Blood Sugar and Weight Control - A series of case studies Suzanne Friesen, RD, CDCES - Saint Luke's Health System
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Blood Sugar and Weight Control
A series of case studies
May 2021
Suzanne Friesen, RD, CDCES
The information in this presentation
is for general education purposes only.
Please discuss your specific health care needs
with your medical provider.
SAINT LUKE’S HEALTH SYSTEM 2
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SAINT LUKE’S HEALTH SYSTEM 3
Blood Sugar and
Weight Control
SAINT LUKE’S HEALTH SYSTEM 4
Strategies to Lower Blood Glucose and Weight
• Follow a low-carb eating plan
oReplace carbs with protein, fat, and non-starchy vegetables
• Avoid snacking
• Restrict eating time/intermittent fasting
• Walk if blood glucose (BG) is high
• Drink plenty of calorie-free fluids
• Understand your diabetes medications/insulin
• Eat healthy foods you love everyday
SAINT LUKE’S HEALTH SYSTEM 5Low-Carb Eating Plan
• 130g carbohydrate daily or less
• Choose high quality, high fiber carbs
oBerries, pinto beans, Greek yogurt are
high quality
oWhite bread, cheese curls, candy are
not high quality
• Add protein, non-starchy vegetables,
natural fats
SAINT LUKE’S HEALTH SYSTEM 6Case Study One
SAINT LUKE’S HEALTH SYSTEM 7Male in His 30s
• Newly diagnosed Type 2 diabetes
• A1c = 7.9%, triglycerides = 275
• Recent hospitalization prior to our visit
• Currently eats a very high carb diet (lots of rice)
• Weight = 230 lbs, BMI = 34
• Exercises 1 – 2x/week, 15 – 30 minutes
• Metformin XR 1000mg twice daily
SAINT LUKE’S HEALTH SYSTEM 8His Goals
• Lose weight
• Normalize blood sugars
• Get off all diabetes medications
• Increase exercise
He was highly motivated to make changes.
SAINT LUKE’S HEALTH SYSTEM 9Plan to Achieve Goals
• Eating 100g carbohydrate daily or less
• Intermittent fasting 16 hours 5 days/week
• Eight hour eating window, typically 12 – 8 p.m.
• Walking 6x/week, 30 – 60 minutes
SAINT LUKE’S HEALTH SYSTEM 10Follow-Up Visit Four Weeks Later
• A1c = 6.4% (was 7.9%)
• Triglycerides = 127 (was 275)
• Weight = 214 lbs, BMI = 31 (↓16 lbs)
• Walking 6x/week, 30 – 60 minutes, added strength training
• Checking BG 1-4x/day, 100% in range
• Off all diabetes meds
• Food records: Plenty of vegetables, chicken, fish, eggs, nuts, olives,
avocados, chili, soup, salad, homemade almond bread, zucchini
noodles, riced cauliflower
SAINT LUKE’S HEALTH SYSTEM 11Eight Weeks Later
• Weight = 208 lbs (↓22 lbs), BMI = 30
• Continues with diet changes
• Continues exercise program
• Remains off diabetes meds
• Liver enzymes improved (fatty liver)
SAINT LUKE’S HEALTH SYSTEM 12Eight Months Later At Primary Care Visit
• Weight = 170 lbs, BMI = 25 (↓60 lbs)
• No medications at all
• Motivated to continue with current plan
SAINT LUKE’S HEALTH SYSTEM 13Case Study Two
SAINT LUKE’S HEALTH SYSTEM 14Female in Her 60s
• Type 1 diabetes mellitus for 35 years
• Insulin pump: Total daily insulin 80 units
• Weight = 232 lbs, BMI = 42
• A1c = 9.1%
• Eats high carb meals and snacks, fast food, processed food
• No exercise
• Goals: Weight loss
SAINT LUKE’S HEALTH SYSTEM 15If You Take Insulin
