Online Health Chat with Andrea Dunn, RD, LD, CDE
November 18, 2014
Diabetes has become an overwhelming public health concern. About 25.8 million Americans (8.3 percent of the population) have diabetes; it is estimated that 7 million of these individuals do not know that they have diabetes. In 2010, 1.9 million new cases of diabetes were diagnosed in people aged 20 years or older. One in three Americans born in 2000 will develop diabetes in his or her lifetime.
Did you know?
- When you eat or drink, much of your food is broken down into a simple sugar called glucose.
- What you eat and how much you eat can help you keep your blood glucose levels in goal range?
- Foods that have the biggest effect on your blood glucose levels are carbohydrates.
Higher than normal blood glucose (sugar) levels may cause serious health problems.
Do you know the target blood glucose ranges for diabetes?
- Fasting or before a meal: 70-130 mg/dL
- Two hours after starting a meal: less than 180 mg/dL
- At bedtime: 100-140 mg/dL
Take this opportunity to ask registered dietitian and certified diabetes educator Andrea Dunn your questions about the importance of nutrition and diabetes health.
About the Speaker:
Andrea Dunn is a registered dietitian and certified diabetes educator with the Center for Human Nutrition. She focuses her patient counseling on diabetes management and prevention, weight reduction and cholesterol/blood pressure management. She takes an individual approach to each patient’s lifestyle, learning needs and readiness to change.
Andrea completed her undergraduate degree at Notre Dame College of Ohio and an internship at Miami Valley Hospital in Dayton. She has volunteered for more than 10 years with the Academy of Nutrition and Dietetics’ Diabetes Care and Education Dietetic Practice Group, serving in a chair role for the past three years. Andrea has been a certified diabetes educator for the past15 years.
Let’s Chat About Healthy Eating with Type 2 Diabetes
Moderator: Let's get started with our questions...
The Deal with Diabetes
lasimon: Will a person with Type 2 diabetes under control end up with the need for insulin? If you do everything right, is there really any control for this disease?
Andrea_Dunn,_RD,_LD,_CDE: As you may have read, Type 2 diabetes is a progressive disease. Will you require insulin? That all depends on individual factors that includes, among many other factors, weight, exercise, genetics, hormones and beta-cells, those cells that produce insulin in your pancreas. Research shows that managing your diabetes early in the disease process can have big payoffs in later years. Joining a support group for people with diabetes can be helpful in keeping you going in your health quest. Following up with your health care team regularly and keeping abreast on the new developments in diabetes management can also benefit you.
Homer: If you have an insulin pump, do you still need to be as strict about diet?
Andrea_Dunn,_RD,_LD,_CDE: Portion control of all foods with nutrient-dense, high fiber food choices that are heart healthy is good for everyone with diabetes – no matter what type of diabetes – or how the insulin is delivered into your body.
Mary_Lou: I have pre-diabetes, not diabetes. Do I need to watch my carbs?
Andrea_Dunn,_RD,_LD,_CDE: Pre-diabetes is becoming more common in the United States. The U.S. Department of Health and Human Services estimates that about one in four US adults aged 20 years or older – or 57 million people – had pre-diabetes in 2007. Those with pre-diabetes are likely to develop Type 2 diabetes within 10 years, unless they take steps to prevent or delay diabetes.
The Diabetes Prevention Program looked at what helps prevent or delay Type 2 diabetes. It found that losing weight – even 5 percent to 7 percent – along with 150 minutes/week of moderate-intensity exercise was helpful. The style of eating they followed was low fat and lower calories to help with weight loss. In pre-diabetes, the weight loss seems to have the biggest impact on diabetes prevention.
MegN: Does having diabetes put me at risk for heart disease? My doctor wants me to start a statin (cholesterol lowering medication).
Andrea_Dunn,_RD,_LD,_CDE: Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes, and the risk for stroke is two to four times higher among people with diabetes. Following a heart-healthy style of eating, managing your weight, blood sugars and blood pressure, as well as having a discussion with your doctor about your heart risk factors, are very important.
MegN: How much exercise do I need?
