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  • Paige Smathers

40: Should I Be Worried About Developing Diabetes?


Melissa Joy Dobbins, MS, RDN, CDE is an award winning, nationally recognized food and nutrition expert, media spokesperson, speaker, blogger and podcaster with more than 20 years’ experience and a proven track record of providing real solutions for real people so they can enjoy their food with health in mind.

She’s known as the Guilt-Free RD and came on NMP to share her experience as a diabetes educator, helping individuals feel empowered as they are navigating diabetes.

Melissa is also the host of Sound Bites. Here’s how you can keep in touch with Melissa and/or find more resources about diabetes.

Links mentioned in this episode:

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Full transcript:

Paige: Hello everyone and welcome to another episode of Nutrition Matters Podcast! I am Paige, your host and today I have Melissa Joy Dobbins with us who is a registered dietitian and a certified diabetic educator and that last part will come into play in this conversation today. So what I’m going to do, is I’m going to introduce her to all of you and then I’m going to explain what we’re talking about and also just let you know how you can in touch with Melissa because she’s doing a lot of really fun things in her professional life too. So Melissa is an award winning and nationally recognized registered dietitian. She’s a speaker, a blogger, and also a podcaster who also trains other dietitians in the world of media for more than 20 years. She has, she’s a certified diabetic educator as I mentioned. She’s a former supermarket dietitian and also a former national media spokesperson for the Academy of Nutrition and Dietetics. And for those of you who may not know, that is our national organization for dietitians. So Melissa is the Guilt-Free RD because food shouldn’t make you feel bad. And she is the CEO of Sound Bites Incorporated where she promotes sound science, smart nutrition, and good food. She’s based in Chicago, IL and you can connect with her on twitter, Instagram, pinterest, facebook, and of course, on her blog. And I will be linking to all of those things in the show notes so you can find out how to get a hold of Melissa there. And this is kind of exciting about her podcast. Her podcast is called Sound Bites Podcast and it recently celebrated its one year birthday and has nearly 30,000 downloads on her show. She interviews food and nutrition experts, takes a closer look at nutrition news and delves into the science, psychology and strategies behind good food and nutrition. So Melissa, welcome to Nutrition Matters Podcast!

Melissa: Thank you so much, Paige. I’m thrilled to be here!

Paige: Me too! I’m so excited to finally connect with you, I think all dietitian podcasters should

unite! So this is really fun to help spread your podcast and help people find out about you and your work. I know you’re doing a lot of really fun things over there. I love the name of your podcast too. It’s very cute. It’s very nutrition-y cute. I love it.

Melissa: Well thank you. I think yours is better.

Paige: Oh!

Melissa: Because when you hear Nutrition Matters, people get it. Now Sound Bites is the name of my company which I love but as a podcast, unless you see the logo with the fork, you may not know it’s about nutrition.

Paige: Oh, ok.

Melissa: So I really love your podcast name.

Paige: Well I guess my brain just goes to nutrition so I automatically am like, Yes! I love it! Well cool so everybody, I just kind of want you to know why Melissa’s here and why I wanted to talk with her. So I’ve been looking for someone to fill this certain sort of role of this interview I wanted to do because I wanted someone with a background in diabetes but I also wanted someone who’s compassionate and kind of down to earth in terms of nutrition recommendations because the world of diabetes can be a little bit confusing and the world outside of diabetes, for those of us who are concerned about it, it may be in our family history or maybe just concerned about it because it gets mentioned a lot. I think a lot of times in the back of our mind, we’re really really scared of it. So I wanted to have a conversation about diabetes with someone who knows what they’re talking about but also who’s kind and gentle. So Melissa came to mind and I reached out and we got the chance to talk so I’m really excited. Thank you for being here, Melissa.

Melissa: Thank you for having me. Yes, I am definitely very familiar with the diabetes fear factor and I’ve been a certified diabetes educator for almost 20 years. So it’s my favorite population to work with and I’ve had family members with both Type 1 and Type 2 and it’s something I’m just really passionate about and I don’t have the opportunity to do a lot with diabetes in my current communications capacity so I’m just thrilled to be talking with you about it today.

Paige: Yay! Me too. So this actually was sparked by a recent conversation I had with one of my clients. So I’m going to sort of paint the picture for listeners out there. Actually before I do that, I just want to let people know my background in diabetes too. I worked in the clinical hospital setting for a few years before opened up my private practice and I was lucky enough to be trained with the diabetic educators at the hospital so I never got my CDE because I didn’t get enough hours under my belt to take that test but I was trained so I do have quite a bit of experience with helping people who are new to the diabetes world and trying to figure out what to eat and in my practice now, I do work with quite a few new diabetics and also people wanting some continued education, help, and support through that. So this is a world I’m comfortable with, this is a world I really actually enjoy a lot too. I agree too Melissa this is a fun place to be and I actually feel very fortunate that we are talking about this in 2016 instead of 1996 because in your 20 years I’m sure you’ve noticed a lot of things have changed in terms of recommendations, how we talk about diabetes and all that.

Melissa: Absolutely.

Paige: We’ll get into that because I think that’s kind of fun and an important part of the piece of what we wanna say here. So I do have a background here but obviously Melissa is more of the expert so we’ll be sort of bouncing ideas off of each other and discussing these topics. So the reason I wanted to talk about diabetes is because kind of like I mentioned I think this is a fear in the back of a lot of people’s minds. I think many people either get the bad news that they’ve been diagnosed with diabetes or their loved one does and they automatically assume that it’s a death sentence and kidney failure and amputations and things like that and so in the past there was sort of a poor prognosis and I really want people to have access to good quality information about it so they don’t need to live in fear. So that’s our goal today, if you don’t relate to that and you’re like, what do you mean fear of diabetes? I still think you should listen because chances are, you know someone who has diabetes. Maybe in your family, maybe a neighbor, maybe someone in your community and being a little bit more educated about it can help you interact with them in a more compassionate and helpful way so listen up! Is what I’m trying to say. Alright, Melissa, so tell us about anything else you want to add about your background or expertise in this area?

