Q&A: Sugar, A1C, Metformin, and More

Dr Jedha Host 01:01

Hello and welcome to episode 10. Joining me today is Emily, our dietitian nutritionist, and
we’re going to be doing a Q&A session answering some of the questions that have been
submitted by you. So welcome, emily.

Emily Guest 01:15
Hello Jetta and all of our listeners out there, so great to be joining you and so exciting to get
this podcast going so we can help more people out there to improve their health.

Dr Jedha Host 01:27
Yes, right, it is so exciting and I’ve really been enjoying bringing Type 2 Diabetes Talk to life
so far. So, for our listeners, you might be interested to know, Emily has been working with
me since 2017. So for about six years now she has both a bachelor’s and a master’s degree
in dietetics and nutrition, and actually we cross paths not long after you finish your
masters, right, emily?

Emily Guest 01:52
Yes, that is right, it’s a very good memory. So I studied nutrition at Framingham State
University, which is right outside of Boston, Massachusetts, and I officially became a
registered dietitian in 2017.

Dr Jedha Host 02:04
Yeah, and what really struck me about Emily at the time was her open-mindedness. Back
over a decade ago, when I started my mission to support people with diabetes, dietary
recommendations I was sharing were considered very controversial and I found it quite
difficult at the time to find dietitians who are open-minded and also, sorry to say, capable.
Emily had a background as a nutrition research assistant and in developing and running
nutrition programs and classes for the community, and she’s had experience in clinical
practice as well as acute care and skilled nursing care. In other words, Emily has a broad set
of skills and experience and, being that she had completed a master’s degree and she’d
worked in research, I knew she’d be able to help me synthesize research for us to share
with people. So, anyway, that’s a bit of background there about Emily and I hope you don’t
mind me sharing a few of those facts to Emily.

Emily Guest 03:03
No, not at all. I thank you for the kind words and it really has been a pleasure working with
you, and I know that our work together has helped so many people and will continue to
help so many people, so thank you for this awesome opportunity.

Dr Jedha Host 03:17
No, you’re welcome. It’s so great to have you on board, as usual, and helping as many people as we can. That’s exactly what this is all about. So, aside from working with DMP, Emily currently also works as a dietitian nutritionist for K-12 schools, and recently she got
awarded $95,000 in grant funding to improve the school meal program to help our kids eat
better, which I find really impressive. Believe me, I know how much it takes to write a grant
proposal and they are really competitive, so it’s a really great accomplishment. And before
we dig into answering some questions, I wanted to give Emily an opportunity to share just a
little bit more about this amazing project, because projects like this really are so important.
So, emily, can you tell us what the project is and what you’re doing with it in the school?

Emily Guest 04:09
Yes, of course, this is something that I’m so passionate about and, honestly, much like the
groundbreaking work that you started with diabetes research 10 years ago, I find myself in
a similar position in schools. The school meal program in the United States is so expensive
for so many students who wouldn’t otherwise have access to food, but some of the
recommendations and guidelines remain outdated and less than optimal. So what I’ve
really been focusing on the past few years in the school district that I work in, and what this
grant will allow me to further expand, is exposing our students to more farm to school
meals. Through a variety of taste tests and even an implementation of a salad bar. At our
middle and high school, our students have tasted different types of local radishes, local
lettuces, local green beans, local watermelon. We get local apples and so much more, and I
believe that the more we expose our young children to these healthy foods, the more likely
they will grow into adults with a better appreciation for healthy food. It’s really exciting and
I love having the opportunity to expose students to this.

Dr Jedha Host 05:20
That’s really great, and I wonder how are the kids reacting to the new foods that they’re
tasting as well?

Emily Guest 05:26
I think we have really great feedback. I’m so passionate when I’m out there with students
and I’ll tell them oh my goodness, this is the best watermelon that you’re going to taste, or
look how bright green this lettuce is. And when you’re excited about something especially
our younger students in the elementary schools they get really excited about it too, and
even if it’s something they don’t love, I tell them that I’m so proud whenever they even just
try it, because, again, that exposure piece is so important, I believe, for young children.

