About Your Diet Q&A With Paulette McMillan

Paulette McMillan, MS, RD, LDN, CDE, L.Ac., Dipl.OM, is the co-founder of the Center for Health and Wellness.

She is a registered dietitian and licensed dietitian/nutritionist, a certified diabetes educator, a licensed acupuncturist, and is board certified in oriental medicine with a master’s degree in Human Nutrition and Functional Medicine.

Ms. McMillan recently took time from her practice to chat about prediabetes from the viewpoint of a nutritionist and diabetes educator.

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?

Both are qualified to work with people with prediabetes. The difference is someone who’s a certified diabetes educator has to have a degree in heath care to qualify for the certification. Most CDEs are registered dietitians and nurses. However, there are pharmacists, social workers, medical doctors and other healthcare professionals.

An RDN has at least an undergraduate degree in nutrition and has completed a practice program, or internship, to qualify to take the RD exam. About half of RDNs also have master’s degrees. But they do not have to have a specialty in diabetes education.

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

Depends on the individual, depends on the experience that person has. One doesn’t have to be a CDE to have worked in a clinic where there might be a lot of people with diabetes or prediabetes. So it really depends on their clinical experience.

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

I would say absolutely. Because prediabetes is reversible and if you wait until you have diabetes, which is sometimes the case, you really can’t reverse diabetes. By then the pancreas is already weakened to the point that they may be able to control it with diet and lifestyle but they will always have diabetes.

This is how I explain it to people: If you don’t have diabetes you can eat a piece of cake and your blood sugar will stay normal. If you have diabetes, even though you have controlled it by eating a low carb diet and now you have great numbers, as soon as you eat a piece of cake, your blood sugars go out of normal range.

With prediabetes you could actually reverse it and conserve your pancreas, your beta cell function.

The other point I want to say about prediabetes is that, once you have prediabetes, you are now at higher risk for cardiovascular disease, so you definitely want to reverse this risk.

What is your definition of the keto diet? (how many carbs a day)

You know I don’t have that on the top of my head but, bottom line, it is a diet that has no more than 20 to 30 grams of net carbs, and most of the calories come from fat. There are specific ratios you’re supposed to use to do the ketogenic diet properly.

What are your thoughts on the ketogenic diet for prediabetics?

When somebody walks into my office and they’re prediabetic and they’re morbidly obese, and they tell me that nothing they do works to lose weight, the keto diet might be a great option for them. If they’re willing to do it.

If the client is truly motivated to start keto, I explain to them that they must commit to the diet for a certain amount of time, like 3 to 6 months, because it takes at least 3 weeks before the body starts burning body fat as energy. So if they choose to play games and go in and out of ketosis, they are not really doing themselves any favors metabolically.  They will actually lose a greater percentage of muscle.

After that, I explain to them that if they’re someone who is truly sensitive to carbohydrates, they may never be able to eat the amount of carbs that someone who has no problem metabolizing carbohydrates can eat. So if they’re in keto at 30 grams of net carbs daily, they might be able to get up to a 100 or 130 grams of carbs a day, and that might be where they have to stay to maintain a healthier weight. In comparison, a man who is not prediabetic might eat 300 carbs or more a day, and a woman might eat 250 carbs a day.

What is your definition of a low carb diet? (how many carbs)

I give someone 150 grams of carbs a day, and I don’t count the carbs in nonstarchy vegetables, like broccoli or spinach, but I would definitely count the carbs in starchy vegetables like potatoes or corn.

I ask them to spread the 150 carbs evenly throughout the day, so they can’t save them up and eat them all at one or two meals. Think of it like this, if you have prediabetes that means your pancreas isn’t working at 100%.  It’s kind of like weightlifting, you might be able to do 15 reps of 30 pounds each but can’t lift all 450 lbs at once.

If they’re comfortable going a little lower, 100 to 130 carbs a day, that’s fine.  It’s just so individual and it’s not just about the quantity of carb but also the quality.  If you’re eating a piece of cake or a piece of white bread it’s not the same as eating a whole grain or sweet potato or something more natural and less processed.

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

I think it’s a good place to start with clients, to help them understand carbohydrates. We want them to understand carbs. However, with prediabetes it’s not just carbohydrates that we’re talking about. If they’re overeating, the first defense is to feed the body proper amounts. If they’re sedentary they have to get moving. If they don’t get moving, they’re going to stay insulin resistant and stay prediabetic. These two things are very important. 

Weight loss is recommended, if they’re overweight. Not all prediabetics are overweight. As people age, they’re more susceptible to prediabetes.

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

Yes, a Mediterranean style of eating and I do give them guidelines on what that means. I do like this approach a lot because there’s a lot of variety. It is an anti-inflammatory and nutrient dense way of eating.

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

From a practical standpoint, people won’t maintain just chicken and a salad and some fat for lunch. I find that they make up for the deficit in their meal with their snacks. Often, people are eating more calories in their snacks than in their meals. When there is a balance in their meals of carbs, fat, and protein, most of the time people are more sated and they’re not looking for more food.

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

It’s individual. Who is the person sitting in front of me?  What is their motivation level, knowledge base and abilities?

