Using Food to Reverse Prediabetes with Peminda Cabandugama, MD

Podcast Transcript

John Horton:

Hello and welcome to another Nutrition Essentials Podcast, a chewier version of our popular Health Essentials show. I'm John Horton, your host.

What would you do if you had the power to beat back a disease that threatened to take years off your life? The answer to that question seems pretty simple, right? You do it, no questions asked. So, with that in mind, let's talk about prediabetes.

It's estimated that 1 in 3 Americans have prediabetes, meaning their blood sugar is higher than it should be, but not high enough to be classified as Type 2 diabetes. It's essentially a health warning stage. Today, we're going to spend some time exploring what that means, and better yet, what you can do about it beyond just eating healthier.

As part of our discussion, we're going to break down some truly fascinating connections between prediabetes and our mealtime habits. As usual, we have registered dietitian Julia Zumpano on hand to cover the food and nutrition angle. To learn more about prediabetes, we brought in an expert from Cleveland Clinic's Endocrinology and Metabolism Institute.

Julia, tell us more about our guest, Dr. Peminda Cabandugama, who, thankfully, says he likes to go by “Dr. C.”

Julia Zumpano:

Thanks, John. Dr. C specializes in diabetes management and weight management, two very connected topics. Having excess weight increases your risk of prediabetes and diabetes. There's even a term for it — “diabesity.”

I'm looking forward to comparing notes with Dr. C on how building healthy eating habits can help reverse — yes, reverse — prediabetes and many of the issues that go along with it.

John Horton:

That's a great goal, Julia. So, let's start talking about how folks can turn things around. Welcome to the podcast, Dr. C. Thanks so much for coming on to talk shop about prediabetes.

Dr. Peminda Cabandugama:

Thank you for having me on, John — excited to be part of this conversation with you and Julia.

John Horton:

Well, I'm so glad you're here. So, Dr. C, I'm a numbers guy, so I want to start with a statistic that just really blew my mind. According to the CDC [U.S. Centers for Disease Control and Prevention], nearly 98 million Americans have prediabetes. And to put that in perspective, that's roughly the populations of California, Texas and Florida, our three largest states combined.

Dr. Peminda Cabandugama:

Yeah, the numbers are crazy, and they're tending to go up further. And we are not seeing this not only in the Western world in the U.S., but we're also seeing it in the rest of the world as well. And it's something that's an eye-opener. And when you tie it into the obesity pandemic that we have going on, I think there's a lot of work to be done in this space.

John Horton:

And we're going to start doing some of that work today by helping people understand what's happening. So, people typically think of a health condition in one of two ways: Either you have it or you don't. Prediabetes seems to fall in a gray area between those two. So, do people have trouble with that concept, Dr. C?

Dr. Peminda Cabandugama:

Yeah, I think they do. Even in diabetic patients, and speaking as an endocrinologist, I see a lot of diabetics along with my obesity patients. Even with diabetics, just getting them to understand the concept of having diabetes and it being a lifestyle disease — meaning that you have to actually change your lifestyle as the disease progresses — getting them to understand now that there's a concept called “prediabetes” tends to be difficult.

It's hard to get into the concept. So, we try to explain to our patients that it's a precursor that can lead into diabetes and it's one of those things where we need to make some changes early on itself to prevent things like diabetes and all the other comorbidities that come with it. You, as a numbers guy, what you should know is what we talk to our patients … which is the A1C.

I think “A1C” is one of those terms that's pretty ubiquitous. Everyone's heard of the word “A1C.” The understanding of an A1C is how much sugar binds to a red blood cell. And so, the A1C cut-off for diabetes is 6.5%. The A1C cut-off for prediabetes is 5.7%. So, we have studies showing that if you have an A1C of more than 5.7%, you need to start making some changes, as that's a diagnosis of prediabetes, to prevent the progression into diabetes.

And so, that is why ... that is how we actually go about explaining to patients the concept of prediabetes and making sure that you don't head into diabetes, at which point you basically have to start making some drastic changes, as opposed to if you're diagnosed in the prediabetic stage, you can actually start these interventions early and hopefully prevent getting diabetes. Because it has a lot of lifestyle changes and options that you can do to prevent progression of a chronic disease that can happen if you don't take these steps.

John Horton:

Right, right. You brought up A1C. For people who don't know, what is A1C?

Dr. Peminda Cabandugama:

So, yeah, so like I mentioned, it's basically how much sugar binds to a red blood cell. So, when patients come and ask me, "Why do we see you every three months?" Because that's the lifespan of a red blood cell. So, that's the reason why we do A1Cs every three months because a red blood cell is born and then dies within 90 days. And within 90 days, the amount of sugar that binds to that red blood cell is an indication of how much sugar is in your blood. And the studies have shown the correlation between that number, that A1C percentage, and the actual comorbidities that it causes.

