Exploring the Impact of Diet on Blood Sugar Control

Welcome to the MedEvidence podcast. This episode is a rebroadcast from a live MedEvidence presentation.

Speaker 2: 0:07

We're going to go ahead and get started. I would like to thank everybody for showing up. This is a great turnout for what's going to be a incredible talk. I'd like to start out by introducing our guest speaker. This is Dr. Alpa Patel. She is an internal medicine physician with Millennium Physicians Group down on Gate Parkway. She has been an investigator here, a principal investigator, a sub-investigator with trials here for almost 20 years? 16. 16. That's almost 20. She knows clinical research as well as a practice very well. Her new study coming up is a type 2 diabetes study. She's got other studies going on right now quite a bit, so we'll get to those. My name is Sharon Smith. I'm Vice President of recruiting and marketing here, f or all of the ENCORE Research Group sites. I'm also a nurse and a diabetic educator. That's why Dr. Patel and I like to play off on each other and co-present on some of the type 2 diabetes.

Speaker 1: 1:09

Yeah, I've had the pleasure of working with Sharon, not just here, but even at my previous practice. She did a wonderful job with our diabetic patients. It's been a pleasure seeing her back here in a different field.

Speaker 2: 1:21

Yeah, and we get to work together. Yeah, absolutely. We're going to go ahead and get started with some quizzes. I'd like to involve the audience and I've got some new ones, Dr. Patel, so you might not know the answer. So you get to play along, ok.

Speaker 1: 1:35

She's going to test me, all right, first question, that's just a title slide. It's trivia, all right, so maybe we should have had some of these in our lunch today. You do have some lettuce, all right, that'll count.

Speaker 2: 1:48

That'll count.

Speaker 1: 1:50

Name the two most popular spices in the world.

Speaker 2: 1:55

Pepper, pepper.

Speaker 1: 1:56

no, you got one of them, a mineral.

Speaker 2: 2:02

You got turmeric. It's one of those. You know the answer, half of that Pepper Pepper.

Speaker 1: 2:13

Black pepper, so pepper and mustard. Oh, I thought it was turmeric. Yeah, in the whole world. Wow, I thought that was interesting. I guess it wasn't ketchup, huh.

Speaker 2: 2:25

It wasn't ketchup, no ketchup.

Speaker 1: 2:28

No ketchup means no fries, so which of the following is not a cruciferous vegetable?

Speaker 2: 2:38

Asparagus, Yeah, Well, that was pretty easy, that was easy. Yeah, yeah, ok, you're doing a hard one, you're right. That's very good. It was that exact question. You all saw it in the newsletter, right? No, oh, ok, ok, well, good job, very good.

Speaker 1: 2:56

But it's not. It's a very healthy vegetable for sure. I'm sure most of you will agree. Yeah, I think most green vegetables and vegetables with a lot of color in them have a lot more antioxidants and more healthier. In fact, even when you're having your plate or whatever, the more color on your plate the better for you. Is eggplant a fruit or a vegetable? I just had eggplant parmesan last night. A fruit it is. It is a fruit. It is a fruit. Eggplants, also in most of Europe known as aubergines, are technically a fruit. They come from a flowering plant and contain seeds, kind of like a tomato is considered a fruit as well.

Speaker 2: 3:40

Yep, ok, I only stumped you on one out of three.

