Manette Rishardson , RDN, CDE, LDN & Master Trainer Diabetes Prevention Program,

Manette Rishardson, RDN, CDE, LDN & Master Trainer Diabetes Prevention Program,


Ask Manette......

If you have questions about your diabetes, what to eat, your medications, or what your numbers mean. then send your questions to Manette.

How do I know if I’m at risk for diabetes? take this simple test to discover if you are at risk fo diabetes.

So what can you eat? I have been avoiding sugar. We know the arguments against eating carbs. Other than fiber, carbs are either sugars or starches that break down into sugars. Since people with diabetes have little to no effective insulin, which is necessary for handling sugars (glucose), they probably shouldn’t eat them.

It seems clear that the successful ones eat very low amounts of refined sugars and simple starches. They may have small amounts of truly whole grains (not stuff that is marketed as “whole grain” but is actually highly processed). They eat small amounts of fruits and starchy vegetables. (Diabetic low-carb guru Dr. Richard Bernstein says he hasn’t eaten a piece of fruit in decades.)

What’s left? Well, from a carb standpoint, you can eat as much animal food, like meat and eggs, as you want. They don’t have any carbs (although dairy products do). You can vary that with sea animals — they don’t contain carbs either. Nuts are also terrific low-carb foods. Another  option are soy products like tofu.

I understand that Gastroparesis is a disorder affecting many people with both type 1 and type 2 diabetes. What can be done to manage this condition? Changing your eating habits can help you manage symptoms of gastroparesis 

  1. Choose small, frequent meals and snacks. With slow gastric emptying, small meals are much better tolerated than typical American larger meals. Try eating small amounts 5 or 6 times per day.

  2. Keep fat content low. Fat can delay gastric emptying, so keeping intake low initially will allow the stomach to empty better..

  3. Keep fiber content low. This may be the opposite of what patients consider “healthy,” as refined, white breads, cereals, and pastas that are low in fiber are the easiest to tolerate. Fiber can be difficult to digest and it may be possible that the undigested fiber can form bezoars (a solid mass of undigested food that gets stuck in the digestive tract (or gut) causing a blockage). Also things like fresh fruit and vegetables, which are normally considered healthful, can be very hard to tolerate. The goal would be resuming a higher fiber diet with more whole grains and fresh produce as symptoms improve, but in the short term the foods that are the healthiest for a person with slow gastric emptying may look different.

  4. Liquids may be better tolerated than solids. Liquids tend to leave the stomach much more easily than solid food. You may want to get nutrients through smoothies, soups, juices and other liquid supplements, especially if your symptoms are severe.

  5. Pay attention to hydration. Getting in adequate fluids, particularly in hot summer months, can be a challenge. Fluids should be consumes in between meals.

  6. Avoid carbonation. Soda and other carbonated beverages. The bubbles can add a lot of discomfort if stomach emptying is slow. Keep the liquids flat until symptoms improve.

  7. Supplementation…. If the diet is quite limited for a prolonged time, supplementation with vitamins, minerals may be needed.

  8. Alternate feeding method such as a tube feeding may be required. If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream.

  9. Other helpful tips are eat slowly, sit upright after eating, and take a walk after meals.


What’s the difference between carbohydrates and sugar?Carbohydrates are the types of foods that break down into glucose (sugar) in your blood. Sugar is a type of carbohydrate that turns into glucose very quickly in the body. Carbohydrates are an important part of healthy eating, but because they will affect your blood sugar levels, the amounts and types that you eat matter.

What can you tell me about a ketogenic diet for diabetes? I have been hearing so much about the benefits as well as the dangers? Originally developed to treat severe epilepsy in infants and children under medical supervision.  Today the ketogenic diet is popular because it works, at least in the short term as a low-carbohydrate tool primarily for weight loss. 

So what is a ketogenic diet?  A Ketogenic is a term for a diet that is very low in carbohydrates (carbs are limited to 20 to 50 g per day, primarily from nonstarchy vegetables, with very low-carb ketogenic diets restricting carbs to 30 g per day) and very high in fat. This can put the body into ketosis which then burns fat instead of glucose for fuel.  The idea is to get more calories from protein and fat and less from carbohydrates. You cut back most on the carbs that are easy to digest, like sugar, soda, pastries, and white bread.