Melissa: Sure. Like you, I did some clinical work my first job was a clinical dietitian and my second job was an outpatient dietitian and that’s when I really got interested in diabetes and became certified. That was really my favorite job. I had gotten a little burnt out on weight loss, eating disorders, therapy and just kind of trying to figure out which path I was gonna go and when I was covering for a colleague who was on maternity leave, they said, well you need to be certified because actually we had a Joslin Center for Diabetes. It was a Chicago suburb and this is back in 1995, 1996 and I was like, ok well I’ll get certified. I didn’t really know what that meant and it’s actually, I’m very proud of this certification because it was really hard to get and it’s been difficult to keep but it’s been a very important and fulfilling, rewarding experience but when I started learning about diabetes, there’s so much to learn and there’s so many ways you can help empower people and so that’s where I try to go because you’ve mentioned the fear factor and it is very complex, depending on what type of diabetes and the medications and the blood sugar monitoring, it can just be really overwhelming and I found that by just empowering people to show them how they can be in the driver’s seat and just seeing that lightbulb go off and seeing them just sort of sigh, let that load off their shoulders just really been fulfilling. After that job, I became a supermarket dietitian as you mentioned and then I went on to work for the Dairy Council and then went on to have my own business but I’ve had, I stuck with diabetes all along as far as I said my passion. I’m currently a spokesperson for the American Association of Diabetes Educators and so I’ll share some good resources from both that site and the American Diabetes Association website too. So there’s just some really great resources out there and I know of course, we want to promote the dietitian and also diabetes educators because if people with diabetes can get the right help and support, it can make all the difference in the world and I loved what you said about saying listen up. Yeah you can be talking to your neighbor or you could be at a cocktail party and just some of the stuff that you’re gonna hear today could help you help somebody with diabetes and make that difference and turn them in the right direction to get the help they need.

Paige: For sure. Yeah that’s great! Alright, so do you mind if we just kind of start off talking about the basic path of physiology of diabetes? I know when I’m working with my clients with diabetes, I will just sort of try to explain this and it’s easier for me to explain if I have a picture so this is going to be a little bit tricky. Just with the audio but I think it’s important at least in my experience I’m interested to hear what you say about this but I think it’s important to understand what’s happening in the body to understand why you need to make certain changes or behavior adjustments, lifestyle changes in regards to your food and your exercise and all that so I know that’s like a huge question and obviously we can spend like a whole semester of college learning about the path of physiology of diabetes, but let’s take a stab at it. Let’s talk about glucose and insulin and let’s just start there and talk about what those words mean. Go ahead Melissa, I’ll let you do this. The expert.

Melissa: Ok well you’re right, I mean the path of physiology is like taking chemistry class and when I took my CDE exam that was one of the sections that was really hard. The medications was also another difficult section. What I usually explain to people first is that there are 2 main different types of diabetes. There are actually several types of diabetes but for the most part, there’s Type 1 which used to be insulin dependent and Type 2 which used to be called adult onset. Either one of those could actually require insulin, well I should say Type 1 must have insulin.

Paige: Right.

Melissa: Type 2 may or may not. And sometimes a Type 2 person might graduate to insulin, that’s what I kind of say. But essentially what’s happening in the body is when we eat food, especially carbohydrate, it breaks down into sugar. And that sugar goes into the bloodstream for us to use as energy.

Paige: Also known as glucose.

Melissa: Also known as glucose right. So there’s all these different words, there’s the blood sugar, blood glucose and we’re supposed to use that glucose as energy. People with diabetes, well again, there’s the Type 1 is a little different but most people are Type 2 so I’m just going to focus on that.

Paige: Sure

Melissa: And we can talk about the differences. People with Type 2 tend to be what we call, insulin resistant. So in order to use that sugar in the blood as energy, our body makes insulin and the insulin is like a key that opens the cell and allows us to use that sugar as energy. It’s calories for energy. But people with insulin resistance, that key is not working, that cell is not getting open, the sugar is not getting in there to be used as energy so it just stays in the bloodstream and when it stays in the bloodstream, it causes damage to our circulation. And that’s essentially where all the complications, the long term complications come from. As it damages the circulation, you’ve got larger veins and arteries, you got smaller veins and arteries. It could affect your heart, your eyes, your kidneys, you extremities and so essentially that damage to the circulation is what we’re trying to prevent and in order to do that we want to keep the blood sugar as normal as possible.

Paige: Yeah, that makes me feel better because that’s sounds a lot like what I say. Hahah. So that’s good. One thing that I kind of like to explain in terms of visualize why we’re worried about blood sugar being too high, is if you think about the consistency of water versus honey, and obviously sugary blood isn’t quite like honey but it does get thicker and it is more viscous so moving through larger arteries and veins- not very difficult but moving through smaller blood vessels as a very viscous fluid is going to be slower and more labored and more difficult leading to complications in those smaller blood vessels like delayed wound healing in the feet and your kidneys have very small blood vessels in them, your eye health. And that’s sort of why you may have heard about some of those long term complications and why we’re nervous about them and it all really does come back to the fact that your blood sugar, your blood needs to have some sugar in it, some glucose in it, but we don’t want it to have too much chronically because that can lead to those issues. Great so that key analogy is what I always say, it unlocks the cell. Every cell in your body needs glucose to function and one thing that I think is an interesting connection to make is in Type 1 diabetes you have probably have heard or seen or know of someone who loses a ton of weight and pees a ton and then that’s what makes them go to the doctor and the reason for that is a very concentrated blood, your body says, wait a minute, I got to dilute this blood, there’s so much sugar in here so the water rushes into the blood which then gets filtered out through the kidneys and then you have to pee a lot. Basically what you’re doing is the sugar is not going into the cell, it’s staying in your blood, your water is running in to dilute that so you’re peeing out not only lots of water but also lots of calories which is why your body is basically starving on a cellular level and that’s why it’s sort of this acute onset where one day you’re fine and 3 days later you’re out of energy, you’re in the doctor’s office, and they take a blood sugar test and they’re like, ok yeah, we need to do some further testing and take a look at what’s going on here. And that’s why you need insulin. So anything to add to that? That was Type 1, I don’t know if I specified but that was Type 1.

