of it and it could have these the detrimental effects so now we're going to talk a little bit about hypertension high blood pressure the target blood pressure for people with diabetes is generally 140 over 90 you know as an upper limit so blood pressure lowering tips include things like weight loss again weight loss helps with your lipids it helps with improving insulin sensitivity so your insulin works better and it helps lower your blood pressure exercise does the same excess alcohol can raise your blood pressure so limiting alcohol and avoiding smoking but the real diet dietary thing is limiting sodium so the the number of milligrams of sodium per day recommended as an upper limit is 2,300 so two thousand three hundred milligrams of sodium a day is considered the cut point many Americans have 4,000 milligrams of sodium a day or more the Heart Association or your particular provider might recommend a lower amount because certain people with certain heart issues or kidney issues need to be unless but that would be for you to discuss with your provider and then of course many people are taking blood pressure medications one two or three different ones when you're looking at the sodium on a label that information can be looked at in two different ways you can look at the milligrams of sodium and if you can't read it it says 160 milligrams or you can look at the percent daily value off to the right side so this is a time when you can get some value out of looking at that and I gave a little key here in the bottom if you look at the percent daily value the definition of low is five percent or less the definition of high is twenty percent or more so if you're looking at a label for a quick glance five percent or less is low in that substance and twenty percent or more is high so of course we love high fiber and we'd love low cholesterol or low sodium so you know it's not always that one is good and one is bad but in terms of sodium we kind of want to go lower if you look at the milligrams 140 milligrams is the definition of low and 400 is high now it doesn't mean you can't have like this frozen meal that has 700 milligrams of sodium because if your daily budget is 2300 and your breakfast is oatmeal you know and you have this nice lunch yeah you could have this dinner that has more sodium because it's still within your daily budget so that's how you would evaluate a label ways to limit sodium would be herbs spices garlic ginger things like that limiting cured meats all of those cured meats have salts added pickled products are high in sodium if your expiration date on your packaged food is 2022 it's probably very high in sodium if your lunches peel back the paper add the hot water it's high in sodium so just pay attention if you have high blood pressure what about supplements certainly people with diabetes are targeted in many ways to buy supplements you know for promising that it's going to help with diabetes management but when you look at the guidelines from American Diabetes Association they're not necessarily recommending that everybody has additional vitamins and minerals or supplements now people who take metformin may need B b12 so you know you can talk to your doctors about that but routine use of antioxidant supplements are not recommended and the diabetes association says that's due to lack of evidence of efficacy and concerns using them long term but there are going to be certain people that need certain vitamins and I'd say a lot of adults don't get enough calcium for example and so figuring out if you know your bones are at risk and you need to take calcium then that's a good thing to do so I thought maybe I'd throw in a couple quick case studies and so this is Bob this is this is somebody that actually came to see me he's 55 years old he does have a BMI consistent with being obese and his lipids are elevated his blood pressure's elevated sedentary lives alone he doesn't read that well English is actually his second language and he wasn't that thrilled to see me he actually told me he was only there because his doctor told him he had to come so that made me feel real good but he hadn't been self monitoring his blood glucose and he didn't have any recent a1c so I thought you know this is not going to be a guy who's gonna want to count carbs so I you know the first thing is is he has multiple issues type 2 diabetes grade 1 obesity hypertension high LDL and his barriers to learning our first of all he wasn't that thrilled to be there but he didn't have a lot of support he lived alone English was a second language and his reading level was pretty low so I thought what can I give him that's going to give him sort of the most bang for the buck that covers across some of his issues and I you know wanted to keep it really simple establishing a relationship or maybe you'd want to come back into multiple visits and I knew his doctor was going to give him certain medications as well but we focused on ways that he could lose a few pounds remember 5 to 10% of your starting weight might be the initial goal so I I figured you know let's start with 5% and that seemed doable to him he was expecting to be told he had to lose you know 70 pounds or something so we talked about ways of managing portions with the plate model and the hand model and he really connected with that and he bought into it and then I did give him just this list of lean protein so I'm you know a shot from this list you keep the protein the size of your palm and he walked out of there a happy guy with some with a plan to get things you know started doesn't always have to be complicated I wanted to talk about alcohol real quick so alcohol does increase the risk of