Speaker 1: 3:43

I'm going to get tougher next time. All right. Two are false. Sugar may be more addictive than cocaine. Yeah, is anyone addicted in here? Who's addicted in here? Is anyone going to fess up to it? Is anyone going to fess up to it? All right, true, this is a smart crowd today. Yes, so as far as addictive substances, even in 2012, sugar was not considered addictive by the American Psychiatric Association, with the criteria changed in 2013, where tolerance, withdrawal or tolerance and dependence became a criteria for addiction and, just like gambling, social media shopping, sugar actually got classified as something that was an addictive chemical. And even, you know, people think that maybe having the diet version is okay versus a full coke. But it's just as addictive, and sometimes having diet drinks makes you crave food more. It increases your appetite and now you might be craving the sugar after a diet type of drink. So even diet sodas are not the best for you. If you don't need to get addicted, don't do either one. So you know, counting calories is one way to maybe help you with diet and keeping your weight down, or your sugar, but calories are misleading, right. So a 300 calorie salmon versus 300 calories of donut the other one's actually going to keep you full for a lot longer. You'll be more satisfied. It will keep your sugars more even, versus this donut where all you're going to do is fill your sugar, crash a couple hours later and now you're going to want something again. Plus, you don't need the extra fat either, so counting calories alone is not the best way to manage your diet. This is one of my favorite slides. It's a little bit busy, but we're going to talk about each organ system and how diabetes affects it, and really even medications that are targeted to help that. So, first of all, starting up, but we'll start with the pancreas, right, because everybody knows that the pancreas is one of the biggest things that fails in diabetes. The longer you have diabetes, you lose more and more pancreatic function, especially in some of the cells called beta cells that produce insulin. One of the main defects in diabetes is you make less insulin and that raises your blood sugar. And insulin has a very important function in the body in bringing glucose to your organs and cells. And when you're not having appropriate levels of insulin, the sugar staying in the blood stream and causing more damage to other organs, it actually causes the fat cells to deposit more fat. It starts breaking down muscle for energy because you're not getting the insulin to move the glucose into the appropriate cells. So the next one we're talking about is muscles. The muscles have decreased glucose uptake when you don't have enough insulin, so you start breaking down muscle. You may find in sometimes in patients that are initially diagnosed with diabetes. They're losing weight, you know. They're hungry a lot, they're thirsty a lot, they're urinating a lot. That's because you're not getting the glucose to the right places. One of the other defects that happens is also that the pancreas causes not only less insulin to be secreted, but it inadvertently increases glucagon secretion. Now glucagon is another hormone that actually raises sugar. It's kind of like a double whammy. Not only are you not making enough insulin, now you're going to push out glucagon that causes more sugar increases. And this happens a lot even at night while you're asleep. I mean, I have a lot of my diabetic patients tell me. You know, when I went to bed my sugar was this one. I woke up it was a lot higher. I didn't get up in the middle of the night to eat, but that's your liver producing glucose from the excess glucagon. One of the newer areas we figured out in the last probably decade now is that the intestine has a big part to play in diabetes. The intestines when you eat this meal, for example, it should trigger some hormones called incretins. The incretins allow the pectus to release insulin. They also kind of work on your brain and what we call your satiety center. That's where you should feel some fullness. In those patients that are diabetic, they have diminished incretins. They don't produce the same amount or they have a delayed response. So sometimes you don't feel full. You're not getting those triggers of hey, I need to stop. This is enough. The rest of this wrap was all I needed. Those signals and those leptin feedback loops are messed up as well. So a lot of the new drugs that they talk about, like the ozempics and these injectables, they work on that incretin effect and helping with making you full quicker. Maybe brain signals that not make you crave some of the things that you were craving and inadvertently helping you to lose weight. And they help you feel full after eating lunch. Yeah, they move the food slower through your gut as well. So that's kind of why sometimes people feel a little bloated or even constipation. But a lot of those side effects also do improve with time with that. And then, like we talked about, there's feedback loops from your stomach to your brain, called the leptin feedback, and those sometimes signals are misconstrued or don't work appropriately in diabetic patients. So you don't get that feedback to your brain telling you to stop eating as well, and then the liver, like we talked about, may produce excess glucose as well, which is something that you don't want. You sometimes see those morning sugar increases because of that. Another area that there's defects that we found in diabetic patients are at the kidneys. There are certain receptors in the kidneys, called SGLT2 receptors that actually they work with increasing glucose reabsorption, so the glucose isn't urinated out but it's actually reabsorbed back in the blood. Well, we don't need that. You already got enough sugar when you got diabetes. So there are a lot of class of drugs called SGLT2 inhibitors that now allow you to really urinate out the sugar, like Invokana is one, Jardiance is one, Farxiga is one of those. I'm sure you guys that are on it know, you know, have heard of some of those names.

Speaker 2: 10:45

And then, last thing to say, Dr. Patel, what I love about that class of drugs that when you're on it is it's the only class of drugs that actually removes glucose from the body. Right, all the rest of them push it out of the bloodstream and get your blood sugar down, but this class of drug removes the sugar from your body.

