 Welcome to Much More on Medicine. I'm your host, Catherine Noor. Do you have diabetes or pre-diabetes? Well, if you do, stay tuned to learn how you can improve your diabetes. Much More on Medicine is an opportunity to learn about all aspects of healthcare. I talk with guests about medical and alternative care treatment, insurance, medication, surgery, rehabilitation, prevention, and Much More. Today I'm talking with licensed registered dietician, Jennifer Papastofano. Jennifer is a certified diabetes care and education specialist and is passionate about diabetes care and improving the lives of those with diabetes through education and technology. She earned a master's degree in foods and nutrition from the University of Utah. She has a private practice in Lutherville, Maryland, where she focuses mostly on diabetes management. Welcome, Jennifer. Hello, Catherine. It's great to have you here, and I understand that you used to live in Hawaii. I did, and that is how we met. How many years ago? It's like half a lifetime literally ago that I was in Hawaii. Absolutely. Yeah, and since then you've become a dietician. Tell us a little bit about what you do every day. So as a certified diabetes care and education specialist, I work with patients at all levels of diabetes, whether it be pre-diabetes or they're first diagnosed with diabetes or have advanced diabetes or they're using multiple daily injections of insulin. And I've been doing this for 18 years. When I lived in Hawaii, I worked in insurance as you remember. And one of the things I started to realize was a lot of the people injured in car accidents who had diabetes didn't recover as quickly as everybody else did. So that sort of got me interested. At the same time, I was interested in nutrition and found that I could get a degree in nutrition and eventually become what used to be called literally a month ago was certified diabetes educator. The rebranding just happened about four weeks ago. So now I'm called a certified diabetes care and education specialist. It's a lot of words. And you actually went to my alma mater, which was University of Utah. Yeah. And so what is diabetes? I know some people, they hear it, but maybe they don't really know exactly what that is. So there are three major kinds of diabetes. The first one, we're not really going to talk too much about it, which is gestational diabetes. And that's for pregnant women. And generally, what diabetes is, is you have glucose or sugar in your blood that doesn't filter into your cells properly. And the reason we need sugar in ourselves is because that's how we get our energy. And so when we don't have sugar getting into ourselves, the sugar that remains in the bloodstream is very damaging to what's called the microvascular system. So having high blood sugars for long periods of time literally damages every organ in your body because it's running through your blood. And so I always say that, you know, if you want to think of diabetes on a very fundamental level, one of the roles of our red blood cells is to carry oxygen around the body. So if you have high blood sugars, you have literally sticky blood and the oxygen isn't able to get to the very tiny spaces throughout our body, like the backs of our eyes or kidneys or fingertips or toes. And so these areas slowly get suffocated. And when you've talked to somebody who's had uncontrolled diabetes for long periods of time, you find out that these areas are the ones that are affected. You know, I think one of the scariest things would be to go blind from uncontrolled diabetes, for example. So there are, as I said, three types of diabetes, gestational pregnancy, then there's type one diabetes. Type one diabetes is an autoimmune disease, your body attacks itself. And these patients will typically immediately go on insulin. There is no oral medication that can help them. And then finally, there's type two diabetes, which is the after step of pre-diabetes. They really are the same thing at a different level, where you start to show some dysfunction and glucose processing. And type two diabetes is a progressive disease. So really what I do is I try to slow down the progression. And in fact, I can, in some cases, reverse the diabetes, but it has to be a permanent lifestyle change for the patients. Okay. And you mentioned the possibility of going blind. I've also heard of diabetic neuropathy. Can you? Yes. Is that where they can't feel their feet or something? Yeah, I mean, some people have numbness in their fingers as well. But numbness in their feet is usually, people will tell you at first, they feel like they have socks on and they don't. Sometimes they have burning in their feet. It's very uncomfortable. But again, this is a progression from poor circulation due to diabetes mismanagement. Okay. And how does someone know to get tested to see if they have diabetes? What kind of symptoms would they have? Well, generally speaking, your doctors should be at your annual physical screening you for diabetes. And they always do a glucose test. Generally, over the age of 45, they should be doing what's called a hemoglobin A1C, or we'll