• Meal-time insulin covers the carbohydrate
• Higher carb meals require more insulin
• Higher insulin doses can cause weight gain
• Timing of meal-time insulin matters
• Rapid acting insulin should be taken 15 – 20 minutes before first bite
• Regular insulin should be taken 30 – 45 minutes before
SAINT LUKE’S HEALTH SYSTEM 16Plan
• 3 meals daily, stop snacking
• 100g carb/day, accurate carb counting
• Start walking: 5+ minutes daily
• Regular communication with doctor/diabetes educator for insulin
pump adjustments
• Know how to treat lows (hypoglycemia)
SAINT LUKE’S HEALTH SYSTEM 17Follow-Up Visit Four Weeks Later
• Weight = 220 lbs (↓ 12 lbs)
• Total daily insulin = 23 units (was 80 units)
• Walking daily 15 minutes
• Eating 3 meals/day, no snacking, no fast food
• Food records: Plenty of vegetables cooked and raw, salads, eggs,
avocados, olive oil, cheese, toast, beef, chicken, pork, tuna, hot dogs
SAINT LUKE’S HEALTH SYSTEM 18Five Month Follow-Up
• Weight = 191 (↓20 lbs)
• A1c = 6.7% (was 9.1)
• Walking 6+ days/week 30+ minutes
• Total daily insulin dose 20 – 24 units
• Continues with same meal plan
SAINT LUKE’S HEALTH SYSTEM 19Eight Month Follow-Up
• Weight = 173 lbs (↓ 59 lbs)
• A1c = 6.4% (was 9.1%)
• Walking/exercising daily 60 minutes
• Continues with low-carb eating plan
• Total daily insulin 20 – 24 units
• Typically only needs 1 – 3 units of insulin before meals
• Basal insulin 20 units (non-food insulin)
SAINT LUKE’S HEALTH SYSTEM 20Case Study Three
SAINT LUKE’S HEALTH SYSTEM 21Female in Her 70s
• Type 2 diabetes 3 years, prior history of pre-diabetes
• Weight = 155 lbs, BMI = 30
• A1c = 8.7%
• Jardiance 25mg every morning
• Walks 5 days per week, 2 miles
• Goals: Lose 10 pounds, lower A1c
• Doesn’t like testing her blood sugar
• Craves starchy foods
SAINT LUKE’S HEALTH SYSTEM 22Plan
• 100g carb/day divided over three eating times
• Avoid after dinner snacking
• Add protein, natural fat, non-starchy vegetables (to replace carb)
• Continue walking 5x/week, 2 miles
• Test blood sugar 2 days per week, 4x/day
SAINT LUKE’S HEALTH SYSTEM 23Four Week Follow-Up
• Weight = 149 lbs (↓ 6 lbs), BMI = 29
• Eating 3 meals daily, no snacks (most of the time)
• Continues walking program
• 4 blood sugar results in meter but all in target range!
• Very pleased with her weight loss
• Food records: Eggs, cottage cheese, Greek yogurt, bread, sausage,
some vegetables, chicken, fish, cheese, potatoes, tortilla chips, some
frozen meals, sugar-free Jello
SAINT LUKE’S HEALTH SYSTEM 24Nine Week Follow-Up
• Weight = 148 lbs (↓ 7 total, ↓ 1 lb in last 5 weeks)
• Disappointed in small amount of weight loss
• Reports feelings of hunger
• Continues walking program
• No blood sugar tests in meter
SAINT LUKE’S HEALTH SYSTEM 25Plan
• Reviewed BG testing and encouraged to test twice per week
• Great walking program: Keep up the good work!
• Hunger: Add more protein, natural fats, vegetables, fluids
• Okay to eat ALL carbs recommended: choose high quality, high fiber
• Low-carb snacks if needed
SAINT LUKE’S HEALTH SYSTEM 26Four Months Later at Primary Care Visit
• Weight = 146 lbs (was 155 lbs), BMI = 28
• A1c = 7% (was 8.7%)
• Jardiance 25mg daily
• Did she meet her goals?