Melissa: Right. So in Type 1 there’s not the insulin resistance, we used to say, the body’s not making, it comes to a point where it’s not making any insulin but some Type 1s might make a little bit but that doesn’t really matter. Basically, it’s not that you’ve got this insulin that’s not working, right? It’s you don’t have the insulin to open that cell. So you’re right. The only way the body can get rid of that sugar and those calories is to pee it out. And that’s where you see this rapid onset of of weight loss and the same can happen with Type 2 diabetes but it’s not as dramatic usually.

Paige: Yeah, great point. Cool. And then just to mention, we don’t need to get into it but just to mention, there are diabetic like symptoms following certain medication regimens that you might have experienced [or] you might know someone who’s experienced it. Elevated blood sugar etc. there’s also gestational diabetes which is another important thing to understand and diabetes during pregnancy, elevated blood sugar during pregnancy that we’re not really going to get into but just sort of to give you that background. Anything else I’m missing?

Melissa: No that’s a good point and some of the, because I’ve mentioned these, other different types of diabetes we’re not going to get into those because they’re kind of rare and they’re evolving and kind of specific. But suffice it to say, some people might have been diagnosed as Type 2 and they find out later that they’re either Type 1 or some called LIODA, Late Immunodeficiency.. I don’t remember what it stands for. But those are really specific, different types of diabetes but I actually worked in a high-risk OB clinic with just gestational diabetes but if you wanna get into that a little bit.

Paige: Oh cool. Awesome. Alright so I think we’ve done a good job of sort of laying the groundwork of understanding what’s going on in your body. I think the one thing that I wanted to just mention before I move on from there is so remember how we said that every cell in your body needs that glucose and then it needs the insulin to unlock it? The other important key to understand is that exercise is the one way that your body can use that blood sugar without requiring insulin. So to connect that to a Type 1 diabetic, that’s where exercise can become a little bit risky unless they plan snacks around it to make sure that they’re not going to drop too low. And then it depends on the Type 2 diabetic but for someone with Type 2, that’s where exercise becomes a really important part of their treatment plan so that they are able to manage those blood sugars, partly through medication, partly through what they’re eating but also through their physical activity level. Cuz if you’re chronically too high, a little bit of exercise can actually make a huge difference, bringing that number down on average so that’s why exercise is part of what we talk about when we talk about diabetes.

Melissa: Exactly. Yeah it’s not just about losing weight, it’s that the act of exercise is using up that blood sugar and it’s helping the body be less insulin resistant so it’s just a wonderful lifestyle behavior.

Paige: Yeah great. Alright, so Melissa, this is where all your experience is really going to come in. I want to hear about sort of, get us in the mode of 1996. And what did it look like working with folks who just found out that they have a Type 2 diabetes diagnosis. Tell me a little bit about what recommendations looked like then and what education, medical nutrition therapy looked like then.

Melissa: Well there’s two things that kind of stick out in my mind, so I started my clinical job in 1993 and then I started my outpatient job in 1995 and I remember right before, or maybe it was right as I started my outpatient job I still had to do some clinical coverage here and there and I remember right around that time, there was diabetic tube feedings. I think it was Glucerna and all of a sudden there were no longer, well Glucerna was still there, but they were saying, they don’t need a diabetic tube feeding, you just need a calculator right? They need the right amounts of carbohydrates. It’s not about the, they don’t need a special formula, they just need the right calculation. And I remember like, What?! That just blew my mind. What are you talking about? This is just, this was really like a game changer and shortly after that is when we really started talking about carbohydrate counting. Prior to that, it was all about the exchanges which is looking at different food groups and the different servings and different amounts of the different food groups and basically, the food pyramid or the MyPlate or whatever which has evolved. But basically saying healthy, balanced diet has X number of servings, depending on your calorie level, you need this many servings of fruit, this many servings of grains, this many servings of protein and so on. But the problem with the exchanges is that, it was pretty involved. A lot of different, all the different food groups, all the different portions, measuring, all that stuff. When carb counting came along, or I should say carbohydrate counting, it really gave people flexibility and permission. So if you knew you needed X number of servings of grains or fruits or vegetables whatever, but then you went to have pizza or a casserole or something you were like, how do I count this? And this was right around 1994 is when the first food label came out and so that was a huge change as far as nutrition information being available to us. I remember buying snickers bars when there was no nutrition facts and it was kind of nice not to know. Hahaha. So I think those were the main changes is that when you tell people, ok so instead of counting your grains, your fruits, your dairy, you can lump all that together and say you need a certain amount of carbohydrates every day. Break that down per meal and snack and you have that flexibility to have maybe a little more grains and less fruit one day or a little more dairy and less grains one day and I think that flexibility is really key for people to live their lives on a daily basis and not be so rigid. So I really think it was empowering.

Paige: For sure. That’s awesome. That’s really in line with what I’ve seen. I know a lot of times in a hospital environment some of the educational materials are a little bit old and so what I would see sort of in the deep, dark depths of the filing cabinets, sometimes I would see some of these old educational handouts and I could just imagine the drugged up, poor patient in the hospital who just found out they have diabetes. The last thing they want is for this little dietitian to come in and tell them what to eat or tell them how they need change their eating and she gives them this list of foods to avoid and foods to eat.

Melissa: The sample menu.

