Ask Dr. Casey: Turning Around Pre-Diabetes.
Dear Dr. Casey,
My doctor told me I was prediabetic at my last annual exam. What is the path forward for making sure I don’t turn diabetic?
- Greg D
Hi Greg, I love that you have this mindset of prevention of progression to diabetes. Prediabetes is a reversible condition, but once diabetes is diagnosed, the medical world will not take it back (even if all numbers normalize). I have seen a number of my patients turn things around with some key nutrition and lifestyle changes. Let’s dive into the details of what I counsel my patients on.
When I begin prediabetes counseling is a bit before conventional standards, with the goal of metabolic health to even prevent prediabetes. Diagnosis of diabetes or prediabetes can be done in a few ways, but the most common is through a lab test called Hemoglobin A1C (A1C). I explain this as how frosted are your frosted flakes? With the flakes being your red blood cells, and the frosting being sugar molecules sticking off of it. Hemoglobin is a part of our red blood cells, and the average lifespan of a red blood cell is about 3 months. A1C is a proxy for average blood glucose over 3 months, so if you had a high sugar meal or day before getting your lab done, it won’t affect this measurement. What will affect it is if you have too many red blood cells or too few. Too many will skew it in your metabolic favor (same amount of sugar spread out over more cells), possibly masking glucose dysregulation. Too few, such as in iron deficiency anemia, will falsely elevate it. Donating blood can also disrupt the accuracy. In these instances, I will use an additional blood test called fructosamine.
An A1C percentage between 5.7-6.4% is considered prediabetic, and diabetic beginning at 6.5% and higher. I start counseling my patients once I see A1C reach 5.5% or see a trend of it increasing over time. With most Americans having some degree of metabolic dysregulation, and the nature of our food system catering to a high sugar or corn syrup additives to satisfy our brains and taste buds beyond healthy ranges, it is really never too early to start thinking about metabolic health. Here are some diet and lifestyle hacks I ask my patients to start with, and then will follow-up with A1C testing in 3 months to see if we are on the right trajectory.
Food Pairing: what you eat on your plate in what order really matters. Take a classic American dinner: steak, potato, side of veggies. Maybe throw a beer in there or other alcoholic beverage. Our brain, still in the mode from 5,000 years ago, wants the thing that will spike our blood glucose (blood sugar) the most because that means we get to live to see another day. Our modern day eating pattern and availability of food has us poorly matched with our brain’s pattern of craving for survival. Knowing this, it can actually help to bring awareness to understand why we crave certain things, and be more able to make a change. The food group that increases our blood glucose the most are simple carbohydrates.
To understand which foods spike blood sugar the most, a term called glycemic index is used. Foods with a higher glycemic index will spike blood sugar more, such as candy, soda, sugary cereal, white bread or rice, juices, even dried fruit. I encourage my patients to take a look at glycemic index food charts while they are getting familiar with a different eating pattern. Whatever is the highest glycemic index on your plate, eat it last. This generally means, start with a protein (like the steak), fat (like avocado), or fiber (like a vegetable or side salad) first and save the carbohydrate (potato) for last. This will prevent blood sugar from spiking, as the protein, fat or fiber insulates the blood sugar rise from a simple carb. I encourage my patients to even think about snacks. Want a banana, apple or piece of dried fruit? Enjoy it with nut butter, cheese or something else that will help to buffer just a straight carbohydrate.
Passeggiata: scientifically termed as “post-prandial movement,” but in Italy called a passeggiata (aka - a lovely stroll), I use this term to better exemplify moving after a meal. I have worked and lived in Europe for a number of years, and I am convinced that the European town set-ups with the need to walk to the train, home, work, etc. after meals helps to decrease their overall rates of diabetes and metabolic disease compared to our American culture. We have dinner, we go sit on the couch. Italians have dinner, and they go walk to the train station or take a passeggiata around the town. When muscles are in motion, they are looking for quick fuel sources to help them continue on that task. After a meal, when blood sugar is raised, that is a pretty easy source for our muscles to use. So muscles moving, say on a lovely stroll after dinner, will use the fuel we just consumed and lower blood glucose levels in the body so they stay elevated for a shorter amount of time. On a daily basis, this can make a big difference in A1C, and also has the added benefit of less going to be stored as fat as fuel for later. Post-meal movement is one of my favorite ways to help regulate blood sugar. The “prescription” I give is 15 minutes of gentle activity after a meal. Washing dishes isn’t enough, but a gentle bike ride, walk, or for me this time of year, a few trips up and down the stairs, works really well.
Apple Cider Vinegar: there are some great studies showing that having 1 tablespoon of vinegar - I prefer apple cider for added health benefits - prior to the largest or highest glycemic index meal of the day, can decrease A1C by about 0.5%. That’s significant! It helps the body to receive the incoming bolus of food at a slower rate of conversion to glucose, overall keeping blood glucose levels lower. Make sure to take the vinegar either through a straw or rinse the mouth out with water following to protect the enamel on teeth.
Supplements: I usually wait to see how much patients can change their A1C before adding on supplements. As I say, supplements are intended to be supplemental, in addition to, the proper nutrition, lifestyle and daily habits. A first supplement I will add-on, that I have written about previously in Natural Wellness, is berberine. There are many herbs and supplements that are helpful, and perhaps I will keep that for a future issue if there is interest!
Glucose Monitors: a continuous glucose monitor (CGM) is a tool I will employ for some patients who really want to do a deeper dive. CGMs have historically been reserved for diabetics on insulin to monitor blood glucose levels closely. However, I find it both enlightening and empowering to have an understanding of what may spike your blood sugar high and be able to see a pattern: is it sharp peaks and troughs like a rugged mountainscape, or more moderate gently rolling hills? (hint: the second one is desired).
Greg, I am already encouraged by your attitude to tackle this. I have been witness to many patient success stories when they have implemented the above three simple tactics on a daily basis. Consistency is key, and so is becoming familiar with what is in your food (high fructose corn syrup) and how it may be affecting your blood sugar. Keep me updated on your journey!
