The Intersection of Nutrition and Diabetes Technology

DO.fm Clinical Podcast

This month we welcome Shirin Doshi, DO to the Clinical Podcast to talk about nutrition and how it relates to diabetes technology. We cover providing advice on eating habits and eating patterns, team-based approaches to nutrition, and how CGMs can influence eating and behavior.

Resources referenced

• CGM and Nutrition
• Continuous Glucose Monitoring and Diabetes Distress

Transcript

This transcript was created with the aid of automatic speech recognition technology.

Stephen Legault: Hello and welcome to the ACOFP DO.FM Clinical podcast. I'm Steve Legault, the director of Knowledge, learning and assessment and host for this episode. Today we're going to talk about the important intersection of nutrition and diabetes technology. For people with diabetes, food nutrition choices carry even more significance. With advances in technology, patients can see the impact of those choices almost immediately. Today we welcome Shirin Doshi DO. She's the lead physician advisor for Sparrow Hospital, where she supplies provider education, reviews hospital cases for medical necessity, assists with insurance denials, and continues to assist the medical staff with coding and documentation requirements, who's also part of the planning faculty for the American Diabetes Association supporting healthy eating habits through CGM program. Welcome to the podcast, Doctor Doshi.

Shirin Doshi, DO: Hi, Steve, nice to be here.

Stephen Legault: Well, thank you so much again for participating, and let's jump right in. But before we get into diabetes specific technology, let's talk about nutrition. I imagine that giving advice on eating habits and food selection can be a tricky area in some cases. How do you go about discussing those food choices that support overall health goals and targets with patients?

Shirin Doshi, DO: Well, every patient is different in the way that you speak with them because it depends on their level of understanding and their primary language, etcetera. So, it just depends on what they come to the table with, with their understanding. But one of the key points is that many of our patients do not have significant financial resources, and so it can be really difficult for them to buy, you know, the healthiest foods, the organic food, you know, the, the convenience of major fast-food chains. And some of those types of things are definite barriers. So, what I do is I discuss with them just a healthy balance. Foods, you know, including the good fats, protein, complex carbs, foods that are really dense and fiber and vitamins and minerals. And I explained to them that, you know, you don't have to go to a fancy, expensive organic food store, that you can go to your regular local market. And even frozen options of fruit and vegetables can be quite healthy, and they tend to be quite cheap compared to some of the fresher options. The other thing is that we talk about avoiding, you know, significant amounts of simple sugars, which are in, like, highly processed foods, like candy, you know, cakes, cookies, ice cream, stuff like that. And a lot of the white things such as white pasta, white rice and white bread, you know, trying to steer patients towards more the complex carbs. Fresh food, even though it still has sugar in it, it's, it's still balanced with fiber and, you know, vitamins and minerals, et cetera, and so it is a better option than food that is liquidities, that you just slurp up, that your body doesn't have to work super hard to actually absorb all those nutrients. And if we can get them to just even start making small choices, little baby steps in their nutrition, we can get them to a healthier point and have them feel like we're not asking them to completely change their diet within a day. We try to partner with them to make small decisions, small steps. You know, maybe the first step that we have them do is to cut out pop or soda for those of you that are not from the Midwest. So, cutting out pop is a huge source of, you know, unhealthy sugars and chemicals and all of that. And even if they cut out that one thing, and that's the only thing you work on at one time, you know, for a solid month, that's okay if you're moving them in the right direction. So that's kind of how I approach it with patients. It is difficult to really get them to start looking at their diet and figuring out how they could make it a healthy diet, because a lot of them have multiple family members who are eating the same things and who struggle with the same health conditions. And so, you really have to explain, like, this is for the whole family, this can't just be for you, because when you are eating healthier, but the rest of your family is not, then it's going to be tough for them to just slide back into that same mode.

Stephen Legault: Excellent. That's great. Appreciate that. And kind of thinking about the care team, are there some ways that collaborative care models or team-based approaches can be used to reinforce that communication you're having with your patients around nutrition?

