211: How to Prevent and Even Reverse Diabetes with Registered Dietitian John Massengale

00:00:00] And that's usually one of the first things I will ask is, do you understand what diabetes is? And I don't know exactly percentage but I would say the majority of people would say no or ask, you know have you ever taken any type of cooking classes? Or do you know a diet that's specific for diabetes? Do you know how to count carbohydrates Do you know how insulin works? 

[00:00:29] And they would have a mother and a father that already had diabetes and them themselves would have had diabetes sometimes for 5,10, 15 years, and they never spoke to a professional about what diabetes is. This is the Healthy Lifestyle Solutions Podcast and I'm your host Maya Acosta. If you're willing to go with me, together we can discover how simple lifestyle choices can help improve our quality of life. Let's get started Type two diabetes has been called the Black Death of the 21st century in terms of its exponential spread around the world and its devastating health impacts. 

[00:01:09] More than 20 million Americans are currently diagnosed with diabetes, a tripling of cases since 1990. At this rate the CDC predicts that one in three Americans will be diabetic by midcentury. Currently in the United States, diabetes causes about 50,000 cases of kidney failure 75,000 lower extremity amputations 650,000 cases of vision loss, and about 750 deaths every year. Join me as registered dietitian John Massengale speaks to us about the prevalence of diabetes the causes, and the long term complications of having diabetes. Learn about what you can do to prevent and in some cases, reverse diabetes through Healthy Lifestyle Solutions. 

[00:02:00] As always, the full bio and the links for each of my guests can be found on the podcast website healthylistlesolutionsrg. And also as a bonus I'm giving you a diabetes info sheet that comes from PCRM. Simply go to bitlydiabetesheet and you will receive a guide with information on diet and diabetes in our newsletter. We send out information about upcoming diabetes classes as well. So, I hope that you enjoy this episode. 

[00:02:30] So, welcome John. Thank you. Thank you very much for having me. Well, I shouldlet our listeners know that we know each other fromt his lifestyle world that we live in. And so I'm in Dallas and you'rein Fort Worth and I always think it's a longer distance than it probably is, but is it about an hour trip between both cities? 

[00:02:48] It depends on what interstate you take. I'm really close tol 30, and really it's a straight shot. I would say probably 30 minutes 35 minutes if you go straight from downtown, one downtown to the other. Okay, all right just depends. But it also depends on traffic. 

[00:03:06] So, in all my years that I've been in Dallas, which have been about ten years now, probably have only been to Fort Worth like three maybe five times I don't know. But I'm beginning to be more drawn. And the last time l was there we went to this Mexican restaurant that is fully plant-based, and it was like, wow. But yeah. Anyway, I'd like our listeners to know that we know each other from the circle. 

[00:03:29] And the last time that we saw each other was at the Tulsa VegFest, which had been promoting on the podcast. And you were therefore the dinner experience which was a lot of fun. Yes. How was it for you? What did you think? 

[00:03:43] It was great. It was a good chance to meet. And the only time l spent some time in Tulsa was when I went back to school. I did my dietetic internship Oklahoma at O.U. in Oklahoma City, and we did a day trip to Tulsa, Oklahoma. And so it was a great opportunity to get back to Tulsa, spend time there and get to meet people like minded people listen to Dr. 

[00:04:10] Loomis talk, and just really also just get back out there and just talking to people. Awesome. And good to see yourself and just catch up. Yes. 

[00:04:22] Thank you. Yeah, it was great charming little city. John, when l first met you, I believe I already knew that you were a dietitian at the time. And then we knew each other briefly. 

[00:04:34] We met and then you moved to Corpus Christi and next thing l know you're specializing in diabetes and so I'd like to learn all about that I have so many questions that have listed here but first I'd love to learn your story of how you got on board. Why did you choose dietetics. Okay. Probably, going a little bit even further back than when I decided to go back to school. 

[00:04:58] My health experience and I believe my time when I decided to look at my own personal health was after my dad passed away from heart disease back in 2006. Around that same time I was working at a job. I was commuting a lot here in the Dallas Fort Wortharea. And so that was a wake up call for myself. I started looking at my own health and I recently had a visit to my primary care physician which ironically recently saw him not too long ago, probably about four or five months ago to get my bloodwork and do my annual physical exam. 

[00:05:39] And he actually retired and he'd been my primary care physician for about 30 years. So around that same time around 2006, 2007, I was overweight high cholesterol and my doctor my primary care physician gave me a stern warning. He said, you really need to start looking at your health. You need to start looking at your diet. You need to start exercising more. 