Speaker 1: 11:03

And as a result they're called SGLT2 inhibitors. And three of them in that class are Farxiga In vokana, Jardiance I think. There's one more with a Steglatro which I don't think you know probably don't use much but you might. All because of because these make you urinate out glucose there is a slight increase risk, especially in women, of like urinary tract infection or yeast infections because they love the sugar too. Right, the yeast loves it just as much as we do. So we have noticed a little bit of that and sometimes we can put people on some preventive medicines to prevent that. But that whole class of drugs has also now been found to reduce your risk for worsening kidney disease and diabetic patients in reducing your cardiovascular mortality, meaning like less heart attacks, less strokes, improving congestive heart failure. They also improve your blood pressure and weight somewhat as well. So this is like a new class of drugs that now we found kind of does multiple different things and the cardiologists are prescribing now. Yeah, and even in non-diabetic patients the cardiologists are prescribing those drugs because it helps with all this cardiovascular function. These classes of drugs, honestly, are quite expensive, and especially on our for elderly patients, on Medicare, and there's a big push with the government over the next year or two in working with the pharmaceutical industry and reducing costs for our seniors, because these drugs, like, have cost the healthcare system and Medicare millions of dollars and even patients can't afford them and we know they're doing patients so much good. So hopefully that kind of legislation will pass and they work with the drug companies and trying to help reduce costs for our seniors as well. So we'll go on to. I think we talked about that a little bit in the beginning, yep, so basically, when you don't have enough insulin, you start kind of the fat cells take up a lot as well. So with diabetes, a lot of the patients actually also have more fat deposition. You're not breaking down fat, you're breaking down muscle for energy, which is inadvertent. You really want to break down fat for energy. I'll let you talk about this one.

Speaker 2: 13:31

This is one of my favorite graphs. It comes from Virta Health and they do a lot of work with diabetics, but it shows the impact that the different macronutrients have on blood sugar. It is on your colorful too, I think, too, just because a lot of people really like this. So this is going to be your carbohydrate impact. Okay, refined carbohydrates obviously will be much higher. You have vegetable that's a carbohydrate a little bit lower, but basically they have the biggest impact on raising your blood sugar. They break down right away. The potato carbohydrates is a vegetable. What is it? It's a carbohydrate. Vegetables are carbohydrates and corn? Yep carbohydrates.

Speaker 1: 14:11

But there are good carbohydrates too. Right, like every carbohydrate is not bad. Broccoli is a carbohydrate, give us examples yeah, that's not too bad, and broccoli is a vegetable. That's actually a good carbohydrate, so you could pick better carbohydrates as well.

Speaker 2: 14:27

Then we have protein. Okay, that's going to be your fish, your eggs, your meat, your cheeses, and that's going to have it's going to go less high than your carbohydrates and it's going to last a little bit longer. Okay, here comes your healthy fats. Okay, think about your eggs, your nuts, your avocados, coconut oil, avocado oil long low impact on your blood sugar. So, if you combine these food groups, so let's say, and I think an egg is 50% protein, 50% fat, that's a good, that's going to have very little impact on your blood sugar. Anybody who tells me a boiled egg raises their blood sugar.

Speaker 1: 15:09

I'd like to look at that a little bit more, and avocado has fat too, but they're good fats.

Speaker 2: 15:13

Avocado has protein and fats. Yeah, so a rib eye steak. I can say that now that the cardiologist walked out of the room, it has the same protein and fat. So it's the combination that makes a difference, because we don't ever really eat just a protein meal or a carb meal or a fat meal. Think about your combinations.

Speaker 1: 15:35

So another quiz how much sugar is actually in our blood?

Speaker 2: 15:40

The answer is up there, five grams.

Speaker 1: 15:43

So you have five liters of blood, yeah.

Speaker 2: 15:46

Five liters of blood.

Speaker 1: 15:48

Five grams about a teaspoon of sugar is what's normal.

Speaker 2: 15:50

This is what's normal in your blood. It's normal, yes To get a normal blood sugar, right, wouldn't you all? Some of you love to see that blood sugar in the morning.

Speaker 1: 15:58

Yeah, and that's a misconception, right? So Sharon said in the morning, a lot of you may get normal blood sugars in the morning and a lot of patients only check their sugar in the morning because it looks better. Right, it's nice to see that number, but the more important sugars that really raise up your A1C, and that three month test that we do what we call post-prandials the sugars that you eat now, in a couple hours from now, if your body's digestive system and endocrine system's working right, you should start seeing lower numbers and really, in a diabetic patient, getting under 160 or so a couple hours later is appropriate. Check yours a couple of hours after a meal If those are running high. That's where you're seeing your A1C jump from.

