Advanced practice dietitian Amy Hess Fischl MS, RD, LDN, BC-ADM, CDE joined The Huddle to talk about the various food factors that can impact glucose levels, how to help people with diabetes address and understand the factors that impact them most, and how people with diabetes may adjust their insulin doses based on these various factors. This podcast is being produced in collaboration with JDRF. JDRF works to improve the lives of individuals living with T1D by providing meaningful educational resources for health care professionals and community members.
Advanced practice dietitian Amy Hess Fischl MS, RD, LDN, BC-ADM, CDE joined The Huddle to talk about the various food factors that can impact glucose levels, how to help people with diabetes address and understand the factors that impact them most, and how people with diabetes may adjust their insulin doses based on these various factors.
This podcast is being produced in collaboration with JDRF. JDRF works to improve the lives of individuals living with T1D by providing meaningful educational resources for health care professionals and community members.
See a full list of factors that can impact glucose levels on Diatribe here: 42 Factors That Affect Blood Glucose?! A Surprising Update (diatribe.org)
Learn more about JDRF here: JDRF - Diabetes - Type 1 Diabetes Research, Advocacy, and Support
Jodi Lavin-Tompkins
Hello and welcome to ADCES's podcast, “The Huddle: Conversations with the diabetes care team”. In each episode, we speak with guests across the diabetes care space to bring you perspectives, issues and updates that elevate your role, inform your practice and ignite your passion. I'm your host Jodi Lavin-Tompkins, a board certified nurse in advanced diabetes management and the director of accreditation and content development at The Association of Diabetes Care and Education Specialists. Our guest today is Amy Hess-Fischl. She's an advanced practice dietitian and CDCES with over 25 years of experience working directly with people with diabetes of all ages. She currently works at the University of Chicago in the Outpatient Endocrinology Clinic.
This podcast is being produced in collaboration with JDRF. JDRF works to improve the lives of individuals living with type 1 diabetes by providing meaningful educational resources for healthcare professionals and community members.
So welcome, Amy.
Amy Hess-Fischl
It is such a pleasure to be with you today.
Jodi
Well, our topic today is food factors that affect glucose. I know there's a lot of them. In fact, you're going to give us a number, I think. How do you determine what specific factors are affecting that person that's sitting in front of you?
Amy
Great, great question, Jodi. And you are correct. I'm going to give you a number. And of course, the number is from Diatribe. So you can take a look at that lovely graphic that they have that there are over 42 factors that can affect glucose. So we know that they're categorized into six different categories: medication, activity, biological, environmental, behavior and then food factors that of course we're going to be delving into so much deeper today. Now, I had a patient tell me that, when the first 42 factors came out I was kind of jazzed about it. So I said, look at this, isn't this great? And he said, oh my gosh, I really don't want to see that. I don't want to know everything that can affect my glucose because it's just going to make my head explode. Like you asked, like how do we really look at what's going to affect the person that's in front of us. You know, it's about that conversation that we have with them, you know, really understanding how overwhelming diabetes is, but really hone in on, you know what, I'm exercising and I'm having so many issues with my glucose, what can I do? And we can kind of delve into that. You know, where are you injecting your insulin in relation to your activity? So we can really want to focus on what's going to be best for them, not necessarily wowing them with all of our knowledge of the 42 factors, but at least listening to what they have to say and what some of their struggles are. And that's really where I start. Again, having the 42 factors in my back pocket and having that as a reference, of course, for all of us, but again, really, really honing in on what's going to really affect them right now for the positive.
Jodi
So I like the fact that you said you need to listen to the person and see what's most important to them. But with all these factors and listening, and I'm sure they have more than one that they're talking to you about, how do you know which one to tackle first and how do you work with people on that?
Amy
Another great question. As diabetes care and education specialists, one of our biggest roles is really prioritizing needs because there's only so much time that we have with them. And now...Of course, we are lucky that with DSMT, we have at least two hours. And then as dietitians, having two hours plus additional unlimited for an additional referral. So again, really hone in on that and capitalize on the fact that you can spend more time with these folks and tackle maybe one or two issues at a time and then reassess and reassess. Because it's all about not the one and done. This is an ongoing conversation. This is an ongoing relationship with these folks to kind of help them to kind of tease out what's going to work best for them.