John Horton:

OK, that's a wonderful explanation.

So, Julia, on the topic of prediabetes and getting a grasp of almost having the disease, but not quite, do you deal with that a lot, too?

Julia Zumpano:

Absolutely. I'd say a good majority of my patients have that hemoglobin A1C between the 5.7% and 6.5%, that prediabetes range. So, I do commonly work as soon as I see that, and I'm always checking for a hemoglobin A1C. I always check for a lipid panel and a hemoglobin A1C. And if they have the ability to get an insulin value, a fasting glucose — those all tell us if they're in … on that road to diabetes.

So, I certainly start to make diet adjustments even if they're on the cusp like a 5.6%. I look at the diet with a different lens. I really look at what type of carbohydrates they're eating, what they're drinking, the sugar content, the fiber content and protein content of their meals. So, I definitely intervene there. And really, nutrition is one of the key ways to prevent you from being diabetic … is changing your diet and then, of course, exercise. But nutrition plays a huge role.

John Horton:

And Julia, building on that, I want to ask an overly simplified question for both of you, and that's, what causes prediabetes?

Julia Zumpano:

Well, I'll let Dr. C provide the clinical reasoning toward that, but unhealthy lifestyle really is what it can come down to. So, high sugar intake, high stress, inappropriate meal timing and getting not enough of the right balance of your macronutrients, and inactivity, of course, can all lead to your blood sugars being elevated.

Dr. Peminda Cabandugama:

Yeah, to Julia's point, that's exactly it. That's exactly it for prediabetes, as it is to any of the chronic diseases that come out of all those factors. So, the answer to your question, John, is it's multifactorial. It's multifactorial why we get prediabetes, it's multifactorial why we get diabetes Type 2, it's multifactorial why we get high blood pressure, high cholesterol.

The world has changed from what we had maybe a few years ago. Our stress levels are higher. Our sleep is not as good. Our diet is not as good. We tend to be more sedentary, especially with COVID. I think we were a lot more sedentary, and now, I think people are starting to realize that. So, all these concepts together have brought out all these chronic diseases, and prediabetes is one of them.

Just like obesity, high blood pressure, high cholesterol is part of it. So, yeah, all these factors caused prediabetes.

John Horton:

Yeah, it seems like a lot of it just goes to the choices that we're making every day. It's a little self-inflicted, it seems.

Dr. Peminda Cabandugama:

I would give you a little bit of a pushback on that just because sometimes, the choice is made for you. I like to bring up the concept that a lot of the points that are brought up — back in the '50s, everyone was healthier than they are now. I would argue that back in the '50s, both parents didn't have to go to work. And so, one parent could be making the meals at home, making sure it's healthy meals.

Nowadays, unfortunately, most families, both parents do have to go to work, and so when they come home from work, maybe they have to order food from out because they want to make sure that their kids are fed on time. So, some factors I think have ... the choices have been made for us. Could we make some better choices? Of course, all the time.

But the idea that it is “self-inflicted,” especially with all the studies that are coming out with the new medications out there, showing, again, that multifactorial nature of everything, whether it's hormones or peptides or just changes in meal patterns, changes in times of eating, all of this comes into play. And then, of course, you always have stress and sleep playing a role also.

So, the concept that this might be self-inflicted, I think we are heading away from it and I think that is the right step.

Julia Zumpano:

I would agree. I do think that when it comes down to choices, in simplicity, you have a choice to eat a bag of chips or a choice to eat an apple. Well, of course, it comes down to a choice in that setting. When you have the option to choose what may serve your body better, what will actually feed you good nutrition versus packaged snack foods, we know that that's the choice.

I think what Dr. C is trying to say is there's so many influencing factors that, unfortunately, in this day and age, we have been provided so little options a lot of times. As you mentioned, both spouses work or we're working long hours, stress level's high. We're not moving or we don't have the ability to move as much because most of the jobs are sedentary.

And if you ever do order takeout or grab something quick, most of the time, the food choices aren't very healthy. So, we don't have many great options for healthy food. Healthy food does come down to cooking at home, unfortunately, and most of us don't have time for that. So, I think it can also be a bigger societal problem of just being able to offer more healthy food choices that could be more quick and on the go.

John Horton:

All right. And on the topic of food choices, when you really start looking at what's good and what's not, I feel like there's not a lot of mystery. Deep down, we all understand that celery is good for us and cookies probably aren't a beacon of nutrition, even though we'd really like them to be. But life is just guiding so many of us toward, as you guys mentioned, these not-so-great options when we're hungry.

So, what's the secret then to, I guess, having a healthy diet and avoiding or steering away from the trends that take you to prediabetes?