just say A1C for short. And what a hemoglobin A1C is, it's a three month average of blood sugar. The reason it's a three month average is our red blood cells live for three months. And then we get a whole new set of red blood cells. And A1C is a marker on these red blood cells that show how much sugar has been stuck there for the past three months. So that's why we'll have this test on every three months on our patients. If the A1C is above 6.5%, then that is a diagnosis of diabetes. If the fasting glucose is at 126 or higher on a repeated test, that is a diagnosis of diabetes. And if you do a random test, whether you're fasting or not, or you just ate, and it's over 200, then you in fact do have diabetes. Pre-diabetes is the other factor. Do you want me to continue? Sure. Pre-diabetes is just a step below that. So normal fasting glucose is 99 and lower. Pre-diabetes would be 100 to 125. And the pre-diabetes A1C would be 5.7% to 6.4%. So there are quite a few people out there with pre-diabetes thinking they're still safe. But really, in fact, that's just a step below diabetes. And if you don't work on that quickly, within five years, the patient will have over diabetes. And the chances of reversing it go down the longer the diabetes has not been managed. At what point do you come in and help and work with the patient? So, you know, that's a great question. And I have to say it really depends on the practice group that you work with. I'm in a large patient-centered medical home building where there are about 30 physicians. They all know I'm there. So when their patients have high blood sugars, they give them my number or they give them the number of several diabetes educators in the area. And it's really up to the patient to come and make that phone call. Unfortunately, what I see is a lot of people think, well, if I just cut back on my food, I'll be fine. And it's not that easy. It really does really behoove you to spend that time with a diabetes educator. Because we do have a little bit more knowledge on how to balance the diets and the lifestyle in order to improve it, as well as manage medications. Okay. So you work with them at the pre-diabetic or a diabetic stage to discuss their diet, correct? Diet, lifestyle, medications. I'll talk to them about their sleep, all of the factors that go into insulin resistance, which is what type two diabetes is. Okay. What we hear a lot when we talk about diet these days is carbohydrates. And let me ask you, do carbs play a role with diabetes? Absolutely. So carbs are the main nutrient that turn into sugar in our bloodstream. And so this is a wonderful graphic showing the types of carbohydrates. And I think just about everybody with diabetes knows that starches are carbohydrates. I mean, that's pretty common knowledge. Everybody knows bread and pasta and potatoes. A lot of people are not aware, however, that beans, even though beans are very healthy for us, things like chickpeas, black beans, these are also a significant source of carbohydrate, corn and peas. So these are other things that we eat that turn into sugar in our blood. And you might be thinking, oh my gosh, those are healthy foods. Of course they are. That's not that we can eat these. The problem with type two diabetes is that you don't filter glucose out of your bloodstream fast enough. So we have to work on how much shows up at one time and then refuel again later when your body has had a chance to absorb the sugar. So it's not a matter of that this food is bad or not. It really is a matter of how much can your body handle at one time. Okay. So carbs are not the enemy. They just need to be controlled, right? Correct. Control portion control and timing is a huge factor. And generally speaking, I like to start my patients. If they're women, I like to start them on 30 grams to 45 grams of carb and men at 45 to 60 grams of carbohydrate at each meal. So that number at breakfast, not that number at lunch and that number at dinner. So at each meal and then a snack for somebody who's not on insulin injections could be about 15 to 30 grams of carbohydrate. Okay. What about that person who says, I don't eat breakfast. I don't eat lunch. I only dinner. Is that a problem? It is a problem. And I'm glad you brought that up. You know, I get a lot of, typically it'll be a male client who's a contractor and or he drives a truck or something like that all day where they really just don't want to stop and eat. And what happens is when you eat all of that food, you know, their meal is not going to be a normal sized meal when you haven't eaten all day. They eat this mass quantity of food and all that carbohydrate, all that glucose gets stuck in their bloodstream and causes extremely high blood sugars. Now you're thinking, well, what about the other, you know, 23 hours when they're not eating much? What happens is our bodies are brilliant. The main reason we need glucose is to keep our brain supplied with a source of sugar. And if we don't eat, our liver has the ability to actually crank out sugar for us. It's our backup plan, I call it. So you end up with this dysfunction where your liver is cranking