Living well with diabetes, Part 2: How lifestyle, nutrition and balance can transform healthspan

So you have diabetes. Now what?

On this episode of Aging Forward — part two of our series on diabetes — registered dietician Laura Knudsen returns to discuss eating patterns for nutrition and weight loss, and how to choose if GLP-1s are right for you.

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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 this episode, we’re back to talk some more about diabetes, which affects about 38.4 million Americans, or roughly 1 in 3 older adults.

We are again joined by Laura Knudsen, a registered dietitian and nutrition expert at Mayo Clinic in Eau Claire and Menomonie, Wisconsin. Last time she spoke to us about how type 2 diabetes becomes more prevalent as we age, and we learned some creative strategies on how to take control on nutrition.

There was so much great nutrition that we’re going to talk some more. And this time, about eating plans for weight loss. And of course, we’re going to talk about GLP-1s.

So, Laura, in the last episode, we talked about that Plate Method, in terms of nutrition portion recommendations. Does it also help with a successful weight loss plan?

Laura Knudsen, R.D.N., C.D.C.E.S.: I do think that Plate Method concept can work well for managing weight. We always think of reduced portion sizes as one of our keys. If this amount of food is maintaining my weight, how can I reduce it from my baseline?

Christina Chen, M.D.: As we’re talking about weight management and lifestyle for someone with diabetes, and the portion management part, it sounds like a lot of calorie restriction. How do you deal with the fact that your clients may be hungry all the time?

Laura Knudsen, R.D.N., C.D.C.E.S.: One of the things I like with the Plate Method: If we emphasize those non-starchy vegetables, that group is very high in water content and very high in fiber. It helps us to give— I call it bulk —in our eating pattern.

We all need a certain amount of volume of food to feel full. So when we can include those vegetables in our eating pattern, or even fruits, we get that bulk from produce. When we have water content in fiber, it allows us to eat more normal portion volume — but create ourselves a calorie deficit.

And I think many obesity experts would probably agree that bulk, or water content in fiber, is one of the keys for long-term success with managing weight so that we can eat more normal volume.

I definitely have seen people in the clinic that I was maybe focusing on glucose management when I had first seen them, and then they come back, and they have lost weight and have told me, “I feel like I’m eating a lot, but I’m eating vegetables very regularly now.”

And in my mind, I’m thinking — this helped you to reduce your portion size of meat, which is a very calorie-dense group that adds up really quick, or helps me to reduce my portion size of the starchy foods.

Previously, before I knew that I was having glucose issues, maybe I had half the plate, starch foods, and I only had a fourth of the plate, vegetables. Where, if I can just reverse those two proportionally, even though I’m eating the same volume, I can create myself a calorie deficit.

And for many people, they find it more practical than maybe specifically writing down every food item that they have ever eaten for the whole day. And trying to figure out how much calories are in all these things is very time-consuming and maybe burdensome, or even challenging. If someone is like, “I don’t even know how to find the calories on this product; it didn’t come with a food label,” it just becomes really impractical for some.

If they can, just learning the food groups and how we would classify them from a nutrition standpoint, to me is one of the most helpful things.

I tell people I have an advantage as a dietician because I know which foods are the most volume-heavy or nutrient dense. And I happen to know which ones are the most calorie-dense, and I want to teach you that so you can know the same, when you are either at home or even at outings, like potlucks and church gatherings and our friends and family’s houses. How can we navigate a food buffet so we can keep it within our calorie budget?

Christina Chen, M.D.: That’s the other thing, is as we get older, we often need less calories than before, but might still be eating as we did when we were younger, and needed more.

Laura Knudsen, R.D.N., C.D.C.E.S.: Yeah, so if we are becoming less active as we get older or we’re losing our lean muscle mass as we get older, our calorie needs are going down. If we always eat the same quantity of food out of habit, we are going to probably see a gradual weight increase over the years as my muscle mass goes down and my physical activity goes down.

And statistically, I think they say 70% of people can lose five percent of their weight, and keep it off long term.