Andrea_Dunn,_RD,_LD,_CDE: General recommendations include 150 minutes or more/week of moderate-intensity exercise. In addition, two weight training sessions/week can help build/maintain muscles. The body benefits from even 10 minutes of exercise.
chickbull: I have been borderline Type 2 with an A1C of around 6.4. However, I have been working hard to get it down with more healthful eating and having a smoothie every morning for breakfast. No bread or cereal, mostly berries, flax seed, almond milk, coconut oil and greens. I lost about 15 pounds since Jan 2014 and my A1C is down to 6.0 and fasting glucose to 99. I find this interesting since fruits have a lot of natural sugar. Also, coconut oil is very high in saturated fat but seems to be working with my weight loss. I have read a lot of bad things about wheat and thought whole grain was the way to go. Are whole-grain wheat and coconut oil bad?
Andrea_Dunn,_RD,_LD,_CDE: First of all, congratulations on your success at weight loss. For many people with pre-diabetes, losing 5 percent to 7 percent of body fat, if they are overweight, along with 150 minutes or more of moderate-intensity exercise, can lower blood sugars to goal range. The bottom line for losing weight is total calorie intake. There is no one diet for diabetes or for weight loss. You ask specifically about whole-grain wheat – which is a carbohydrate – and coconut oil – which is a fat. Moderating carbohydrate intake can help with blood sugar lowering. There is no reason to avoid whole grains – they contain fibers as well as many nutrients – unless you have an allergy or intolerance. Regarding the coconut oil, recommendations suggest using this in moderation and not for all your oil/fat needs. Fat does provide satiety – the feeling of fullness – since it takes longer to digest than the carbohydrates and proteins we eat, which is why you may be feeling fuller after drinking your morning shake.
lasimon: I have mixed connective tissue disease and want to know about the Type 2 diabetes that may be the result of autoimmune issues.
Andrea_Dunn,_RD,_LD,_CDE: I'm sorry, I am not able to answer this question for you. I would refer you to your rheumatologist or your primary doctor.
Balancing blood sugars
Safeme: What else affects my blood sugar besides what I eat? I think I am eating OK but still not where I am at with my blood sugar readings.
Andrea_Dunn,_RD,_LD,_CDE: Exercise, sleep, stress and medications can all have an impact on your blood sugars. A recent study showed that people with diabetes and sleep apnea lowered their blood sugars without the addition of medications by using a CPAP. (CPAP, or continuous positive airway pressure, is a treatment that uses mild air pressure to keep your airways open while you sleep). Be sure to let your health care team know if you snore.
lasimon: I am taking metformin 1500 mg daily. Should there be anything done if my blood sugar is in the low end of the fasting range at bedtime?
Andrea_Dunn,_RD,_LD,_CDE: Are you having any problems with low blood sugars during the night? Is the "low end" (80s?) making you feel like you are having a low blood sugar reaction (shaky, sweaty, panicky hungry)? If not, you may not be having a problem at all.
Ann77: My glucose reading is typically highest the first thing in the morning after the overnight fast. What is the best way to manage this?
Andrea_Dunn,_RD,_LD,_CDE: There could be a few things going on:
1. Sometimes, the liver makes and releases sugar into the body during the times when we are not eating (fasting), as might happen during the night when we are sleeping (and not eating). This release of sugar makes the morning blood sugars rise. This happens because the liver gets mixed signals from the body (often due to being overweight or having fat around the abdominal area), and it thinks that you do not have enough sugar in your system. One of the first-line medications to treat diabetes – metformin (or Glucophage) – tells the liver to stop doing this, which helps the morning fasting blood sugar to be in goal range. For some people, losing 5 percent to 7 percent of their body fat, if they are overweight, and exercising regularly prevents this from happening.
2. Are you going to bed with a high blood sugar reading? Perhaps your body is not making enough insulin (or your diabetes medications need adjusting) so that your two-hour after dinner meal or your bedtime blood sugar readings are in goal range.
3. Are you eating a bedtime snack? How much you eat before you go to bed can have an impact on your blood sugar readings.