hypoglycemia low blood sugar if you take insulin or certain medications that lower basically it's the pills that cause your own body to make more insulin sulfonylureas you know like glipizide glyburide things like that or injected insulin so what this curve shows is what the blood glucose might be doing after a meal again I said the highest blood glucose might be in one to two hours and the meal might take about four hours to digest so that's where the available glucose is at first that you're surviving on is the digestion and absorption of the carbohydrate remember some of that gets stored in the liver and when you're between meals or overnight you're using the glucose from your liver and that's what you're surviving on when you drink alcohol alcohol goes through the liver to be processed and it is going to be turned into usually triglycerides it's a chemical reaction that I wrote up there that you don't really need to know but the thing that you do need to know is alcohol is processed in the liver and while the liver is busy doing that it can't let glucose out as well I can't do gluconeogenesis which is the making of sugar when it's needed now the issue is if you've got somebody who's taking insulin and that insulin is in here expecting this certain level of glucose to be available and now you take that away you cut off the supply the insulin is too strong and the blood glucose level drops so the risk of drinking if you take insulin or certain pills is low blood sugar so be aware of that now some people say but don't you does an alcohol turn to sugar alcohol doesn't turn to sugar and hard alcohol has no carbs bourbon gin vodka whiskey Scotch even wine you know we're from California we know that wine is fermented the juice is turned into wine you lose the sugar there so there's only about 2 3 maybe 4 grams of carbohydrate in a glass of wine now if your drink has fruit and umbrellas and things like that then I'm sure it's got lots of sugar but beer would be another one that has a little bit of carbohydrate so beer has about 13 grams and that varies some beers the good beers have a little bit more so recommended limits on alcohol if you want to be wise about it generally the Heart Association I think Diabetes Association agree women limiting to one drink per day men to two and what counts as a drink is a 12 ounce beer not the kegger cup and a 5 ounce glass of wine not the wine you'd like to pour at home and then one and a half ounces of hard alcohol and the real key is is just don't drink on an empty stomach be safe because if your livers busy with the alcohol as long as your stomach's busy digesting some carbs you've got carbs you just don't want to be drinking on an empty stomach but when do people drink the older generation it's the pre-dinner cocktail what if lunch was five or six hours ago you've got no lunch left the younger generation late nights parties clubs bars and that becomes a dangerous thing because how late are you out drinking how many hours how many drinks the thing is is when you're drinking and your livers not letting out sugar at some point you might get low and if people saw you're drinking and you're stumbling around everybody sort of assumes you're drunk and that's an issue if you're low and then what about when you go to sleep if you're severely low why you sleep that can be life-threatening so when you are treating lows since we're talking about lows I just want to remind you what I said earlier fat delays digestion so don't use chocolate to treat your lows chocolate is delicious and have it when you want a special snack but don't use it to treat lows the things that will get through your system the fastest are those liquids like juice so four to six ounces of juice or a tablespoon of sugar mixed in water or some honey for glucose tablets those would be things that would raise your blood sugar quickly but always remember to recheck your blood sugar in 15 or 20 minutes a lot of people forget that step also think about where your insulin is if you do take insulin here's two different this is what this diagram shows is the blue line the injection action of the insulin at the three meals the green line might be the Lantis leva mere or something like that if your blood glucose is low and you took your insulin an hour ago pay attention because that means you still have three hours of insulin that's gonna crank on you versus out here if your blood glucose is low and your lunch shot is worn off there's not as much crank down on the insulin so when you're treating although think about where your insulin is in your system because certainly the first one is going to take more carbohydrate to bounce back let's talk a little bit about exercise in terms of everybody we all benefit from exercise but in terms of type-2 it really is a treatment strategy it decreases insulin resistance your muscles are burning glucose helps with weight management helps with lipids fitness blood pressure reduces stress it's super important for everybody to do the prescription on it is including something aerobic and that's not going to be the same for everybody in the room we're not going to go the same pace we're not going to go the same distance if right now you're not doing anything maybe you're going to do five minutes so pick something that's realistic for you and start with that and maybe you start with three times a week but work your way up the goal really as a treatment for all the things we're talking about the recommendation is to get at least 150 minutes per week not more than two days in a row without getting some activity but also to include resistance exercises like the machines at the gym or the we'll hand weights while you're