I always tell people if they feel discouraged, maybe from things they’ve tried in the past, I’m like, “I believe in you. I know more than half of people statistically can see five percent weight loss and maintain it long term.”

Some people I have been fortunate enough to work with have seen maybe 10 or 15 percent weight loss and have been able to keep it off, so far, long-term. That percent of people that are able to do that does tend to go down. But we can see glucose improvement with modest weight loss — even to seven percent weight loss, we already can see better glucose metabolism or less insulin resistance with small amounts.

I would always want to reassure someone, you don’t have to lose 50 pounds to see good results. Maybe seeing a five to 10 pound weight loss, you will already probably see a difference in the way your body can use glucose, reducing that risk of pre-diabetes or diabetes.

Christina Chen, M.D.: You answered my next question beautifully. You know, many people struggle with that sustainability piece. The key to maintaining that long-term success is really understanding a different mindset of how to eat and what to eat, and then building that into your day-to-day routine.

And then the second part is just not to be frustrated with slow progress. Because progress is still progress, right?

Eventually, you will get to a successful — clinically successful— improvement. And that could take time. That could take months, to sometimes years. But that’s what long-term success is, is being able to do it for months and years and do it well.

Laura Knudsen, R.D.N., C.D.C.E.S.: Managing weight is a chronic condition. I always tell people it doesn’t just go away and stay away. It’s persistent, just like managing heart disease or managing diabetes. These are lifelong journeys that we are always in the back of our mind, trying to be conscientious around. Those habits that you build are incredibly important for that long-term success.[2]

And I also think having a support system is also one of the keys: Is that support system going to be a family member? Is that support member going to be a friend? Is it going to be your diabetes care and education specialist? Is it going to be your provider? Are you going to the senior center? Do you have a gym membership that you’re going to go to?

Not even from a food standpoint, but I think even from an exercise standpoint, statistically, people do better when there’s a social aspect to it.

If someone is at an assisted living facility or a nursing home and they offer an exercise class, I’m always like, please take advantage! Even if you can’t do all of the exercises, do what you can, show up, and socialize. Start where you’re at and you just build from there, so that you can keep those habits that help you to be successful.

Christina Chen, M.D.: Yeah, and that’s a big theme of our podcast too, is movement, exercise, staying active, reducing our stress experience, good sleep. Because all of that has impact on cortisol levels and blood sugar control. It really is looking at things holistically and making sure that all of it has impact on each other.

Christina Chen, M.D.: This is probably a whole other topic on its own, but just briefly, would you mind sharing your thoughts and observations with the newer GLP-1 medication use?

Is this a treatment that you typically recommend early on in the course of weight loss and diabetes efforts, or do you encourage lifestyle portion first, before incorporating some other treatment options?

Laura Knudsen, R.D.N., C.D.C.E.S.: When I see somebody, I try to take a person-centered approach, so usually I’ll try to feel out what the person came to the appointment thinking.

Did they come to the appointment ready, like they wanted to add a medication to their treatment plan? Versus, were they wanting to start from a lifestyle standpoint? Because until they had their doctor’s appointment, they had no idea that there were any kind of glucose issues. They were not trying any lifestyle changes to begin with.

I certainly see lots of people that are on these medicines, and I find them to work well.

Christina Chen, M.D.: And does someone’s age affect whether they might be a good candidate for a GLP-1?

Laura Knudsen, R.D.N., C.D.C.E.S.: The older somebody is when they get diagnosed with diabetes, sometimes I think: Could we focus on lifestyle first?

If they’ve never tried any lifestyle things yet, we have room to increase movement, change up our beverage choices, change our diet.

Versus, if somebody is very young — maybe they’re only in their twenties or thirties when they got diagnosed with diabetes— I might be a little bit more likely to be aggressive on the medicine end of things, because I think of their beta cell function as maybe not as strong.

I’ve done it both ways. I think that if somebody wants to try something for a lifestyle for a little bit and see how their glucose goes, and then come back, and we’re like, you know what? I have tried lifestyle, and I’m not getting as much results as I wanted.