SAINT LUKE’S HEALTH SYSTEM 27Yes!!!
SAI NT LUKE’ S HEALTH SYSTEM 28Resources
SAINT LUKE’S HEALTH SYSTEM 29Saint Luke’s Diabetes Centers
We offer:
• Individualized diabetes education, on site or virtual visit
Centralized locations
• Saint Luke’s Hospital of Kansas City
• Saint Luke’s North Hospital
• Saint Luke’s South Hospital
• Saint Luke’s East Hospital
• Hedrick Medical Center
Schedule an appointment
• 816-932-2707 (referral required)
SAINT LUKE’S HEALTH SYSTEM 30Saint Luke’s Primary Care
KANSAS MISSOURI
Blue Valley Barry Road Lee’s Summit Shoal Creek
913-323-8830 816-880-6100 816-347-5100 816-437-8161
Cushing Blue Springs Parkville Smithville
913-651-6565 816-347-4600 816-569-1506 816-532-3999
Mission Farms East Platte City
913-317-7990 816-347-5600 816-858-7050
Southridge Independence Plaza
913-317-3200 816-251-5200 816-932-3100
SAINT LUKE’S HEALTH SYSTEM 31Additional Resources
Saint Luke’s Community
Resource Hub
• saintlukesresources.org
SAINT LUKE’S HEALTH SYSTEM 32COVID-19 Vaccine Information
• For more information on the COVID-19 vaccine, please visit our
website.
• saintlukeskc.org/covid-19/vaccine
• This offers the most up-to-date information we have on the vaccine,
its availability and distribution.
SAINT LUKE’S HEALTH SYSTEM 33SAINT LUKE’S HEALTH SYSTEM 34
Questions?
SAINT LUKE’S HEALTH SYSTEM 35Q&A
• Q: Can I get the recipe for the Almond Bread?
A: https://www.allrecipes.com/recipe/263032/90-second-keto-bread-in-a-mug/#nutrition
• Q: Once your A1C has normalized, will you always be a diabetic?
A: Studies show remission is possible. See the DiRect trial for details
• Q: Would you consider white rice a good quality card? or should I do brown rice?
A: No, white rice is refined. Brown rice only slightly better in that it has a small amount of fiber but just as much carb as white
rice.
• Q: I eat mid-meal snacks like carrots or nuts. Should I not eat mid-meal snacks at all?
A: It’s best not to snack
• Q: i thought "grazing " would keep blood sugar levels more even?
A: Grazing is not recommended
SAINT LUKE’S HEALTH SYSTEM 36Q&A
• Q: Is low carb good for someone that has heart stents
A: A low carb, fresh, whole foods eating plan is good for anyone. High blood sugars are bad for the heart and bad for blood flow
• Q: Is peanut butter an alright protein?
A: Peanut butter and nuts are healthy fats and protein
• Q: For the fasting, does that mean nothing to drink as well?
A: Drink plenty of calorie free fluids during the fasting time
• Q: Thoughts on 8 hour eating intermittent fasting vs 5-2 plan?
A: Both are good. I often recommend the 5-2 plan when someone has hit a weight plateau
• Q: Which is more effective in weight loss---counting calories or counting carbs?
A: Counting carbs is best especially if diabetes or prediabetes is present
SAINT LUKE’S HEALTH SYSTEM 37Q&A
• Q: What are examples of non-starchy vegetables?
A: Everything but peas, corn, potatoes
• Q: When you are a sugar craver, is having sugar free jello, pudding, popsicles, etc... ok?
A: yes
• Q: Please refresh on how to count carbs
A: Recommend you meet for an individual consult with an RD, CDES virtually or in person. You
will receive an individualized plan as well as written resources. 816-932-2707
• Q: If you don't love water and dislike tea or coffee, are diet sodas and Crystal Light ok to rely on?