Julia Zumpano:

Well, certainly, I think planning. So, I think you need to plan a little bit more about what you're going to have, and the planning starts with the grocery list. So, starting to plan what foods you want available to you in the home and being able to put meals together that are equally balanced. And I know that can be difficult or daunting, but most of the time, I see my patients starting their day off with carbohydrates.

So, they might be eating cereal or toast or bagels, waffles or something very carbohydrate-laden and that's only going to cause your blood sugar to spike and then drop, and then, you're feeling hungry again. Your blood sugar's dropping, you need energy. So, it only leads to you grabbing those carbs again and it's this vicious cycle throughout the day.

So, if you're not consuming enough protein and healthy fat with your meals, you're going to get into that blood sugar trap of the elevation and then decline, and then, consistently trying to feed that energy with carbohydrate-based foods because carbs are our body's main source of energy — and we certainly need them — but it's just the balance. So, I educate a lot on providing enough protein with each meal.

Starting off your day with protein is ideal because it really starts that blood sugar off in the right level. So, protein and healthy fats are essential. A little bit of carb is fine, but protein and healthy fat should be the foundation. So, that could look like a veggie omelet with some avocado. It could be some plain Greek yogurt with some berries and nuts on top. So, something that is more protein-laden, and then, continuing that same trend throughout the day. So, making sure you're getting enough protein, healthy fat and that your carbohydrates contain fiber. So, fiber is essential for slowing down the rate of glucose. So, if you are going to eat carbs, you want to choose ones that have high fiber, which, bonus, carbohydrates that have fiber tend to have protein, more protein when compared to a simple carbohydrate that does not have fiber.

So, that is going to be the ideal to balance blood sugars and balance appetite. So, as I mentioned, we're grabbing carb-based foods. We're hungry after a couple of hours, we're grabbing more carbs and it's this vicious cycle of never feeling fully satiated. So, fiber and protein really lead to that full feeling of, “I'm satisfied. I can go three to four hours before I need to eat something again.”

John Horton:

And diet-wise, Julia, I take it the Mediterranean diet, is that the big one that comes up? Because it seems to be the answer to just about every health question.

Julia Zumpano:

Yeah, I think the Mediterranean diet would be great from a prediabetes standpoint. I focus more on looking at the balance of macronutrients when I see someone who's prediabetic versus a style of eating. So, I really take a detailed diet history and just try to infiltrate healthy protein, healthy fat within what they're already eating and make alterations that I think are more feasible just to really target that hemoglobin A1C and really try to get it down.

So, I think the key is the meal timing and the macronutrient composition of your meals.

John Horton:

To that idea, Dr. C, I know when we were talking ahead of time, you explained it in a way that I really loved and it was this analogy of thinking of your diet like you're dating.

Dr. Peminda Cabandugama:

Yeah, that's exactly how you want to think of it. So, the best diet, to Julia's point, is the one that works for you and this is backed by the studies that we see. So, none of the diets work at two years if you also don't have exercise, we already know that. We also know that the best diet is the one that you can stick to. So, it is just like dating.

If you can find the right one and stick to it, that's where you're going to have the most amount of success. The Mediterranean diet does show the best cardiovascular benefits, but if you look at it, that's for people who have cardiovascular risk. Now, you can make the argument that prediabetics do have a high incidence of cardiovascular risk, but it doesn't mean that that's the right diet for everyone.

I'll give you a good example. The Mediterranean diet sounds great, but what if it's a night-shift workout? Are they going to be able to go out and find the flour beans and everything that's part of a Mediterranean diet? Maybe not, not at 2:00 or 3:00 in the morning. So, it has to be something that they can kind of have.

I also want to definitely mention — this is a great conversation because you can see the great work that's been done by Julia and all the other nutritionists, dietitians out there because they do the product of not just planning, but they also help educate our patients on why it's important that they have these kind of foods. And I think that is one of the keys that we have in our prediabetics, as well as weight loss, which is to make sure that they're educated on why they are going for certain foods.

So, Johns Hopkins did a study that they showed that when a baby is in a mother's stomach, in the womb, the baby tends to drink more amniotic fluid when it's sweeter because it actually hits the part of the baby's brain called the hypothalamus, which calms them down. So, all of us, when we are stressed out — we talked about choices. There's a reason we go for carbs or pastas, bread, rice, sweets because it hits that part of our brain called the hypothalamus to calm us down. So, when we see weight loss patients are prediabetics or diabetics, we explain to them why this happens, that when you're stressed out you're going to reach for these foods because automatically, you're going to reach for something that's going to calm you down by hitting those receptors in your hypothalamus to calm you down.

So, this is why we use our endocrine psychologists in our department to help them divert their minds away during times of stress so that they don't pick up these kinds of foods. So, the work that they're doing is not just helping with meal planning and everything, but also educating our patients on why they pick up certain foods and why the other option is the better option. So, I think that point needs to be stressed pretty highly at this point.