Speaker 2: 16:44

You know Two hours after the first bite. So this just gives you five grams is in your body, in your blood. So think about a soda. How many grams sugar in that?

Speaker 1: 16:58

Like 45?

Speaker 2: 17:00

45?. Look at what that does to your body. You're used to five like nine times more, right? So people who are sensitive to insulin non-diabetic their blood sugar is going to go up but it's going to come right back down. They're going to be able, their insulin's going to be able to come and bring that sugar down. But people with type 2 diabetes have a hard time with that. Your blood sugar goes up and it stays up and sometimes if you start the morning with a high blood sugar, it's hard to get it down the rest of the day. Okay, checking it regularly it not easy to come down. So just want you to think about when you look at a label and you see how many carbs, total carbohydrates not just sugar total carbohydrates are in that package. Think about it. My body has five grams. What's in this? What am I giving my body and how hard is my body going to have to work to bring that blood sugar back down?

Speaker 1: 17:57

We talked a lot earlier about the pancreas not making enough insulin. But I would say the majority of you in the room probably have type 2 diabetes adult onset, which really insulin resistance is a big part of that. You probably make enough insulin in the beginning, sometimes even more insulin to try to overcome the insulin resistance. And so insulin resistance pays a big part in diabetes for adults or type 2 patients and that's why you know, really working on that whole neuroendocrine brain loop, we have so many different signals and pathways now that we can target to help improve that insulin resistance as well.

Speaker 2: 18:36

You want to talk about this. Yeah, this is just a neat graphic that comes from Dr. Unwin, out of the UK, and it gives you an idea of these are your five grams, one teaspoon, five grams of sugar, how many teaspoons of sugar are in certain foods, and it kind of gives you an idea. And so here's your white boiled potato. That's the one you asked about. The only one above it is rice on this chart. But again, notice, a lot of times a lot of the diabetics I work with will notice their sugars go up more from this kind of white carbohydrate food than a piece of candy sometimes it's not or a piece of pie. It's these kind of carbohydrates that break down so fast in their bloodstream and spike their blood sugar. So this chart does go on and on. You can kind of look at it and then, with rice especially, you want to talk about.

Speaker 1: 19:30

Like so rice, if you cook it ahead of time and let it like sit or, like you know, have rice from a day ago, you have less starch in that versus just fresh rice that you bake. You want to kind of talk about that, yeah we got a slide on that.

Speaker 2: 19:44

We got a slide on it. Okay, well, I won't get ahead then.

Speaker 1: 19:48

So the elevated insulin levels that I talked about earlier, which probably a lot of type two diabetic patients have. They prevent that breakdown of fat to energy that we talked about. They have more fat deposition as a result of elevated insulin levels. It also interferes with that whole brain signal leptin loop in preventing the signals that stop you from eating more or keep you from getting full, and so a lot of those patients they feel hungry all the time. I have many of my diabetic patients that are uncontrolled tell me like I don't know how to control this, I'm always hungry. So at least now we have better ways that we can control this, because all of this then just leaves the more fat deposition and just worsening that whole signal pathway.

Speaker 2: 20:35

So I go back to insulin is your fat storage hormone, so think about that. That's why we don't like to raise our insulin level. Type 2 diabetes so you've heard of people who are lactose intolerance. I really like to let people know that, as a type 2 diabetic, you need to look at yourself as you have a carbohydrate intolerance. You just don't tolerate carbohydrates like other people do. Because of all the reasons that Dr. Patel just went over, your blood sugars are going to stay high with carbohydrates longer than a non-diabetic, so they do. They just call it here basically dietary carbohydrate restriction. That's, if you're intolerant to the carbs and you just try to avoid them as much as possible or have just a little bit at the end of the meal or combine them with a lot of protein and fat, those blood sugars.

Speaker 1: 21:32

And even the order in which you eat them. Right, like you don't want dessert first. We've got a slide coming up, too.

Speaker 2: 21:39

She knows these slides so well.

Speaker 1: 21:42

Here's some sneaky ways that this is all sugar sneaky names for sugar. Yeah, sneaky names for sugar. You may see these in a lot of products. There are a lot of these. For a while we had a lot of things that would say sugar-free. People think that if they had sugar-free ice cream it's probably better than not, but they still raise your spike, your blood sugar, up.