Paige: Yeah, sample menu and I found myself really using language like, you know after I got kind of used to these educations I found myself saying, you know I’m not here to put you on a special diet, I’m here to help you learn how to eat a healthy, well balanced way of eating that I should be eating and I don’t have diabetes. And you should be eating and you don’t have diabetes or your wife or your spouse or your whatever, your cousin. This is not special, this is just healthy and well balanced and I think that gives people a lot of peace of mind when they don’t feel like they’re doomed to never be able to eat a piece of cake ever again or never be able to do their favorite food ever again. More like what you were saying with like budgeting, like knowing, ok I’m going to have pizza tonight so what does that mean? And how many pieces should I have and how does that fit in? In reality, everybody should sort of be thinking a little bit along those lines, maybe not too rigid or anything like that but we all should be sort of doing that, barring any very serious dietary restrictions.

Melissa: Mmhmm. And I love how you say budgeting because that’s how I explain it to people too. You have a certain amount of carbohydrate to spend for the day because you have diabetes, it’s better if you spend it in, spread it out instead of spending it all at one time. Always tell me kids, don’t spend your money all in one place! But you want to spread it out and you can choose then how you want to spend those carbohydrate points or servings or however you’re counting that.

Paige: Yeah exactly. And I think a lot of people might get diagnosed in their doctor’s office and their doctor just doesn’t have the time and so they might hand them a piece of paper that’s just sort of the best that they can do. Where it’s like, don’t eat these food and eat these foods but in reality, you can eat too much of anything, right? So I think it’s really important to have that frame of mind where it’s like, this is just a healthy, well balanced way of eating. This is not doomed to this repressive way of eating forever.

Melissa: Strict. Yeah, I agree. And not to bash doctors but it is frustrating that they don’t have the time and may or may not have the expertise and it’s interesting, I did a podcast interview with Dr. Katz and I asked him, I was bold enough to ask him, do you think doctors refer enough to dietitians? And if not, why not? And he of course talked about insurance reimbursement but he said something that sort of shocked me and I thought, oh my god you’re right and I guess I was blocking it out or in denial. He said, some doctors aren’t even talking about nutrition or diet. So if they’re not even talking about nutrition or diet why would they refer to a dietitian? I was like, Oh my god! Putting my fingers in my ears and saying Lalala I don’t want to know.

Paige: Nooo!

Melissa: But to your point, when a doctor’s trying to simplify things and giving someone a sample menu or just say, oh just avoid orange juice. It drives me crazy because a patient needs to hear that they can have the foods they love, they’re just going to need to plan it a little bit and figure out how much does that piece of chocolate cake count and how much does the glass of orange juice count? And really have the flexibility to make those choices and I think just knowing that takes a lot of pressure off.

Paige: Yeah and often leads to better choices anyway because if you feel like you can never have a slice of cake and you find yourself at a wedding and it’s calling your name and you’re like, I haven’t eaten this for 2 years and I don’t know when I’m going to let myself eat this cake ever again. So I might as well go in the corner and shovel it in as fast as I can, right? And I mean that happens.

Melissa: Right. Yes.

Paige: So it’s so much better to be able to say, you know what? I can have cake but I can have a small amount. Does this cake really look worth it to me? Do I really want it? Does it sound good? Will it satisfy me? I mean these are the same questions you and I should be asking ourselves about cake too. I would argue.

Melissa: Exactly. I agree. And yeah, it takes that bit of obsession and sort of white-knuckling off of it and like you know what? Cake, I could kind of, I enjoy it. It’s alright but brownies that’s where I’m at.

Paige: There you go.

Melissa: I wanna spend my carbs on brownies so I save it for that.

Paige: Yeah, totally. I think another thing that trips people up, just in terms of what diabetes looked like in the past versus what it looks like now, I think is just the quality of life expectation. I have seen so many people who really put some hard work into this and really make some changes, bring down their hemoglobin A1C which is, if you don’t know, that’s the sugar, it’s the measurement of the sugar coating on the red blood cell which is sort of the way that you diagnose diabetes. We want it under 7 once you’re diagnosed. I’ve seen multiple people start off with their A1C at 11 which is really high and then bring it down to 6.4 within 3-6 months just by doing these things and just seeing like, that is a perfectly reasonable A1C to have. You’re going to live a high quality, long, beautiful meaningful life. You are not confined to be bedridden with amputations. If you’re able to get on the right medication if necessary and/or lifestyle changes. Anything else you’d add in terms of like, I know my grandma was diagnosed with diabetes and I’m pretty sure her mother had it and so my dad has, I’ve had to kind of help him work through this because he’s like, Ahh I’m scared of what I’ve seen. It’s like, no dad like really let’s talk this through. So tell me what your perspective is on that.

Melissa: Yeah, several things come to mind, I did want to share with you, my niece has Type 1 and that’s a little different but to your point about the quality of life and making some changes and getting really good results, she is 17 and she was diagnosed a couple of years ago. Her A1C is 7.4. most teenagers with Type 1 are like 12, 13, 14 because even if the teenager is doing everything in their power, they’re still growing, there’s hormonal changes, it’s really hard and so we were just visiting them this last weekend and my sister in law told me that her A1C was 7.4 and I was like, oh my god! That’s phenomenal.

Paige: That’s amazing!

Melissa: Yeah!

Paige: And an important note about teenagers, that I just thought of here and I want to mention is, parents who might be listening or maybe teenagers who do have Type 1 diabetes, I think what I’ve seen a lot of in the hospital setting was teenagers who came in often to the hospital with diabetic ketoacidosis which is a serious complication that means high blood sugar, I think a lot of times parents take on too much of the meal planning and eating and portioning out and counting and whatever that kids struggle to learn that so once they’re in that transitional period of becoming an adult. Lot of times they just kind of take a few years to really have to learn that themselves. So if you’re a parent listening of a young child with Type 1 diabetes, I would just encourage you to involve them in their food and their choices as much as possible to set them up for success as they leave the nest.