What I'm going to really start first with people is carbs. Let's talk about carbs because we know that this is going to have the biggest impact on glucose. So we want to kind of separate it into two kind of categories, carbohydrate quantity and the carbohydrate type. Carbohydrate quantity, when we think of the volume of carbohydrate that someone has, the more that they consume at one time, the slower it's going to digest. So we really want to tell people about that first. And we want to talk about the different types. So I want to kind of talk a little bit about glycemic index, talk about sugar alcohols, fiber, and as well as liquids and solids. So when we think of glycemic index, we know that it has been found that higher glycemic index foods may require a change in timing of dose. Now, glycemic index does not impact everyone the same way. And glycemic index is not something that they're going to find on a nutrition facts label. So when we think of glycemic index, this is really individualized, identifying are there particular foods that impact your glucose faster? If they do, then we can change the timing of the dose. Now polyols or sugar alcohols, they are usually going to break down into some type of glucose, but not all of them break down 100%. So knowing different sugar alcohols may not break down into glucose, that may also need an adjustment in their insulin doses to reduce their risk of hypoglycemia. Now, again, one thing that I always have to kind of throw in there is that sugar alcohols are still calories. They're still, you know, again, looking at the nutrition facts label of a particular food that may be sugar -free that has sugar alcohols, there may not be that big of a difference in calories or fat. So they need to kind of have to identify, do they want to choose something that has sugar alcohols? And it still may have the same impact on their glucose. So again, that's really an individual thing that they have to ask.
Fiber, same thing. Large quantities of fiber may impact insulin dosing. Large quantities. Now, the average individual is not eating very high fiber. So again, looking at if somebody is using insulin to carbohydrate ratios and eat a high fiber food and they use the same carb ratios they always do, does it cause hypoglycemia or not? If it doesn't, there may not need any adjustment at all. So it really does come down to taking a closer look. But the general recommendation is if the total fiber content is greater than five grams, they can subtract half of that total fiber from the total carb and then just dose for that. So that is an option, but it may not have any impact whatsoever.
Liquid and solid, we know that liquids are going to increase glucose more quickly than solids. So again, it may need a timing of a dose change. So again, really hitting some of these types are important for people just to understand how they're going to impact glucose levels. But as I was telling a patient yesterday, you know, again, he called it a game. I like to call it experiments. You know, experiments with the foods that you're eating, identify how they impact you. Because that's really the key. How they impact you, not generally you. Again, what's happening? And then we could come up with a plan to kind of attack that for you so you're not as frustrated when you're eating these particular foods.
Jodi
Okay, that makes sense. So in addition to carbs, are there other key areas of focus that you typically want to hone in on?
Amy
Absolutely. We know that quantities of protein and fat can also affect glucose levels. So we want to discuss that in just general, you know, a healthy eating pattern. You know, we want to kind of go over that, but we know that a lot of people eat much larger quantities of protein as well as larger quantities of fat, and that's going to impact digestion. So there's really no true consensus on, you know, kind of how to adjust insulin for all of these particular kind of situations that are occurring within eating patterns. But, you know, the research is clear that for protein itself, when somebody is consuming the equivalent of like greater than 75 grams of protein at one time, that's the equivalent of about 10 ounces of some type of meat, chicken or fish. So again, their hand is usually somewhere in the four-to-five-ounce range. So just kind of putting that into perspective. So large quantities of protein, it may cause the glucose levels to rise later. And we know that large quantities of protein may have an impact on hepatic gluconeogenesis. So again, that could very well be part of what's happening. But like I said, there's no consensus on how to make adjustments to insulin on that, but there is some interesting research on fat.
So when we think of high fat, they consider that greater than 30 % of the total calories coming from that meal. So again, anytime somebody's eating out, anytime, again, that they're having larger quantities of even like olive oil or butter, again, it doesn't have to be saturated fats, but that does seem to need an increase in total insulin dosage for that fat itself. So the general kind of recommendations that have been done in very small studies, anywhere between 20 to 30 % extra. And the recommendation usually is just dosing, giving that all at the beginning of the meal. But again, we know that just kind of giving people the baseline saying, yes, all right, now I understand why my glucoses are rising is really a good place to start and then start making some adjustments, but looking for the trends. Again, doing the same thing a couple of times to gain a better insight into, yes, all right, I got it. This is how much insulin I need to take for this.
