The Dialogues – Episode 4

Welcome to the fourth episode of The Dialogues! In this episode, we have a lovely talk with Nicole – certified diabetes educator, and dietician. We will talk about diet! We will tackle down digestive problems and weight loss, more specifically the keto diet and intermittent fasting. We will myth-bust carbs and discuss the future of diet.  Just remember, when it comes to diet everything is about trial and error. The key is to just keep trying!

Watch the entire video here:

 

Hi, Nicole, and Welcome to episode four of the dialogue series that we’re running and thank you for taking out your valuable time to talk to us today. Nicole has a pretty impressive background as a CDE (credentialed diabetes educator), a dietitian and a nutrition coach. Welcome again and  thanks for joining us.  How about we begin with you telling us about your background. experience and your areas of interests. 

Hi. Thank you for having me. My background is in nutrition. I’ve been a dietitian now for about eight years and I’ve been working with patients with diabetes for most of the time in different areas such as clinical including inpatient, outpatient,  dialysis units and I have my own private practice that is known as “Demacie Nutrition.” Basically I’m based in Los Angeles and I see all different types of patients and a lot of them are diabetic either type one or type two. or it could be kidney disease, weight loss, digestive issues so the people that I usually do not have just one thing,  It’s usually a combination of different things. 

 

What was it that got you into the diabetes space?

I guess as a dietitian we see a lot of patients with diabetes just because the need for a dietitian is so strong in that area. I was seeing a lot of people when they’ve already got to the point where their diabetes was so uncontrolled that they were now having secondary issues like kidney disease, cardiovascular disease and other diseases. So I also wanted to get more into diabetes in order to learn about the prevention of other diseases.  Also, just to help people to develop better control and to give them more education because I found that education was sporadic in the field. You would be diagnosed, and then you might not get adequate education from a health care provider for about years unless you look for it yourself. So I chose this field as it is really interesting and I just was seeing so many people on a daily basis that I just wanted to get better at it. Another thing is that I did most of my work in diabetes as I recently worked for Omnipod. They make tubeless insulin pumps  so I had been working in an outpatient clinic before that, seeing patients and I really got into pumps, so when I started working with Omnipod I realized that pumps are just so cool. They’re so amazing, so most of my work was with type ones. I currently don’t work for them any longer, but I did in the past, and I loved it. I learned so much about pumps and CGM including all the tips and tricks of the pump world to really help people in managing diabetes which was really fun.

 

Yeah! you’re certainly right, I think about this concept that when you get diagnosed, you’re in a health system where there is probably help available, but you have to  go out looking for it and need to go and find a diabetes educator and you need to find an endocrinologist which can be really challenging. For example, I’ve had experiences where I visited an endocrinologists who would just keep on asking me the same questions every time I visited them, and I  started feeling like it was a waste of time because I wasn’t really getting a lot of value out of it that is why I’m really interested in knowing about the different areas of help that are evolving in this space to tailor to the different types of people with diabetes and their different needs so how did you find your way through that? I also would like to hear about the Omnipod like what was your role when you were working with the Omnipod? 

 

Well, before that, I actually wanted to mention something that you said about the lack of education because I think that’s really important. When you first get diagnosed with type one, especially, it is scary, I mean, you’re now being thrown into this new world of having to live and manage yourself 24*7. I think that in the first few months or even years when you first get diagnosed are so critical to teach you how to take care of your diabetes. And if you’re not getting the proper care that you need you’re gonna probably learn some pretty bad habits right from the beginning. So you need to work with somebody to help you better manage it and to help you make realistic changes. It might not seem to be as overwhelming for you right in the beginning, so you’ll be able to better manage it moving forward. 

 

Now that leads to the question about pumps. I think a lot of physicians don’t like to put people on pumps right away because they want to make sure that they have really great blood sugar levels, they’re checking their sugars and their A1Cs are perfect which is not realistic. While working with Omnipod, I was just getting doctors to understand that pumps can actually be a tool to help patients get to that point where they actually can manage their blood sugars better. It’s basically like a calculator so it’s actually taking the guesswork out of having to calculate insulin to carb ratios and correction factors that could be really intimidating for people. 