Dr Jedha Host 05:56
I agree. I agree, I love it. This is such an important program for our kids. So thanks for
sharing that, Emily, and we’ll definitely have to check back in at a later date for an update
about that. Okay, so we’ll dig into the first question in just a moment, but firstly I’ll let you
know that we’ll be having these Q and A’s from time to time, so if you do have a question
you want answered, you can send us a voice message or email at type2diabetestalk.com.
Okay, so I’ll kick off with the first question for Emily. So Jane sent in a question and asked do
I have to stop eating sugar every day?

Emily Guest 06:36
So first, thank you for submitting a question. We really appreciate it, and I would say that if
you’re eating sugar every day, that’s probably not a great thing and you definitely want to
work on cutting it down. Sugar will drastically increase your blood sugar levels. It’s the
number one factor that’s going to cause your blood sugar to be elevated, and we know that
sugar also increases your risk for many other health conditions like obesity, heart disease,
memory concern and many other issues. So, although sugar is tasty, I think we all know it’s
not good for us. Start by eliminating obvious sources of sugar, such as soda, candy and
desserts. What else, Jedha, do you have to add to?

Dr Jedha Host 07:17
Look, I just think I absolutely agree, and I would say to Jane yes, you do need to stop eating
sugar every day, and you want to for optimal blood sugar and for your overall health too.
Like Emily said, I talked a bit about sugar and provided some great tips for taming sugar
cravings too, so I definitely check out episode number eight.

Emily Guest 07:39
Great, let’s go ahead and move on to the next question, jada. The next question we have is
from Dave. He asks is it possible to lower my blood sugar without any diet?

Dr Jedha Host 07:50
Well, yes, you can take medication, and that will certainly help to lower your blood sugar,
but the thing is, you don’t really want to be relying solely on medication alone. You can
exercise and, again, that will certainly help to lower your blood sugar, but if you can’t
exercise or you don’t like to, well, that’s not going to be a good solution, is it? So the thing is,
as we talked about in previous episodes, diet and nutrition are the most important part of
your treatment and they are going to have the greatest impact on your blood sugar. I mean,
the thing to realize is that your diet is just the way you eat on a daily basis. It’s best that
your diet is an eating plan that helps support you to normalize blood sugar. I mean, you
can’t just live on sugar and junk foods. None of us can if we want to be healthy.

08:46
A better question might be what can I do to improve my overall wellness? And with type 2
diabetes or pre-diabetes, blood sugar is the priority focus. The next question we have is
from Dan, who asked does metformin cause B12 deficiency and what do I need to consider
with this?

Emily Guest 09:09
Great question, dan. So yes, metformin is known to cause deficiency of B12. We don’t
actually know the exact mechanisms of why and there are a bunch of theories on this, like
altercations in the bowel and gut bacteria, but what is known is that it can reduce
absorption in some people, so it is important to be aware of this if you’re taking metformin.
We need B12, it’s a vitamin for many important functions in the body, like nerve function,
the production of DNA, red blood cells, so you definitely want to have your B12 levels
checked periodically if you’re taking metformin. There’s also some research showing B12
deficiency from metformin becomes more of a problem around four and a half to five years,
so that’s something to consider as well. Ultimately, you’ll want to discuss this with your
doctor or physician and definitely consider getting monitored at least annually for B12
deficiency.

Dr Jedha Host 10:10
Right and it can take some time for deficiency to become noticeable. Years ago, when I
followed a vegan diet for four years, I actually became B12 deficient and for me the
symptoms were extreme fatigue and things affecting my cognitive ability, memory and
confusion and that type of things. And the good thing is there are effective treatments for
B12 deficiency and for me I had to have regular injections. In other cases oral supplements
could be effective, but the point is there are effective treatments.

Emily Guest 10:45
Yeah, that’s a really good point, and while symptoms can vary, fatigue is definitely one of the
typical symptoms of B12 deficiency due to anemia. Other things you might experience are
loss of appetite and constipation, depression, irritability and balance issues and, as you
said, Jedha, the cognitive impairment is pretty common as well.

