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Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie: Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Amy Warriner. She's the Director of UAB Weight Loss Medicine, and she's here to talk about nutrition and diabetes. Dr. Warriner, thank you so much for joining us today. As we start this topic and, wow, we're really seeing this real increase in diabetes, speak about how the landscape of diabetes nutrition has changed over the years. What do we know about the role of diet in diabetes that we didn't know, say, 10 years ago?

Amy Warriner: Thanks for having me, Melanie. I think the biggest change is the increase in type 2 diabetes and the change in medical therapies that we have for the management of diabetes, in addition to the recognition of pre-diabetes and diabetes earlier in the disease state and our ability to manage these diseases with medications that have a lower risk of low blood sugar or hypoglycemia, and the option of medications other than insulin.

When I look back historically on the way that our diabetes educators have been trained to teach our patients about diabetes nutrition, so much of that nutrition education has focused on some of the premises that are important for preventing low blood sugar and people who are treated with medications, especially insulin. And nowadays, with our newer medications, we really can start veering away from those methods and focusing on nutrition in a way that helps a patient eat healthy and obtain all of the nutrients that they need in a day, rather than focusing solely on the prevention of low blood sugars.

Melanie: Well, that's certainly true, and it's been a really exciting time in your field to watch these advancements happen over the last bunch of years. What does designing a nutrition plan for a patient with diabetes look like in the diabetes belt as compared to elsewhere in the nation? Speak about within your community area and then what you've seen as far as the trends around the nation.

Amy Warriner: I think the biggest part of creating a plan for a patient is to look at each patient individually. I think a lot of us, especially in the medical profession, have a view of what we feel is the best meal plan or the best diet for patients. But in many instances, what we view as the ideal meal plan may not fit in a patient's lifestyle. And so, especially here in the diabetes belt, we find that nutrition in general, in many of patients at baseline, is very poor and is limited not only by knowledge of nutrition, but also access to healthy foods.

And so, when we are looking to help a patient improve their nutrition overall, we need to start slow and provide them proper nutrition education that can be built upon at each visit. And the possibility also of including nutrition experts, dieticians, or diabetes educators is really important to allow our patients access to different methods of education. I think the way that my patient may hear me give recommendations is going to be much different than the way that they would hear those same recommendations from a dietician or a diabetes educator. And so, involving those other health providers in the care of our patients is important.

But I think taking a look, having a patient explain to you what they consume in a day at baseline, and then helping them think of ways that they can make improvements. For example, if a patient is consuming all of their foods from fast food restaurants, thinking about easy, realistic ways for them to start cooking at least one meal at home or using a prepared meal even, a frozen meal or a meal replacement product to replace just one fast food meal can make a large impact on that person's overall nutrition. Another example would be if a patient is solely consuming high fat foods, highly processed foods, having them integrate vegetables into at least one meal a day, so that they're getting not only the nutrients, but the healthy fibers from those vegetable sources.

Melanie: Well, I agree with you, Dr. Warriner, that certainly wherever you are in the nation, whether it's kind of an urban desert or a rural area or wherever you are, that it's difficult to get those healthy foods, that does affect that nutrition for your diabetes for someone to work with.

Now, I like that you brought up the multidisciplinary approach for patients because that's so, so important. But at some point, the patients are taking control of this on their own. So, speak to other providers about some of the tools that you find most helpful when you're working with patients. How much do you really rely on patient-provided data when it comes to managing diabetes? And speak about some of that technology. There's so much of it out there today.

Amy Warriner: There is. And the technology that is available is immensely important, especially for those patients who have good base knowledge. So if a patient has the ability to use technology, has the insight to understanding some of the basics of nutrition, tools like electronic food journals, some of food journaling apps such as MyFitnessPal is one of the most popular ones, but there are so many others out there, are incredibly important for allowing patients to start understanding what is in the foods that they are eating.

Many patients have limited knowledge of basics of even macronutrients. What is a carbohydrate? What is a protein? But, moreover, even less have knowledge of the caloric intake, the basic nutrition, the number of calories and the percent fat, percent saturated fat, the amount of sodium within the foods that they are eating. And so, especially in those who have a good baseline knowledge, using those food journaling apps so that they can start looking at the foods that they're consuming on a day-to-day basis, recognize where some of the hidden calories and hidden fats are. It can be very eye-opening. There are multiple situations where a patient has come in. We've talked to them about what their base calorie intake should be. We have them do food journaling for a week. They come back flabbergasted by some of the foods that they've been consuming, not recognizing at all the number of calories, the amount of fat, the amount of sodium in some of the foods that we eat on a day to day basis.

