Nutrition For Prediabetics

Yulia Brockdorf, RD, LD, CDE, CST, MA, NCC, LPC, BC-ADM, is the Clinical Director of Nutrition For Success, LLC.

Ms. Brockdorf is a registered dietitian, a licensed dietitian, a certified diabetes educator, and a certified sex therapist. She holds a master’s degree in clinical mental health counseling and is a national certified counselor and licensed professional counselor, as well as holding a board certified—advanced diabetes management credential.

In her spare time, she serves as chair of the Oregon Board of Licensed Dietitians, counsels patients to explore and move through their relationship with food and nutrition, and sits on the Editorial Board for Multinational Association of Supportive Care in Cancer Journal and the Research Advisory Board with the Community-Academic Consortium for Research on Alternative Sexualities.

When asked if she would answer some questions about prediabetes and food, she said, “Sure, send them over!” She took time after work and between patients to provide thorough responses, and that valuable information is what follows.

What’s the difference between an RDN (Registered Dietician Nutritionist) and a CDE (Certified Diabetes Educator) when it comes to the dietary needs of a prediabetic?

A registered dietitian nutritionist is a professional who has an in-depth knowledge and training that pertains to all areas of human nutrition, as well as medical nutrition therapy in treatment of the disease.

A certified diabetes educator is a licensed healthcare provider who demonstrated competency and experience in treating, educating and supporting people with diabetes.  This can be a licensed nurse, dietitian, pharmacist, physician, psychologist or another licensed provider (please see page 4 here).

A certified diabetes educator is required to meet nutrition competencies standards. However, their knowledge of nutrition is often not as in-depth as is that of a registered dietitian nutritionist.

When it comes to intricacies and nuances of applying nutrition recommendation, standards of practice, and latest research in practical everyday life, meeting with a registered dietitian nutritionist who is also a CDE may be beneficial for a patient.

Do you consider them equal in their expertise when it comes to instructing prediabetics on food choices?

While some providers who are CDEs gained the knowledge and mastered a sufficient skill set, in general, since there are so many professions that are eligible to become CDEs, not all will have the in-depth training, understanding of nutrition, nutrition biochemistry, and nutrition relationship between health and disease development, as most registered dietitians do. A CDE is a diabetes expert and an RDN is a nutrition expert, but most RDN training also includes an in-depth study of diabetes and prediabetes prevention and treatment.

Should prediabetics visit an RDN or CDE to get guidance on their prediabetes journey and if so, why?

Yes, they should. And oftentimes the services of a registered dietitian are covered under health insurance as preventive care. This may not be the case for all those who have CDE certification.

What is your definition of the keto diet?

The classic ketogenic diet distributes macronutrients in a ratio of 4-1.  For each 4 g of fat, which accounts for about 90% of the total calories, one consumes 1 g of protein (6% of total calories) and carbohydrate (4% of total calories) combined, with protein being the more dominant macronutrient of the two.  It’s very seldom that this diet is implemented in its classic form.  And there are many variations of ketogenic diet currently circulating online.

What are your thoughts on the ketogenic diet for prediabetics?

Research supports caloric restriction as a means of prediabetes treatment. This may be accomplished with a ketogenic diet. I would like to emphasize that we are discussing nutritional ketosis, not a life-threatening diabetic ketoacidosis.   

One of the outcomes of a ketogenic or modified ketogenic diet is a reduction of circulating insulin and an increased cellular responsiveness to insulin. A ketogenic diet can be successful in decreasing the total glucose burden in the cells of the body.

If embarking on a ketogenic diet, I strongly urge prediabetics to meal plan to ensure an adequate intake of fiber and micronutrients which may be missing when carbohydrate-containing foods that provide them are removed. Grains, for example, provide manganese, b vitamins, fiber, magnesium, and phosphorus.  I do not recommend implementation of a ketogenic diet without the supervision of a trained professional.  

What is your definition of a low carb diet?

This definition varies a lot from under 130 grams per day, or under 100, or between 30-60 or under 40, or below 20 (now venturing into keto world).

What are your thoughts on a low carb diet for prediabetics?

Decreasing carbohydrates does appear to have a benefit in prediabetes. 

Like any diet, carb restriction will lead to weight loss and improved metabolic profiles. But research does not show that these benefits have a long-term viability. 

If prudent carbohydrate intake that is both nutrient rich and portion controlled is incorporated into a long-term lifestyle change, consumption of under 100 grams a day may be a sustainable practice.

I do not support long-term carbohydrate restriction, but rather a reasonable carbohydrate intake.  This number is individual for each person with prediabetes.

Is there another way of eating, besides keto or low carb, that you prefer to recommend to prediabetics?

The POUNDS LOST study looked at four diets with fat, protein, and carbohydrate distribution:  20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%. They concluded that reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.

There has been a lot of research supporting the Mediterranean diet as a means to prevent diabetes and reduce blood pressure.

Plant-based diets were associated with significant improvement in emotional well-being, physical well-being, depression, quality of life, general health, HbA1c levels, weight, total cholesterol and low-density lipoprotein cholesterol, compared with several diabetic associations’ official guidelines and other comparator diets. (BMJ )

Most recently, there is an increased surge in research looking into various forms of fasting: intermittent fasting, restricted feeding, etc. 

A recent study published in the Obesity journal showed that fasting not only improved postprandial glucose response (the blood sugar after eating) but also fasting glucose. Do not attempt fasting on your own without proper support.  Long-term fasting may lead to death or severe and dangerous complications such as refeeding syndrome.

Is it important to have a balance between carbs, proteins, and fats at each meal or snack? Why?

It is important to consume balanced and nutrient-dense foods. Such foods would be high in necessary micronutrients such as vitamins, minerals, and various phytonutrients, while also delivering necessary energy (in the form of protein, fat, and carbohydrate). 

This balance is the balance of the whole lifestyle. While each individual meal and snack can lean more toward one macronutrient or another, overall balance of food consumed in a given day, in a given span of time is important. 

Including fiber will support a sense of satiety, and may help with reducing cardiometabolic risks, as well as promoting gastrointestinal health. 

On the other hand, consumption of high fat and high carbohydrate foods in one meal may have a deleterious impact on prediabetes. This may result in an elevation of blood sugar, and this elevation may be sustained over a longer period of time. 

As far as the balance of carbohydrates, proteins, and fats, it’s based on the lifestyle of a person and the advice of their healthcare provider. The ratio may vary. 

I do advise that whichever approach is chosen, this decision is made on an individual basis and is sustainable as part of an overall healthy lifestyle.

What are your top five general recommendations for those working to reverse their prediabetes?

Don’t eat too much, and eat mostly plants

Exercise

Get enough sleep

Do things that bring joy to your heart

Spend time in nature and practice non-violence, respect, and kindness toward self and others

Which online resources for prediabetes could you recommend and share?

Keto and low carb resources:

Diet Doctor

LCHF-RD

JAMA Network

Fasting resources:

The Fasting Method

Obesity: A Research Journal

Metabolic Health Summit

Cell.com

Plant based:

PCRM

Spectrum Diabetes Journals

Vegetarian Diets and Incidence of Diabetes

Does a Vegetarian Diet Reduce the Occurrence of Diabetes

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