Speaker 2: 22:06

I think it's honey nut cherries. I know when I started this slide honey nut cherries, I used to put the label up five sources of sugar in honey nut cherries. So again, sometimes people will bring me a bar or something and say, well, what do you think of this? And I'll go through sugar, sugar, sugar. But it's just label. So you really have to look at that, uh-oh.

Speaker 1: 22:30

So tips for managing your diabetes. Number one fluid intake. So we tell people half your body weight. If you weigh 120 pounds, 60 ounces is what you want to drink a day, like most of these larger bottles of water are usually like 16 ounces each. This 20 ounces. There should be three of these, and so the more hydrated you are, the better for your blood sugar and some of these medications that we talked about too, like those SGLT2 inhibitors. You need to drink a lot of water for those to work well, because, think about it, you're going to be peeing out sugar. We got to increase that urine flow somehow too right. Another way to kind of help you eat less is maybe keeping drink more water, like drink some water before your meals. Maybe not during or immediately right after, but before kind of keeps you full and it makes you not eat as much.

Speaker 2: 23:27

Put some whey into it. So nowadays you know there's so many protein shakes out there. We keep them at work all the time. But they did do a study where they had 50 grams of whey protein oral placebo 30 minutes before eating three slices of white bread with jelly on it. I wouldn't that throw all of our blood sugars through the roof. But guess what? Blood sugars for the whey protein three hours post-prandial were 28% less and the early insulin response in that early insulin response was at 30 minutes post-prandial was 96% higher. So that protein. Think back to the graph of the macronutrients A big bolus of that protein. Whatever shakes you bite got very little carbs in it. I think you can get below 10 grams of carbs and they're all like 25,. 40 grams of protein is a great way to. Okay, I'm going out to dinner. I know I'm not going to eat. Well, we're going to Mexican and we're going to have chips and margaritas. Drink a protein shake before you go and just relax and eat what you want. Or you go into family dinner and you know they're going to have your favorite macaroni and cheese and all sorts of things that aren't good for your blood sugar. Drink a protein shake before you go and enjoy. Enjoy the time we need to learn to live with this disease. Right, got it being torture, so it's just a good way to manage your blood sugars and control it yourself. Sometimes, when I travel, I take the protein and I put it in a little Ziploc. You can buy a bottle of water, pour it in, take it and then I can go get the firehouse sub the back of the airport.

Speaker 1: 25:05

The food is a big part of diabetes and one of the things that Sharon's talking about the early response. A lot of times with diabetes you don't have that initial release of insulin like right after a meal. There may be a delayed response, so your sugar stays spiked up for a long time but then later on, if you really had like a high carb meal, you could start noticing your sugar crashing because you have a delayed elevation of insulin which is why sometimes people who have a lot of hypoglycemic events, they say might be prone to developing into prediabetes.

Speaker 2: 25:43

This is a really exciting.

Speaker 1: 25:44

This is always getting ahead of. She knows this really well.

Speaker 2: 25:48

But this was. They took a submarine sandwich. Okay, you got the bread, turkey cheese, lettuce, tomato and that's going to be the green line. They ate the sub. Their blood sugar went up and came back down and then they said, okay, I want you to disassemble the sub, eat the bread first and then the turkey cheese, lettuce, tomato. And this was the carb first. All the way you went much higher and, look at this, you dropped a whole lot lower. That's that hypo-filling for some people, but if they took and ate the turkey and cheese first, the carb last. Look at this effect, not much. So consistent with the protein shakes, consistent with your food order, is go ahead and eat the protein first. So you sit down for a family meal and you've got your baked chicken, your green beans and macaroni and cheese. Eat the macaroni and cheese last and you should have a less effect on your blood sugar than if you started with the macaroni and cheese. So food order it's hard to do it on a day with what we served you.

Speaker 1: 26:57

You could have eaten the chicken out of the bread first, or just the chicken and salad, and sometimes, after you eat that protein, you probably don't even want the rest of that pito. Whatever, right.

Speaker 2: 27:10

Yeah, and let me tell you why. I love eggs for dinner, even if you have three eggs or two eggs are what? 50 cents an egg? That's like a deal. Okay, you can get by and have dinner for a dollar 50. And even though eggs are going up, they're still hanging around 50 cents so you can still eat a good egg dinner for less than $2.