[00:06:08] And so, that was a wake up call for me. He gave me a pamphleton the Mediterranean Diet and really just sort of sent me on my way. At that time I didn'teven really don't think at that time knew there was things called registered dietitian. Anyway, I spent the next several years starting to get into exercising mountain biking which led to road biking which led to doing triathlons. And what l quickly realize is thatyou can't exercise a bad diet. 

[00:06:43] So, that led me to nutrition and studying nutrition and how to not only fuel myself as an endurance athlete but also how can I potentially help people like my father maybe catch it earlier, touch it in the earlier signs. And at the same time at the job I was at it just didn't feel like I had much of a purpose at that job. It was more of a corporate in the financial services industry. So from there my introduction to the plant-based world actually happened. It was actually at a triathlon training camp in Las Vegas, Nevada. 

[00:07:29] Believe it or not. There was a bunch of triathletes there. And we were all staying at this house in Henderson Nevada. And so when I first got to the house, I walked in and there were all these crates of bananas and mangoes and papayas, and I was like, whatis going on here? And I grew up as a Southern diet in Texas. 

[00:07:55] Mississippi is my upbringing. Eating meat chicken with some of my staples, eggs. And so I started talking to the people that were hosting. They were triathlon coaches. And they told me about a plant-based diet that was one of my first introduction to a plant-based diet. 

[00:08:15] And so, from there I said, hey, I wantto learn more because they were blending up these big smoothies and they would go for these long three four hour rides and come back and get out their Vitamix and all these bananas and mangoes and that's really all they were having. And I was like, where's your protein? So from there they told me to watch the documentary. Forks Over Knives and from there that started my interest in going back to potentially going back to school. And then l also had been datinga female in Dallas before and this is actually moved to Denver around that same time and she was a dietitian. 

[00:09:06] So, I started getting interested from that relationship. And then eventually again, the Forks Over Knives, I made that sort of that lightbulb moment went off after watching that documentary in the link of having more of an animal based diet and potentially the cause of things like cardiovascular disease and diabetes. It's incredible the effect that that movie has had, Forks Over Knives, and how it has impacted so many people and for my listeners who have not seen it, please go watch it. 

[00:09:44] Hard disease. It's the number one killer of Americans. So, I'm so glad that you're sharing that to remind ourselves that are always we're not taking care of ourselves. We are at risk not only for diabetes but heart disease. I don't know if I ever mentioned to you that yes, learned. 

[00:10:01] I came about learning all this information when I saw the book Doctor McDougall book The Starch Solution. But really it was a vegan athlete on YouTube that learned about. She used to go by the Banana Girl. Do you know freely? The Banana Girl. 

[00:10:18] It was like 30 bananas. When you're describing seeing all these fruits around and doing the smoothies. And that's when I first probably. I already had a Vitamix I want to say. But the thing is that she really seen her a living example that you can be an endurance athlete and look great and have energy is what got me on board.

[00:10:39] Do you still stay in touch with these people? No, they're actually in Colorado. It's actually Pete and Kathy Alfino. They actually run a coaching triathlon service called Mile High Multisport and they were living in Denver at the time and now they've moved to Steamboat Springs. 

[00:11:03] And so I've moved back from when I went back to school in Denver. After I got my degree, I moved back to the DFW area. So, when I decided to go back to school in 2014, I did an Ironman that year. I haven't really done anything, I think I've done maybe, I've done one triathlon since then. 

[00:11:26] So, I've sort of gottenout of the triathlor world and stick more to most of my time is dedicated to learning about nutrition starting a new career, and also having my own personal coaching business. And so mostly I'm due as far as exercises. I did the Cowtown Marathon. I'm part of a running group here in Fort Worth and I'm planning to do my first gravel ride I did leadville 100 mountain bike race last year, so I still do endurance. 

[00:12:03] It's just the time commitment training for triathlons because you have to do swim bike and run. It's really hard to fit it in, butI'm starting to actually get the itch to possibly sign up for an Iron Man in the next couple of years. I, so I'm still not in touch with them but I'm sure they're still active in the triathlon community. Yes. What I gather from you, just from our brief conversations that we've had is that you are very focused and very passionate about what you're doing right now. 

[00:12:39] And that's why I was excited. One of the reasons, I was excited to have you on the show, so I think early when l met you and we talked about your studies as a dietitian I may have even asked, do they recommend wholefood plant-based diet lifestyleas the optimal way of eating for people in general? And I think you kind of said, no, they don't. Yeah, it was surprising I think that what went back to school in 2015, one thing that was happening at about the same time is Netflix.