Melissa: Yeah, there’s a lot that goes on with that. With Type 1s especially adolescents. I’m sure you’re aware, there’s pretty high risk for eating disordered or disordered eating I should say. So it can be really touch and go and I do want to say, I thought after I said this and you were talking, when we were visiting with my brother and his family, we went out for ice cream, in fact my niece works at an ice cream shop. So she eats ice cream and she still had an A1C of 7.4 so it is possible and that quality of life and doing what you can and knowing what tools you have is important. The other things that you mentioned that I wanted to say too that’s changed from 20 years ago, is earlier diagnosis and even the phrase, prediabetes, wasn’t around back then. And it still, people still are not getting diagnosed as early as they should be for a variety of reasons but the key is the earlier we can diagnose it, the earlier we can treat it and the better chance of delaying or preventing those long term complications. So that old school model of sort of don’t ask don’t tell, the doctor’s sort of like, you’re borderline which we don’t use that term anymore hopefully. And we’re talking about prediabetes which is a little bit more descriptive of you’re headed in this direction, don’t wait to make changes, make those changes now and like you said, these are healthy eating habits that everyone would benefit from, whether they have diabetes or not.

Paige: Exactly. Ok, well great points about teenagers and really cool to hear about your niece how she’s able to sort of find that balance and still have an awesome A1C. That’s really exciting. So in terms of you’ve brought this up a little bit, you were saying sort of, I’m going to be paraphrasing but there’s certain things that are in your control and certain things that aren’t in your control in terms of development of diabetes and also progression of diabetes. So let’s talk about the components of what contributes to risk factors of developing diabetes and then I think the rest of the time, what we’ll do is focus on what’s in our control in terms of prevention or in terms of treatment and yeah. So what are the components that lead to development of diabetes.

Melissa: Well, the risk factors are different for Type 1 and Type 2.

Paige: Let’s just talk about Type 2 because I think most people, when we’re talking about fear of development, they’re talking about Type 2.

Melissa: So then like you mentioned, you have a family member who had it or maybe your weight is creeping up and you’ve heard that being overweight is a risk factor. So definitely family history, being overweight. However, some people could be morbidly obese and never get diabetes and never get that insulin resistance so there is that family history aspect that’s really strong with Type 2. And the way I like to say is if you gain weight, that could trigger that predisposition also the older you get. If you live long enough that could trigger the predisposition. So my grandfather got Type 2 diabetes at 80 years old. My father was diagnosed at I think he was 64 and my grandfather really was pretty much normal weight. My father was overweight at that point so that triggered it earlier.

Paige: Well that’s another important point is just like you said, you could be morbidly obese and never develop diabetes but you could also be very health conscious and exercise a ton and take care of yourself and be at a really healthy great weight for you and still develop it just due to a really strong genetic tie so we can say that it’s correlated with weight perhaps but not necessarily caused by, in terms of direct causation.

Melissa: Right, and then the other, we’ll talk about this probably, but the other aspect is even if you’re headed toward diabetes, whether the weight is triggering that or not or it’s just strong family history, your weight, your blood pressure, how heart healthy a lifestyle you have, all of those things can contribute to how healthy overall you are with regard to diabetes. Because of that damage that happens to the circulation from high blood sugars, everybody with diabetes should be looking at a heart healthy diet. A cardiovascular, healthy diet.

Paige: Which again isn’t too different then just an overall, well balanced, reasonable, moderate, variety filled.

Melissa: That everybody should be looking at.

Paige: Right, exactly. Cool so interrupted you a little bit there. So you were mentioning family history

Melissa: Obesity, overweight or obesity, a sedentary lifestyle. That can cause you to be more insulin resistant I should say and again, regardless of your weight, exercise helps your body use that sugar better. I think those are the main things, getting older.

Paige: Smoking is another one. Am I right or no? Am I off on that?

Melissa: Well, it’s a cardiovascular risk factor.

Paige: So like you said, sort of cardiovascular health correlates to less of a risk of diabetes.

Melissa: Right.

Paige: So when we’re talking about what’s in our control and what isn’t, obviously we can’t

control our genetics.

Melissa: Cannot pick your family.

Paige: Cannot pick your family. As far as the bigs things that stand out, it’s the boring stuff that we hear all the time but hopefully you have enough of a foundation to really understand why we’re going to be talking about the nutrition side of it and why exercise matters. I mean it’s basically, those are our things that we can work on and that we can try to improve and then we also have to just trust our body that it’s going to adjust and improve as we do our part. So yeah, it’s interesting. Exercise and eating a well balanced, reasonable, moderate diet and not a diet like a fad diet. Just diet as in the way we eat is probably the best way to prevent and/or treat a Type 2 diabetic risk factor. Is that right?

Melissa: Absolutely. And it’s not extreme or sexy or whatever but it does work. All those little things do add up and it’s sort of like the good thing with diabetes or prediabetes is if they’re checking their blood sugar, they will see right away what’s working and what’s not and they can make little adjustments versus somebody who is just trying to manage their weight. You’re not getting that immediate feedback and so it’s more like you just have to trust and keep working and going the long haul versus with diabetes it is nice to get a little bit immediate feedback that’s not just what the scale says.

Paige: For sure! And the scale is so tricky, I mean it can go up and down by a few pounds even though you’ve been working as hard as you can making these lifestyle changes so I think that’s a really good point that you do get that sort of objective information almost immediately to kind of check in about hey, how did yesterday go? Instead of, ughh I’m up 5 lbs even though I made all these changes. So yeah that’s really good point.