watching TV or push-ups yourself something like that in general we could all just stand up and move around every hour or 90 minutes rather than being locked to the computer screen or something like that move around reduce sedentary time even somebody with limited mobility could be doing upper-body activities there are sit and be fit armchair kind of YouTube videos you go on YouTube you search for exercise for seniors you search for a seated exercise and you'll find all kinds of things you can watch on your computer and do in your house to do some fitness at home don't forget to drink plenty of fluids when your glucose levels are elevated your kidneys are working hard to get rid of the glucose they're making more urine and you get dehydrated if you don't put back in the fluid and as people age they naturally lose that thirst mechanism or I used to have to tell my dad you know this is what you need to drink today and put it in a pitcher because he wouldn't ever be thirsty exercise safely keep your meter and supplies handy be prepared for hypoglycemia if you're somebody who's taking medications carry your carbs keep hydrated take care of your feet if you've had diabetes for a long time you have any foot problems you have any nerve problems in your feet you want to have the proper shoes and socks you want to visually inspect your feet you want to avoid jumping rope and pounding your feet if you have some some nerve damage in your feet you want to wear medical ID be a wise thing to do so let's talk about this little quick case study we have a female 63 years old she's had diabetes 20 years not her fault she ended up with some neuropathy and her feet she didn't really have access to healthcare they didn't really know as much 20 years ago either in terms of treating diabetes and her blood glucose levels ran high for a long time she also has a family history of heart disease she has grade 3 obesity and her blood pressure's elevated so what's going to be realistic for her so the most important thing about her is she's telling me that she can't feel her feet very well so what I would suggest is something that is you know not so heavy of weight bearing so it could be something like cycling or swimming or a water aerobics class chair exercises but not a Stairmaster or you're pounding your feet down and not positioning your feet properly kids get type 2 2 so if you have type 2 diabetes it's important to think about the offspring the kids the grandkids and take a look at them who's at risk and who should be screened children should be screened who are overweight so I did about 16 18 years in the pediatric diabetes clinic at UCSF and we had quite a few kids with type 2 diabetes but none of them were thin you know when you're talking about type 2 diabetes those kids generally have a family member you know you're looking at what are the risk factors they're listed here so kids who are overweight and have at least one risk factor should be screened the risk factors are family history mom has diabetes or Dada's diabetes they're from a high-risk ethnic group they have hypertension themselves a can ptosis is the dark skin on the back of the neck you can see it if that teenager has that that's a risk factor dyslipidemia PCOS is polycystic ovarian syndrome even kids that were born small-for-gestational-age are at increased risk for type 2 diabetes or if their mother had gestational diabetes particularly uncontrolled so when should these kids be screened starting at age 10 or puberty if it occurs before then and it should be every three years I think too many people walk around with diabetes for too long and because diabetes doesn't hurt it's really easy to ignore and not know you have it and so there should be a critical push for getting people screened so healthy tips for healthy kids balanced meals appropriate snacks you know fruits and vegetables the good things that they should be eating leaner proteins limiting the fried food fast foods and staying off the juices and soft drinks the the pediatricians are saying young kids limit to four ounces of juice a day and older kids eight ounces it's just too many calories 16 ounce juices 300 calories provide healthy snacks is what you keep in the house for him get them active get them exercising doing sports too bad that the schools often pull sports and PE but that's a really important thing for them to be involved in and limit screen time and I have two teenagers and I know that's a really really hard one so trying to get everybody out and moving so as a quick review before we take questions diet and exercise our foundation treatments for anybody who has diabetes type 1 or type 2 and if there is a weight issue and you want to get some of the weight down don't be discouraged start with 5 percent of whatever your starting weight is and go from there and carb counting isn't always necessary for somebody with type 2 but it is a it is a method that can be used for making sure that you're eating an appropriate amount of carbohydrate distributed throughout the day but carb counting is really really critically important for somebody with type 1 who's trying to adjust their insulin to the different foods that they eat simple strategies for a lot of people work well like the plate method that we looked at or the hand method really simple thing is get the sugar sweetened beverages out of the house remember that type-2 diabetes runs in families and it's important to be screened diabetes is largely self-managed and you're all here which is great and there just needs to be a big push to get the education so that you can do a good job at that okay four minutes before my cut time [Applause] yes so um question was does is brown