[00:13:17] And so documentaries were just slowly starting to come out. As far as from a curriculum standpoint, I had a few of my nutrition focused classes that had to do with human nutrition that still followed more of your standard omnivore type of diet. And I would even talk to the professor after class and say, hey, look, these types of animal proteins they can create things like Tamao and IGF one, and things that are moreinflammatory sort of brush me off. I just think that maybe the sign of the times just the information the studies were just starting to come out the research and I think that the information was just slowly coming out at that point. 

[00:14:21] So, I just really did my own thing. That's what I've always done I know that the science I know it works for myself it works. So, many studies were coming out at the time there was so much research. 

[00:14:37] I always think of Dr. Garth Brooks Proteinaholic because we are so protein obsessed, especially coming from Texas. And so the information thought was overwhelming but they didn't really teach it at that point. And my understanding at places like Oklahoma University, they have a more plan-based focus curriculum a class or two. So, I think universities are starting to take that on over the last several years. 

[00:15:14] Well, it's good to know that the information is gettingout. John, I've said in the past I don't have a background in nutrition but took a nutrition class, and then stopped eating red meat and pork in college. And spend most of my life trying to figure out how to eat or at least tryingto be a vegetarian pescetarian. So, I often purchased books. So, I did research on my own, and yet I still felt lost. 

[00:15:43] And I can imagine how many people feel lost right now unless they are guided towards always looking for books to give away. And you have all the diets. All sorts of diets are blended with health information which in dieting restricted along with other fad diets. I stand there sometimes and I think wow, that's why people are so lost. 

[00:16:16] It's all blended into one category today. We know that there are fields dedicated to this information. We know that what we talk about is evidence based. There's science behind this and we direct people towards the right materials. So, let's talk about having said that let's talk about how you made your way towards specializing in diabetes. 

[00:16:39] Was that when you moved to did that transition happen when you moved to Corpus Christ? Yeah, I think eventually it did. It was probably halfway through my time at Corpus Christi maybe taking a little bit of a step back. Usually, when you leave your university and get your degree the next step is to do an internship which I did again, I think l mentioned at Oklahoma University and the reason you take an internship is so you can actually spend time in all these different areas of being a dietitian. 

[00:17:18] So, I spent time as an example at the VA hospital in both the clinical setting and in the foodservice section of the VA hospital. I spent time at the Oklahoma Heart Hospital which is more of the intensive cardiac rehab that I'll be talking about eventually. I spent time at the Oklahoma School district to get an idea of how dieticians play a role in school nutrition, spent time at the Indian clinic because there's a lot of high Indian ethnic populatior in Oklahoma. Again, the reason do that so you can get a feel for what area of nutrition you want to specialize in. 

[00:18:03] And so after doing that I still didn't know. Usually a good default is if you do have an interest in clinical nutrition which I did have an interest. The reason I have an interest in clinical nutrition is that there's science and then there's an art to clinical nutrition. The science part is using evidence based solutions to help your patients. But also there's a subjective and objective part of being a clinician. 

[00:18:38] Objective is looking at things like lab values, like A one, C cholesterol levels, creactive protein which is an indication of inflammation. But also thereis a more of a subjective part which is how the patients presents which is how do they feel, are they fatigued.

[00:19:02] Are their energy levels high or low? So, I was fascinated by understanding from the patient and interviewing the patient. And it's called the actual process. It's called the nutrition care process, which is a four step process. The first step is an assessment portion where you do a physical assessment.

[00:19:22] You're looking for nutritional deficiencies with a patient. You're also doing a background of their family history is there a history with diabetes or cardiovascular disease in the family? Then you're looking at the typical food. Their 24 hours diet recall what types of foods that they're eating. 

[00:19:41] So, you do a full assessment. You look at your anthropometric like BMI, which is an indication of, if they're in a healthy weight range or if they're overweight or even I saw a lot of malnutrition people that were underweight. So, after spending time talking to patients and doing the nutrition care process, I started to realize that there were so many people in Corpus Christi in South Texas that suffered from either prediabetes or diabetes. And so from there toward the end of the time. l was at the hospital we had a dietitian that came and talked to us from one of the major dialysis companies. And when she came in, she talked to the dietitians at the hospital. 

[00:20:36] She talked about how in the Renal world and dialysis clinics, her company is taking a more plant-based approach to nutrition. And so that really poked my ears up and I was like, okay, so from there to become a certified diabetes care and education specialist there is a prerequisite. You have to log 1000 hours of clinical time with diabetes patients. So, I started tracking how many hours. I was spending in the hospital. And I knew I still needed a lot of hours. 

