Living well with diabetes, Part 1: How lifestyle, nutrition and balance can transform healthspan

The prevalence of diabetes increases with age — in fact, nearly a third of older adults have the condition, and about half have prediabetes.

But on this episode of Aging Forward, registered dietician Laura Knudsen says the story never ends with diagnosis:  Through our dietary choices, regular movements, and focus on sustainable habits, we can successfully lose weight, reduce our medication needs, and even reverse early signs of diabetes.

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Christina Chen, M.D.: This is “Aging Forward,” a podcast from Mayo Clinic about the science behind healthy aging and longevity. Each episode, we explore new ways to take care of our long-term health, the health of our loved ones, and our community, so we can all live longer and better.

I’m Dr. Christina Chen, a geriatrician and internist at Mayo Clinic in Rochester, Minnesota. And in this episode, we are talking about Diabetes, a condition that affects millions of people. About 38.4 million Americans, or roughly one in 10 people, have diabetes, and up to 95% of those cases are Type 2, which is also deeply manageable — and in many cases — preventable.

Diabetes isn’t just about blood sugar; it’s about how our bodies process energy, how lifestyle habits accumulate over the years, and how nutrition plays such a central role in maintaining health and independence. And while the risk of diabetes increases with age, the story does not have to end there.

We are joined by Laura Knudsen, a registered dietitian and nutrition expert at Mayo Clinic in Eau Claire and Menomonie, Wisconsin. She has dedicated her career to helping people optimize wellness through food, science, and lifestyle. Welcome, Laura. Happy to have you on the podcast today.

Laura Knudsen, R.D.N., C.D.C.E.S.: Thank you.

Christina Chen, M.D.: We would love to get to know you a little bit. How did you pursue a career in this space of nutrition and dietetics?

Laura Knudsen, R.D.N., C.D.C.E.S.: When I was in high school, we had to take these little questionnaires to figure out what we might want to do when we grow up. And this is how I even learned that there was a career in the dietetics field to begin with.

I went to the U.W. Stout for college and studied dietetics. I initially thought I would do sports nutrition. And then I met my husband, who has Type 1 diabetes, and it changed my path forward. I’ve been a certified diabetes educator since 2018, I believe.

Christina Chen, M.D.: I love hearing your background, what sparked your interest, and what drove your interest because it sounds like it’s a very personal thing for you as well, to help your husband through it.

I’d love to have our audience kind of understand the basics, the details behind diabetes, and the link to aging. Maybe we can start with that background. Can you explain what exactly is diabetes? And there are the different types, right? Type 1 and Type 2 — what’s the difference between those types?

Laura Knudsen, R.D.N., C.D.C.E.S.: Diabetes affects the way our body uses blood sugar. Or the medical term for sugar is glucose. Type 1 diabetes, it’s an autoimmune disease. The body kind of attacks the beta cells in that pancreas, and we don’t make any more insulin. With Type 1 diabetes, the only treatment we have right now is insulin.

Christina Chen, M.D.: Meaning, the insulin people use to inject themselves.

Laura Knudsen, R.D.N., C.D.C.E.S.: Yes. And then with Type 2 diabetes, we have probably two problems going on. One, we don’t make enough insulin, and we don’t use it well. We have more than 10 different medication classes that we can pull from.

Both types of diabetes, our lifestyle, play a role in how we manage the condition. Both types don’t make enough insulin, but Type 2, the insulin resistance is probably maybe even an underlying issue or the contributor of it.

Christina Chen, M.D.: Thank you for simplifying that for us. I know Type 1 typically is a younger onset. And as people age over the years, Type 2 then becomes more common. Can you describe some of the changes in the body that can contribute to the insulin resistance you’re talking about in Type 2 diabetes?

Laura Knudsen, R.D.N., C.D.C.E.S.: Definitely, I even heard in your introduction you were saying one in ten people have diabetes. When we get older, that statistic is much tighter. It’s approximately one in three people, 65 and older, who have diabetes, with Type 2 being the most common. Definitely something is changing in our body to increase that risk as we get older.