Are they sedentary? How much activity do they do on a regular basis?

People need to get moving and the minimum requirements are 150 minutes a week of aerobic activity which is moderate walking not a stroll, two to three days of strength training per week, in addition to cardio, because we need to build up muscle mass. Muscle helps our bodies respond to insulin signals and metabolize sugar.

If they’re overweight, aim to lose five to seven % of body weight to start.

Teaching them about carb quality and balance throughout the day.

Any last suggestions for prediabetics that you’d like to share?

Look into the CDC National Diabetes Prevention Program, find a local community group who’s using it.

Also, I’d use an app like My Fitness Pal to track carbs and calories that way, whatever works for them.

And you should look at supplements. Fish oil for omega-3 fatty acids, zinc, magnesium, vitamin D – they’re important for prediabetes and for all of us.

Food and PreD

Most of us are prediabetic because our food choices aren’t healthy, and we don’t get enough exercise. It’s a lifestyle thing.

Multiple studies[1] show that, if you are prediabetic, one of the better ways to reset your body is to lose weight, change your diet, and exercise.

Before going any further, let’s pause for a minute to say: talk to your healthcare provider before changing what you eat or how much you move.

Today, we’re going to talk about food. We’ll save exercise for another time.

Research[2] suggests that when it comes to what we eat, a lower carb regimen of 20-50 net carbs a day is one way to get those blood sugar levels down.

As we launch into this topic, it’s important to remember that what works for one person may not work for another. This journey of resetting what you eat will most likely be a trial-and-error effort for the first few months.

Diet, when used as a verb, isn’t fun. We start out in a negative place when we go on a diet. It seems like work, and that we’re giving up enjoyable foods for foods that are bleh.

It’s not a journey that we begin with a smile.

Diet, when used as a noun, simply means the food and drink one typically eats.

No negatives there, right?

We’re talking about your diet (what you eat and how that might change) but not about you going on a diet, with all of the negative “celery sticks and rice cakes” connotations.

Most of us don’t like to weigh or measure food, or follow set recipes that don’t even feature foods that we prefer.

We just want to eat and let nutrition figure itself out.

That’s what we want to do, but hey, we put in the work to get ourselves to this chubby and prediabetic state. Now we have to do some work to get out of this mess.

We can lose weight by simply not eating as much food each day. Slash those calories and say bye-bye to a few pounds.

However, unless we also change what we eat[3], we’re less likely to leave prediabetes in the dust.

We can do this. Together, we can trial-and-error ourselves out of prediabetes land.

There is no one-size-fits-all way of eating that will lower your blood sugar and help you lose weight.

You need a personal plan that includes foods you like and leaves out foods you don’t like. Talk to your healthcare provider and get a referral to see a registered dietician or certified diabetes educator. Your local hospital or health clinic may provide this service free of charge.

Until you get the advice of a professional, there are some basics you can follow that apply to most of us.

Do a bit of homework. CDC explains carb basics,[4] and websites like endocrineweb.com[5] and diabetesfoodhub.org[6] can start you on a path toward restructuring your diet.

Eat to your meter. The amount of carbs you should eat in a day will be different from the amount another prediabetic should eat. An expert can help you design a diet, but you’ll need to use a meter and test various foods to see what affects you and what doesn’t.

Don’t give up. If you’re disciplined about the trial-and-error approach, you will end up with a way of eating that you like and that (usually) keeps your blood sugar levels in the normal range.

It’s not only about your diet. Other factors can affect your blood sugar, like certain medications[7], stress, lack of sleep, and illness­­—all of which may keep your numbers elevated even if you’ve reduced your carb intake.


[1] Harvard School of Public Health/The Nutrition Source, Simple Steps to Preventing Diabeteshttps://www.hsph.harvard.edu/nutritionsource/disease-prevention/diabetes-prevention/preventing-diabetes-full-story/#diet, (May 2, 2019).

[2] PLOS ONE, A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabeteshttps://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0091027&type=printable, (May 24, 2019).

[3] BMJ Journals/BMJ Open Diabetes Research & Care, Remission of pre-diabetes to normal glucose tolerance in obese adults with high protein versus high carbohydrate diet: randomized control trialhttps://drc.bmj.com/content/4/1/e000258?cpetoc, (June 12, 2019).

[4] CDC Centers for Disease Control and Prevention/Diabetes, Diabetes and Carbohydrateshttps://www.cdc.gov/diabetes/managing/eat-well/diabetes-and-carbohydrates.html, (June 24, 2019).

[5] Endocrineweb, Diabetes Diet: The Best Way to Eat for Type 2 Diabetes, https://www.endocrineweb.com/conditions/diabetes/diabetes-diet-best-way-eat-type-2-diabetes, (June 24, 2019).

[6] American Diabetes Association/Diabetes FoodHub, https://www.diabetesfoodhub.org/, (June 24, 2019).

[7] Diabetes in Control, 390 Drugs That Can Affect Blood Glucose Levelshttp://www.diabetesincontrol.com/drugs-that-can-affect-blood-glucose-levels/, (June 24, 2019).

Nutrition For Prediabetics

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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