[00:21:16] And about the same time it was about a year and a half that I was at the hospital Covet had started to come in the Corpus Christi area, so I found it as an opportunity to maybe go back to the Dallas Fort Worth. There is getting homesick. And then from there that's when I realized that one of the two leading causes of chronic kidney disease, which can lead to endstage renal disease, which is dialysis, which we require that dialysis. The two leading causes are high bloodpressure and diabetes 

[00:21:50] So, I knew that if I became a renal dietitian that I'd be able to speak to a lot of people and work with a lot of patients that had diabetes. 

[00:22:01] But I also have been interested in cardiovascular. And that's one thing love about being a dietitian and nutrition in general is that there's so many areas of nutrition there's so many specialties whether it's intuitive eating, eating disorders working with people with cystic fibrosis to again, chronic kidney disease, cardiovascular. And what like about diabetes in particular is that it is probably the number one chronic disease that you can affect through lifestyle modification. And there are studies that back that there's the finished Diabetes Prevention Study and the Diabetes Prevention Program. 

[00:22:57] DPP that approved that Lifestyle over medications are one of the best ways that you can help prevent if you have prediabetes or if you do have diabetes which I'm a big believer in lifestyle medicine. From there l just kept logging the hoursand then eventually became a certified diabetes educator. Passed the board exam approximately six months ago. Congratulations! 

[00:23:27] You are in the perfect field to help create change and to empower patients. Diabetes is the number one chronic condition that could be the most affected by just making tweaks and changing our diet. What is the percentage if you happen to know what is the percentage of improvement or even preventing diabetes. I believe if you're a one C is between 5.7 and 6.4, then you're considered a pre diabetic. But the two main things that are driving so maybe even taking a little step back, step back from that is that the two underlying things that start to create that inflammation in the body, number one is that the pancreas is not secreting enough insulin. 

[00:24:21] So, that's usually one thing and you can measure that by testing. C Peptide is the test that you can run to get an idea of how much insulin that your pancreas is secreting. So, a lot of times it's more of a pancreas that's just been sort of overworked. And the second underlying cause of diabetes is insulin resistance meaning that when we eat food. The food for it to work properly needs to get inside of the cell, whether it's in the muscle cell or inside the fat cell. 

[00:24:56] So, when that food especially glucose, gets up to the cell, the cell starts to reject that insulin meaning that the insulin goes up to the cell and insulin. And I like how the guys from Mastering Diabetes, Robby Barbaro and Cyrus Khambatta put it is that basically insulin gets up to the cell wall and says, knock knock, I've got some glucose. I want to bring it in the cell. And so when the cell becomes insulin resistant it doesn't recognize the insulin. So, those are the two underlying drivers of diabetes which the causes of those are multifactor and it can depend on. 

[00:25:42] It could be ethnic groups. You see higher prevalence in Asian Americans, African Americans the Native American populations. Also, if you have a family history someonein your family has had diabetes in the past. And then from there there's a lot of underlying lifestyle causes being inactive eating the standard American diet which causes weight gain, and for you to be overweight high stress and other things like just feeling good. So, there'sa lot of things that can factor into causing those two main drivers of diabetes which again, is the pancreas not secreting enough insulin and insulin resistance at the cell level. 

[00:26:40] Okay, before we focus a little bit more on the role that nutrition plays in terms of contributing to insulin resistance before we talk about that are there physical symptoms that people began to have or they're starting to develop diabetes? Yeah, I think that some of the main symptoms are. Number one is fatigue. If someone is not getting the glucose inside the cell, they'regoing to feel fatigued because glucose, after it gets into the cell, it actually goes into the mitochondria which turns into energy ATP. So number one is being more fatigued. 

[00:27:17] Second, is that you tend to go to the restroom more often and your thirst increases. So, those are a few of the main symptoms that there could be something happening at the cellular level. So, say a person feels like they mightbe at risk. You said there are many factors that contribute to that lifestyle. How huge of a role does nutrition play? 

[00:27:46] If it's the number one chronic condition that is highly affected by eating plant-based foods then how much of a role do other foods play in contributing to the development of diabetes? That's a good question. Nutrition plays a very big role I forgot who described it this way, but if you think of a puzzle, and there being several puzzle pieces to the puzzle, nutrition and being active and stress and feeling connected sleep patterns if you think of those all being a piece of a puzzle, nutritior is the biggest piece. Okay, and why is that? 