John Horton:

That's unbelievable to me that in the womb, you're already craving sugar, just what you get out of that.

Julia Zumpano:

Well, it certainly also hits — they also call it the pleasure center — so, it calms you down but also gives you that feeling of euphoria, that pleasure. So, that's another reason why it's very addicting. Your brain lights up when you have sugar. And then, when you have that, you only want to recreate that feeling and that's how sugar can get very addicting.

And another great point that Dr. C made is that there is no one-size-fits-all diet, and I think that's really important to understand. Yes, I think the Mediterranean diet is great, but really, we really need to understand how food affects us, what we're eating and how it's affecting our bodies, and how we can change what we're eating to better improve our health outcome.

So, it can be very specific to you. If there are food choices that you really like and you don't want to give up, we can certainly build those in. It's just a matter of understanding how to build them in, what time to build them in, what to combine them with and how much to eat of them. So, it's not a one-size-fits-all, it's very personalized and individualized.

And everyone even responds to different foods differently. So, for instance, I have diabetics that say they can eat some ice cream and their blood sugar's great, but they may eat a grapefruit and their blood sugar skyrockets. So, that may be against what we might think happened, but we just need to really educate and help people make better decisions and pair foods appropriately to help manage blood sugars.

John Horton:

Julia, you laid out a lot of … just the foods that, for the most part, you should be looking for. You had mentioned proteins, complex carbs, fiber, healthy fats, all of that — and here's where I'm really excited for where this conversation's going to go — it's not just about what we eat; it seems that how we eat can make a difference, too.

And I know I read one study that showed people who gobble down their food quickly are more likely to develop prediabetes. Why is that, Dr. C?

Dr. Peminda Cabandugama:

Truthfully, I think it has to do with the gut transit time. So, if you tend to actually eat the food a little bit faster, you probably don't get absorption of all the nutrients that you need. There are studies that are out there actually on the effect of exercise and how that affects your sugars right after. I think there's more work to be done on it.

But the reason why they're more likely to have prediabetes — and this is something we see a lot in healthcare people because we tend to eat faster because we need to get back to work quickly — it probably has to do with the gut transition. I'm assuming Julia probably has a little bit more information on this. But from what I've seen, it probably has to do with the transition time that food has with the intestines.

Julia Zumpano:

So, I also think another reason for that is because people are eating so quickly, they're eating so fast that they're not actually letting their stomach catch up with their brain. So, their brain's like, "I'm hungry, I'm hungry. I'm going to eat, I'm going eat." And their stomach might be like, "OK, I'm full." And their brain might be like, "No, no, I'm not. I'm still hungry."

So, they're overconsuming food, too. Another reason I think that happens is when people eat fast, they're not paying attention to how much they're eating and they're more likely to overconsume food. So, I think that could be another reason, too.

John Horton:

That makes a lot of sense. If you spend the time and you chew everything and think about what you're eating, odds are you're going to put down a little bit less and just get filled up a little quicker.

Julia Zumpano:

Another point to that, too, if you're eating with a group, with a family or friends — meaning not eating alone — you tend to eat slower, you tend to chew your food more and you're creating conversation and you tend to eat less. So, that also helps. So, if you're on your phone or watching TV, there's the mindless component of eating that you may have consumed way more than you realize. And then, at that point, your stomach hasn't caught up because you're eating so fast that finally you're like, "Oh, wow, I can't believe I just had a whole pizza," or whatever you may be consuming. So, I think it's really important, the distraction piece, because when you're distracted and eating, you tend to eat faster and more.

John Horton:

See? And that's fascinating because this seems to be getting to that whole notion that both of you were talking about earlier, which is just how lifestyle changes have helped drive people toward these prediabetes diagnoses.

Julia Zumpano:

Absolutely. There's so much that goes into play when you talk about eating habits. It's not just the food you're eating, it's how you're getting it, who you're eating it with. There's so many things that play a role, so that's why it's really important to look at the whole picture versus just one specific diet or one specific lifestyle change really is a holistic approach.

Dr. Peminda Cabandugama:

Yeah, it definitely, again, plays into that concept of being multifactorial. Like Julia mentioned, there's so many things that go into lifestyle changes, whether it's diet or exercise, which, let's all be clear, that is the bedrock of everything that we do for chronic disease management. You can read absolutely any algorithm that you see for any chronic disease.

Again, diabetes, high blood pressure, weight loss, it always starts with diet and exercise, but there's so many factors that play into diet and exercise itself where, truthfully, just part of it is the actual component of what you're eating. It's timing of meals, it's ability to get foods, the stress levels. Some people eat more to sleep.