Dr Jedha Host 11:07
Yes, exactly, b12 deficiency can manifest blood-related neurological and gastrointestinal
symptoms, and often the symptoms are not specific, especially in the early stages. And so, knowing that there is potential deficiency of B12 from metformin, yes, just definitely
continue to get that monitoring with your doctor.

Emily Guest 11:44
All right, Jedha, our next question is for you. This question came from Sally, who said what I
struggle with is understanding what my HBA1C reading means in terms of actual blood
sugar level. There are so many different measurements out there and I have no clue which
one the UK uses.

Dr Jedha Host 12:04
OK, this is a great point, Sally, and I understand it can be confusing when you go search the
Wild West Web and all sorts of things come up. So I’ll actually be covering blood sugar
numbers in the next episode. But, briefly, there are two different measurements. In the US,
milligrams per deciliter are used and most other places in the world millimoles per liter are
used. So for you, Sally, being in the UK, you want to look for measurements in millimoles per
liter. So, for example, you’re looking for numbers like 7.8 to two hours after meals, or
morning levels at 6.0. If you see things like 140, 110 or 180, those are in milligrams per
deciliter, which, again, are predominantly used in the US. This can be a bit frustrating, I
know, but once you know which ones to look out for, you’ll be fine.

13:01
And when it comes to understanding what your A1C means in terms of blood sugar, well,
they are different, of course, but they also share a close relationship. I’m not going to go into
that too deeply now because I’d recommend you tune into the next episode, as I’ll have
more info on that and also some resources and charts to share. That will really help you
understand what HBA1C means in terms of your actual blood sugar level, and I’d also
recommend that if anyone listening has a specific question about their numbers, please go
and leave us a voice message or an email at type2diabetestalkcom, because we can do a
follow up Q&A session on that as well. Next, we’ve got a voice message from Sylvia.

Sylvia, Voice Message 13:49

Emily Guest 13:55
First, I just want to say I love the background music and that voice message and thanks for
the topic, sylvia. So hypoglycemia, medically speaking, is the term for low blood sugar. Low
blood sugar will make someone feel not great. You might feel a fast heartbeat, sweaty,
clammy, shaky, extreme hunger, headache, experienced blurred vision or pale skin color. It
actually can feel like an extreme workout that shakiness, fast heartbeat. And if you suspect
that you’re having those symptoms and you think you might have low blood sugar, the first
thing you want to ideally do is check your sugar levels. In terms of a low blood sugar, a level
below 70 milligrams per deciliter or four millimoles per liter is considered low. If you check
your levels and they are low, you need to treat accordingly. Typically, this is by having about
15 grams of quick acting sugar, such as fruit Hypoglycemia if untreated, it can be dangerous.
So it is important that you’re aware of this.

Dr Jedha Host 14:55
Exactly. It is dangerous if you’re untreated. So, Emily, can you also let our listeners know
who might be at high risk for experiencing hypos?

EmilyGuest 15:05
Great Good point. Hypoglycemia is going to be the most common on people who take
medications that increase insulin levels in the body. So things like insulin and some oral
medications like sulfonylureas those are not common in prediabetes or those who don’t
take insulin or may be on other meds. It doesn’t mean they can happen, but just less likely
compared to those other types of medication.

Dr Jedha Host 15:30
Yeah, exactly right, and people can also have hypoglycemic-like symptoms that aren’t
actually hypoglycemia, right.

Emily Guest 15:39
Definitely, and we do see this often and we’ve had other people submit this question. If your
blood sugar levels happen up in the 200s or 300s or 11s to 17s, and you drop them down to
140 or 7.8, that’s a pretty big drop. So you might get similar symptoms that shakiness,
headache, dizziness and sweating but it’s not really a hypo. It’s just your body adjusting to
those changes, which can take a few days or weeks to resolve, depending on the situation.
But ultimately it’s not really a hypo. It’s just your body adjusting to those changes, which is
a good thing in the long run for your health. And, as I’ve said before, hypoglycemia is
defined by a blood sugar level below 70 milligrams per deciliter or four millimoles per liter.
We’ll share some more info about hypoglycemia in the show notes which you can find at
type2diabetestalk.com.

Dr Jedha Host 16:36
I just want to say that if you do leave us a voice message with a question, it does help. If you
can be specific with your question as well, we may be able to provide some more useful
suggestions rather than just a general overview.