For individuals with diabetes,  a low-carb diet seem to help keep your blood sugar lower and more predictable than other diets. Recent research has shown that in some individuals with type 2 diabetes the diet contributed to an improved insulin resistance.  But when your body burns fat for energy, it makes compounds called ketones. If you have diabetes, particularly type 1, too many ketones in your blood can make you sick.

There are challenges in following an extremely low carbohydrate diet. Ketogenic diets don't just eliminate sugar and refined carbohydrates; they also restrict whole grains, fruit, and starchy vegetables. All of these foods contribute essential nutrients -vitamins, minerals, antioxidants, phytochemicals, and fiber—including prebiotic fiber that promotes a healthy gut microbiota. 

Some side effects aren’t usually serious but one may experience constipation, mild low blood sugar, or indigestion. A low-carb diet can lead to kidney stones or high levels of acid in your body (acidosis). Other side effects can include the "keto flu," which may include headache, weakness, and irritability; bad breath; and fatigue.

Just because the ketogenic diet is currently trendy and can have health benefits for some individuals doesn't mean everyone needs to try it. There are other dietary patterns that are shown to promote health and a healthy weight, including Mediterranean and vegetarian dietary patterns. The bottom line it is very important to work with your dietitian on any changes in your diet.

I have been hearing about the importance of prebiotics as well as probiotics. What are they and what foods contain them? A number of diabetes experts believe in the benefits of probiotics, even if it’s more for gut or immune health than specifically for diabetes. There is also research focused on probiotics use and better blood sugar control for people with diabetes.

Probiotics are live bacteria in the gastrointestinal tract that play a role in strengthening the immune system. They help the digestive system stay healthy by helping to clean out the gut. Ingesting foods that contain them or taking probiotic supplements can help repopulate the beneficial bacteria, overwhelming the bad bacteria. 

Probiotics can be found in fermented foods: yogurt, kefir, cottage cheese, cheddar cheese, sauerkraut, kombucha, pickled vegetables, kimchi, miso, and tempeh.

Prebiotics are much lesser known but we are learning more about them daily. They act as food for probiotics. They are undigested plant fibers that feed the probiotics or the good bacteria inside the large intestine. In other words probiotics eat prebiotics.  The more prebiotics the probiotics have to eat the more efficiently these good bacteria work. Also the healthier the gut will be.

Prebiotics can be found in: onions, garlic, leeks, soybeans, chicory root, honey, banana, Jerusalem artichoke and some prebiotic supplements.

Is diabetes reversible? Most people with diabetes will have it for the rest of their life or until there is a cure. Even if diabetes cannot be reversed, it can definitely be managed to prevent or delay complications. You can do this by keeping your blood glucose (sugar), blood pressure and cholesterol in target. Physical activity and nutrition are great ways of meeting these targets. Medication can also help.

What is the GlycoMark test ? I understand it could help monitor my blood sugars.  

Traditional Tests to reach ADA goals for glucose and A1C can be sometimes be challenging.  A  meal periodic finger stick glucose test is not always reliably timed or performed, and may yield inaccurate results. A quarterly or bi-annual A1C is a glucose average – make it difficult to detect glycemic variability and incapable of detecting recent hyperglycemia.

The GlycoMark test is an adjunctive test and specific indicator of recent glycemic variability and hyperglycemic excursions over the past two weeks. The test can be useful for determining whether a person has blood glucose “spikes” after meals.  An abnormal GlycoMark test result indicates significant hyperglycemia and/or glycemic variability occurring in the fasting state, postprandial or both, and is independently associated with diabetes complications.

The GlycoMark Test can provide additional information to help identify patients that may benefit from closer diabetes management, including continuous glucose monitoring or other treatment modifications.  

For more information

Type 2 Diabetes and Erectile Dysfunction (ED): Is There a Connection? Although diabetes and erectile dysfunction (ED) are two separate conditions, they tend to go hand-in-hand. ED is defined as having difficulty achieving or maintaining an erection firm enough for sex. Men who have diabetes are 2-3 times more likely to develop ED. When men ages 45 and under develop ED, it may be a sign of type 2 diabetes.

The Boston University Medical Center reports that about half of men who are diagnosed with type 2 diabetes will develop ED within five to 10 years of their diagnosis. If those men also have heart disease, their odds of becoming impotent are even greater.