out sugar frantically, you don't make enough insulin or you don't use your insulin correctly. So you can't get your cells open to get the sugar in the cell. So there's this dysfunction that the liver is now an overdrive. And so just by backing up and eating three small meals at least a day, you can certainly balance your blood sugars out much better than one, what I call the bear kill meal where you have this massive meal at the end of the day. Okay. And one thing that we might not think about when we're drinking five cans of soda a day or whatever, or coffee or whatever, what about liquid calories? Absolutely. So, you know, most of my type two patients will have a weight problem. Most of my prediabetes patients will have a weight problem. And one of the easiest things you can do to correct that is stop drinking calories. One of my biggest selling points to patients that are addicted to sodas is I tell them, look, if you cut out one can of soda per day, you'll lose about 14 pounds in a year. So a lot of those, these people are going, you know, getting these big gold sized drinks, filling them up, and they say, well, I drink them all day. But, you know, think about that if you can switch to something with zero calories, you're going to lose significant amount of weight and weight is something we can all see it's tangible, we can feel it. So that's something that the buy-in is really good for patients, whereas like these blood sugar things, if you're not testing your blood sugar, it's much harder to get compliance that way. But the liquid calories, we generally have patients that have low blood sugars, we have them drink liquid calories like juice, soda, anything like that, because it brings their blood sugar up so quickly and it doesn't take a lot. So why would you do that if you have prediabetes or diabetes? Why would you drink something that would bring your blood sugar up quickly? You're actually trying to not do that. So that's my advice on liquid calories. Sure. And of course, water. Yeah, I'm sure that people will say, I don't like water. Do you hear that sometimes? Oh, I don't like the taste of water. That's shocking to me. Why does your water have a taste? And I hate to say we need to grow up a little bit and do it anyway, because it is really one of the most important things we do is to hydrate ourselves. Years ago when I was getting my master's degree, I actually was going to do a research project on hydration and metabolism. There was a pilot study done at the University of Utah, but unfortunately, I would have had to wait another year and a half to graduate because the lab wasn't finished yet, but they did do a subsequent research project and found that hydration certainly helps your metabolism. So who wouldn't want to help their metabolism, right? We all need a little more metabolism. So water is definitely one of those essential pieces to get health. It dilutes your blood sugar if you have a high blood sugar. And of course, it helps with so many other things in the body. Sure. Well, I love to drink water and I quit soda. I think I was in my 20s when I quit soda and have been happy ever since that I quit. But you know, sometimes you want some other drinks. When we come back from the break, we can talk about other drinks like coffee and alcohol. But at this time, we're going to take a short break. I'm Katharine Nora. This is Much More on Medicine on the Think Tech live streaming network series. We're talking with Jennifer Papastofano and on five things you can do to improve your diabetes. Physical therapy specialist and the host of Movement Matters. My show is designed to teach you the simplest and most effective treatment strategies to get you out of pain and back to doing what you love. If you or someone you know is having pain in a certain area of the body, it would like a free assessment in treatment over media or in person. And then come on the show to talk about it. Email us at thinktechmovementmatters at gmail.com. Or if you have a topic you would like to know more about, please email us. My goal is to decrease pain all over the world, inspiring people to take better care of their bodies to enjoy life to the fullest. I look forward to hearing from you. We're back. We're live. I'm Katharine Nora and this is Much More on Medicine on the Think Tech live streaming network series. And we're talking with Jennifer Papastofano on five things you can do to improve your diabetes. Jennifer, before the break, we talked about liquid calories. Let me just ask you, what about alcohol? Can you drink alcohol if you're diabetic? Yeah. So I want to say first that alcohol and insulin are a dangerous mix. So contrary to popular belief, a lot of alcohols can drop your blood sugar. And that's usually a very big shocker for people. The problem with, you know, and don't think, hey, I'm going to manage my diabetes with alcohol, because that's a really bad idea. The problem is we don't know when your blood sugar is going to drop and your blood sugar will drop quickly. What makes your blood sugar go back up, I had mentioned, is your liver, right? So if your liver is busy fighting off