Number one, our lean muscle mass tends to go down. We lose maybe three to eight percent of our muscle, probably a decade, after the age of 30. That is one of the areas that we are trying to maintain our lean muscle mass to reduce our risk of developing Type 2 diabetes.

We may sometimes gradually see a weight increase over the years. Maybe sometimes it’s common for me to see somebody in the clinic — and I see a fair number of people for weight management as well — and they will tell me their usual adult body weight. And maybe by the time I see them, they’re saying, “Man, I gradually have put on a little bit of weight over the years.”

That weight increase also contributes to insulin resistance, which increases that risk of diabetes. And then our pancreas also doesn’t make as much insulin as we get older. Somebody’s body just truly might not make quite as much insulin as it used to do 5, 10, 15, 20 years ago.

Christina Chen, M.D.: You mentioned the weight changes and the loss of muscle mass — but are there other warning signs that someone may be at risk of insulin resistance or pre-diabetes?

Laura Knudsen, R.D.N., C.D.C.E.S.: I would say that there are things that people potentially overlook, because when I see people in the clinic, the most common thing people would say is, even if they’ve developed diabetes, they didn’t know until they had blood work done that showed their numbers were higher than usual.

I would say a lot of the time, people don’t notice any symptoms. Whether they come on so gradually, we just don’t pay enough attention to notice. But sometimes, if I ask more in-depth questions like, “Have you noticed any of these things?” Those might have been signs that we overlooked.

Probably the top two that I’ll ask about sometimes is like, if someone is just generally starting to feel more fatigued and tired out than usual, I sometimes wonder, is that insulin resistance? Or is the way our body uses our blood sugar not as efficient as it used to be?

Another question I’ll often ask is if they’ve had any increased cravings for sugar or increased cravings for carbohydrates. That can be a sign of insulin resistance. Because what can happen is, as our blood sugar goes up, our insulin levels also go up to compensate for those higher blood sugar levels. And when we have high insulin levels, we tend to feel more hungry.

If somebody tells me they eat a bowl of cereal for breakfast and they are hungry an hour or two later, sometimes I wonder if that insulin resistance is a part of that driving of that appetite, especially after meals that are maybe higher in carbohydrate or higher in refined carbohydrates. It can especially start this cycle of feeling munchy and snacky all day long.

Christina Chen, M.D.: Right. I am glad you mentioned that. I often see those early symptoms as well. And it’s something they often overlook because it seems, “Well, I’ve been tired for a while now,” or, “You know, my appetite changes here and there. But I have been eating more, it seems like, and the cravings are more prevalent.”

Or they’re more thirsty, too. They tend to drink more and urinate more. And they don’t come in until it’s time for surveillance blood work. And all of a sudden their A1C is 11. Then you ask, “Oh my gosh, how long has this been going on?”

Let’s talk a little bit about how uncontrolled diabetes impacts overall health, especially for older adults. Sometimes we just don’t know they’re diabetic, until it’s noticed on blood work. And by then, they could have had the condition for years. How does that impact overall health, especially if it’s untreated?

Laura Knudsen, R.D.N., C.D.C.E.S.: High blood sugar levels can take a toll on a microvascular level and a macrovascular level. The organ systems that I am very sensitive to, when I’m seeing somebody that has diabetes, is the heart. When somebody has diabetes, they’re twice as likely to have a major cardiovascular event than someone without diabetes.

From a nutrition standpoint, I am automatically thinking: I’m also gonna make sure that we eat well from a heart-healthy standpoint to reduce that risk, heart-wise, as well.

Neuropathy: Often, people have so much pain with damage to our nerves. And it is so uncomfortable, and maybe some of our medicines don’t manage as well as we wish they would, to take away pain or discomfort.