 

Besides that,  I do think it’s important to know how to manage diabetes because you can’t just go straight to a pump and that’s not what I’m saying, rather you need to have a backup and  it’s also really important to know what type of options are there for you in terms of technology. Now let me tell you a little bit about when I worked with omnipod, I was a clinical services manager so what that means is I was part of the sales team, but I was the person who was managing all the patients that were going on the pump. So from start to finish, I would see them if they were currently on multiple daily injections or if they were on another pump, I would have to start them on the pump or transition them to it and then to follow them closely for at least a few weeks and then all the way up to three months, For that, I had to do check-ins and see how they were doing with it. I was also working on giving them education like teaching them how to use the pump, checking in with their doctors or other health care providers to make sure that the transition was smooth, helping them to figure out all the tips and tricks that they can do with the pump and making sure that they were successful. 

 

I’m interested in knowing how the patients felt and to what point you were engaging with them in that process and how the decision around omnipod was come to, for the patient? Given that you worked for omnipod, probably you had a hands-on role with the patient. That’s what I suppose, in my experience, there is a different approach in the companies, in Australia and UK, where I’ve worked a little bit around health care, the companies probably have a bit more of a distance from the patients so I’m kind of interested in that role where you got time with the patient and whether it was an omnipod specific clinic or something similar to that?

 Yeah, it honestly depends on the rules and regulations of the country or even from state to state. So because Omnipod is a medical device, It’s not pharmaceutical. For example, if you were just a pharmaceutical representative for a drug company, say insulin, you might not actually have access to the patients rather you just have to talk to the health care providers. But because it’s a medical device, you have to actually teach the patient how to use it. Some offices actually didn’t let us in. They wanted their diabetes educators or nurse educators to do all of the training with the patients, and they didn’t want us to do that. We would just train the nurses directly but for the most part, I was doing about 90% of the training with the patients. I have experienced that a lot of doctors don’t have the capacity to do that and they even don’t have the time to do it or sometimes they just don’t have extra help to train their patients so they welcomed our presence in their offices a lot of time. 

 

How many pumps were available on the market to choose from, for a patient in the US? 

Yeah, so in my experience, in a lot of offices health care providers like to be pump-neutral. Which means that they don’t wanna push the patient to choose any particular pump. They tell them all the options, and then they let them choose on their own. Some offices are very picky on which ones they should choose but some doctors will push certain pumps on people. At the time, there were three main pumps, the first one was an Omnipod to boost pumps. Second was the Medtronic tubed pump and there were a couple different ones. So I worked for Omnipod a couple years ago, but now there’s the closed-loop system like we have  670g. Now there’s also the tandem pump as well which is mostly Medtronic omnipotent tandem. These were the three pumps available. 

 

Wow that sounds really interesting. Actually, we could spend quite a while on that, but I am  really keen to talk about the nutrition and dietitian side of things because it’s such a crucial part of the life of a diabetic patient and I think it’s interesting. One thing that I have realized recently is that through the understanding of my blood glucose levels, I’ve been able to develop a more intimate relationship with food. I now have a better understanding of the impact of food on my body, and that is a really helpful part of life in general and can you please talk to us a bit about your work in that space in terms of dietitian and nutrition stuff and its relevance for controlling type one diabetes. 

Yeah for sure, diet has a huge role. I mean it’s not the only thing that affects blood sugars, but it has a huge part to play and  it really does affect your relationship with food. This is because a lot of times you can’t just go and eat whatever you want. You have to think about it and how it’s gonna affect your body later on. Technically, you can’t eat what you want as long as you have the right strategies to prevent your blood sugars from spiking. For suppose, if you want to have dessert,  you can have it but you just have to get more insulin for it. It is the strategies that help in keeping your blood sugar under control  and it is definitely a tricky part because it depends on case to case basis so it is quite variable. This means to look at the diet as a whole and to see what types of patterns are evolving in your blood sugars. Also you have to see how exercise affects it and how stress affects it. However,  when we talk about nutrition specifically, carbs get a bad reputation but you need carbs as soon as your blood sugar starts dropping. We need some carbohydrates so we know that carbs are really important. But it’s the type of carbohydrates that really matter, so you need quick carbs typically when you’re having low blood sugars. What I mean by quick carbs is that they are the simple sugars that are more processed. They are the ones that we use to track limits most of the time. The simple sugars are needed and it’s not like you could never have them. There’s this stigma around sugar for people with diabetes, it’s like the elephant in the room, and either you avoid it completely or you obsess over it, you can have these things and I think it’s really important to work with a dietitian to see how you can add some foods back into your diet that you really enjoy after all, food is meant to be enjoyed and It’s not meant to be feared. It serves a purpose in culture,community and family so whenever I work with people, I try to go over with asking them  what are your favorite foods? What is your diet like? How can we incorporate these in? But it is important to have a plan around it, to have a strategy to figure out what’s the best way to add these foods into their diet. 