alcohol, sometimes your blood sugar doesn't go back up. And this is when, especially young people that are drinking in college and they're on insulin, it's very dangerous. And they can actually, I've known a couple of people, unfortunately, have died from this. So alcohol and insulin is a dangerous game. I would say if you're going to have a drink, make sure you eat something with it. And it's just such a bad idea to have more than one drink if you're a woman or two small drinks if you're a man. And you do need to monitor your blood sugar frequently after you've had some drinks, because it can, in fact, randomly drop your blood sugar. For people on oral medications, it's generally safer. But again, you want to be reasonable about alcohol, not only because of the calories, but because we don't know when your blood sugar is going to drop and it could have a side effect that you're not, that's not expected. Okay. And what about coffee? Oh, I will defend coffee to my grave. It is one of my favorite things. You know, if you said Jennifer, alcohol or coffee, I'd be coffee all the way. The problem with, I mean, I love coffee, and I don't drink too much, but I have a cup or two a day. But the problem with coffee is Starbucks has evolved. The problem and the good thing about coffee, I should say, is Starbucks has evolved. And Starbucks, as wonderful it is, some of these these drinks there are five and 600 calories. I think last time I looked at the Carmel Macchiato, and I don't speak Starbucks fluently, but it was like a venti, something like that. It was five or 600 calories. And I thought, Oh my gosh, that's like more than a meal. So if you're really trying to slim down, really look at Starbucks and how it's affecting you, you can get some of their sugar-free syrups that would cut significantly down on the calories. You can put some low fat or skin milk in there that would significantly cut down on the calories. But really think about that. If you're addicted to Starbucks, you may need an intervention and you need to cut back and just stick with the coffee milk and some stevia and save yourself the problems that occur with too much Starbucks. My friends will laugh because my favorite drink is grande non-fat, no whip, no foam, extra hot, hot chocolate. And I will defend that till my death. But as long as it's not every day, Catherine, and you zoom all that off. So you'll there you go. You got it, man. So, okay, you mentioned that you lived in Hawaii for a while. And do we have a problem with diabetes in Hawaii? Yeah. So prior to our interview today, I actually succused me for looking away. I'm reading some shocking statistics that I printed off just because I was curious, what is the prevalence of diabetes in Hawaii? So this is the burden of diabetes in Hawaii is from the American Diabetes Association. And this is approximately 154,365 people in Hawaii, which is 13.1% of the adult population has diabetes. Let that sink in for a minute. It means more than one in 10 people that you know have diabetes. The cost to Hawaii is $1.5 billion per year. There are an estimated 41.5% of the population has what's called prediabetes. So it's that little step below. They're almost there. They have prediabetes. So can you imagine the cost in healthcare, just to the state of Hawaii? I was looking at like what the national burden is. And I found that one out of every seven healthcare dollars is paid for, paying for, excuse me, paying for diabetes. And the other thing was 67% of all of diabetes care is paid for by government based insurance, meaning Medicare or Medicaid. So, you know, if you want the cost of healthcare to go down, we really have to start taking care of ourselves. I mean, it is an amazing burden on society. And you know, we talk about the cost of drugs, the cost of insurance. And honestly, if you look at the cost of diabetes, it's magnificent how much of a problem it is in the United States. Wow, those are shocking. And if we just can make some good decisions ourselves, we can make a big dent in that, is that right? Absolutely, absolutely. So, okay, let's move on to non diet things. Is sleep a factor in diabetes? Yes. So, you know, when people come to see me, they expect to just talk about food. And I start asking them, so what time do you go to bed? What time do you get up? Do you sleep well? How many times a night do you get up? And they're always like, what the heck is she asking me this for? Like, it's getting kind of weird. But sleep apnea is a significant problem. And I would say probably out of 10 patients that I see, eight of them have sleep apnea. It's a shocking statistic again. And sleep apnea is when you stop breathing when you sleep. And that can be life threatening. And so if you have a snoring problem or your spouse says you don't do because you probably don't hear yourself, you should certainly get that tested. And the testing now is great because you can actually take it home and sleep in your own bed, which is easier than having people watch you. And then you bring the machine back to your pulmonologist and they can evaluate your data and let you know if you have sleep