[00:28:38] It's because the studies show that with weight loss, you can help reduce with seven to 10% weightloss, you can reduce your A one C and your insulin resistance. So, what does that mean? It means eating a nutrient rich, but you have to reduce your calorie intake. And so when you eat a whole food plant-based diet a lot of the thingsthat you'll be reducingis going to be refined grains as long as you're increasing our whole grain intake. Why is that important? 

[00:29:23] Well, whole grains are complex carbohydrate which is going to be lower on the glycemic index, which the glycemic index has to do with how big of an impact when you eat a carbohydratehas on your blood sugar levels versus more refined grains and sugars. Also, when you eat a whole food plant-based diet you're going to be eliminating animal proteins. And animal proteins are where you'll find most of the saturated fat in a diet. In saturated fat we can as humans we can consume saturated but we can only consume so much of it, and it becomes more inflammatory. And fat has nine calories per gram versus carbohydrates have four calories per gram and protein has four calories per gram. 

[00:30:33] So, when you eliminate or reduce animal products when you significantly reduce animalproducts you're reducing the amount of fat that you have in your diet which fat and especially saturated fat has been linked to insulin resistance because the saturated fat gets inside of the cell, and it's called an intramyocellular lipid which increases the insulin resistance inside the cell. So the advice of the American Diabetes Associationis one of the recommended dietary patterns. There are three main dietary patterns that they recommend. Number one is a Mediterranean Diet which has a lot of really good benefits because it is more plant-based. Number two is a low carbohydrate diet. 

[00:31:26] And then three is a vegetarian or plant-based diet. Those are the dietary patterns that the American Diabetes Association recommended because. Again. You're eating these wholefoods that should help with the weightloss. 

[00:31:42] Which is one of the key drivers of reducing insulin resistance and the A one C. And then again. You'll be crowding out those things like refinedgrains. Salt. Which causes overeating. 

[00:31:58] And saturated fat which causes too many calories. And the insulin resistance inside of the cell. I actually think that you explained it very well. Can we talk about what it looks like when diabetes is not well managed.

[00:32:14] They go home after they've been diagnosed and don't make any significant changes. What are the consequences of living with diabetes? Yeah, that's a good question. Number one, I think it starts with the smaller, or let's say smaller, the things that aren't as. Again, more of the subjective things the things we can't put a number on, which are feeling more fatigued less energy, having to, again, urinate more often more trips to the bathroom probably feeling more lethargic or some of the initial signs. 

[00:32:55] But the things that are more down stream. Because one thing with diabetes and type two diabetes. I sort of think of it as swimming against the current If you ever swam in a river when you first get in and maybe the current is not really going too hard it's kind of easy. You sort of okay, you start to deal with it. But as time goes on, if diabetesis not managed properly it's a disease of progression the current will get harder and harder. 

[00:33:29] And so some of the other things is that if you're not in control of your diabetes you can go, what's called hypoglycemic. Meaning especially when you start to take medications like insulin and if you're not and if you're skipping meals because that insulin is expecting a meal to come in. And so what that can do is make someone actually go low glycemic. And so they're going to be lightheaded maybe even shaky, or some signs of low glycemia and that's below 70 milligrams per deciliter I believe it is. 

[00:34:14] Signs of being hyperglycemia are, again, things that you may even need to be hospitalized. I've had some patients that had to be hospitalized because their sugars are even too high. But what happens downstream from internally it affects your whole body. So macrovascular types of things that happen are going to be cardiovascular disease, peripheral artery disease, strokes and then microvascular types of diseases will be retinopathy. l've had many patients that have either lost eyesight in one eye or totally blind. 

[00:35:04] Also they'll start lose feeling in their feet and they'll have ulcers that will get out of control because they don'teven feel it because they don't boss their feeling in their feet. So more of a neuropathy and that can lead to loss of blood flow to those areas as well and potential amputations. And so the downstream effects are if you don't have a good control those are some things that happen. And I've seen it in the clinical setting in Corpus Christi and I've seen it with the patients in the dialysis clinic. So, these things can be easily avoided by just really controlling checking your blood sugars. 

[00:35:55] And what's great is the continuous glucose monitor CGMs, the technologies out there. And so that's part of my job is to help people with behavior change and help them in those areas. If you want to spend a few minutes talking about your experience in cardiac rehab and then how you come to now develop your own programs where you're coaching one on one. And do you also do group coaching? Yes. 