Melissa: Yeah, people can use blood sugar monitoring to see how did their morning walk affect their blood sugar. I say this really up close and personal with the gestational diabetics that I worked with but that’s kind of a specialized group but how did their morning meal or their lunch, people can check their blood sugar before they eat and 2 hours after they eat to see how did I do? And that can also give them feedback as to if and how well their medication is working so this is probably the most important thing that I tell people with diabetes is it is a progressive disease. So even if you’re perfect and you do everything right, which nobody does, but even if you did, it’s still going to progress. So what you’re doing today, might give you beautiful blood sugars and a few months from now or a year from now, those blood sugars might be creeping up and you might be saying, but I haven’t done anything differently. But maybe we need to tweak your diet or your medication or your exercise and just kind of keep on it. And I’ve seen this time and time again, patients will come to me and say, my doctor keeps changing my medication, they don’t know what they’re doing. I’m like, well, it’s kind of the nature of it. We kind of have to keep making adjustments to stay on top of it and I think if they look at it from that perspective. It’s like, oh ok. Now I know to sort of expect this because if you’re looking at it as my doctor doesn’t know what he’s doing, he keeps changing things, how invested are you going to be in doing your part and being empowered and seeing everything in a positive light.

Paige: Yeah. That’s a really great point. Ok so here is the thing that’s sort of sparked me wanting to have this conversation, here’s the question I really want to parse out with you, so a lot of people, I’ve just heard this sort of here and there socially, a lot of people talk about how, I’ve heard a mom say, hey! Don’t eat that! You’re going to get diabetes. Don’t eat that sugar. Don’t eat that cake. Do you want diabetes or no? it’s sort of like it’s this thing where people think that if you eat sweets, you will develop diabetes so when we’re talking about and describing the development of diabetes, we did mention that a poor nutrition on average and on the whole can lead to diabetic symptoms and development but let’s talk about that. That relationship and whether or not people should be afraid to eat the occasional chocolate chip cookie or the brownie or whatever it might be.

Melissa: Yeah, so just like I mentioned somebody could be morbidly obese and not have diabetes. Somebody without diabetes or who’s never going to get diabetes could eat a whole cake and their blood sugar will be normal. Now, if they continue to eat that way and they continue to gain weight and they do have the genetic predisposition for diabetes, it’s going to catch up with them at some point. And I’ll take this one step further, so not only does eating sugar not cause diabetes in and of itself, what you hear even more often is that sugar causes hyperactivity and if you eat this, your blood sugar is going to spike and crash and it’s one of the biggest pet peeves I have because unless you have diabetes or reactive hypoglycemia, your blood sugar will stay within a normal range. Now, if you just have pure sugar, it’s going to go up quicker and fall quicker than if you have a mixed meal, like for example, ice cream. We would actually tell patients with gestational diabetes, one endocrinologist that I worked with said, at bedtime have a ½ cup of regular ice cream because it’s the right combination of carbs, protein, and fat and your blood sugars the next morning should be pretty good. And I’ll tell you, all of the pregnant women loved hearing that.

Paige: I’m sure they did.

Melissa: They just take ½ a cup! Who wouldn’t like that? But because that ice cream had protein and especially fat in it, then it wouldn’t raise the blood sugar or drop the blood sugar as quickly as just pure juice or candy that’s just pure carbohydrate. So even though it might go up and down quickly, it’s still going to stay in the normal range.

Paige: There are very specific mechanisms in place in your blood to keep your blood sugar within a certain range for a normal person.

Melissa: Right. So it’s going to trigger the release of insulin and now long-term, if you do that a lot and you are predisposed to diabetes and you are wearing out your pancreas by shooting out all this insulin every time you eat sugar that could cause problems down the road but it’s not that you’re going high or dropping low. It will be staying in the normal range.

Paige: So that’s a really important piece that I didn’t even actually think to ask you but I think is important to talk about because so many people just kind of talk about how they have low blood sugar and how that means they need to eat. What is that? If it’s not hypoglycemia, is it just hunger? Is it just cues that your body needs to eat? What would you say about that?

Melissa: Right. Well, I actually, back in the day when we actually had the ADA manual of clinical dietetics. It was a big binder, in the year 2000 I authored the Reactive Hypoglycemia chapter and I edited the Diabetes chapter and since then it’s become the nutrition care manual, the electronic one.

Paige: Great.

Melissa: You’re familiar with it.

Paige: Yeah.

Melissa: But that was the predecessor. I learned a lot about reactive hypoglycemia and there’s really not that much information out there but what happens with those people, those are the people who are typically thin, they might be a little overweight but they are typically thin and they’re the people who hit a wall and they’re like, I need to eat now. I’m going to eat this table. Ahah. And if they check their blood sugar at that time it is low. And there can be different causes for that. Sometimes it happens if they eat sugar. Then their bodies are overreacting by making too much insulin and they go low or they just kind of run on empty and they go low. But it’s interesting if you’re somebody who feels like, oh my gosh, all of a sudden, I’m like starving, I’m hungry, I’m getting irritable or whatever. I would encourage you to get a monitor and check your blood sugar and find out if you’re really low or not. And it could be that you just dropped quickly but you’re still within normal. It could be a lot of different things.

Paige: I’ve actually done that before too because I’ve had, I don’t have diabetes but I have had times where I’m like, I NEED, I’m going to eat this table! Like you were saying. Hahah. And I was always normal but just very low end of normal. And that was in a certain time in my life where I felt my metabolism was just going nuts. You know? I could just tell that I was like, it was like breastfeeding and I had to eat or I couldn’t make it anywhere.

Melissa: You were running on empty.

Paige: Yeah, I just was like I had to eat so much food all the time and I always felt starving and I always ate more than anybody else at the table. Anyway so I don’t think if I checked right now, I don’t think it would look quite as low when I feel hungry so I think it probably can depend on what stage of life you’re in too.

Melissa: And you know how quickly it’s dropping and that’s why, back to what we would recommend for people with diabetes is what we would recommend for the average person and is probably not the best thing just to eat carbohydrates like just fruit or just juice or just bread or just crackers. It’s best to pair it with something else like yogurt or cheese or something that’s got some protein and maybe a little bit more of a mixed meal or snack.

Paige: Yeah. Great point.

Melissa: Stays with you more.