There's so many concepts that play a role in diet and exercise that it would be very simplistic to say it's more just the food choices when there's so many factors that play a role into what goes into diet and exercise.

Julia Zumpano:

Yes, even just stress creates so many different eating behaviors, too. Like you mentioned, what you're eating, how often you're eating, just calming that stress down, again, hitting that pleasure center in the brain. So, there's so many factors for sure.

John Horton:

Now, another habit to bring up, I read that people who skip breakfast are also more likely to possibly develop prediabetes. How would skipping that first meal cause a problem, Julia?

Julia Zumpano:

So, I think if you're skipping a meal and allowing yourself to get too hungry — so when you don't eat, your blood sugar drops. And then, when you're getting that low blood sugar, maybe that jittery feeling if that would happen, you just then want something to eat immediately.

And you might grab whatever is available and most likely, it's going to be carbohydrate or sugar-laden, and then, that may cause you to overconsume that food because you're starving and you're just frantically eating to get that feeling to go away. So, I think that's where it can lead to poor outcomes when it comes to managing blood sugars.

If it's done routinely like you're practicing ... I think first of all, you shouldn't skip meals at all. The only time I recommend maybe skipping a meal or creating a shorter window of eating would be when I suggest intermittent fasting in the form of time-restricted eating, and that could be where you're eating more of a smaller window anywhere between an eight to 12-hour window.

So, it's very controlled. The goal is really to minimize how much we eat after dinner and minimize snacking and lump all of our food into a shorter window and create balance within the meals that you are consuming within that window. But skipping meals in general does not ever lead to a positive outcome.

Most of the time if I see patients skipping breakfast or lunch, they're overconsuming in another meal or they're mindlessly snacking in the middle of the day just to make up for what they lost. So, that's where I could see that skipping meals and breakfast could create a problem.

John Horton:

And since we're on this topic of eating behaviors, I want to spend a moment on a tidbit that Dr. C shared with us ahead of time, and this is one of those things that you learn it and it just sticks with you, and it really wowed me. And it had to do with when we eat out in restaurants and the pattern in which they bring you certain foods. So, Dr. C, I'll let you take it from there.

Dr. Peminda Cabandugama:

Yeah. So, to lay the background of what this is, and again, I think the importance of understanding why we have the behaviors that we do. So, there are studies done out of Harvard that showed that one of our eating hormones, which is a hormone called ghrelin, and then one of our other eating hormones called leptin, which is our satiety hormone, they actually respond to different foods in different ways.

So, carbohydrates versus proteins, again, to Julia's point. The studies showed that with carbohydrates, the level of hunger will actually go up within one hour of having a carbohydrate, as opposed to when you have proteins, your hunger tends to be satiated a lot longer, which is about four to six hours. So, putting this background in the back of your head, think about the concept of when you go out to eat.

So, if you go to a Mexican place, you'll get the free chips. If you go to an Italian place, you'll get the free bread. If I ask most of my patients why they get that free stuff, the answer that they mostly give you is that they want to fill you up. And I tell them, "Do you really think that they're trying to give you free food to fill you up? They obviously want to make money from you. That's how a business works."

So, the concept behind it is that we go out to eat … as soon as we sit down, we all love the free bread and free chips. I can tell you my wife and I, all the time, we would go to Cheesecake Factory, we love the free bread. We eat it straight away, our sugar spikes up. And like I said, carbohydrates, the sugar spikes up and one hour later, there's a spike down, which makes us a little bit hungry again.

So, think about a typical meal. We have the bread or chips, our sugar spikes up. We have a meal. A typical meal with friends and family takes roughly about an hour. And just when that spike drops at the end of your meal, what do you do? You look across the table to whoever you are with and then you're like, "Hey, do you want to share dessert?"

And that is that little drop that makes us think that even though we are full, we still want to have a little bit of dessert. And that's how the companies make their money because you're going to order dessert. If they gave you, let's say, small pieces of steak or something right at the start of your meal, you probably would not even finish your whole meal because you would feel full because those pieces of protein will sit in your stomach for four to six hours and keep you full.

And so, there's a reason why, even when we go out to eat, there's certain reasons why these foods are there for us even when they're free foods. So, again, it's the concept of understanding why we eat the way we do and then making some good choices.

Julia Zumpano:

I have one thing to add on that, Dr. C. That's such a great point, such an amazing point. Even just looking at cuisine, when you go to an Asian-style restaurant, what you're served before may be a broth-based soup with vegetables and a little bit of protein. It might be something like edamame. So, think about that.

Think about how that manages and stabilizes your hunger and how you feel differently when you're eating lighter versus heavier and how your blood sugar's not all over the place. So, I think that's a great point to note, and it's also great to recognize which certain foods are causing those spikes in blood sugar and the timing that that occurs so you can plan ahead. Knowledge is power.