Emily Guest 16:51
All right. Our next question is another voice message from Fay.

Faye, Voice Message 16:57
When you go to hospital. There are no things for a diabetic. You just get a normal meal
which affects your diabetes.

Dr Jedha Host 17:10
Thanks for the voice message Bay. This really is a terrible situation. We know the typical
hospital food is high in carbohydrate and low in quality nutrition. I would say you can try
taking a proactive approach and communicating with the doctors, nurses and hospital staff
about your eating needs, because in some cases they may be able to make adjustments to
the menu and what you’re being served. That might still be limited. So then I’d also say
bring food from home, if you can. Or if you have family, you might ask them to support you
by bringing in fresh and healthier foods and meals. Sometimes it might be a case that you
end up in hospital unexpectedly and aren’t able to plan to take meals ahead. So again, if you
have family or friends you might be able to rely on, I’d suggest talking to them early and
have a plan in case these things do happen, so then they can be the ones to communicate
with the doctors and hospital staff on your behalf and to bring in that healthier food for
you.

Emily Guest 18:09
Yeah, that’s great advice and I agree that relying on family and friends in a lot of situations
is probably the best thing to aim for. But something else I’d recommend is really asking to
speak with the hospital food service staff or the dietitian. Sometimes, and I just know this
from working in a hospital, but sometimes there are other options than what’s published
on the menu. Also might be able to ask if you can get double protein, so you can kind of
eliminate the carbs and again maybe get two pieces of chicken or two slices of pork, and
although it might not be ideal, at least it’s a step in the right direction.

Dr Jedha Host 18:46
Exactly. So. That’s a really great point, Emily, and again, it is just taking that proactive
approach. So you’re looking for those other options, because often there are other options,
and do you have anything else to add to that Emily?

Emily Guest 19:01
Yeah, this is something else that I’ve seen patients do, and this again might depend on
where you’re located. But if you can utilize a meal delivery service like Grubhub or
DoorDash, you might be able to get a little bit of food delivered to the hospital from the
outside. And again, you have to be careful about where you’re ordering from. You certainly
don’t want to be ordering more junky food from another fast food chain, but there might be
a restaurant in the area where you could get some salad, some protein, some fish on top of some veggies and you might be able to get that delivered right to the hospital. So another
idea that you should keep in the back of your mind for these types of emergency situations.

Dr Jedha Host 19:42
Great point, emily. I don’t tend to use too many meal delivery services myself, so I often
forget how useful these can be for situations like these and many others. And you’re right,
there are many meals you can get delivered that are still healthy options and certainly
better than hospital food. If you find yourself in this situation so hopefully, Faye, or anyone
else in this situation this gives you some great ideas if you find yourself in this situation
again. So thanks for sending in your topic. Next up, we have a question from Billy, who
asked how often do we need to go for a checkup to see whether sugar has gone down or
not?

Emily Guest 20:24
Good question, Billy. When you start making positive changes in your diet and lifestyle,
you’ll definitely want to know how well the changes are working. Most people will see their
doctor every three months and have their A1C checked at those visits. Remember that A1C
is the blood test that reveals average blood sugar levels over the past three months. If your
blood sugar is well controlled and your A1C is within range, then you might be fine going
for a checkup every six months.

Dr Jedha Host 20:53
Yes, definitely have those regular checkups. When I was recruiting participants for my T2
diet study randomized control trial, one of the criteria was people had to have an A1C test
within the previous six months, and I was so surprised by how many people hadn’t had an
A1C test for more than 12 months. Please don’t do that. These tests are really important for
you to know how your health is tracking. So please do have them regularly, right, Emily?

Emily Guest 21:23
Yeah, and one thing I would add is sometimes, when people don’t have very good control,
it’s easy to want to avoid going to the doctor or avoid having that number checked, but
really that doesn’t change the outcome. So, in the best interest of your health, it’s better to
get the checkup, know what your number is and then address it and make the changes that
you need to make in order to have better blood sugar control and ultimately live a healthier
life. So, just like you said, it’s very important and make sure to get your regular checkups.