[00:36:25] So, when I was in Corpus Christi one of the things that l felt was missing was a missing opportunity to affect people on a longer term basis. Because one of the drawbacks are just for people in general. One of the probably the few times that they'll ever come in contact with a healthcare professional unfortunately is in the hospital setting. Sometimes they'll just put off some things that they need to take care of until they actually have to go to the hospital which can totally understand. 

[00:37:05] Once they get to the hospital then i don't know the exact rate but the referral rate to a dietitian, I  don't think is very high. And even if I did get a referral and get a consultation from let's say, a cardiologist or for diabetes education. I would get to the room and they'd already be discharged. So, they'd already left and gone home. But you try to put myself in the patient's shoes when did get to meet with patients in the hospital in the inpatient setting it's a traumatic experience for those people. And they've got people coming in and out of their room on probably an hourly basis. 

[00:37:50] It's probably really hard for them to get any rest. We're asking questions we're probing. And so it was a big challenge to be able to create habit change or behavior change in the five or seven minutes that I have with the patient in the inpatient setting. And so what's thought was a big need was to meet people on their own terms. And so the part of the hospital that was at they had a cardiac rehab division of the hospital where people would come back on an outpatient setting on their own schedule. 

[00:38:33] And so they would come and they would exercise. And I remembered the experience that had at the Oklahoma Heart hospital in Oklahoma City. I spent about months there and it was one of the best experiences. l had, because patients would come in, they would exercise, they would have a registered nurse monitoring their vitals, they would have an exercise physiologist monitoring their vitals as well and helping them exercise and get the heart pumping. And then they would go to classes and watch videos on diet cooking classes on how to eat with less salt and less fat eat more plant-based. And so I wantedto bring that back and do that in the hospital. 

[00:39:27] And so I just went over to the cardiac rehab. They didn't have that there, so I went over there one day with my boss, Kayla. If you're out there she was one of the best bosses ever, so hopefully she sees us at some point. So, she was very open. 

[00:39:43] She's like, let's go talk to them so we talked to them said, hey, I want to talk to the patients because, again, they're coming their terms and so they can be in a more comfortable position to learn I want to do some cooking demos talk about the Nathan Pritikin Protocol which is a flexitarian diet which is more plant-based. And so they were like the people over there were game. And so we were able to fit in. 

[00:40:12] Once a month I would do a cooking demo. People would even still be on their exercise bikes whilel taught the cooking demo and I would do a presentation on how to transition to eating more plant-based, less animal proteins eating with less salt using healthy fats like mono unsaturated polyunsaturated fats like avocados, nuts and seeds, things like omega three. And so it was a great experience and then that led to doing outpatient consulting with the patient. 

[00:40:50] So that's where could start to practice motivational interviewing which is coming alongside the patient being a partner trying to take off that expert that. Because I think that from the patient standpoint nobody wants to be told what to do. So, really finding out the patients why do they want to make a change. Maybe they have someone in the family that they want to see a graduation or grandkid and then second is really coming to shared and collaborating with the patient on what they want to accomplish and just really shining a light on maybe the ambivalence they have on making change because it's really hard at the end of the day to adopt a new way of eating and to start an exercise program. 

[00:41:44] And so then after speaking to patients starting smart goals, which are specific goals because it can be overwhelming trying to take on a whole new diet style. So, just establishing specific small goals which once they accomplish those the goal of a dietitian ultimately is to help build their self confidence that they can do these things that self reliance and they can make those changes. So that went on for probably about six months a monthly cooking demo and then started with the outpatient consultations with patients and then coveted so that only lasted for a few weeks and so they shut everything down because probably the biggest thing learned and this goes to more of the art of being a dietitianis that motivational interviewing. 

[00:42:45] Understanding what the patient wants to accomplish is the art of being a dietitian because it's so easy for us to have the expert hat on and just be because we're very passionate about nutrition and exercise to go in and say. Hey. You need to start doing this and this is going to fix everything. All you need to do is do this. But I quickly realize that people would shut down when you have that expert hat on and it's really being more of a partner with the patient I believe is what shows in the science, is what helps people make those behavior changes in their life. 

[00:43:28] Right? It's about building trust in a sense. I'm trusting you that you know what's best for me because apparently don't. In a way that's kind of what it feels like. But I'm also wondering having had your experience in South Texas Corpus Christi is a little further south so there is more of a Latin X Community there.