Speaker 1: 27:29

And you can add a bunch of veggies and stuff into it like peppers and onions and like whole bunch. Yeah, and then that's, you get all your vegetables too, right?

Speaker 2: 27:38

Yeah, that's too much work. Come on. Yeah, you keep them pre-cooked yeah.

Speaker 1: 27:47

I love a bunch of bell peppers and all that in there and onions here you go. Here's your other favorite side, yep, the resistant starches, that's what we were talking about earlier. So potato cooking rice and then cooling it Same thing with the potatoes, the green beans, you know how, like you do the overnight oats. All that stuff like kind of prevents the carb from breaking down easier and it helps improve the insulin sensitivity so you may not see your blood sugar spike as much. If you've cooked that earlier, let it cool down and then eat it Like probably like day old rice is probably the best thing.

Speaker 2: 28:28

The other place. I see this in type one diabetics who are very, very sensitive. One of them came to me and said he noticed he could have the sushi but not the fried rice. No, the other way around. He could have the fried rice but not the sushi, and he didn't know why. And when he asked them, they said that the fried rice was leftover rice from the day before they made into fried rice. So they cooled it overnight. He became a resistant starch and then they made fried rice out of it.

Speaker 1: 28:57

Yeah, yeah, you also have to be careful sometimes with fried rice, as though you can get other bacteria as well, so you got to make sure it's cooked all the way here.

Speaker 2: 29:08

And this study that they did back in 2010,. It says that using resistant starches in your diet actually improved insulin sensitivity in some people with metabolic syndrome. So that's going to actually improve your insulin response sometimes. So it's something we're trying. Green bananas you'd have to put them in a shake probably.

Speaker 1: 29:28

And one of the things that's very helpful too is good gut bacteria. There's a lot of evidence now that many diseases are caused by inappropriate gut flora. You need certain healthy bacteria in your gut. So I turned 50 last year and I finally got my colonoscopy 10 days ago. What an experience. So now at least least me bugging all my patients about it I can say I did it right, but I think it wiped out everything from my like. I've had to start back eating very slowly, taking probiotics, because it probably you need good bacteria for digestion, for insulin sensitivity and maybe there's more targets of treatment and improving that whole what we call gut microbiome. We think it maybe even helps diseases like Alzheimer's as well. There's a lot of research and investigation going into that.

Speaker 2: 30:22

So for some people rice is worse, potatoes are better. That's where you need to know your own and, like Dr. Patel said, if you check your blood sugar before a meal and you check it two hours after, called the poor man's continuous glucose monitor, you should go up and come back down to where you were before the meal. If you didn't, there were too many carbs in that meal for you. So everybody's a little bit different. We're going to throw all those in the same category.

Speaker 1: 30:52

I think there's differences in metabolism and food sensitivities based on ethnicity too. So a couple of years ago you know everybody goes on a kick and does a diet in January, right? So I went on a high protein diet. Well, I'm vegetarian and Asian, so rice and vegetables are a big part of my daily meals and I stopped eating those. I was eating a bunch of healthy fats and protein. You would have thought that would have been good for me. I gained like seven pounds in two weeks and I was supposed to be on a diet and I felt awful and I told Sharon about it. I'm like look at this diet change I made. And this has been the worst thing for me because I think, based on my ethnicity and how I've been brought up and what my food intolerances were, that was not appropriate for me. So going back to maybe just smaller portions of what I was normally eating was probably the best thing for me. So I think you have to kind of see like we may tell people go on a high protein diet, you'll lose weight. Well, that backfired for me quick like. So I think you have to really figure out for yourself what works for you.

Speaker 2: 31:59

And the other side of that is when your mother made me that beautiful meal, vegetarian meal with all the Indian spices, and it was amazing, my blood sugar went from 100 to 280. I went up 180 points in one meal and it was like, well, my body's not used to that.

Speaker 1: 32:16

Yours is not used to that. No, not used to that.