If somebody wanted to add one of those medicines, I think I would consider it as one of our first-line medicines if somebody has diabetes, and also weight loss is one of their goals.

And[3] for some people, if they have a history of cardiovascular events, whether heart attack or stroke, sometimes this can help reduce a risk of having another heart attack or stroke. To me, the GLP-1 medicines are a tool to help, but lifestyle is the foundation, no matter what option I pick.

Christina Chen, M.D.: Yeah. For your patients who usually choose to try lifestyle measures first, what do they usually say is their reason?

Laura Knudsen, R.D.N., C.D.C.E.S.: Many of the older adults that I see sometimes would prefer not being on excessive medications, if possible. They might say, “I am retired. I have a little bit more time to focus on myself than I did in my working years.”

“I want to try lifestyle first, because I have the time, I have the energy to commit, and I may be a little bit scared about my diagnosis of pre-diabetes or type 2 diabetes. I have an extra level of motivation that I didn’t have before I was told that my glucose levels are running high.”

Sometimes I’ll see somebody like, definitely choose to be like,
“I think I can do this from a lifestyle standpoint.” But I’m like, it is okay to use a tool to help on that journey.

Christina Chen, M.D.: It sounds like the bottom line is this is a very individualized decision. It has great benefits. And the goal is to optimize success, and to empower them to ultimately get on a better health course while feeling their best along the way, and learning new habits and sticking with them.

But let’s talk a little bit more about the diet portion of this all, and how GLP-1s can change how we eat. Because at that point, we’re drastically reducing how much someone is eating.

Laura Knudsen, R.D.N., C.D.C.E.S.: Yeah. If somebody has really struggled with reducing portion sizes, that’s maybe starting on those medicines — they feel like they’re eating about half of the amount compared to usual — I love that I get to be the educator, mentally preparing somebody if they’re going to start one, what they might expect, and how we’re going to keep somebody well nourished. Because if they’re going to be only eating half of the amount, how are we going to keep you lean and strong?

Maybe a lean protein source at least three times per day. I might be like: How can we get you enough fiber in your eating patterns so we maybe reduce your chances of being too constipated on that journey?

I always will talk about keeping our lean muscle mass on. This is one of our keys as we get older. We do not want to see lean muscle mass loss. How can I make sure that we have some exercise, ideally some resistance exercise?

Maybe some things that work core muscles like our arm muscles and leg muscles, and back muscles, so that if I were going to see weight loss as we get older, we want to be really careful not to lose the wrong kind of weight.

If you’re nauseous, we cannot only eat crackers all day, and you cannot skip lunch, because you are hungry. We have to find you a way to keep your body well-nourished so we can also see those lower glucose levels.

Christina Chen, M.D.: How do we help people adapt to nutrition plans based on their lifestyle and abilities, including their physical limitations, for example? If they can’t make it to the store, or know how to pick nutritious foods?

How can we effectively partner with caregivers and family members to make sure that their nutrition and health needs are met?

Laura Knudsen, R.D.N., C.D.C.E.S.: I love when I see the caregiver or the support person educating themselves about the condition that their loved one has.

I often will see somebody come with their friend or their significant other to an appointment. I just love that they are also trying to truly learn what the evidence says about the condition, versus maybe using TikTok or Facebook as their education tool.

I love when they’re able to truly learn and go to reputable sources, even if it’s on the internet. Can I use the American Diabetes Association or some reputable sources?

I think, especially for people that have type 2 diabetes, we consider it a progressive disease. Maybe what started as one medication, somebody is now on two medicines, or three medicines; or on insulin; or on multiple daily insulin injections per day. At each level of progression, that burden on the person that is managing that diabetes goes up.

As a support person, I think if you can help with any of the daily tasks or the daily management to reduce the burden on the person managing that condition — and especially if that person managing that condition now has neuropathy, or has things that make managing those daily tasks even more challenging. As if it wouldn’t be challenging enough if I was perfectly healthy, to have to check my glucose levels multiple times per day, have to think through, how much insulin do I need to give? They also wanted me to dose this off of the amount of carbohydrates I ate. Every level of that adds complexity.