rice a soluble fiber source and many things have both soluble and insoluble brown rice is one of them barley I think has a little bit more some even rice bran has some of the both types of fiber and it's hard to get that information because they don't list it on labels and they don't really have that many tables even if you go to calorie King to look foods up you can see the fiber but they don't break it out so I would just do a search online for you know like soluble fiber sources I listed some of them yes what about intermittent fasting I think that that is something that you'd have to look at personally according to whatever your reasoning is and what your overall metabolic you know system is in terms of what are your lipids and so forth what's your weight but one one concern about fasting is if your fasting too long you are tapping into your muscles to convert your muscles into glucose and you are breaking down fat of course and turning that into ketones but if people do that on a regular basis their bodies can adjust the metabolism down you can kind of slow down your metabolism because your body is breaking itself down and it's gonna do that protectively so I think that it would be something to discuss with your provider and it depends on how often you do it and I know that there are certainly people for religious reasons you know that don't eat from dawn until dusk you know and that we have to work with that situation and make that work yes okay so the question is she pointed out that the guideline that guideline that I gave about half and to screen kids is from the American Diabetes Association guidelines her question is is what about adults I believe the age that they list that everybody should start being screened as age 45 but if you have risk factors sooner and how often your question was should it be annual and I think if you're getting an annual exam and you're getting blood drawn anyway yes I would definitely would because you can get an a1c that tells your average blood glucose over a three month period it kind of gives you the big picture and you could also get a fasting done at the same time and that's two out of the three ways of screening for diabetes so it would be a wise thing to do if you have risk factors yes so I'm not sure I understand the question so you're talking about when mom is pregnant are you talking about a mom who has gestational diabetes is the baby going to have diabetes yes okay so yes so in pregnancy the baby is taking glucose from the mothers bloodstream and using that for growth and development and in fact it's critically important that pregnant women have enough carbohydrate during their pregnancies and that they don't restrict when they're pregnant if the mothers breaking down her own body and making ketones during pregnancy the ketones pass to the baby and they're not especially healthy that's like third-world stuff not enough food so the mother having diabetes doesn't impart the risk directly what happens is if her blood glucose levels are elevated if they're running high too frequently when the glucose levels and the mother are elevated the extra sugar goes to the placenta and gets to the baby then the baby gets extra calories and the baby doesn't need that much glucose oh the baby converts it to fat and then the baby gets bigger so that's macrosomia that in itself is a risk for diabetes when they when they do ultrasounds on infants and see all this abdominal fat that's an a big risk for metabolic disease in the future including obesity and type 2 diabetes the other thing is is the bay his pancreas has to make all the insulin to deal with that influx of glucose and so the baby's pancreas is working turbocharged trying to deal with all that glucose and that effect on the upon crius of the baby can also play into the risk of developing diabetes but if mother's blood glucose is well controlled and she's checking frequently and there's you know really strict guidelines we go through a really strict diet and remember her carbon needs are higher her minimum carbs are 175 grams per day minimum and and we have hundreds of moms having babies here healthy and with well controlled diabetes totally possible yes so III recognized that when I had my fat list up there is coconut oil healthiest the question I recognize that he didn't mention it I don't know if it was like subconscious because I always you know there's gonna be a different opinion about coconut oil but I don't think all it was on the saturated fats list along with the meats and the dairy fats coconut oil and palm oil are listed there as saturated fats I don't think they're all equally you know when you when you look at chemistry of fats it has to do with the chain length of the carbons in the triglyceride and they're not all the same so I think they're ranked Abell you could rank them and I don't think coconut fats the same as bacon fat but as much as I want to move it to a different list because I love my green curry the Heart Association and the Diabetes Association and nutrition you know Academy of Nutrition and Dietetics is still listing it with the saturated fats and so that's where it sits on our handouts and I think moderation I think the fad of cook everything in coconut oil make your popcorn and coconut oil fry your fish and coconut oil is over the top and not a healthy thing to do but I think in moderation okay we're at 833 if anyone has any other questions I'll answer them so feel free but there [Applause] [Music] you

Channel: University of California Television (UCTV)

Views: 42,890

Keywords: diabetes, carbohydrates, insulin, diet, nutrition

Id: iJowWOrPFKk

Length: 87min 28sec (5248 seconds)

Published: Sat May 04 2019