Speaker 2: 32:18

No, it is different to other people. Okay oatmeal and I just heard something on this this morning from a cardiologist so in my experience doesn't mean it's your blood sugars. I have seen oatmeal spike blood sugars in type 2 diabetic quite a bit and usually they don't have just the oatmeal. Steel cut oats are a little bit more fiber, they're a little bit more of a whole kernel. But what I really love is you know we're in clinical trials here and we look at the data that comes from trial. So they did a trial with children and they said overweight children one of the three either the instant oatmeal deal, cut oats or an omelet for breakfast. And then they checked their blood afterwards. So instant oatmeal throughout the day those children ate 81% more food. They were hungry, kind of like she said with the donut versus the salmon. They're hungry. Steel cut oats they ate only 51% more food. All of those compared to the omelets. Plus. When they checked the blood levels in the oatmeal group, insulin, sugar, adrenaline and cortisol were all elevated. Cortisol is your stress hormone. So in these kids, feeding them instant oatmeal which has sugar in it, raise their blood sugar and stress out their body, probably trying to get that blood sugar down. So does that mean you can never have oatmeal. No, there are ways that people combine the oatmeal with a scoop of protein powder or their protein shake, so now you've got maybe 30 grams of protein to help that blood sugar down. Some people put peanut butter in it. I would just say, or put nuts on top, so try to find something if you like oatmeal.

Speaker 1: 34:07

The fiber with chia seeds, things like that, I hope.

Speaker 2: 34:12

Well, now I'm running in your bread. Actually it's going to ruin your whole lunch by the end of it. Dr. Hyman at Cleveland Clinic did a study on the two slices of bread and it was a whole wheat bread and it raised the blood sugar faster than a tablespoon of sugar. So again I said some people, candy or the pie doesn't raise it as much as the carb does. And again it's all individual. You need to check what works. But some people say, well, it was whole wheat bread.

Speaker 1: 34:43

It wasn't wonder why you want to do more of like the high fiber bread.

Speaker 2: 34:50

Has anybody ever tried the Ezekiel bread that tastes like cardboard but you make it flavorful. Is that the sprouted?

Speaker 1: 34:57

ones the sprouted.

Speaker 2: 34:58

Yeah yeah, that's just something good. I mean, you can make it. It's not the toast with butter. You have to do something with it.

Speaker 1: 35:06

So there's some things that you know can definitely raise your sugar. Whenever you're sick, you also may notice your blood sugar is higher, especially if you have an infection. On those patients that are on insulin, we sometimes have to even increase the insulin levels, even when they're sick and may not be eating as much, because the infection itself may be increasing Cortisol and things like that. Dress definitely is a big component to increasing blood sugar because it increases all your adrenaline and cortisol, lack of sleep, pain, of course, the donuts and the food that we're not supposed to eat. You know, keeping your medicines, I think, is a big part and sometimes you know it's difficult or side effects from medicines, which I think all of you should work with your doctors because we have a lot better options with medicines. If you have side effects, there are definitely other options that they can work with you on instead of skipping. Many diabetic patients do have gum disease or gingivitis, but that also can increase your blood sugars, and getting routine dental care once a year is very important for anyone who is sick. It's very important for anyone with diabetes. What we talked about with that dawn phenomenon was that surge in hormones that sometimes happens while you're sleeping. Glucose production increases because your liver is pushing out blood sugar from elevations and glucagon, of course, you know, going to high altitudes can raise it, which you know down here in Florida we shouldn't have a big problem with. And then just, you know, being sedentary, not enough exercise we find, you know, it's harder as you get older, right Like mobility is decreased, there's pain, there's all of that, but there's still ways to be active. So my mom recently just started doing chair yoga with a few of her friends. They get together on Zoom and one of them is supposedly a retired doctor who she does this with them and she's actually noticed that she has much more energy, she's moving a lot better. I don't know about her sugars we're going to find out when she comes to me next week but you know, I think overall it's helping with her energy level and so I'm hoping many of the other things are better. But there's still ways to do some activity even when your mobility is not that great.

Speaker 2: 37:26

Sunburn too. Sunburn is one believe it or not, and that's probably more of a problem than high altitude here in Florida.