So if I can, I will count your carbohydrates — I’ll help with that. I’ll make sure we have food so we can follow this Plate Method, so it’s a balanced meal. Helping with daily tasks, I think, would show a lot of support.

I think of emotional support if you’re managing a chronic condition. I think of the increased rate of depression when you’re managing something that is chronic.

When we are told, what I have is not going away, and it’s just a matter of managing it, I’m like, “I don’t even need you to help with managing the condition, but can you just understand and have empathy for me from an emotional standpoint?”

And then, as the dietician, if somebody wanted to plan my meals out for me or plan balanced meals, that would be helpful for me. If somebody could just help me out, I will eat whatever. I’m not picky.

And I’m like, but can I offer healthy foods? If I want somebody to eat healthier, I’m like, I will make this really nice meal for you, and I show I understand what you’re going through as you are trying to manage all these. And I’m here with you to walk on this journey.

Christina Chen, M.D.: Oh, this is great. Because caregivers — they want to be helpful. And when they see bad habits, it’s so easy to have blame, rather than, okay, what can I do to take some of the burden off your shoulders so that I can be helpful and turn things in a better direction?

And sometimes it’s just partnering to say, “Alright, let’s try a meal plan,” and getting creative too — like, “This week, let’s try a meal plan. Next week, I’ll do the groceries for you. Let’s just see what works for you and me.”

And then we can integrate this into our lives somehow, to do something different, because something has to change. We can’t keep doing the same thing every day.”

Laura Knudsen, R.D.N., C.D.C.E.S.: Yeah, there’s even meal services out there. Now that people don’t have to cook for a whole family of people and there’s just one or two people, they’ll enroll in meal plans where they can just order a balanced meal online and maybe do minimal prep.

And some of those are even very low-processed. Very nice and handy when somebody doesn’t want to have to cut up everything separately or buy things in bulk when they don’t need bulk.

And often on these sites, you can choose if you want diabetes-friendly eating patterns. You can choose the condition that, maybe, I’m trying to eat heart healthy, these are the conditions I want, these are the options we have in these meals.

Even if nobody wants to plan this meal, there’s convenient ways to still eat well, without the burden.

Christina Chen, M.D.: I should totally take advantage of that, as well as on the days that I don’t feel like cooking.

Laura Knudsen, R.D.N., C.D.C.E.S.: Mm-hmm.

Christina Chen, M.D.: Well, Laura, I know you have helped so many people over the years. Do you have any success stories that stand out to you of someone who really transformed their health and lifestyle through nutrition and lifestyle changes?

Laura Knudsen, R.D.N., C.D.C.E.S.: Yeah. This is one of my standout ones. It was a gentleman, he had recently retired. He came to his appointment. He just recently had his lab work done. So this was within two weeks, probably, of his diagnosis. His doctor prescribed him metformin. I think they even ordered him his blood glucose testing supplies, everything.

He comes to this appointment. He has done nothing yet. He’s like, “I was waiting until I came to this appointment because I just need to figure it out.”

He is like, “I have not started the metformin yet. I haven’t started checking my glucose yet. I am just here because this is brand new. I want to see if there’s anything from a lifestyle standpoint I can change first.

Tell me what I need to change, what I need to do. I want to see how I can manage my diabetes.”

We talked about his target glucose numbers, and I’m like, “These are the numbers your doctor is going to want you to hit.”

And I had seen him back, like three months later, and then six months later, when he had his A1C checked. His glucose levels went into the normal range. — he had already been diagnosed with type 2 diabetes — completely in the normal range.

He never started the metformin. He originally thought he was going to need to take [it], but he’s like, “I haven’t tried anything.” And I think he did probably two things that I think, for him, were his keys.

Had recently retired. I think he was a firefighter. But he was like, “When I retired, I wasn’t really exercising.”

He started biking, and he said he used to bike in his 20s, 30s, and you know, his middle-aged years, he stopped biking, probably because of business and his life.