Dr Jedha Host 21:54
Exactly. Don’t stick your head in the sand, because it really doesn’t help.

Emily Guest 21:59
Not at all. So let’s move into our next question, Jedha. This question is a submission from
Rinda, who said I live in Peru, a country that has many products for diabetics. It also has a
more lenient definition of what one can eat. I would like some tips on how to choose
products in countries that have different products or advice for diabetics. For example, I
had a consultation with a dietician. She recommended pasta or rice once a week, dried fruit
every day, getting up the same time every day and nothing else.

Dr Jedha Host 22:36
Okay, well, interesting question, or should I say situation, Rinda, I don’t think it matters
where you live in the world. Actually, there are lots of different products for diabetics
everywhere. I also think that most of the dietary guidelines for people with type 2 diabetes
are pretty lenient. I mean, the medical care guidelines around the globe basically say there
is no ideal macronutrient range for people with diabetes. If that’s not lenient, then I don’t
know what is, but I know this leaves a lot of confusion in the minds of people and health
professionals as well.

23:11
I’ve spoken about dieticians previously and that, unfortunately, majority of dieticians are
underqualified in terms of diabetes. Most only have a bachelor’s degree and they don’t
specialize in diabetes, so they often give generic or inappropriate advice, and it sounds like
in your particular case, Rinda, this could be true. So, in terms of choosing foods, I’d say that,
no matter where you live in the world, please go back and listen to episode 6, where I talked
about what to eat to treat diabetes, and I provided the types of foods and some guidelines
to work around, and no matter where you live in the world, the same guidelines apply, and I
think you’ll find that you can use what I talked about to find what works for you, so I hope
that helps address that question, Rinda. So the last question on our list for this episode is
from Troy, who asked what’s the best low carb nut milk replacement?

Emily Guest 24:12
There are a lot of options available these days. Troy, almond and coconut seems to be the
most readily available in my area, so I might recommend looking for either of those. You
could also look for cashew, macadamia, walnut. As far as other nut milks, or hemp or flax
seed milk, which are technically seed milks rather than nut milks, in terms of nutrition,
there isn’t really a best option because they all vary in terms of macro and micronutrient
content, and most nut milks are fortified with vitamins and minerals to boost their
nutritional quality. The most important thing that you really want to pay attention to is
looking for an unsweetened variety. Some will have vanilla or chocolate flavorings, and
those often contain added sugar, so make sure your label says unsweetened and contains no
more than three grams of carbs per serving. Many will even be one gram or less, so that’s
ideal. You can get some unsweetened vanilla flavored varieties too, but just make sure you
check the label for the ingredients.

Dr Jedha Host 25:15
Thanks, and I hope that helps answer your question, troy. Well, that brings us to the end of
today’s Q&A session. Thanks for joining me today to dig into these questions, emily. I think
it’s been fun.

Emily Guest 25:27
It has been a lot of fun, I’ve really enjoyed it and I look forward to hopefully coming back in
a few weeks and doing another session.

Dr Jedha Host 25:35
Yeah, me too. So for all our listeners, find today’s show notes at type2diabetestalk.com
Members. You can head to the members library to find episode 10, where we’ve added a
range of links to extra resources. Plus, we’ve added a new section to our beverages guide
that includes a comparison chart of the nutrients for the various different milks, including
the nut milks and seed milks that we just talked about. So head to the library to find that
with episode 10, or look for it in the beverages guide.

26:09
As I said at the beginning, we’ll be having more of these Q&As in future, so if you have a
question you want answered, we’d love to hear it, and you can send us a voice message or
email at type2diabetiestalk.com. Earlier in the show, Sally asked about what her HB1C
reading means in terms of actual blood sugar level. We’ve also had questions about what
are good fasting numbers, what should numbers be after meals, and are there specific goals
to aim for? If you’re feeling confused by the numbers, you’re not alone. Please make sure
you tune in to the next episode, where I’ll be talking about normal blood sugar ranges and
goals for type 2 diabetes and pre-diabetes. Knowing this information is very important, as it
forms the foundation of all the actions you take. So be sure to tune in next week.
Have a great week ahead. Dr Jedha over and out.