Speaker 1: 37:33

So some of the newer drugs out there the GLP1 agonist I'm sure all of you have heard of those Ozempic and Trulicity and Bydureon, Victoza. Mounjaro is actually a dual, it's a GLP slash GIP, which we'll talk about on a different side. But these are all injectable medicines, majority given once a week, except for Victoza, which is daily. They actually trigger the prank areas to produce more insulin after eating and so maybe you think, well, too much insulin is not good either, right, but this produces it appropriately. So what we talked about was in diabetic patients you have an inappropriate insulin increase too far out after eating. You need it more closer to the timing of the meal so that you're using the food and things that you just put in to actually get to your organs, to get to your muscles. It actually even slows down gastric emptying, so food sits there longer, you may feel full quickly, you may not get hungry as often, so that helps with some of the weight loss. As a result, I guess some people feel constipated. There are some black box warnings now on these medicines of gastroparesis where it actually had a case. I think of someone who was in the media a few months ago where it actually just slowed down their gut to the point where they had gastric paralysis. It's very rare but we have to tell patients about that. They reduce your postprandial glucagon so it prevents more of that glucose going into your bloodstream and it actually makes you feel full quicker, like you might be pushing back from that after quarter of that meal versus three quarters of the meal, so that actually overall helps with your weight and glucose levels. One of the things you have to be careful with with these medicines or classes of medicines is if you have any hereditary forms of thyroid cancer, ones that run in families, a particular type of thyroid cancer, then you cannot use these in those patients. So if you get put on these medicines and your doctor doesn't ask you about your family history of thyroid cancer, if you have one, please tell them. So the next slide talks about the newer classes of these injectables, which there's only one right now, Tirzepatide, which is brand named as Munjaro for diabetes. Now it's also being used for weight loss alone, called Zepbound, and this actually does the same type of thing, but it also inhibits dipolysis. It really prevents the fat deposition and helps you to break down fat. So it actually has two different GLPs and another one called what we call a GIP, the gastric inhibitory peptide. It's actually making both of these stomach hormones work better to not only improve your blood sugar, make you feel full quicker, but also to break down fat. Like we always worry, like with patients on diabetes, a lot of the medicines even we had in the past, like Actose or Pyaglidazone maybe another name for it it used to put on like 20, 30 pounds on patients. Now we have drugs where we can help diabetic patients even lose weight. So we'll talk about some of the gut dysfunction. We kind of gave you a little prelude on that. So you know, gut microbiome, gut flora, actually has a big part in like blood sugar homeostasis and we found that restoring good gut bacteria and good duodenal health can actually improve your overall metabolic health, improve glycemic control, improve all these signals that help patients with diabetes. We actually are going to be doing a study here. Part of it's going to be here, part of it's going to be in Orlando, where the actual procedure will be done, where through an endoscopy, which is a similar type of procedure to a colonoscopy, but the other end, so through the endoscopy procedure, they will be using a device that actually kind of resurfaces that duodenal lining. So the duodenum is the first part of your intestine. After your food moves out of your stomach it goes into the duodenum and duodenal dysfunction we found can lead to increases in blood sugar. So this procedure will actually cause like that uses. It's almost like a little clipper. That kind of clips little areas of your duodenum and it allows that surface to come back again with good gut bacteria and what we'll be doing is then monitoring these patients very closely to slowly try to take them off of some of their medicines. Some of these patients in the early studies were able to get off of insulin. I don't know how long they were able to get off of it, but it was a year study and during that time people were able to get off of insulin. So these are some newer studies we're looking at like non-medicine. This is just a procedure, right? You're not even going to have to take any additional medicine. Oh, they're only looking at those studies right now. For patients on insulin. You can be on other medications but you have to be on insulin. But I think down the road, if they find that this helps people come off of insulin, they'll maybe looking at it for other patients too that are not, on insulin related medications and clinical trials. I don't know how many of you in here have participated in a research study with us before. Yeah, a few. So all of this is no cost to you. In fact, we very much appreciate all of you coming here today, and if you do participate in a study, I think you're not only helping us learn better about medicine, helping create better products, not only for yourself, but for your children, for your grandchildren, and we reimburse you for time travel. You get paid to do the studies there's no cost for any participation to you and you'll be monitored much more closely with it, and instead of the 15 minutes that we have in our office, you'll spend a much longer visits here with the physician, with dietitians, with nurses, with the whole team that's going to be taking care of you. One of the other things in patients that have never done a research study is they worry about well, what if I'm having an adverse effect? Everything that's happening to you we want to know about, because we want to know if there's trends. If we find that in this study, everyone's blood pressure is going up, well, maybe we need to stop the study right. So you're going to be watched very closely. Your labs will be monitored by us closely and if we even see something that's not going in the right direction, sometimes we may stop a patient from the study or even stop a study altogether. So you will definitely be safely monitored throughout the study as well. Thanks for joining the MedEvidence Podcast To learn more head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.