And he’s like, “Well, now that I’m retired,” he’s like, “I have time to do this”. So he would bike probably 10 to 15 miles a day. And he did make some nutrition changes, too. I tell people when I’m telling his story, I’m like, “He biked his way out of diabetes.”

You know, he’d come into his appointment in the morning, he still had his biking clothes on. He is like, “I already got 12 miles in this morning.”

And to see his A1C be back in the five percent range — after his diagnosis, it was probably like a 7.3% or so, so it was certainly high enough to qualify as having diabetes — but he, significantly, more than a one percent or two drop in A1C, off of significant biking.

I’ve seen many people with their food changes using their glucose checking as a tool. Things that are always fun for me to hear is, I can talk to somebody about types of carbohydrates — like, are these simple carbohydrates or complex carbohydrates, and how do they affect our glucose?

But I love when somebody comes in, and they’re like, “You know what? I was experimenting at home, and I ate this food, and I noticed that when I eat breakfast cereal in the morning, it makes my glucose spike up higher than when I eat these other foods.”

Now they’re like, “I am just choosing to eat different style breakfasts because I noticed. Now that I know and I have this tool to see that this made my numbers run high, I’m going to pick different things.”

Or they’ll be, “I was surprised to see this food make my glucose run higher. Now I eat smaller portions of it. Or I have switched out, and I’m choosing something else instead.”

I will often have people check their glucose one to two hours after a meal. And I tell people, “This is how you can evaluate your tolerance to that carbohydrate load, or your insulin resistance, or your insulin production.”

When people are able to experiment with that and figure out what works — and then make the adjustment. It’s one thing to check it, and it’s another thing to see it and be like, “This doesn’t work for me. I’m going to try something different next time.” And to find something that works better.

Christina Chen, M.D.: And you don’t need a continuous glucose monitor for that. I mean, you can just use regular Accuchecks. Or is it better to use a continuous monitor for that?

Laura Knudsen, R.D.N., C.D.C.E.S.: I have people use both. So for Medicare, they have their own rules oftentimes.

For somebody that has diabetes, if they are not on insulin, oftentimes Medicare is not going to cover a continuous glucose monitor. I think a blood glucose meter is going to be enough, even though I do have to choose a specific time and day to do that, and I cannot see it continuously.

Christina Chen, M.D.: Yeah.

Laura Knudsen, R.D.N., C.D.C.E.S.: If I see somebody that is on insulin, I will always advocate for them to be able to get a continuous glucose monitor. I think it’s the gold standard, if somebody qualifies for that.

But usually, with Medicare specifically, currently, the guidelines are that they need to be on at least one insulin injection per day. And I think it’s incredibly eye-opening.

Then I can see this internal pride when someone’s like, “I was in my target range 88% of the time.” And being able to self-adjust things to keep a high percentage of numbers in their target zone.

Christina Chen, M.D.: Yeah. I hope that insurance plan changes someday. Because, like you said, I think it’s a gold standard. We all need to know more about what our blood sugar’s looking like, especially with new diabetics. Because that’s the prime time to make changes and understand what the data looks like from a blood sugar perspective, and how to make those adjustments with our diet and lifestyle.

Laura Knudsen, R.D.N., C.D.C.E.S.: People can use their health savings account money. Even if they didn’t do it continuously their whole life, but they’re like, “I want to do this for a while just to learn which foods affect my glucose.”

Christina Chen, M.D.: Yeah.

Laura Knudsen, R.D.N., C.D.C.E.S.: Yes, get a Stelo or a Lingo, and you can just wear it for two weeks.

You know, see what your numbers are. Maybe you take a break for two weeks and then see it again. You’ve made some changes in your style. You’re eating a little different, exercising a little bit differently.

Christina Chen, M.D.: Yeah. After having worked with so many people, what do you feel like living well with diabetes looks like for people? How do we all age forward with better balance, nourishment, and vitality? People can do it well — and so what does that look like to you?

Laura Knudsen, R.D.N., C.D.C.E.S.: I want people to consider themselves healthy. If somebody came into my office and they said, “I am diabetic, this is why I am here,” I would try to correct them and say, “One, you may have diabetes, but you are not diabetic.”