A: In moderation-should not be 100% of your fluid needs. Encourage you to give water another
try. Add lemon or lime wedges or cucumber slices. Sparkling water ok too (LaCroix, Mendota
Springs, etc)
SAINT LUKE’S HEALTH SYSTEM 38Q&A
• Q: Do the sugar alcohols count as carbs? Malitol, xylatol, sorbitol, etc. Some sources count those like any
other carbs, others say to exclude them.
A: Sugar alcohols are carbohydrates but feel free to subtract them from the total carb grams on a food label.
• Q: Is elderberry supplement good for lowering blood sugar?
A: No idea but I am not a fan of supplements which claim to lower blood sugar. We already know what
lowers blood sugar and it is a fresh, whole foods, low carb diet, exercise, weight loss if needed, and diabetes
medications.
• Q: I get nauseated frequently I think due to Ozempic so I tend to eat to stop the nauseusness then I gain
weight. I am on insulin at night only now as got off of the novalog. Any suggestions for me?
A: The GI side effects from Ozempic tend to subside with time. However I suggest you try drinking some hot
broth or perhaps herbal tea rather than eating. If you can, lie down until the nausea subsides.
• Q: What about sugar free vitamin water?
A: In moderation. Try to drink water without artificial sweeteners mostly-sparkling or still water
SAINT LUKE’S HEALTH SYSTEM 39Q&A
• Q: I'm a type 2 diabetic august a1c was 13.9 started taking my glimepiride ate right - went in 8 weeks later -
a1c 8.2 - but the Dr wanted to put me on more meds -including ozempic and metformin - why?
A: Possibly because the A1c is still above 7. And possibly because the addition of ozempic allows for weight
loss and blood sugar lowering and may allow you to stop the glimepiride. Glimepiride is a weight enhancing
medication. Metformin improves insulin resistance without causing weight gain. It is a good idea to discuss
your medication concerns with your doctor.
• Q: My worst numbers are first thing in the morning, when I wake up. Options to help with this?
A: It is common to have highest blood sugars first thing in the morning due to release of stored glucose from
the liver overnight. Are your blood sugars in target range at other times during the day? Focus on the
cornerstones: low carb diet, increase exercise, lose weight if needed, take diabetes meds as instructed. Are
you snacking at night? If so avoid.
• Q: are you seeing that patients using the Libre freestyle monitor (the one that stick on your arm) having
better BG control?
A: In general yes because it allows you to see what your blood sugar is every few minutes if desired. It allows
you to see patterns and track the blood sugar rise and fall after any food or meal is eaten.
SAINT LUKE’S HEALTH SYSTEM 40Q&A
• Q: What is the best time to take metformin rx is 2x a day morning and evening
A: this can vary depending on the individual. Sometimes recommend twice daily with first and last meal of
the day, sometimes one dose at bedtime, sometimes all of it in the morning. Everyone is different and we
really look to individualize based of blood sugar data, side effects, etc.
• Q: Can you suggest a good phone app for recording food and counting carbs?
A: Loseit.com, carbmanager.com, mysugr.com
• Q: I’m diabetic as are both parents - whom I share a house with. Are the guidelines for carb levels the same
(130 or less) no matter age or gender?
A: These can vary individually and I recommend meeting with an RD, CDES to set up an initial plan. However,
130 grams of carbohydrate daily or less is considered a low carb eating plan.
• Q: How much fiber should you eat each day?
A: A good rule of thumb is 25 g daily or more
SAINT LUKE’S HEALTH SYSTEM 41Q&A
• Q: About how long does it take to bring high blood sugar (185 average) down if I eat correctly and continue
with my walking 150 min per work, get enough sleep, etc. I am currently not able to get my Ozempic and am
having to go it alone.
A: As you can see from the case studies presented, significant change happened after 4 weeks of following
the new plan.
• Q: need ideas for snacking. what do you think about glucerna and or protein powder
A: I am not a fan of either. Research shows better results/outcomes with limiting eating to 3x/day, no
snacking. It is almost always best to eat real food rather than supplements and meal replacements (which are
highly refined). In my opinion meal replacements are for people who are unable to eat solid foods. If you must
snack, choose low carb snacks (less than 5g carb per serving).