 

Now, of course, there are the long-term effects of that even if your blood sugars are normal and you’re eating a ton of junk food, it’s still gonna have other effects so it’s not just about your blood sugars causing all sorts of things like inflammation. 

 

Certain foods can increase your blood pressure and cause digestive issues, so it’s really about the diet as a whole and not just about your blood sugar.

 

I absolutely agree with you that the diet is a little bit more important for diabetes than it is for anyone else. Actually all the same things apply as the excess carbohydrates are bad for anyone and they can be worse if taken in excess. There’s certainly a group of type one and type two diabetics. Basically type two is a different conversation I think in terms of diet and their considerations are different because it has partly been the reason for getting a type two. 

 

For example, last night I had a massive bowl of pasta and It was delicious. I loved it and I don’t think I could ever give it up, But what I have to do is that I just have to be more proactive with my levels, and wearing a  CGM allows me to do that though a pump probably would even be better to manage it, But what I did was that I had this bowl of pasta and I gave myself six units of Novorapid then I kept checking every 15 minutes or half an hour until before going to bed. I saw that it was slowly starting to drift up and I was in range then I gave myself another three units of long-acting and two units of Novorapid before bed so when I woke up I was in the normal range. Now when I have the same situation again, I have to consider multiple factors in terms of what exercise I’ve done and various other things. It gives a really good feeling when you can eat what you enjoy and then by taking the right steps we end up waking up in range which is such a satisfying feeling. 

Yeah, absolutely. And it’s great because it is all about trial and error, right? I mean, it’s not about beating yourself up for the times that you don’t get it exactly right and it’s not about perfection. It’s about consistency,  Just if you keep trying or when one thing doesn’t work, try something else, don’t beat yourself up about it, as I see so many people just get really stressed out about their blood sugars not being in range, and they can’t figure it out. Maybe you just need to tweak something or you can talk to a dietitian so that they can look at it holistically like seeing your patterns etc.  We can see patterns if we download your data from your CGM, we can see likes if you might have spiked up from the pasta, but you don’t realize that you were already running high because of what you ate for breakfast that day, It might not be because of the pasta. It could have been something that you had previously, but you had never come down from it so there are so many little things that you do have to look at, that can really make a difference. It really helps when you have a second set of eyes to look at your data to figure it out. 

 

As you have a vast experience with the number of patients you’ve dealt with and your background in nutrition, what are the big mistakes that type one diabetics make when it comes to managing their diet? What are the things that we need to be aware of and learn from those that are doing well?

 Yeah, in terms of mistakes, I try not to label things as good or bad, because then you kind of get a negative stigma around it, but in terms of some of the things that I’ve seen,  it comes from a lack of education by the health care providers like I had someone recently who was accidentally giving himself the short-acting insulin, but skipping the long-acting insulin because he thought he only had to take it when his blood sugars were high so he wasn’t taking any long-acting at all and just keep giving himself short-acting. 

 

Some of the biggest things that I’ve seen recently in terms of diet, though, would be Keto Diet or any of these kinds of fat diets that are out there. The Keto diet is interesting because there’s a lot of studies that show if you do it the wrong way, which means if you’re having a lot of food that’s high in red meat or processed meat like sausage, bacon, a lot of animal protein in general, it can actually be pro-inflammatory which means that it can increase oxidative stress in the body that can lead to other issues like cardiovascular disease and it can also be quite taxing on the kidneys in long term, especially if you’re already at high risk for kidney disease like if you have uncontrolled blood sugars, so that’s the biggest thing that people do and end up having complications.

 

Do you get into a lot of discussions or debates with people about these topics? Because there is a big Kato movement going on these days. I think some people would look at ketos being potentially helpful as it’s low in carbs, therefore you’re not gonna get spikes with your blood sugars. I’ve dabbled with intermittent fasting for a while now. I would just have a black coffee most mornings of the week and then on some days I just have some nuts and a piece of fruit until dinner, doing that I actually feel clearer, and the same thing happens in Keto, right? There are some similarities in them but I find that I feel clearer and generally better if I give my gut some time or break effectively so how do you handle those? Do you have a kind of fixed attitude to fasting and keto? Or is it dependent on the patient to patient basis? 