Peripheral neuropathy often will develop first. I will see people that come out — they happen to be on a walker or a cane, and they say that their feet feel like pins, or feel like they’re falling asleep. Or they’re just numb in general and they have spots on their feet. They don’t feel anything.

Many people have said that they have a family member or friend that lost their foot or their leg to neuropathy. Or from a hand standpoint, I have to have people check their blood glucose often. And they’ll say it just hurts really bad, because of that neuropathy pain and just being so sensitive.

I will also see people that have autonomic neuropathy, where they have gastroparesis in their stomach. Even tolerating food is hard. They also have to change the texture of their foods to be able to eat well.

Then the kidneys also can be impacted, as one of those bigger organ systems that we maybe worry the most about  — that high blood sugars, and also high blood pressure can increase that risk of damaging those kidneys.

Christina Chen, M.D.: It’s really the downstream effect that occurs years later, where then it affects the symptoms, the burden, and the quality of life. Neuropathy, living with pain every day, is not fun. Living with heart failure symptoms every day because you’ve had a heart attack at age 40 is not a good thing.

These are all things that we don’t realize how much they impact our function and quality of life until they actually happen. And then it’s irreversible, or harder to reverse, at least.

Christina Chen, M.D.: I love talking about nutrition and prevention because there’s so much that’s still within our control that can prevent disease onset and bad outcomes. As a nutritionist and a dietician, what do you feel are the most effective nutrition strategies to reduce the risk of developing diabetes in the first place?

Laura Knudsen, R.D.N., C.D.C.E.S.: An emphasis on vegetables, particularly the non-starchy vegetables, is a big piece of things. And this is a challenge for many of us, because 90% of Americans don’t get enough vegetables in our eating pattern.

I always say that: “We’re not alone. All of us could work on this. This is something many of us can work to improve on.”

As we get older, including enough lean protein sources in our eating pattern is important. Because if we’re trying to maintain that lean muscle mass  — to maintain what we have or to build from where we’re at — we need sufficient lean protein in our eating pattern.

And as we get older, we don’t use protein as efficiently as we did when we were younger. Not that we need to be on an extra high protein eating pattern, but it’s a nutrient to be thoughtful around, to get enough of.

If somebody comes in and they tell me that their eating pattern is garbage and they just don’t know where to start, often I like to start even with the beverages. And just see if we can clean up the beverage piece of things, because it can give a lot of results for one change that can be quite significant. Not overdoing it on sweetened drinks.

I always think, can we make water our primary drink? Occasionally, I’ll run into somebody that just does not drink any water, for whatever reason. Then I’ll wonder, “Well, maybe our second best choice… I start to go through… “Can we drink unsweetened tea or black coffee?” Or, “Can we put lemon in our water or lime in our water to give it a little bit of flavor?”

But I don’t want somebody to drink all of their carbohydrates, because in beverages, they’re always simple carbohydrates. They seem to make that blood sugar go up very quickly, because there is no fiber.

We slow down as we get older; we need fiber to slow our digestion down a little bit, and our blood sugar does not go up before our pancreas can respond to give us that insulin.

Christina Chen, M.D.: Right. I have one comment and one question. My comment is: I’ve had a lot of success actually with the carbonated flavored sodas. People just like sweetened drinks because of the carbonation. There’s something about that, that they really like the fizz, you know?

Replacing it with bubbly drinks. I’ve actually had a lot of people successfully switch their habits to that. My question is: What’s the verdict on the diet sodas with aspartame and zero calories, zero sugar? Is that safe to still drink in excess?

Laura Knudsen, R.D.N., C.D.C.E.S.: I always rank them in order when I’m seeing somebody. I rank water, then the unsweetened tea and the coffee, and then the bubbly and LaCroix waters that are carbonated but have no non-nutritive sweeteners in them as potentially higher ranking.

If someone is going to choose between the sweetened drink or the diet soda when we’re at risk for diabetes, I would prefer the diet version of things. Whether it’s diet soda or if it’s going to be in Crystal Light or some of our flavored water enhancers, like Mio. They are not going to impact glucose. If they did, it’s very small.