[00:43:50] I'm wondering if you can kind of give me some insight to that I had a dietitian on Lili Coria, who you may know she was on a couple of years ago and talking about how she did a hospital visit kind of like what you were talking about these missed opportunities where you may see the patient and if you do, it's only for a few minutes And she walked into this room where it was full of Hispanic. The Hispanic family was there and she spoke to them in Spanish, and she said to the patient have you ever received diabetes education and the individual said no. 

[00:44:25] And she just like, her heart just broke on that whiteboard where they put the physician name and all of that Lily started to explain what nutrition looks like for diabetics and that's when she realized l need to work more closely with people in Spanish who like this information. What has been your experience with Spanish speaking people. Yeah, that's a great question So. 

[00:44:53] Yeah. I think that my experience is very similar to what you're describing in that a lot of times. One of the first things l do when I walk to a room and first introduce myself. I want them to have a good understanding of what l do and that I’m a registered dietitian and that I'm really there just to help and to understand what their needs are. And that's usually one of the first things will ask is, do you understand what diabetes is? 

[00:45:25] And I don't know exactly percentage but would say the majority of people would say no. I would ask, have you ever taken any type of cooking classes? Or do you knowa diet that is specific for diabetes? Do you know how to count carbohydrates? Do you know how insulin works? 

[00:45:48] A lot of those questions a lot of times. And they would have a mother and a father that already had diabetes and them themselves would have had diabetes sometimes for 5, 10, 15 years, and they never spoke to a professional about what diabetes is. So, at that point I try and keep everything very basic and try to ask them what would you like for me to explain? Or whatwouldyou like for me to start? What wouldyou like to and then also whatis a big key of motivational interviewing is asking open ended questions. 

[00:46:34] Tell me how you currently manage your diabetes Aand then start to just get a feel for it's, almost like a funnel of starting really broadband then let the patient take me where they want to go. And I think that one thing l try and also get across to, especially the Latin community is have them think about because a lot of the foods that they eat in their culture are plant-based foods beans and rice and vegetables, things like that are more of Hispanic culture. So, what was seeing a lot in, let's say in the hospital setting was a diet based around a lot of processed foods flour tortillas and water. Burger was founded in Corpus Christi so it ends up being whenl dig down into their diet it ends up being not really the diet that their ancestors ate, which is more of handmade types of meals. 

[00:47:48] Hispanic meals ends up being more of the standard American diet with little bit of more of the Hispanic culture tied into it and then going into chronic renal disease. CKD they're different levels of chronic kidney disease. And one of the ways to avoid getting to end stage renal disease is to give the kidney a rest meaning let the kidneys not be overworked. And so one of the things that causes a lot of stress on the kidneys is protein especially animal protein because the majority lot of people that I've experienced with the Americans, the American type of diet still have this thought of wanting to always get a lot of protein in their diet because they think that they'll waste away or something. So you actually need to take in a lot less protein anywhere from say, like. 4 to 6 grams/kg so you can give the kidney a rest. 

[00:49:05] And so what's so great about a plant-based diet is that it's naturally lower in protein. When you switch to a plant-based diet you must automatically go to a lower protein diet. But it's really the amount of protein that we should be eating because the recommended daily allowance for protein for just the average American is actually zero 8 grams/kg of body weight. So, when you eat more of a Western style, Americanstyle diet that's more heavily centered around animal proteins it can be a lot more than that. And then second, one of the things that is one of the hardest things that l find with my dialysis patients was that when they went to end stage renal disease, then they needed to switch to a higher protein diet. 

[00:50:00] So they needed when they went fromchronickidneyto disease, stage fourto stage five, which is dialysis, you have to go fromlow proteinto a higherproteindiet Making thatswitch can be really hard because whatI foundwith a lot of my patientsis two main things is that dialysis causes a reduction in appetite with a lot of the patients so they're eating less. And then second is phosphorus control. Our bodies have phosphorus which is needed in the body. And a lot of foods that are more animal based and plant-based have phosphorus in it. 

[00:50:43] But one of the things that can help control phosphorus is not necessarily just what's the amount that's in the food that you're eating is the absorption rate. And with animal based proteins because the protein in animals the enzyme is a phytate enzyme ,our bodies don't have the enzyme that breaks that down very well. So we don't absorb as much protein, 'Im sorry plant phosphorus as we do with animal or processed foods phosphorus. And so what see, again, with a lot of patients is they have trouble controlling their phosphorus levels, they go up too high, which if their phosphorus levels are high that can then combine with calcium levels. And when those things combine together in the bloodstream then that can cause hardening of the arteries and potential cardiovascular problems like strokes and cardiovascular disease. 