4. Are you taking a diabetes medication that is causing LOW blood sugar? Sometimes, an undetected low blood sugar during the night triggers the liver to produce sugar, which can cause the morning sugar to be elevated.
Because there are a few reasons your morning blood sugar can be elevated, discuss with your health care provider the benefits of more frequent blood sugar testing – two hours after dinner, at bedtime, in the morning when you wake up – to see what your specific problem is, and work with your health care provider to correct it.
14petluver: I have a condition in which my body does not maintain my autonomic nervous system correctly. This means my blood pressure, digestive system, anxiety, fight-or-flight level are often working incorrectly. Even if I stick to my carb limit, there are times when my glucose levels are high for these other reasons. Should I eat even fewer carbs? Do the high levels for these other reasons affect my body as badly as eating the wrong things?
Andrea_Dunn,_RD,_LD,_CDE: You raise a good question. Stress, even the stress caused by exercise, can raise blood sugars in some people. Does that mean that you should not exercise? No. But from what you are describing, working with your health care team may help you to reach and maintain the blood sugar goals that they set individually for you.
bobcat72737: A co-worker's doctor said the guidelines had been adjusted and the target A1C is 7 rather than 6. Is that correct?
Andrea_Dunn,_RD,_LD,_CDE: The A1C guidelines will vary as to your age and health. For most adults with diabetes (non-pregnant), the goal will be an A1C of 7 or less.
14petluver: You use the term "health care team". I tried to have my primary care physician (PCP) keep track of everything; but the first year, I was not getting enough information, and lately, he was having trouble finding a second medication that had side effects I could handle. I started with an endocrinologist, who gives different limits and opinions than the dietician, who gives different rules than he does, and my PCP has different limits than either of the other two. A team should work together, but these three don't agree on much at all. It's stressful.
Andrea_Dunn,_RD,_LD,_CDE: What you may be describing are different sets of guidelines for diabetes management. The American Diabetes Association guidelines (that your primary doctor/dietitian may be following) may be slightly different than the American Association of Clinical Endocrinologists guidelines (that your endo doctor may be following). However, they should not be that different. I would take your concerns to your primary doctor and have him formulate the plan best for you.
14petluver: As you can see, I feel very confused. My PCP says only the A1C counts. My dietitian says testing three times a day is important for me since my numbers vary, and my new endocrinologist is testing everything, things I've never heard of before. Do you know what a 24-hour urine is for?
Andrea_Dunn,_RD,_LD,_CDE: The A1C is just the average reading. It looks back at the last three months. The actual blood sugar reading you get is more about the point in time that it was taken and can tell you much more if you need that information. The 24-hour urine can give you information on kidney function, as well as other parameters of health.
14petluver: I was diagnosed with diabetes Type 2, two years ago. I was on one oral medication and now have just added a second. Being totally realistic, I will never go the rest of my life without ice cream or candy, so that is why my numbers are sometimes too high. A year ago, after eating what I wanted for months, my A1C was 8.4. When I followed the limits very strictly, it dropped to 7.2 five months later. After eating ice cream and candy again for three months, the A1C was up to 7.5. Do you have any suggestions? Moderation doesn't seem to exist in my world. It's either all or nothing.
Andrea_Dunn,_RD,_LD,_CDE: Have you considered carbohydrate counting? For some people, having a “budget” or a number of carbohydrates to have a day – and spreading the carbs throughout the day – allows them to have the carb choices they want, within reason. Knowing the carbohydrate values of the sweets/treats you eat, and then planning them into your day, helps some people with diabetes keep their blood sugars (as well as their weight) in check. You may also benefit from psychological counseling if you feel your eating is out of control.
Viv: Can I eat sweets if I have diabetes?
Andrea_Dunn,_RD,_LD,_CDE: Sweets and other desserts may be eaten as part of your carbohydrate and calorie budget for the day, not in addition to it. In other words, plan the treats/sweets that you want to eat.
R2Da: My doctor suggested I eat fewer carbs, but what can I eat instead?