Shirin Doshi, DO: I believe there are. I mean, a lot of the primary care offices now are trying to have multi discipline teams, like present in the office. I'm not as familiar with most of them having a registered dietitian as part of their team in the office. But when a lot of the offices are part of a big health system, it's easier to partner with a registered dietitian. And, you know, if you could get an RD in every PCP's office across the country, we would probably make great strides in helping to teach our patients whose multiple chronic medical conditions are greatly affected by their eating habits. So, I think that would be a great goal for us to do that. But in the reality, we have to reach out to resources that are local to us. And so, it tends to be that nutrition consult or we are referring people to the local diabetes education classes that often are put together by the endocrinology, you know, services that are in the community. So, every and some of the states have, you know, with their department of health, they have some resources there that can be used. You know, even though those providers may not specifically be in the same. Housed in the same office, they're still part of that collaboration to actually come together and to be that multidisciplinary approach to take care of these patients, because patients need to hear, most patients need to hear the same message multiple times and from multiple people in order for it to make sense and to sink in. That's great. That's great advice on how to use some of those local resources.

Stephen Legault: Thank you for that. Digging a little bit more into nutrition, what can you tell me about evidence-based eating patterns and how those can be used to treat prediabetes and type two diabetes?

Shirin Doshi, DO: So, for patients to avoid unhealthy dips and spikes of their glucose levels, we're really trying to encourage people to eat well balanced meals and snacks throughout the day. What this does is it supplies a steady amount of energy for the body and it helps with the metabolism and just overall, I mean, overall energy and sense of well-being. Like, whenever you go throughout the day and you're starving yourself, which is what a lot of our patients do, they don't feel good. Part of that is because of their eating pattern and their choice to just, you know, fast throughout the day and then just eat something huge at night. So, when people skip meals, what we know is that they often are so hungry that their ability to make good, healthy choices is hampered. And what they'll do often is they'll overeat. They'll overeat, and then after a large meal, especially if you are a diabetic, you will have a significant spike in your sugar. And the more your sugar spikes, spikes in either direction. That's why we are interested in this continuous glucose monitoring. The more that it spikes in either direction, the worse the outcome. So that's why we really are trying to get people to think more along the lines of steady, sustained nutrition throughout the day. If you eat a few meals a day, if you eat the right combination of meals, it will sustain you for the time in between to when you get to your next meal. And that's part of the education that, you know, goes along with. It's not even just for diabetics, it's for everybody, you know, getting a good amount of protein, a mix with the complex carbs and the healthy fats. And a good amount of fiber, whole grains, those types of things really do help to reduce the acceleration of the blood glucose as you eat. It kind of reduces that spike because your body is working harder to really digest all of those foods. And so that helps to kind of limit the major spike with your eating. And obviously, it depends on what you're eating. So, you know, if some meals are more carb heavy versus others, then you can have more of a spike. But it's really trying to look at that sustained, healthy eating pattern throughout the day that is going to be the most beneficial for most patients. Awesome. And when you're having those conversations or you're educating them on nutrition, how do you go about addressing any misconceptions around nutrition and the treatment of diabetes? If those come up? I think a lot of patients feel that if they're diabetic, they can never have sugar, they can never have a treat, they can never have fruit. So, a lot of that is, it is a misconception because you can, even a diabetic can have, can go to a birthday party and have a little bit of a treat. You don't want to do that every day, multiple times a day. You know, an occasional treat is not, is not looked down upon, but it's making sure that you're looking at your feeding, you know, your food pattern throughout the day, to make sure that the amount of good nutrients is there and to accommodate, especially if you're on insulin, to accommodate for that extra burst of sugar that you may get from having a treat. So, there's a lot of education when you're using insulin to cover for the meals that you're eating. And, you know, you do need to think about the carb counting and trying to figure out, like, oh, you know, I'm going to a party tonight. I normally use this much insulin. I'm probably going to need to monitor it a little bit more closely, and I might need to adjust. I might need to give myself some more. What I try to teach patients is that it's okay to treat yourself. You just don't want to do it all the time. And it is okay for a diabetic to eat fruit. Fruit is good, healthy, natural source of sugar, complex sugars. There are simple sugars there, too, but fruit is healthy. It's healthy for you to eat. Now, do you only eat fruit all day? No, that would not be good. That's not a balanced way to eat. So, there's a, there's a lot of those types of misconceptions and again, like, well, my favorite food is pizza. Well, it doesn't mean you can never have pizza. And there's healthier ways to make pizza. So, it's trying to explain to them that, number one, we want you to eat healthier, but number two, we're not going to ask you to make all of those drastic changes overnight. And number three, there are delicious alternatives to a lot of your most favorite foods that will still make you feel satisfied as if you were eating the thing that you really love and think you're going to miss. So that's sort of how I approach it with my patients.