Christina Chen, M.D.: Minuscule.

Laura Knudsen, R.D.N., C.D.C.E.S.: If the difference between staying hydrated or not hydrated, I would rather see somebody drink those non-nutritive sweeteners. I certainly think: Better than sweetened drinks because we do know that regular soda or sweetened drinks do increase risk of heart attack or stroke.

But sometimes I might challenge someone to see, can it be a stepping stone? Or can we incorporate it in as a treat, and not drink six cans of diet soda a day? But save it more for when I go out once a month. And it’s kind of my treat when I go out.

Christina Chen, M.D.: Yeah.

Laura Knudsen, R.D.N., C.D.C.E.S.: Just keeping it in moderation is probably a good rule of thumb.

Christina Chen, M.D.: Yeah. Thank you for that. I imagine these recommendations, these strategies of prevention, apply to the person who was also diagnosed with diabetes, too, as these first nutritional changes that you would recommend. Just cut out the sweetened drinks; things in moderation; try to amplify the vegetables in your diet.

Are there any other first kind of nutritional changes you would recommend in that population? Someone who’s first diagnosed with diabetes?

Laura Knudsen, R.D.N., C.D.C.E.S.: I sometimes worry if somebody is getting older, and maybe they live by themselves, or even if they’re just them and their spouse. But they used to have a whole family that they took care of for meals. Sometimes I worry that somebody, as they’ve retired, is not going to eat nice, balanced meals.

And instead ,what they start to do is to snack, instead of eat meals. And then when that snacking occurs, they tend to be more carbohydrate-based snacks. They seem to lack produce and protein.

Something to think about is: Do I still eat three balanced meals? They can be small, they don’t have to be big meals. But people that eat meals tend to eat more fruits and vegetables than people that don’t eat meals.

If I’m not going to eat meals, it just requires extra thoughtfulness to include the produce, and maybe extra thoughtfulness to make sure I have a protein source to go with my snacks — hopefully my glucose levels can stay stable throughout the day, rather than not eating very much stuff and then eating one really big meal.

 If I gave any other kind of tips, I’d say, eat at regular intervals throughout the day to stabilize my glucose levels; manage my appetite throughout the day; and give me the best opportunity to eat meals.

Because many people are so wonderful at planning balanced meals. It just takes more effort if we’re cooking for one, whereas if I used to cook for five or six or seven people… sometimes we don’t love ourselves enough to prepare those meals. We tend to snack instead of eating balanced meals.

Christina Chen, M.D.: I love that you mentioned that, Laura, because that social aspect is so important. Also, if older adults can’t get to the grocery store, it’s easier for them just to buy in bulk. Snacks. Also, to understand the educational aspect.

They don’t know that this is a bad eating habit. If you get into the fine details, they’ll say, “Oh, I don’t eat much to begin with.” It’s because they’re just snacking all day. They’re not eating full meals. But that’s not healthy, either. I’m really glad you mentioned that aspect.

Christina Chen, M.D.: Are there misconceptions about diabetic diets? And I mention this because I work in nursing homes. I see patients when they’re out in the dining room eating, and they’re on this diabetic diet, so to speak. And I look at their plate, and it’s French toast with syrup. And it’s this sugar-free syrup, and that doesn’t look like a diabetic diet to me.

And then we ask people to curb the carbohydrates. I don’t think there’s a clear description of what a diabetic diet is. Can you clarify that? Can you describe what a healthy diabetic diet truly looks like?

Laura Knudsen, R.D.N., C.D.C.E.S.: One: I do not like when people feel like they have to follow a specific diabetic diet. There is no diabetic diet in my eyes, whatsoever. But it’s definitely a common question that I get all the time: “I was diagnosed with diabetes. I need a meal plan to follow this special diet.” To me, there is no special diabetes diet.