Andrea_Dunn,_RD,_LD,_CDE: You need to be aware that calories come from three sources – carbohydrates, protein and fat. When you lower or moderate your carbohydrate intake, you will need to include adequate calories from the lean protein and healthy fat choice food groups in order to maintain your weight. Choosing lean protein sources – chicken or turkey without the skin, fish, low-fat cheese, nuts, nut butters – may help provide satiety (the feeling of fullness). Foods with fats include spreads such as mayonnaise, butter, margarine; salad dressings; nuts and seeds; olives and avocados. Choosing foods that are baked, broiled and grilled will be lower in calories (and carbs) than those that are breaded, fried or have added sauces and gravies.
lasimon: What would be the total carb gram suggested at each mealtime and snack for a Type 2 patient with an A1C of 6.0? Currently, I try to do 45 grams at meals and a 15-gram snack three times a day.
Andrea_Dunn,_RD,_LD,_CDE: The answer would depend on your calorie needs. The carb meal amount will also depend on what your after-meal blood sugars are. Occasionally, monitoring your blood sugar BEFORE a meal and then TWO HOURS AFTER a meal will let you know how what you ate affected your blood sugar. Your goal might be:
Pre-meal: 70-130 mg/dL
Post-meal (two hours after starting meal): less than 180 mg/dL
Bedtime: 100-140 mg/dL
With a goal of more than 50 percent of these values within target range. But check with your doctor for the blood sugar goals best for you.
al4lexie: Do I need to “count” the vegetables as part of my carbohydrate budget at meals?
Andrea_Dunn,_RD,_LD,_CDE: Non-starchy vegetables – such as asparagus, beets, broccoli, carrots, cauliflower, green beans, greens, salad lettuces, peppers and tomatoes – have small amounts of carbohydrates in them. If you are on an insulin-to-carbohydrate ratio and having problems fine-tuning your blood sugars, then you may want to count the carbohydrates in these non-starchy vegetables also.
BellaRose: If my blood sugar is affected by what carbohydrates I eat, what foods contain carbohydrates?
Andrea_Dunn,_RD,_LD,_CDE: You are right. When you have diabetes, eating too many carbohydrate-containing foods at one time can raise your blood sugar too high. Moderating the amount of carbohydrate you eat at any one meal or snack can help keep your blood sugars in goal range. Carbohydrate foods include: starches (breads, pasta, rice, beans/lentils, potatoes, corn, peas, crackers and chips), fruit and fruit juices, milk/yogurt, sugars and sweet desserts. Non-starchy vegetables such as broccoli, carrots, green beans and salad greens also have a small amount of carbohydrate in them.
Robbno45: My doctor says my body still produces insulin. Do I need to watch my carbohydrate intake?
Andrea_Dunn,_RD,_LD,_CDE: Carbohydrate is the body’s main source of fuel. Carbohydrates break down to glucose or sugar. Insulin is a hormone made by the pancreas to help the blood sugar enter the body’s cells. Some people with Type 2 diabetes are making enough insulin, but their bodies may not be able to use it well because of insulin resistance. Exercise and weight loss, if you are overweight, can help maintain goal range blood sugars.
Ann77: What are good resources for guidance in planning meals with very limited carbs? I am limited to seven carb servings per day (30 grams per meal, one 15-gram snack), and I have difficulty planning fulfilling meals. The resources that I have found have three or more carbs per meal.
Andrea_Dunn,_RD,_LD,_CDE: First, think about the carbohydrate foods that you like to eat, and try to choose whole grain, high-fiber foods and other plant-based foods (fruits, vegetables) as often as you can within that tight carb budget. Thirty grams of carbohydrates could be all the same carbs (2/3 cup whole-grain pasta) or it could be two different carb sources (two slices of light bread for a sandwich and a lite yogurt). Add in ½ of a plate of non-starchy vegetables and you can get a lot of nutrients and food for a moderate amount of carbohydrate. You may want to try the public library and look for low-carb cooking recipes to expand your meal planning ideas. Also, if you haven't seen your registered dietitian recently, you may want to set up a visit to discuss some creative meal planning for your lower-carb style of eating.