That doesn't mean you can never have breadsticks at a restaurant or order dessert, but you may minimize how many breadsticks you eat or you may realize that you don't need dessert as often. So, it's just knowledge is really power when it comes to food choices and food behaviors.

John Horton:

With everything we've just covered, I feel like for a lot of us, we need to relearn how to eat.

Dr. Peminda Cabandugama:

Yeah. Again, I think it's relearning how we eat with the understanding of why things are happening. Now, I think Julia brought up a very good point. Nobody here is, I don't think, condoning that you give up eating anything. I tell my patients, "I'll never tell you to stop eating chocolate cake because if you do, all you think about is eating chocolate cake."

And also, if you go to a birthday party or Christmas party or something, nobody likes the person who's on a diet. So, we're not trying to make people miserable here, but it's to have that understanding of why you eat the way you do, why you make the choices that you do, and then, have that awareness so that the in-between days when you're doing the same leftovers for a while or if you notice you're having cake every day of the week for five days, those are the choices that we are making you understand. That if something is stressing you out to the point that you are eating dessert every day, five days in a row, understanding why that is happening and then, making the right choices so that you prevent things like — to take us back to our original point — prevent things like prediabetes and diabetes and high blood pressure by just understanding how nutrition plays a role, but how your thoughts and ideas about nutrition plays a role in preventing disease.

John Horton:

Moderation is always what Julia has brought up time and time and time again on this podcast.

Julia Zumpano:

Yeah, deprivation is not our goal, by any means. Food gives us pleasure and joy and it's a great way to create, building relationships and routines and traditions. So, there's so much embedded around the way we eat and what we eat, but it's when it gets out of hand, like Dr. C said. Why are you eating cake every day? Let's understand why this is happening, why you're craving it, what's happening in your body that you're needing this. Let's figure this out because that should be not an everyday food, but a special occasion type food. So, we want to be able to create some of those foods that you can still have on special occasions, but we want you to understand what it does to your body and be able to prepare for that.

And also know that ... set boundaries on some of these foods we know that aren't safe to consume every day. But there's no food that we would ever say you can't ever consume. It's just a matter of understanding what it does.

John Horton:

So, Julia, let me ask you this. How do you put that safeguard in place? I think we all have stress foods that we lean on. You mentioned if you're having a tough day, whatever else, you might grab that ice cream. What things should you do or what sort of mental conversation should you have when you find yourself in that position to maybe avoid making that same kind of not healthy decision three, four, five days in a row?

Julia Zumpano:

So, the first thing I educate on is trying not to have those trigger foods in the house. So, if Hershey's® chocolate bars are a trigger, then don't have chocolate bars in your house. Try to not have that be readily available so when that stress occurs, you're automatically grabbing it. So, that would be one thing. And trying to create a healthy alternative that won't create such a trigger.

So, like ice cream. So, ice cream in a pint is sometimes hard to control and you may be overconsuming it, trying to eat the whole thing till you're feeling stressed. So, trying to find things in small portions like maybe an ice cream bar that's a single portion or individualized pre-wrapped chocolate. So, something that's a little bit more controlled so you can have a little bit more of a stopping point. So, the portion is controlled, so it creates a natural form of stopping for you.

The other thing is, well, let's look at what's causing you to want to eat that food. So, it's the stress. So, what are we doing to manage stress other than eating food? Are we doing anything else to manage stress? Are we trying to do any meditation? Are we getting enough sleep, blood sugars?

We had a podcast on stress and anxiety, and food can affect your stress level and anxiety level. So, what are you eating the rest of the day that could be causing you to trigger and want to eat this pint of ice cream or chocolate cake? So, it's really managing the root cause of what you're feeling so we can help control that feeling, minimize it, therefore, we'll minimize the behavior.

Dr. Peminda Cabandugama:

Yeah, absolutely. And I just wanted to jump on that. So, Julia brings up some excellent points. Just wanted to jump on a couple of them. One of them is we talked about celebration foods. So, when we were all ... I don't want to date any of you, but let's just say when I was a lot younger, birthday cakes were a big deal. You go to a bakery, you get your name on the cake. Now, if you want to, you could have birthday cake for breakfast. So, just the availability of everything, you're not going to be able to stop that. What you can stop is having it in the house if you don't need it. So, we talked about leftovers. If you do have a birthday party or something and there's leftover cake, yeah, share it with your neighbors. It doesn't have to be in your house for multiple days.

The other thing — I really like the point that Julia brought up about alternatives. And depending on which part of the country you're in, I know some people call it soda and some people call it pop. Hopefully, there's no big argument about this. But when I do talk to my patients about this, that's one of the biggest things we encourage our patients to stop, soda/pop.