And I would be trying to convince them that we are going to help you to be the healthiest version of you possible. Because if we can change our mindset to associate with being healthy, to me, it helps us to make healthier choices.

I am somebody that values health, so I’m sometimes a little biased, but I’m like, if I can associate with being healthy when I am given a choice each day to decide, am I going to plan to exercise today or not? I think I’m going to be more likely to do that because I told myself I’m healthy. And I told myself my plan is going to be to do resistance exercise twice a week.

And I told myself I’m going to get 150 minutes of moderate-intense activity a week or whatever my goal is. And I can adjust it down if I need to, because maybe I’m not fit enough to get that level in.

But I’m like, start where we’re at. If we start saying we’re healthy, we’re going to do that. Even when I think of when I’m in the grocery store, or I’m ordering my groceries online, I am going to focus on the nutrient-dense foods. I think if I consider myself healthy, maybe I value the quality that I buy more than the cost.

Like, man, it might cost just a little bit more to get this more nutrient-dense food, but we can just eat a little bit less of it. Hopefully, your overall grocery bill does not cost more.

Because I don’t want somebody to pick more processed foods and poor quality foods if that’s going to increase my risk, not just of pre-diabetes or diabetes, but other chronic health conditions. I think it’s a good investment in myself if I can consider myself healthy in that respect.

Christina Chen, M.D.: Right, right. Now that really resonates with me because if you say, “I’m a diabetic,” it’s like, that’s your permanent identity. It’s who you are now, which is not necessarily true.

You are a healthy person. You just have this condition that can be managed. And I just love that perspective where it shifts the focus from: There’s no hope, to there is plenty of hope.

We have one closing question that we like to ask all of our guests. How do you personally age well?

Laura Knudsen, R.D.N., C.D.C.E.S.: Well, I am somebody that’s bound and determined to make it to a hundred years young and still be at home and thriving.

I’m in my 40s, but I run 15 miles a week. To me, it has been my tool. I know I can get at least 150 minutes of moderate-intense exercise if I run my 15 miles.

For me, I started this goal a long time ago, and I actually started with 10 miles a week. And I had that goal for a couple years, and I’ve, maybe in the last five years, increased it to 15 miles.

One of my favorite work challenges was our employee wellness challenge. We got prizes if we met. They had us walk or run a hundred miles and a hundred days over the summer months. And that’s maybe what started this whole journey to begin with. I’m like, “Oh, I just have to average one mile a day for a hundred days, so if I skip a day, I just have to do two miles the next day to make up for it”. And then I just have built it over time. So, movement is definitely one piece.

And then nutrition, I definitely value quality food. I think of food as medicine. Even when given the choice, like: Man, would this taste, like, really good? I’m like, is this going to nourish my body?

I still eat anything. I’m not very picky as far as eating goes, but I definitely can tell I value quality, for fiber and produce and plant proteins, when possible. I like those foods to taste good, so I won’t just eat them plain. I go out of my way to season them up and flavor them well.

Christina Chen, M.D.: Well, thank you so much, Laura. This has been such a fun conversation, and you have definitely reminded us that with the right nutrition and movement and small, consistent habits, it’s possible not to only manage diabetes, but to thrive with it.

And it’s proof that healthy aging isn’t about restrictions. It’s about understanding how to nourish — I love that word now, nourish — your body and in turn, how to have a more resilient body.

You have inspired me to run again. I don’t like running. I can barely make it a mile before huffing and puffing. But again, it’s consistency, and one mile a day is not much.

But after so many days, it’s hopefully going to be easy again. So thank you, Laura.

Laura Knudsen, R.D.N., C.D.C.E.S.: Thanks for letting me participate in this podcast.

 Christina Chen, M.D.: That’s all for this episode — hopefully you’re feeling a little more informed, inspired, and empowered.

If you have a topic suggestion for a future episode, you can leave us a voicemail at 507-538-6272 — we might even feature your voice on the show!

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Thanks for listening, and until next time, stay curious and stay active.