• Q: Is it ok to take Apple Cider Supplements and being diabetic on Metformin? Will it interfere with the
medication?
A: Rather than take the supplement how about mixing 1 tablespoon of real apple cider vinegar with 8
ounces of water and drinking? This would be ok to do daily and will not interfere with the metformin.
Supplements are not regulated and so I /you don’t really know if they contain what they say they do.
SAINT LUKE’S HEALTH SYSTEM 42Q&A
• Q: What are the best nuts to eat ?
A: All nuts and seeds are fine. However some contain more carbohydrate than
others. Pistachios and cashews are a bit higher carb that others.
• Q: There is an business in Overland Park named "Help your Diabetes". Do you
know anything about this group? It looks like it is a franchise
A: I’m afraid I have never heard of this company.
• Q: What is a good resource for learning more about Intermittent Fasting? I've
never heard of it for diabetes II.
A: Diatribe.org; good books: The Obesity Code or The Diabetes Code by Dr. Jason
Fung, MD
SAINT LUKE’S HEALTH SYSTEM 43Q&A
• Q: I don't get off of work until 2300. I go home and my husband and I eat dinner around
midnight. Our blood sugar in the morning around 0900 my blood sugar is anywhere from 100 to
135. what would you suggest I do.
A: A fasting blood sugar of 100-135 is good (goal less than 130). In general I would recommend a
light/low carb dinner meal and try to have a 12 hour overnight fast before you eat the next day.
• Q: If you are taking metformin tablet, how long should they be taken before a meal?
A: Typically recommended to take metformin right before the meal or the middle of the meal or
at the end of the meal. Really depends on if you are having any GI symptoms.
• Q: What is a good daily exercise routine for the average person who wants to lose weight.
A: Exercise guidelines for people with diabetes are strive for a goal of 150 minutes moderate
intensity exercise per week-minimum-and no more than 2 days in a row without exercise.
SAINT LUKE’S HEALTH SYSTEM 44Q&A
• Q: I have been reading quite a bit about fat being a big part of insulin resistance so I confused
about recommended fats?
A: I recommend you eat a MODERATE amount of healthy fats (avocados, nuts, nut butters, olive,
olive oil, fatty fish). Avoid deep fried foods and man-made fats and processed foods high in fat.
• Q: Are Type 1 diabetics even supposed to be fasting? Is this for type 2 only?
A: Intermittent fasting can be done safely by persons with type 1 or type 2 diabetes. It should
only be done under the guidance of your diabetes care team.
• Q: where can I find more info about the intermittent fasting?
A: Diatribe.org, books: The Diabetes Code by Dr. Jason Fung, MD or The Obesity Code
• Q: In the first case study, not sure why one would not take metformin with A1c of 6.4? Thought
metformin was beneficial by working only when it needs to?
A: I guess I would ask why continue taking a diabetes med if able to maintain an A1c below 6.5%
without it? This patient and his care team decided this was the best route for him. Always best to
discuss medication changes with your doctor and make a decision together.
SAINT LUKE’S HEALTH SYSTEM 45Q&A
• Q: Is it good/bad for insulin to stay in your system longer?
A: This depends. In general with meal-time insulins you want them to work fast, do their job and leave!
Then there is less likelihood of low blood sugars between meals. But with basal insulins such as Lantus,
Levemir, Tresiba, Toujeo, which cover the NON-FOOD needs, long is good because it allows for only taking one
shot daily.
• Q: If you do intermittent fasting what are concerns about regulating blood sugars first thing in the morning?
any dangers with going too low not eating? what if you have other meds where taking with food is
recommended?
A: It is important to consult with your care team BEFORE undertaking intermittent fasting as diabetes
medications as well as other medications (particularly blood pressure & heart meds) may need adjusting.
There is a danger of low blood sugar if you are taking insulin or other diabetes meds.
• Q: What do you think about the nutritarian or vegan/vegetarian eating style?