apnea. So sleep apnea certainly in sleep deprivation certainly contributes to insulin resistance. Remembering that that means that you don't filter glucose out of your bloodstream fast enough. And so getting significant and adequate sleep is important. And most of us, I think, sleep less than five hours, which is unbelievable. And a minimum of six hours is needed for benefits for health. And every time I read about weight loss, I read that you do much better with weight loss if you're actually sleeping eight hours rather than much lesser period. Absolutely. Correct. So when we sleep, we produce something called growth hormone, which when you were little, we all got bigger when we were little. Now we repair our bodies. So growth hormone is a significantly important part of our sleep that if you're not sleeping well, then you aren't getting that repair. One of the shocking things that's coming out now is that sleep deprivation is actually being linked to Alzheimer's and dementia. And as we're living longer, this is becoming a bigger problem. I've known many, many friends who have parents that have Alzheimer's and dementia. And they're thinking that when you don't sleep, the toxins and all the buildup in your brain doesn't get removed. And so it's sort of like your brain takes out the trash when you're sleeping. So not only is it for our physical health, sleep can reduce cravings in the afternoon. It helps repair your body. But the brain health is extremely important. And of course, lack of sleep contributes to insulin resistance and that snack attack that we all get at three o'clock if we haven't slept well. Sure, absolutely. Okay. So when I go to, as you know, I like to do Zumba. And when I go to Zumba, I see people of all different sizes and ability levels. I see people that are very large and people that are very small and muscular or fit. And I get the impression that some of those people are being told that they need to move in order to become more healthy. Is that true with diabetes as well? Yes, absolutely. So if you ask me, what's the antidote to insulin resistance? So remember that your cells have kind of closed off when you have type two diabetes and you need to reopen them so the sugar gets out of the bloodstream and gets in the cells. The best way to get those cells open is activity, movement, exercise, whatever you want to call it. It's get up and move more than you're doing right now. And, you know, I have patients that telling them to exercise for an hour, it's out of the question. They won't be able to do it. They have this sense of failure. I also think as Americans, we overcomplicate activity. We have to wear the right shoes. They're white, right outfits. You know, you've been wearing those shoes all day, just go out and walk for five minutes. And that's what I tell people, you know, 10, five minute walks is great. Go ahead and do that. Has to be above and beyond what we're doing now. And what that does again is it opens up your cells. It is the antidote to insulin resistance. And it's one of the hardest things to get people to do. Remember, exercise and activity never has to be heroic amounts of anything. It just has to be activity. And one of the things I loved about Hawaii was that the Asian culture taught me a lot about just lifestyle. I don't think I ever lived next to an Asian neighbor that wasn't sweeping cleaning, doing something active all the time. And I really admired that actually. Sure. Well, I prefer to use my two legs rather than my car to do things. And I prefer to walk to the store or walk to the movie theater or walk to work instead of or walk to Starbucks and have something horrid or wonderful actually. So I'm going to ask you, what about vegetarianism or veganism? Is that a good thing for diabetes? I think vegetarian actually works fine. If you're eating eggs and some people consider vegetarians also to eat fish, pescatarian, they're called. And dairy products, that works out very well. If you're going to be a vegan, however, your diet predominantly is carbohydrates and some vegetables, which are lower doses of carbohydrates. It is a very difficult thing to manage diabetes as a vegan, but it's not to be said. It can't be done. I just feel like that's going to accelerate the insulin burnout. I hate to say that to people. I know I'm offending somebody out there, but I do currently have a client like that. And it's going to be very challenging for her to eat the amount that she needs to eat in order to control her blood sugars. Okay. Well, we've learned so much today, Jennifer. Thank you so much. We've learned about what you can eat and what you shouldn't eat and also that you should increase your movement and increase your sleep. So we're out of time and we'll have to wrap it up. I'm Katharine Norr. This is much more on medicine on the ThinkTech Livestreaming Network series. We've been talking with Jennifer Papastafano on five things you can do to improve your diabetes. Thank you for joining us today. Thank you to our broadcast engineer and to Jay Fidele, our excited producer who puts it all together. Please join us for future ThinkTech productions.