And there's a simple way that even our patients can do this. It's the same way I do it with my patients. I ask them, "So, what do you like? Do you like the carbonation or do you like the flavor?" For those of them who say they like the carbonation, I tell them, "OK, consider investing in something like a SodaStream® machine. Get water, make your own bubbles and that can be like your seltzer."

If they say it's the flavor, then I tell them, "OK, look at flavor alternatives, zero calorie, natural flavor alternatives and put that in your water and drink that." And believe it or not, that allows a lot of patients to actually get off soda/pop.

So, there's a lot of alternatives that, again, if you have the mindfulness to think like, "OK, I like this because I like the carbonation or I like this because I like the flavor." The patients themselves can actually decide, "OK, this is what I am looking for, so this is what I'm going to do, but in a healthier alternative."

John Horton:

And I love everything you guys have brought up because it's a matter of really thinking through what you're eating, how you're eating — just all of those sorts of behaviors — and then, making adjustments so that you're in a good position when you get hungry.

Julia Zumpano:

Yeah, I couldn't agree more about the alternatives because I think that's really where a registered dietitian can come into play because we have endless alternatives. We ask those same questions. What is causing you to want this food? Is it the taste? Is it the texture? Is the flavor? So, we really try to come up with what's causing you to want it and how we can create a healthier alternative. So, I think meeting with a registered dietitian is key here.

John Horton:

I want to make a big pivot right here and talk about weight loss medications, which seem to be grabbing just a lot of headlines these days in part because they've been extremely effective for anyone who's taken them. On the surface, this seems like really good news when it comes to combating prediabetes. But Dr. C, I know you said you have some worries about the long-term picture. Can you explain that?

Dr. Peminda Cabandugama:

I do have to start off by saying I think weight loss medications have ... I mean, they're calling them the game-changer and that is the name for them, truthfully, for a multitude of reasons. And I would just like to highlight a few of them. One of them is this proves the whole idea that if you eat less and move more, you're going to lose weight.

We've been saying this for many years. I know when I first started training in weight loss, that's what was told to me. But these medications have proven that there's so many factors that go into losing weight and preventing chronic diseases like obesity and diabetes and prediabetes, high blood pressure. It shows the role of peptides, it shows the role of hormones, and it really shows that it's not as simple as “eat less and move more.”

The second thing is the understanding — especially among the medical community and now spreading out more toward the lay community also — is that these medications, just like weight loss surgery, just like weight loss devices, are just a tool that we add on to the bedrock that is that an exercise. So, these medications by themselves — John brought up the fact that I have concerns about this — I've spoken publicly on multiple news articles, news outlets about this. My concern is that two years from now, there's going to be a deluge of articles that's going to say that these medications do not work. Unfortunately, that's because there's a lot of these medications currently being given out from online clinics on different social media where they just pretty much roll out the medication to the patient and don't have the diet and exercise and everything else that goes into it.

To Julia's point, here at the Cleveland Clinic, we make sure that we have multidisciplinary clinics for all our weight loss patients. So, all our weight loss patients are offered the option of seeing a dietitian/nutritionist. All our weight-loss patients, prediabetics, diabetics, weight-loss patients, are offered the option of exercise physiologists who are trainers.

All of our weight-loss patients are offered the option of endocrine psychologists if it is due to eating disorders or eating indiscretions, mindful eating indiscretions that are affecting their food before we talk to them about medications or devices or procedures. And that is how things should be working. It should be a multidisciplinary approach to make sure that these patients not just lose weight, not just prevent diabetes, not just prevent high blood pressure, prediabetes, high cholesterol, but they should be able to sustain their successes.

So, it's not just about getting to a goal of losing weight, but then, being able to sustain it, and that is what you need long term. If not, again, the studies clearly showed it, even with weight loss surgery, it'll take two years for the patients to gain the weight back if we just throw a medication at them or send them for procedures without the diet and exercise component behind it.

So, my concern is, to John's point, two years from now, we will be starting to hear more things about how these medications do not work, but in reality, it was probably because we fail these patients in not providing them all the resources that they need to not only be successful but stay successful.

John Horton:

It's not just about losing the pounds, it's about building good, healthy, long-lasting habits.

Julia Zumpano:

I couldn't agree more. I think when you're on these weight loss medications, you see a decrease in appetite, obviously, and you have a little bit more ability to control what you're eating. So, I think we can really harness that opportunity of this control by educating on what you're eating and then building good habits.

When you don't have that noise, constant noise in your head telling you to eat something, it's easier to build better habits. It's easier to make better choices. So, I think it's a great opportunity to step in and really educate versus just allowing the drug to create the weight loss.

But really educating on meal timing, meal composition, good eating habits, and then, being able to create that as a habit so when the medication may not work or decreases its effectiveness, then you can fall back on the nutrition component, which will really continue the rate of weight loss as well as really improve overall health.