Stephen Legault: Excellent, thanks. And that kind of segues nicely into the technology side of things. So how could the use of a CGM in the treatment plan both inform food choices and also aid in the behavior modification aspects?

Shirin Doshi, DO: So that's a really good question. Continuous glucose monitoring has now been in use for a little while, and we really were looking at how can we use this to our advantage in our diabetics and even patients who are pre diabetic to really help them kind of look at their eating pattern and to make adjustments in either choices for future eating or, you know, for how they're covering their sugars for their meals. It definitely can be used as a guide to help with lifestyle decisions. You know, you need to know what your targets are for your glucose levels, and it helps patients to kind of monitor their trends. And specific foods that are eaten can affect patients differently. And so, knowing how a specific food or a combination of foods affects them individually and what it does to their sugar, that's very useful information. So, we, you know, work together in this group, and the bulk of the work was done by the nutrition team and the staff side on these American Diabetes association. They were just wonderful to work with and very, very knowledgeable. So, they created an infographic that they basically really explain how to monitor your sugars and why it's important and why it's helpful.

Stephen Legault: Excellent and that kind of segues into the next piece here. So, when you're talking about CGM as an aid for nutritional decisions, what resources are you using to inform the conversation provider?

Shirin Doshi, DO: So, I think for the purpose of CGM, something I'm going to be using is the infographic that we just talked about is on the diabetes.org website. Really, it just explains, you know, in a very easy way, how to look at your sugars and why it's important to do that. It also shows how you want to split your plate up, you know, to make sure that it's the healthiest ratio of foods. So, you know, half of the plate is vegetables, a quarter of the plate might be carbohydrates, and then a quarter of the plate is protein. And so. And that may vary like meal to meal, but it gives an example of how sugars kind of are lower. And then there's a meal, there's a meal with vegetables and how it shows that the sugar doesn't rise as much, but then the meal without vegetables is rising a lot higher. And it also explains that, in general, some people can get very overwhelmed with the idea of continuous glucose monitoring. That was something that we discussed at length because we were worried about patients getting information overload with having their monitor on and constantly getting alerts on their phone or their computer, however they look at it. And so, they're really trying to, you know, explain, like, you don't have to worry about every single reading. You obviously need to worry about those that are extremes, those that are super low or super high. But in general, if your numbers are sort of in an average range, just check that average every couple of weeks. We want to try to get patients into the target range. You know, if you're in the target range more than 70% of the time, then that's associated with better outcomes. And every 5% increase in the being in that target range is clinically beneficial. And so, it kind of helps to show that. And the target range typically is between, like 70 to 180. And so, again, people are going to go below or higher than that, depending on their medication regimen and their nutritional intake. But the graphic that we created, I think, is very helpful. And again, going to the other resources would be the diabetes education classes. The Department of Health for each county or state usually has good resources, and as well as the CDC has some really good diabetes resources as well. And obviously, if you have, again, you're in a system or you're lucky enough to have a nutritionist, then that nutritionist or the registered dietitian is a very good resource as well.

Stephen Legault: Excellent. So, it sounds like there's quite a few places where both providers and patients can go to get this information. Excellent. Well, I think that's it for the questions today. Doctor Doshi, thank you so much for being part of the podcast.

Shirin Doshi, DO: Thank you very much. I appreciate your time. Thank you.

Stephen Legault: And thank you for listening to the ACOFP DO.FM podcast, a production of the American College of osteopathic family physicians.

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