A: Vegetarian/vegan can be very healthy and I think it’s great! I have done both. It is important to
remember to eat fresh, whole unprocessed foods when following any eating plan.
SAINT LUKE’S HEALTH SYSTEM 46Q&A
• Q: I was also told that diabetics should not do intermittent fasting.
A: Intermittent fasting can be done safely by persons with diabetes. As mentioned above—
consult with your care team BEFORE doing intermittent fasting.
• Q: Is butter a natural fat?
A: Yes.
• Q: My dad (74 yrs. old) was just recently diagnosed w/adult onset type 2 diabetes. Interestingly
he already was a healthy eater and exercised regularly. I believe the doctor told him it was
genetic. Is it likely that at some point I will get diabetes also, especially if I don't eat well and
don't exercise? I just turned 50 in December. I just did a biometric screening about two weeks
ago and all of my #s were good. Sugar level was 87.
A: Type 2 diabetes does not have to be your destiny even if there is a genetic component.
Maintain a healthy BMI/weight, stay active, eat a fresh whole foods diet, and keep checking those
labs.
SAINT LUKE’S HEALTH SYSTEM 47Q&A
• Q: On intermittent fasting, can beverages be taken? (morning coffee)
A: Yes, drink plenty of calorie free liquids during the fasting period.
• Q: How many meals do we eat during the restricted eating time of 12 - 8pm
A: This is up to the individual however I think it is reasonable to keep it at 2-3 eating times.
• Q: Do you have a vegan nutritionist for diabetics?
A: All of the dietitians in our diabetes clinics can help with vegan/vegetarian eating plans
• Q: Can protein supplements be taken safely?
A: They can be used safely but I encourage people to eat REAL food rather than meal
replacement shakes/bars/ etc. These supplements are all highly processed, many are expensive,
and they are not regulated by the FDA. Spend your money on high quality foods instead! And by
the way, excess protein will raise blood sugar and slow down weight loss.
SAINT LUKE’S HEALTH SYSTEM 48Q&A
• Q: How does stress impact my BG?
A: Stress, both physical and emotional can raise blood sugars. Stress can cause an increased release of stress hormones which
raise blood sugar. I encourage people to focus on ways to manage the stress in their lives because it’s probably not going to go away
completely.
• Q: What has the greatest impact on A1C - diet, exercise, or ??
A: Food, activity, stress, diabetes medications all impact the A1c. The answer will depend on the individual. I have patients who
cannot exercise at all but with diet changes have significantly lowered their A1c. We know exercise has so many benefits andwill
improve insulin sensitivity so we encourage exercise of some sort for all.
• Q: What is insulins role in losing weight? And what's the best way to raise a blood sugar when low and trying to lose weight?
A: Insulin is a fat storage hormone so as insulin levels increase (either by injection or naturally because a person is eating more)
the weight will rise. As insulin levels are decreased-naturally or less injected-weight will decrease. If a person is taking insulin and
having a pattern of low blood sugar- they need less insulin. During a low blood sugar reaction it is important to eat or drink 15g of
fast acting carb immediately and re-check blood sugar in 15 minutes to make sure it has risen to a safe range. For low blood sugar
pattern, it is a good idea to speak with your care team to figure out why the low blood sugars are occurring.
SAINT LUKE’S HEALTH SYSTEM 49Q&A
• Q: What are good snacks to eat between meals
A: Ideally no snacking is recommended. If you must snack choose low-carb (less than 5g carb per
serving) such as raw veggies or handful of nuts, cheese stick, dill pickle.
• Q: With IF can I put calorie free stevia in my coffee
A: Yes
• Q: why does insulin affect you less in the summer?
A: Not sure this is true. Perhaps people are more active in summer or eat healthier/lighter in
summer.
• Q: what if you are loosing to much weight
A: This is very subjective and best to speak with your care team for an individual answer/plan.
Unexplained weight loss could be a signal of trouble in the body and best to discuss with doctor.
SAINT LUKE’S HEALTH SYSTEM 50You can also read