So, those food journaling apps especially are important. For those with somewhat lower knowledge, nutrition knowledge, websites like the American Diabetes Association has wonderful nutrition information for the population in general. And so, directing patients to the American Diabetes Association and the patient resources on that website can help them think about basic nutrition and also provide them access to numerous recipes to help them start working on integrating healthier foods into their day to day.

Melanie: That's so important and great resources for other providers. Tell us a little bit about what nutrition plans, if you were to look, and we certainly know there's an obesity epidemic in this country and, as a result, that increasing prevalence of diabetes. But if you were to discuss with a dietician or with other providers what you feel like are the most successful. We hear about local glycemic index. Patients do not understand this. They don't know what it means. Speak about some of those things that they're going to see and your best advice to counsel their patients, because I think that's where that disconnect takes place.

Amy Warriner: You're absolutely correct. And I think the challenge is that when we look at the science and we look at the comparison of different meal plans; if we think about low carbohydrate, frequently termed keto diets; if we look at whole food, vegetable, plant-based diets, or vegetarian or vegan diets; if we look at Mediterranean-style diets versus low-calorie diets and compare those across the board in large groups of patients, what we find is that there's not one specific diet that consistently helps patients do better. And so. What I think that we take away from that is that, again, we have to think about each patient and we have to think about what is going to work for them in their lifestyle. Yes, there are components of a plant-based diet that are great. There are also components of a low-carbohydrate diet or ketogenic diet that are beneficial as well, especially for someone who has type 2 diabetes or pre-diabetes.

What we can take away from a lot of these meal plans that are very effective in helping people control their blood sugars, helping people lose weight is that, in general, the effective meal plans are removing a lot of the highly processed foods. And so, if we go back in my house with my children, we talk about does it come from a farm? Does it come from a factory? Let's pick the food that comes from the farm. And so, if we go and we start selecting foods that are less highly processed, we get rid of a lot of the chemicals, the highly processed carbohydrates that very rapidly cause our blood sugars to go up and lead to insulin secretion in those of us who can still make insulin. And we don't have to avoid carbohydrates in order to get some of those benefits. And so, when we look at the absorption of glucose from, say, a bowl of cereal compared to the absorption of glucose, even from a white potato, that there is incredible differences. And it's that highly processed carbohydrate that is more challenging for us to accommodate from a glycemic perspective.

Melanie: I couldn't agree with you more, and the confusion, we could do a whole podcast on the confusion surrounding carbohydrates. I mean, it really is something that it's just confusing for patients to see all that stuff, but this is so informative. As we wrap up, I'd like you to speak about the unique areas that set you apart at UAB Weight Loss Medicine, any new advancements in the field of nutrition for diabetes that you're most looking forward to, and why it's so important to refer to the specialists at UAB Medicine.

Amy Warriner: I think there are multiple aspects in the care of patients with diabetes, but also with obesity who are at risk of developing diabetes, those who have prediabetes, those who have a strong family history of diabetes. Number one, I'll just make a little plug in recognizing that the prevention of progression to diabetes. If we catch someone who has prediabetes, it's much easier to reverse prediabetes or prevent the progression to diabetes than to be able to reverse diabetes once it exists. Even more so than waiting until someone has diabetes, recognizing early, testing, evaluating and monitoring our patients is very important.

For those who already have diabetes, the newer medications that specifically affect our insulin production after meals, which is the first insult that we see in someone who's developing glucose intolerance is really important. And these are groundbreaking medications. We're challenged by the fact that these medications are also expensive. But I think when we use them appropriately, we have great success in helping our patients in many situations reverse their diabetes, especially early on in the disease process.

There are other technologies that are very important and hugely beneficial to us and our patient population. We haven't talked about continuous glucose monitors and the impact that they have on our patients with diabetes. But just like those tools, like food journaling apps, continuous glucose monitors can be very helpful for our patients in understanding what foods for them specifically are causing their blood sugars to go high so that they can start making modifications on their own and tailoring and changing things within their day to day to prevent some of those high blood sugars, especially in the after meal time period.

Melanie: Thank you so much, Dr. Warriner. We can do many podcasts on this because there is, as you say, so much we didn't cover and so much information in your field right now. Thank you again for joining us.

And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.