To me, it can be individualized. But like you said — you work sometimes in a nursing home — it is provided to them. It can not be tailored individually quite as well. But the big keys to me are: It has enough non-starchy vegetables, lean protein, and quality carbohydrates. The plate method is a common concept that I use in the clinic. It can be practical as far as seeing what that looks like.

Christina Chen, M.D.: As you’re talking about the plate method, I can’t help but think about those plates that we give our toddlers, it’s got the dividers in the middle. I thought, “How cool would it be to have an adult version of that?”

And it’s got dividers that have the protein portion. These are some ideas you can choose from. Here’s your vegetables and your plant proteins. And just give ideas to people so that they can just look at the plate and go, “Oh, we’ll do fish and beans, plus a small sliver of mashed potatoes today.” Just to give them something to know how to portion plan, I suppose.

Laura Knudsen, R.D.N., C.D.C.E.S.: Yeah! They actually do sell these kinds of plates.

Christina Chen, M.D.: Oh, they do?

Laura Knudsen, R.D.N., C.D.C.E.S.: And even if somebody does not want to spend a lot to buy a very fancy one that has color-coded little corners — even the three container divider plates that they sell in the disposable section, where they have maybe paper plates or styrofoam. They’ll have about three little pieces, as a guide.

If those are the plates you’re using, so you don’t have to do all your dishes, it helps us to maybe balance our macronutrients out for good quality in our eating patterns.

Christina Chen, M.D.: Let’s say we have a portioned plate, where one portion is half of the plate, and the other two are a quarter of the plate. How would you usually divide those up into the recommended food choices?

Laura Knudsen, R.D.N., C.D.C.E.S.: I’d say, “Can we include half of the plate of non-starchy vegetables?” And can a fourth of it be lean protein sources? And even a bonus if they can have some plant protein sources in there to help with that insulin resistance piece of things. And then a fourth of it is quality carbohydrates: types of carbohydrates that have fiber. Or complex carbohydrates would be another term that maybe people have heard. Or maybe lower glycemic index-type carbohydrates, like beans or lentils.

An emphasis on non-starch vegetables, limiting added sugars, and refined grains. Of the sweetened drinks and not too many sweets and desserts for assisted living or nursing homes, I’d say, “Man, I don’t want to offer dessert at every meal for a population that maybe can’t be as active as they once were.” And thinking of it more as a treat. Because even if somebody does not have diabetes, this is not how any of us should be eating on a regular basis.

And then less processed food, to the extent possible. We can call it whatever eating pattern we want, whether we say it’s low carb or if we consider it more vegetarian or more of this Mediterranean, which is a high-ranking diabetes eating pattern, as well as a heart-healthy eating pattern.

Christina Chen, M.D.: As you’re going through these food choices, talking about quality carbohydrates and plant proteins, I’m just thinking, “How much of these foods do I know about?” I’m sort of scratching my head trying to think of the variety of foods, and there’s only so much I can think of. Not to mention cooking them well and tasting good.

Do you have any resources or handouts that you give to patients about, what are quality carbohydrates, aside from beans? What are other plant proteins and non-starchy vegetables? How do you guide people through that?

Laura Knudsen, R.D.N., C.D.C.E.S.: Right, how do I find these things on my own? There’s only a handful of vegetables that are starchy, but things like corn, peas, or potatoes are considered starchy vegetables. It is not that it’s not healthy.

Christina Chen, M.D.: Those are my favorites.

Laura Knudsen, R.D.N., C.D.C.E.S.: They are healthy. And they have fiber. But if that plate method, I would just tell somebody, this is when I would put it under the fourth of the plate.

Christina Chen, M.D.: Okay.

Laura Knudsen, R.D.N., C.D.C.E.S.: I might say, “I don’t want you to have both potatoes and peas at the same meal, or potatoes and corn at the same meal.” I might say, “This is why they invented peas and carrots.” I can have this for starchy food, and I could have carrots for the non-starchy one. Or if I had corn on the cob, maybe I could have a lettuce salad to go with it.