Paige: Yeah. So I have kind of a tricky sort of food psychology way of thinking about this where I’ve had people ask me so how often should I eat sweets? I’m worried about diabetes. Should I avoid them? What should I do? I actually kind of prescribe eating a sweet every single day as sort of my nutrition prescription just because, and I’ll explain it because it might be confusing to some people, but from like a food psychology standpoint, if you allow yourself and you know that a treat is coming, sometimes you end up not even wanting it. Or if you know it’s coming then you can say no to that donut at 10am because you’re like, ehhh it doesn’t really sound good. I’m full from breakfast or whatever it might be. I don’t think that the idea of never eating sweets as a way to prevent diabetes is actually helpful. I mean research actually does pretty conclusively prove that when you do that you end up making poorer nutrition choices than when you just give yourself that permission to choose from a wide variety of foods. So what are your thoughts about that though, Melissa?

Melissa: Yeah, I’m glad you brought this up. That brings to mind for me deprivation.

Paige: Yeah.

Melissa: I don’t do well with deprivation. That just kind of puts me over the edge.

Paige: Me either.

Melissa: And certainly, I think when you make something taboo or off limits, it makes it that much more desirable of course, we talk about that with children and that whole Ellyn Satter approach. Let’s let children have, this applies to adults too, let those things be allowed and not off limits and I don’t know, are you familiar with Gretchen Rubin?

Paige: I don’t know if Gretchen Rubin.

Melissa: Ok so she has a book called Happier and she has a podcast called “Happier.”

Paige: Oh cool.

Melissa: And I’m completely addicted to it. And she has these 4 tendencies that are kind of like 4 different personalities and the reason I’m sharing this is because obviously as dietitians as we counsel one on one, we tailor everything to them and their personality and in talking with them we find out, well are they more of an all or nothing person or they more a moderate person and Gretchen Rubin has categorized them into different tendencies or personalities and there’s the Upholder, there’s the Rebel, there’s the Obliger, and there’s the Questioner. And depending on your tendency, again I like to call it a personality, can dictate whether you’re somebody who can be all or nothing about something or you’re more of a moderator and I would suffice, I would go so far to say and I think Gretchen would agree and she’s talked about this, it could almost be situational. So I can be for example, I can have ice cream in my freezer and my family is a huge ice cream obsessed family and my little flavor will have freezer burn on it because I just kind of forgot about it. And they just tease me about it. They say, what is wrong with you? I’m like, I forgot about it. But I will find your Easter chocolate bunny and I will eat him if you don’t. I will hunt him down and it will be mine.

Paige: Hahah

Melissa: It’s just like I can be very moderate with ice cream but with chocolate, it’s a little trickier for me. So I think and this is what we do with patients one on one is try to get them to understand their own preferences and thoughts and when they’re feeling deprived versus that’s something that I can have in the house cuz it’s not really tempting to me or that’s something that’s really a trigger food for me and it’s just a little difficult so maybe I want to have that when I go out to a restaurant but I don’t want to keep it in the home.

Paige: Totally.

Melissa: That’s basically what I just really want people to think about. Know thyself and work with that and don’t judge it or try to change it. Just [??] that work for you.

Paige: That’s a great point. Yeah so not necessarily just being so clinical about our approach with healthy eating but also thinking about our relationship with these foods and also the thoughts were having about them and for some people it might actually be a good idea to say, hey you can eat a sweet every day and I’m just going to be intentional and mindful about which one I choose and how I eat it and I’m also not going to engage in this negative doom and gloom mindset about how this is leading to diabetes because in the end, the science doesn’t even support that eating sweets leads directly leads to diabetes devolvement so that’s an important point and that’s actually again, like I said, just one of the biggest reasons I wanted to have this conversation so thank you for your perspective on that. So I just want to sort of get into a little bit more about your experience with being a diabetes educator. What did you, what have you taken away from that experience? What did you find really actually worked for people? Cuz I know a lot of time you learn something in a textbook or you learn something in school and then you go out in the real world and it’s like, wow, this is so different than school. So tell us kind of what practically you’ve found worked.

Melissa: Well always wanting to give them everything I know about diabetes and knowing that that isn’t going to help them but what helps the most is asking them what their fears are, what they’re afraid of, what their questions are to kind of find out where they’re at. I had a situation with a patient, this was a couple years ago when I was working in a high risk OB clinic, and I had to teach pregnant women to give themselves insulin. Well when you’re pregnant, you give yourself insulin shot in the belly which just freaks people out. It’s a subcutaneous shot so it’s not affecting the baby or anything but just sounds horrible and pregnant women are like, that’s the last thing I want to do. I mean nobody wants to give themselves a shot and a pregnant woman really doesn’t want to do it in the belly. So needless to say, these were hard conversations with women and also as an aside, a lot of people with gestational diabetes even if they do need insulin, the diabetes goes away after they have the baby but then they are predisposed to get it later on in life. Well this one woman, just cried and cried and cried. She couldn’t even speak and I, of course gave her time and space, and I was like, I can show you how to do this but I can’t do this shot for you. You have to do it yourself but we don’t have to do it today. You can come back tomorrow, we can gently do this but if it was my baby, I would do this and obviously there’s a fear factor but I wasn’t sure exactly. I knew she was clearly very upset and I wasn’t sure what the tears were about. Fortunately, for me I had the social worker following me that day, shadowing me. Because we were working on ways to work better so it was just the perfect opportunity for somebody who has those skills to, I’m like, I’m a dietitian I have a lot of experience but this woman’s clearly just wrought with emotion. As it turned out, when she could finally speak, she said my grandmother went on insulin and she died. And so in her culture and her family insulin was a death sentence. It wasn’t just nobody wants to give themselves a shot, it was so heart wrenching and long story short, we gave her some space and time and we reassured her and we worked with her and I told her a would call her and I called her, I gave her the prescription, I said fill the prescription. You don’t have to start it tonight but at least fill the prescription. I will call you tomorrow. I called her the next day which shocked her. She said, I can’t believe you actually called me. I said, I told you I was going to call you, I said did you get the prescription? She said yes. I said did you take the shot? She said no. I said that’s ok. And talked with her some more. I said I’ll call you tomorrow. This went on for some time. Eventually she did take the insulin and eventually she gave birth to a healthy baby boy and eventually I ran into her at the hospital gift shop with her beautiful baby boy and she just hugged me and said thank you. Thank you so much and it was just one of the best days of my life. It’s just a long way of saying, what works for people is to meet them where they’re at and not to push them too hard, let them come to it. Let them know that there are tools and that they can have a good quality of life and they can be in the driver’s seat and that doctor can give them a road map but they’re the ones who are driving and they’re the ones who have to ask the questions and sometimes push their doctor a little bit and be more assertive and figure out are they on top of their medication regimen? And are they doing their best with exercise? Because diet is just one piece of it. It’s the whole picture.