Jodi
Right, so that makes it easier. They don't have to really think about, is this high fat? Is it high protein? What's it going to do now? What's it going to do later? If you just experiment with the same meal a few times and see a trend, that's the bottom line.
Amy
Absolutely. So again, I think that we want the patient involved in their care, but what the level of their experimenting is going to be so very individualized.
Jodi
Now we need to move into like other considerations to think about and address in the context of meal planning. So tell us what else we need to think about.
Amy
Sure. You know, when we think of, you know, caffeine can impact glucose levels. And, you know, again, it may just have a counter regulatory effect causing the liver to kick out glucose. So again, in my clinical experience, I have so many patients like me that are drinking, you know 12 ounces of coffee in the morning without anything in it and it's still causing a rise. Yet again, we've just established that it's taking a little bit of insulin for that large cup of coffee that doesn't have carbohydrate, but the caffeine is impacting your numbers. Kind of blunts that response.
Alcohol is another that I like to just have a conversation about. We do know that the more alcohol that somebody consumes, the longer the liver's gonna shut off. And so it's something that we need to kind of discuss, that insulin dosing may need to be altered in those situations. And it really does depend on the type of insulin regimen that they're using, what we can actually do to reduce their risk of hypoglycemia. Because again, we know that initially some types of alcoholic beverages are gonna cause the blood sugar to rise. It's the after effect with larger quantities of alcohol.
Jodi
That reminds me of somebody I worked with in my practice in the past. And she would have overnight hypoglycemia almost every night. And I was struggling to figure out what was causing that. And then I found out she just had a glass of wine with dinner every night.
Amy
Exactly. Exactly.
Jodi
And she was just super sensitive, I guess. Her liver just really shut off and she went low every night. So. We eventually figured that out, but it was, I just remember her because that was so pronounced.
Amy
You know, I think that we should have a bigger conversation and just understand people's alcohol consumption. I have to be very diplomatic of, of course, you're well aware of the recommendations of how much alcohol a female should consume. But if you're going to continue to do this, then we have to make some concessions with your insulin dosing to reduce this profound risk of this prolonged type of hypoglycemia that you're having. So yeah, absolutely. Looking at, is it just one glass of wine versus one drink versus multiple drinks and how that's impacting them is a conversation that we need to have, no judgment. But again, we need to really, really impress upon them what it can do to their glucose levels.
We know that meal timing also is going to have an impact. So larger meals might impact glucose levels hours later. So, you know, again, we have to look at those. Again, I had a gentleman that came in not that long ago on multiple daily injections and he's from India and he eats very traditional meals and a lot of his meals are very, very large. You know, again, he's consuming 130, 140 grams of carbohydrate along with high fat, along with high protein. And it's impacting his numbers six, seven hours later. Everything looks wonderful up until bedtime and then overnight it rises so dramatically. And so we want to really kind of take a look at how do we adjust your insulin doses on multiple daily injections to kind of help reduce that hyperglycemia that we're seeing so long after a meal. But again, it's just an interesting conversation to have like, oh, wow, I had no idea that that was my meal. Again, I thought that my carb ratio was fine. No, again, it's fine up front, but there's still all of that food that's digesting.
We also know that dehydration, again, for our athletes that are out there, you know, could falsely elevate glucose levels. So just making sure that they're not giving insulin doses if they have even mild to moderate dehydration, you know, so again, making sure that they're staying hydrated surrounding their workouts.
We also have to just touch very shortly on the personal microbiome. We know that there's so much research coming out and we know that gut bacteria is influenced by so many things, including the foods that we eat. So, we want to make sure that we're maintaining a healthy microbiome. And that's not really rocket science. Again, eating healthy, making sure that we're eating more fruits, vegetables, more fiber, beans, nuts, whole grains. But stay tuned because again, we are gonna be seeing more interesting research coming out on the impact of digestion and glucose utilization, because that's really the key. We know we see it with celiac disease. Again, if something isn't digesting, of course, we're going to be seeing that it's going to impact glucose levels. So does that also kind of translate to a more unhealthy microbiome? Again, the answer, maybe yes.