But most vegetables are non-starchy. Some specific examples would be green beans or asparagus, brussels sprouts, and leafy greens like lettuce and spinach. Even sugar snap peas, grape tomatoes.

I was thinking of some I can eat, maybe cooked versus raw, because how it’s prepared doesn’t matter. Or if I need to do it seasonally: Maybe with winter coming, I would like to eat more cooked vegetables, where maybe in the summer months I just prefer them to be more raw.

Christina Chen, M.D.: And what might that Mediterranean-style portioned plate look like?

Laura Knudsen, R.D.N., C.D.C.E.S.: I still picture this emphasis on vegetables. I still picture a fourth of the plate foods with fiber, whether it’s brown rice, a whole grain pasta, or beans or lentils. Sweet potatoes, regular potatoes.

The part that changes the most to me is that protein section. What is unique with a Mediterranean eating pattern compared to many other high-ranking eating patterns is they seem to be a little bit more specific on where the protein comes from.

They will say, “We want an emphasis on plant protein” as the soy groups. Tofu or tempe. Of our beans and lentils. Black beans or kidney beans, brown lentils, or red lentils.

We can get a little bit of protein from the nuts and seeds, but I would primarily classify those as healthy fats. Or we are going to run ourselves up in calories before we can get enough protein. But they are great to include in a healthy eating pattern.

But when it gets to the animal proteins with that Mediterranean eating pattern, they seem to have an emphasis on fish. Could we incorporate fish a couple times per week?

Then I tell people, the two-legged animals are above the fish with no legs. And then above the poultry are chicken and turkey, and the beef and pork are four-legged animals.

Christina Chen, M.D.: And do you have an eating strategy for how you space things out during the week?

Laura Knudsen, R.D.N., C.D.C.E.S.: Maybe one concept, if someone is still at home and meal planning for themselves — this is a strategy I personally use for myself — but I’ll do Meatless Monday, and I try to do fish on Tuesdays and Fridays. I do red meat on Wednesday. And I do poultry on Thursday. And it’s my strategy to try to align better with that Mediterranean eating pattern, with attention to the protein source, the protein type.

And then I still try to think: What vegetables are going to go with this item? Or, what starch food is going to go with this protein source?

Christina Chen, M.D.: You’re planning ahead. I like that. You’re sort of already knowing what’s going to happen on Monday through Friday.

Laura Knudsen, R.D.N., C.D.C.E.S.: To be successful at managing anything in life, we want to be a planner.

Christina Chen, M.D.: That’s true.

Laura Knudsen, R.D.N., C.D.C.E.S.: For nutrition, if we want to be successful, we probably want to have a plan. For me personally, it has worked well to do once a week, and then I try to go grocery shopping once a week.

I know you mentioned sometimes the people you see can’t always get to the grocery store each week. It’s just not the reality. Maybe they can only get to the grocery store every other week. I love it when someone can go at least every other week.

It becomes really challenging to get enough quality produce when somebody can only go grocery shopping once a month. But I mean, we can certainly use freezers and use our frozen vegetables and frozen foods and canned things as well.

But, ideal if someone could go grocery shopping once a week, or ideally, no more than going two weeks without getting to the store.

Christina Chen, M.D.: Thank you for these ideas. I really love hearing about it… It’s one thing to talk about diets and buying healthy things, but really helpful to give our listeners practical tips on how to actually apply them to our lives: how to plan, how to portion, and how to shop. Thank you so much for that insight, Laura.

Laura Knudsen, R.D.N., C.D.C.E.S.: Well, thank you.

Christina Chen, M.D.: That’s all for this episode — hopefully you’re feeling a little more informed, inspired, and empowered. Our guest today, Laura Knudsen, had so much to say that we are actually going to be back with a second episode on Diabetes, where we’ll talk about dieting for weight loss, GLP-1s, and much more. And just so you know, we’ll be taking a break for the Christmas holiday, and we’ll see you back after the new year, for Diabetes Part Two.

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