Paige: Thank you for that story. That was so beautiful to hear about the successes she had. That’s what makes your job worth doing I think. I think one of the most reassuring things people can hear whether you’re someone who’s trying to prevent diabetes or you know someone who has it or you have it yourself, I think it’s just hearing and knowing that you don’t have to be perfect to be progressing and to make a big difference even if you’re working on getting your A1C down. You don’t need to eat perfectly because like you mentioned earlier, it doesn’t exist so get that out of your head. Stop aiming for that. Just aim for better, aim for the best you can do that day and you’ll end up actually making a lot better decisions when you give yourself that room and that space and also that compassion. I think that’s really important.

Melissa: And having that better quality of life. That’s the goal.

Paige: Yeah! For sure and a big part of what makes your life worth living is having a happy, healthy mindset.

Melissa: Yes.

Paige: And so if you can work on that, I think any major diagnosis or health condition, such as diabetes, can really take some time to grieve. I mean it’s a hard thing to wrap your head around that that’s what you have to live with forever but hopefully hearing some of these things today have been helpful that you really can be happy, healthy, thriving, wonderful, normal person. You can eat normal, healthy, well-balanced foods that you like and you can function and you can live and everything can be ok. You just have to do the best you can with your situation and also work with your doctor on medications if necessary but also do what you can do that’s in your control, including eating and exercising. So let me just close off by asking you what do you wish people knew about diabetes? And it can be sort of a repeat of something we’ve said already or something new, I’m just curious if you could get a message out there, what would it be?

Melissa: Well I’m glad you asked because as you were just sort of wrapping up, we covered all of the basics but something did pop up into my mind. A lot of people feel like they have failed if they’re on medication or that they should be able to get off of medication and you see a lot of information out there about curing diabetes, reversing diabetes, getting off of diabetes medication and while it’s so important to do the best you can with those lifestyle factors, there’s no substitute for that. You could still be doing again, nobody’s perfect. You could be doing close to perfect as possible and you still might need a little help from some diabetes medication. You might need something to help with your insulin resistance. You might need something to help with your post prandial or post meal blood sugar. May not necessarily be insulin, there’s a bunch of different pills so I like to sort of not demonize medication because that is one of the tools in your toolbox and we always want to be on as little medication as possible but it’s not that we should be worried about side effects or risks or that we’ve failed and we’re not doing a good enough job if we’re on medication. A lot of people who have controlled blood pressure take blood pressure medication and people aren’t saying to them, well you need to get off of that, just don’t eat any salt and you’ll be fine. It’s not necessarily going to fix the problem. Yes, you don’t want to have this high sodium diet and not exercise and all the things that are bad for blood pressure, and just take medicine and just be like, oh well whatever. It’s the whole picture, it’s the whole package. So that’s something we hadn’t talked about but I do think is important.

Paige: That’s a great point. That is really really important and I know I just had some work done on my mouth. I had a gum graft and I had to take steroids and antibiotics and I was like, ohhh! I was like freaking out. I was like this is making me so nervous so I can see why someone who’s told, here’s the insulin. First of all, it’s a needle. Second of all, it’s a daily thing. I can see, I can empathize and see why someone’s like, woah, I gotta get this out of my daily routine. But at the same time, I really appreciate your perspective that that does not mean that you’ve failed. And that everything can continue on if you stay compliant and maybe you might not even need the medication for a long period of time. Sometimes it’s more of like a get you through that first part where you’re newly diagnosed and we’re figuring things out.

Melissa: Absolutely.

Paige: Well, Melissa, this has been such a joy. Oh, I did not even realize that pun until just now. It’s been such a joy to talk with you. I think I’m just so excited about all the work you do and are doing and have done and I appreciate your perspective and your experience on this conversation about diabetes. Do you have anything you want to add or maybe tell the listeners how they can keep in touch with you and make sure we’re on that.

Melissa: Sure! Well thank you so much for having me on your show and for doing a podcast to begin with. I’m just so excited that more dietitians are getting out to the podcast space. And thank you for focusing on diabetes for one of your shows. It’s just such an important topic that affects so many people directly and indirectly. So thank you. People can check out my podcast. My website is soundbitesrd.com and it’s on itunes, Sound Bites with Melissa Joy Dobbins. They can follow me on twitter and Instagram @melissajoyrd. They can follow me on facebook and it’s kind of long, Melissa Joy Dobbins, I think it’s Guilt Free RD Sound Bites, it’s got all that on there. And also pinterest. But if you just go to my website you can find all of that and Paige, I can share some links to some diabetes resources for people where they can find out more information about diabetes, find a dietitian, find a diabetes educator and any other information that they might be looking for.

Paige: That’s great. Yeah, I’ll plan to link to all your social stuff and also your website on the show notes and then once I hear from you about those resources that would be really helpful, I’ll add that as well. So thank you, Melissa, so much for being here. I’m looking forward to keep in touch with you.

Melissa: Oh me too, thanks Paige!

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