The connection between diabetes and ED can stem from damage to nerves and blood vessels caused by poor long-term blood sugar control. Damage to the nerves that control sexual stimulation and response can impede a man’s ability to achieve an erection firm enough to have sexual intercourse. Reduced blood flow from damaged blood vessels can also contribute to ED.

There are several risk factors that can increase your chance of diabetes complications, including ED. You may be more at risk if you:

  • have poorly managed blood sugar

  • are stressed

  • have anxiety

  • have depression

  • eat a poor diet

  • aren’t active

  • are obese

  • smoke

  • drink excessive amounts of alcohol

  • have uncontrolled hypertension

  • have an abnormal blood lipid profile

  • take medications that list ED as a side effect

  • take prescription drugs for high blood pressure, pain, or depression

Having erectile dysfunction can be a real challenge. Studies suggest that if you have diabetes but adopt a healthier lifestyle, you may reduce your diabetes symptoms and improve your sexual health. These lifestyle habits, the cornerstone of diabetes management, include eating a balanced diet and getting regular physical activity.

Sexual problems can affect both men and women with type 1 and type 2 diabetes. Learn your best care and treatment options!

Resources: American Diabetes Association, Sex and Diabetes: For Him and For Her, Janis Roszler, RD, CDE, LDN & Donna Rice, MBA, BSN, RN, CDE

What can you tell me about the diabetes medication I hear advertised that you take once a week?There has been a lot in news about this class of diabetes medication with the newest one to be in the market in 2018. These are drugs are GLP-1 receptor agonists which is another class of drugs used to treat type 2 diabetes. Like insulin, these drugs are given by injection. 

A GLP-1 agonist has multiple mechanisms of action that can be beneficial for a person with type 2 diabetes. A GLP-1 agonist increases insulin secretion from beta-cells and suppresses glucagon secretion from alpha-cells. In addition, a GLP-1 agonist can slow gastric emptying and promote satiety. Once-weekly GLP-1 agonists can provide reduction in fasting blood glucose levels and promote weight loss; in addition, the risk of nausea is lower than a short-acting GLP-1 agonist but there is a higher risk of injection-site nodules.

This class also has the side effect of modest weight reduction and reduction of systolic blood pressure. GLP-1 receptor agonists are counter-indicated for patients with a history of pancreatitis.

GLP-1 receptor agonists are injected into the upper arm, abdomen, or thigh either  twice a day, once a day, or once a week. Your schedule for taking the injection varies depending on which drug you are taking.

Attached is a list of the current GLP-1 medications. As with all medications, be sure to review important instructions, contraindications etc.  with your physician, diabetes educator or pharmacist  before starting this class of medication. 

For a Clinical Review of GLP-1 receptor agonists: efficacy and safety in diabetes and beyond you  link to this summary from National Center for Biotechnology (BCBI)

Is it true that that there is a way to test my blood sugars without sticking my finger?In 2017 the FDA approved its FreeStyle Libre Flash glucose monitoring system as a replacement for blood glucose monitoring for adults with Type 1 and 2 diabetes. It was designed to eliminate the need for daily finger sticks . The system includes a sensor the size of two stacked quarters that’s placed on the back of the upper arm. Users can capture real-time glucose readings using a hand-held reader by simply swiping a phone over a small sensor worn on their upper arm that picks up signals from the sensor. Users can review eight hours of glucose history and keep an eye out for glucose level trends, monitoring fluctuations throughout the day. 

Initially it was approved to last 10 days.  In July 2018 the FDA approved its 14-day FreeStyle Libre flash glucose monitor, making the device the longest lasting self-applied glucose sensor on the market.

NOTE: Medicare Coverage. ... Just months after FDA approved Abbott's Freestyle Libre continuous glucose monitoring (CGM) system Medicare announced it will cover the product for certain seniors that qualify.

Does insurance cover the Freestyle Libre? Similar to any new device or medication, not all insurances provide coverage. You would need to check your specific plan since costs for both the reader and sensor vary. 

Abbott’s FreeStyle Libre ) continuous glucose monitor (CGM) are available on the shelves of major pharmacies in the US, including CVS, Walgreens, Walmart, Rite Aid, and Kroger’s/Smith’s. Prices will vary depending on location and pharmacy.