Fruit and Fiber
nutzy: I'm 69 years old and my HbA1C is 6.5. I try to eat healthy food most of the time but I don't have an active life. About my diet, a friend told me that I make a mistake by eating an apple late in the evening. Is he right and why?
Andrea_Dunn,_RD,_LD,_CDE: If your A1C is 6.5 and you have Type 2 diabetes, you may be at your goal range with nothing to worry about. Check with your doctor for the A1C goal that is right for you. Have you ever checked to see what your blood sugar is before you eat the apple and compared it to what your blood sugar is two hours after eating the apple or with your morning blood sugar (fasting)? This might help you understand how what you eat and when you eat it are affecting your blood sugars.
Sugarbun: Do I need to avoid bananas if I have diabetes? I was told they are high in carbohydrates.
Andrea_Dunn,_RD,_LD,_CDE: One extra-small banana (4 ounce weight – that includes the weight with the peel still on) is about 15 grams of carbohydrates, or 1 carb choice. Compare this to the same amount of carbs in ¾ cup blueberries, 1 cup cut-up melon or 1 small apple or pear (4 ounce weight with core still in the fruit). Weighing the fruit on a food scale can help you determine how many carbs it has. A recent honey crisp apple weighed in at 13.4 ounces. That would be about 2.5 carb servings or about 50 grams of carbohydrates.
Ann77: I understand that foods with high fiber content can be counted as net carbs rather than total carbs. Please explain net carbs and whether this concept of net carbs is valid for counting carbs in a diabetes meal plan.
Andrea_Dunn,_RD,_LD,_CDE: The updated nutrition guidelines for diabetes no longer include the need to subtract anything from the total carbohydrate amount. If you are on insulin and have an insulin-to-carbohydrate ratio and are not at your target after-meal blood sugar reading, you can discuss with your dietitian or certified health educator if the total amount of fiber may be affecting your blood sugar reading.
lasimon: Fiber grams can be deducted from the total carb gram number, correct?
Andrea_Dunn,_RD,_LD,_CDE: Unless you are having difficulty fine-tuning your insulin-to-carbohydrate ratio, we no longer recommend subtracting fiber from the total carbohydrate amount.
bobcat72737: Could you suggest a site with portion sizes? For instance, I seem to remember protein the size of your palm.
Andrea_Dunn,_RD,_LD,_CDE: The American Diabetes Association (diabetes.org), The National Institute of Diabetes and Digestive and Kidney Disease (www.niddk.nih.gov), eatright.org and choosemyplate.gov may be helpful.
lasimon: Would a DDI unit be for celiac disease patients? If so, please provide the phone number to call.
Andrea_Dunn,_RD,_LD,_CDE: Yes, both gastroenterologists (GI doctors) and registered dietitians are under the Digestive Disease and Surgery Institute (DDI). You can make appointments with them by calling 216.444.2273.
Moderator: That is all the time we have today for questions. Thank you everyone for participating today; and thank you, Ms. Dunn, for your insightful answers to our questions about diet and diabetes.
Andrea_Dunn,_RD,_LD,_CDE: There is not one meal plan that fits everyone's needs. Your individual meal plan should be based on your personal lifestyle, health needs and food preferences. If you are new to diabetes, you may benefit from meeting with a registered dietitian or a certified diabetes educator to help create an eating plan that is right for you. Most people with diabetes benefit from a yearly follow-up with their dietitian once they have the initial education and information on nutrition and diabetes. To schedule a visit with a registered dietitian at Cleveland Clinic, call 216.444.3046.
lasimon: This was great. Thank you.
Moderator: On behalf of Cleveland Clinic, we want to thank you for attending our free online health chat. We hope you found it to be helpful and informative.
To make an appointment with Andrea Dunn, RD, LD, CDE, or any of the other specialists in our Digestive Disease and Surgery Institute, Center for Human Nutrition at Cleveland Clinic, please call 216.444.3046 or toll-free at 800.223.2273, ext. 43046, or visit us online at www.clevelandclinic.org/nutrition.
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