Jodi
Let's move on to talk about management with insulin pumps. So what practical tips do you have for our audience for medical management on pumps and how you've adjusted for some of these factors you've talked about with some of your patients?
Amy
Sure. Let's start with just pumps that are not automated. These recommendations are very similar to somebody that's on multiple daily injections. You know, again, I'm thinking of one particular young lady who I was emailing earlier today. She is not using AID just yet. So she is able to adjust the amount that she gets upfront and she can extend the amount of insulin over a longer period of time. So non -automated pumps at this time can have that ability to do that. So it just makes it so much easier that again, what she eats, you know, high pro, you know, high fat, you know, higher cal. We can say, all right, let's increase the dose by about 30 % for that extra fat, and then she can extend it over five, six hours. And that with all of these little experiments that we've done multiple times with that food that she consumes, again, we've kind of hit the sweet spot of what her insulin needs are. Now, not everyone's gonna wanna do this, but again, I think that really kind of helping that person with diabetes, to kind of make adjustments based on the information that you have is going to be useful. But again, she finds that using that extended bolus for long periods of time has really been helpful. And she's not seeing that hyperglycemia that was lasting for five, six, seven, eight hours in the past.
Jodi
OK, and what about with people moving to AID systems?
Amy
Absolutely. We see that there are some other differences. So we know that not all of the pumps have the extended bolus available. So again, if they do, it may only allow for extended for about two hours. So that might require that someone kind of splits the dose like in multiple daily injections. But we do tend to see that with those higher fats, again, just by increasing their total dose upfront by 20 to 30 % tends to do the trick. Again, so I think we have to acknowledge the fact that this is so very individualized. But again, I'm thinking of patients that I have. I have two particular patients, one that has gastroparesis, and she is on a pump that has that extended feature. And so she really finds that doing kind of a 50 -50 split over two hours for most of her meals keeps everything nice and flat. Whereas another patient that doesn't have that extended feature, it just kind of increases their dose by about 20-30% upfront, and the pump kind of takes care of the rest for them. So, you know, I think that, you know, it really just comes down to really kind of diving into the data and helping them to kind of troubleshoot and problem solve based on that. But, highly motivated individuals that say, Hey, I want to work on this. I need to figure this out because this is what's happening to me every day. So again, I think AID, you could still have some amazing results just knowing how these types of carbohydrate and other things within the composition of our meals are going to impact them.
Jodi
Well, Amy, you've shared a lot of great information, and I want to thank you for that. Anything else you'd like our listeners to take away from this conversation?
Amy
Well, sure. I think that I'm not telling anybody that's listening anything that they don't already know, but when you're talking with that person with diabetes, tell them to take a deep breath. Again, there's gonna be a lot of things that affect glucose. Let's kind of chip away at it a little bit at a time. We're collaborating. Let's work on this together. Use that glucose data to assess how certain factors affect glucose. Again, CGM has been just a godsend in my career to be able to help people to better understand and say, hey, yeah, look at this. You know, you can see this cause and effect. Now you can make that change. You can make that change. It's that empowering that person to really see how much that they can do and what they have at their fingertips. You know, trends, as I said before, you know, I work with a lot of highly motivated folks, but it does take at least two to three different experiments to really come up with a better understanding of how changes really impact to kind of come up with that final goal for them. So, you know, it takes time. Time and patience, again, is really important. And knowing that there is somebody for them to collaborate with, it makes all the difference.
Jodi
Well, thank you so much, Amy. This has been great. You've shared quite a bit that I think will be helpful, and we appreciate it.
Amy
It is such a pleasure to help. Thanks.
Jodi
Thank you for listening to this week's episode of The Huddle. And thank you again to JDRF for their partnership on this episode. To access the notes and resources from today's episode, head over to adces.org. And remember, ADCES membership gets you free access to resources, education, and networking that improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at adces.org/about-us/membership. The information in this podcast is for informational purposes only and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your health care professional for any medical questions.