John Horton:

Let's do a little of that educating right now, Julia, because as we emphasized at the start of this podcast, prediabetes is not a permanent diagnosis. It's very much reversible. So, if someone is in that spot right now, what's the best thing they can do to get their blood sugar under control? And Julia, why don't you get us started with this with some tips?

Julia Zumpano:

Well, I think it would be really looking at the composition of what they're eating. So, looking at sugars first and foremost and complex ... sorry, simple carbohydrates. So, sugar and simple carbohydrates. Really looking at how much of those foods they're consuming and looking for alternatives to those would be my number one step.

And then, secondly, looking at the composition of the meals. Are you getting enough protein and fiber with each meal?

John Horton:

Dr. Dr C? Yeah, I was going to say, do you have any wisdom to add on top of that?

Dr. Peminda Cabandugama:

If you talk to an endocrinologist, nutritionist, dietitian, any medical doctor 40, 50 years ago and told them that we can reverse these diseases, we can reverse Type 2 diabetes, we can reverse prediabetes, we can reverse sleep apnea … these chronic diseases can now be reversed by actually making healthy choices just with weight loss. That is astounding, and we're not just using these words.

It's not often that you hear that you can cure diseases, but we have the Swedish study that initially showed that helping patients with weight loss, with diet, exercise and other procedures, devices, medications, can actually cure Type 2 diabetes, which prediabetes is a part of. The original study here out of the United States at the VA showed that weight loss can cure sleep apnea. That itself is astounding.

So, to the point that Julia had, I think the tips for this is knowing that whatever facet of weight loss or chronic disease management that you use, the fact that you have the bedrock, again, of diet and exercise in place and making sure that you're hitting your goals, whether it's metabolic goals, whether it's weight loss goals, but also sustaining it with building up healthy lifestyle choices.

And we talked about diet a lot, but even exercise because as you lose the weight and you feel better, you will move more and be able to show this to our patients in their labs also. That's going to be the key to make sure that long-term, you can not only reverse these chronic conditions, but you can also prevent them from coming back by getting yourself into a position to be successful in the long run.

John Horton:

You've both given our listeners just a great place to start to take control of their health. So, before we say goodbye though and head our separate ways, is there anything else you'd like to add regarding prediabetes?

Julia Zumpano:

One thing I'd like to add is just understanding that you can completely take ownership of the situation. So, as we mentioned, prediabetes is reversible and you can really take ownership to reverse it. So, it may seem daunting, but small, gradual lifestyle changes will make a huge impact. So, utilize your healthcare team if you need any health or support. The Cleveland Clinic website has a ton of great resources and articles, but really, you are in the driver's seat here.

Dr. Peminda Cabandugama:

Yeah, and I'd like to add that one thing that I mentioned, like I said, we talked about diet and exercise. To lose weight, we cut down on what we eat. That's what the studies have shown. To maintain weight loss, it's exercise. So, I just want to make a small plug for the exercise guidelines, which is 150 minutes a week of exercise, aerobic exercise a week. It can be split however you want to. It does not have to be half an hour, five days a week. Again, tailor it to your lifestyle. If you only have two days a week, you can do one and a half hours on Saturday and Sunday to hit your goals. If you have three days a week, you can do one hour, but make sure you're hitting those goals.

Again, Julia mentioned this over at the Subspecialty Medical Institute at the Cleveland Clinic where I work, there's multiple great programs in place to make sure that we help people with our nutritionists and dietitians in terms of healthy eating. We also have places like the Langston Hughes gyms, which is available for our community so that they can exercise.

So, especially for our minority populations and everyone at large, we have so many options that will help make this transition easier. To Julia's point, it's about ownership, but we are always there also to help guide you through everything. Cleveland Clinic also offers body composition for those of you who want to monitor your body composition. So, plenty of options out there that if you come to us and say, "Hey, you know what? I'm ready to now take control of this." We are more than happy to help you.

And also do not have a fear of failure. Just like any chronic disease, weight, diabetes, high blood pressure, they can come and go as long as you have the understanding that all of these are chronic conditions and all of these can be helped when they raise their head, but then you can go back down when they're back to normal. But if it raises their head again, that we are always there to help you and help make sure that we set you up for success in the long run, because that is the goal here, success in the long run.

John Horton:

That's a perfect note to end on, Dr. C. So, thank you very much to both of you for your time today, and this was just a fascinating discussion. Thank you.

Julia Zumpano:

Thanks, John.

Dr. Peminda Cabandugama:

Thank you for having us. Thank you.

John Horton:

If you've been diagnosed with prediabetes, consider it an opportunity to make changes and improve your health before larger problems set in. View it as a second chance that isn't offered by many life-changing conditions.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Till next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.