 

It’s not on a patient by patient basis. Generally, I don’t recommend Keto specifically just because of the fact that we don’t know much about the long term effects of it so far, that’s because a lot of the studies that are done they aren’t actually the long term studies as it’s such a hard diet to follow. If you’re actually doing a true Keto diet or when you’re in ketosis for a long period of time, it’s difficult to follow as the problem is that if you’re cutting out these foods like carbs for a long time, sometimes that can cause obsession over carbs so it becomes an unhealthy relationship with food. Plus, you do need carbohydrates because your brain needs energy to function. 

 

What about intermittent fasting? Am I doing the wrong thing? 

So this is another one where it’s tough to say because intermittent fasting has so many different types. There are people who fast for about 12 hours a day or overnight, some people do16 hours of fasting, some people fast for a whole 24 hours. So when you say intermittent fasting, it really depends on the person and what it means. Well, I don’t recommend going for long periods of time without food because you need vitamins and minerals to help your body function properly Right? It’s not just about blood sugars, it’s not just about energy levels but It also means to get the right amount of nutrition for your body so that you don’t lose too much weight or muscle mass. There are studies that show that intermittent fasting can actually aid in longevity. 

 

I have heard that fasting cleans up the body from free radicals and gives your body time to focus on removing unhealthy things that might exist in your body. I mean, is there any evidence present on prescribing fasting for cancer patients?

Yeah it’s kind of a slippery slope because it really depends on the person. If you’re someone with cancer and your muscles are wasting which means you’re losing muscle mass, that can decrease your immune system even further so you wouldn’t want to necessarily rely on intermittent fasting to help to cure your cancer. But again I’d say it depends. It’s hard for me to say specifically, but with intermittent fasting, one of the reasons why people do it is that they wanna limit their calorie intake and if it is for weight loss, a lot of studies have shown that no matter how you limit your calories, whether it’s through Keto, whether it’s through intermittent fasting, over time, people lose the same amount of weight. With the Keto diet, people tend to gain it back later on because it’s not a long term strategy for people. So when you go back to eating things like carbs, a lot of times you can gain back that weight pretty quickly, especially if you’re eating the wrong type of carbs.

 

Now talking about these carbs and foods is making me hungry Actually!! Let’s start to wrap things up a little bit. I find Keto, fasting and all of this nutrition stuff really fascinating and We could probably run a whole session just on intermittent fasting, right? I just have one question to finish off. I’m curious to know whether you have any insight into where we’re moving with diet, like what the future holds in regards to the different types of diets? What are the diets that we are going to see in the upcoming 10 years? 

I think a lot of the research that’s out right now is kind of leaning towards plant-based diets. This is why I don’t really like fat diets too much. I mean, some of them have benefits in different ways and that’s why I can’t give you a straight answer on which diet is best for you. In general, a diet that’s balanced with carbs, protein, and lots of vegetables is going to probably be the best option for you. 

 

There’s a lot of research that shows animal protein specifically can increase insulin resistance so if you are using insulin, your body is not going to use that insulin as efficiently due to the resistance that has been built up which can affect your blood sugars that way. Also  the long term effects of animal protein have been shown to increase inflammation and cardiovascular disease, so I’m seeing a lot of plant-based diets for the future. Honestly, I personally recommend a plant-based diet for most people. Even I personally do a plant-based diet most of the time. The reason being that it is high in fiber and high fiber diets help to feed your gut.  I could do a whole episode just on gut health. When we say gut health, we mean digestive health. That’s basically your mouth through your intestines all the way down.. You also have little bacteria that runs throughout your tract so you need to feed that bacteria and make sure that it’s healthy. Studies have found that the more you feed these healthy bacteria, the lower your risk is for diseases. 

 

Diets that are high in sugars and processed foods tend to cause unhealthy gut bacteria that can increase your risk for diabetes so half of your plate should contain low carbohydrate vegetables 

 

That is one of the really, really fascinating subjects and topics and I would love to explore this more and we can also keep it as a subject for future episodes. Thank you so much for giving us your time. If there is anyone listening and he wants some help regarding nutrition for diabetes, where can they find you? 

you can find me on my website. It is https://www.nicoledemasi.com/ and I’m also on Instagram @nutritionbynikki and I have a Facebook page as well it is “DeMasi Nutrition” 

 

Awesome. Thank you so much, Nicole. Take care. Thank you.

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