[00:51:52] So, one of my favorite books is the Plant e-d Kidney by Jennifer Moore. So, it talks a lot about how if you have chronic kidney disease, this is a great resource or if you're on dialysis, on how adopting a plantb-ased diet. And like I mentioned earlier in the interview one of the major dialysis companies are telling their dietitians to promote plant-based diets. And at the dialysis clinic that I worked at about six months ago, our medical director said we need to be promoting plant-based diets. It was the first time I heard that at the company worked at which was amazed. 

[00:52:43] But that had been what I've been advocating for my patients the wholetime because it allows their patients to get adequate protein but keep the phosphorus levels low. That way they can avoid, which is, like you mentioned it's, the number one killer is cardiovascular events. 

[00:53:08] It's a great way to, again, give the kidneys a rest by introducing plant-based proteins in the diet. Those can be beans, legumes tofu which also helps with calcium levels and whole grains. So it's really a win-win when you switch to a plantbased-diet Right? Thank you for mentioning that book. 

[00:53:32] I've never heard of that one. And also for just really going into detail about how we can support your kidneys. Also, since you are talking about some of the foods. I had a question about the glycemic index. If you are already diabetic, should diabetes patients still remain low on the glycemic index when it comes to fruit I don't think not necessarily. 

[00:53:55] I thinkit needs to be individualized It needs to be look at the individual situation. Because if you look at the Mastering Diabetes which is a book by Robby Barbaro and Cyrus Khambatta, so they're both type one diabetics and they eat a lot of fruitin their diet. 

[00:54:26] When we think about fruit it's really designed for us to eat. We were designed as humans to eat fruit. And so there are some foods that are fruits that are higher on the glycemic index. As an example I know watermelon is higher on the glycemic index but what you should also take into account is glycemic load, which is the actual amount of that food combined with the actual food itself. So, as an example if I had two pieces of watermelon it may not have a big impact on my blood sugars, but if I had a whole watermelon without any other foods without any other proteins without any whole grains in that meal, then it probably could have a higher impact on my sugars. 

[00:55:16] So, it needs to be individualized. But the beauty of fruit is that especially if you're an athlete or if you're wanting to exercise, that's one of our main fuel sources. Fruit and whole grains, carbohydrates are really that's what our preferred fuel source in the body. And so our bodies naturally will and it has a perfect blend of potassium and vitamins and minerals wrapped up in this beautiful package of, let's say, a banana or an apple. 

[00:55:52] And so it also has protein in it. But the number one thing that also comes along in that package is fiber. And so fibre really helps with blood sugar control versus if you take, let's say an apple and if you juiced it well, you're taking all that fiberway. So, that will increase the impact of that on your sugar levels. So, I think you have to look at it as more of a whole meaning that not too many. 

[00:56:24] If you're having it as a snack, then you are eating it by itself. But second is take into account other things. Let's say if you're having a meal and you're having a protein like, let's say garbonezo beans, you're having a starchy grain starchy vegetable, let's say like a sweet potato you're having your cruciferous vegetables which are high in fiber, broccoli carrots and then you're having your fruitat the end. That total package is what you should be looking you can be looking at when it comes to blood sugar control butit needs to be very individualized. It depends on probably someone's a one C, someone that has an A one C of six versus someone that has an A one C of eleven. 

[00:57:15] Especially if they're on insulin they may impact them someone differently. So other things that come into play is maybe if you didn't have a good night's sleep that night if you're high in stress, if you have high stress levels, there'sa lot of things that come into play. So, I think that using the glycemic index and glycemic load is a useful tool but it needs to be individualized in looking at the full picture. Yes. Well, that makes sense. 

[00:57:47] If you'd like to tell our listeners more about your programs and how they can sign up, please share with us. Sure. So, I've just developed whatl think is the future of medicine is personalized medicine in really patient centered medicine and making dieticians and healthcare professionals health coaches more accessible to 

individuals. And so I developed l do have a private practice where l see people one on one, if you're in the Fort Worth area. But to make myself more accessible, I developed an online nutrition program. 

[00:58:30] I just developed it recently. This is my first time to develop something like that. My first course is designed around eating more plant-based and weight loss. It's called ten week weight loss kickstart. But it's a lot more about weight loss. 

[00:58:48] It's about looking beyond the scale, looking at your total health it's ten weeks long. There are online courses, there'llbe weekly zoom teaching wherel teach live, but you can then watch the recording if you happen to miss it so accessible, so you don't have to drive to a clinic. You can just watch out of the comfort of your own home It's ten weeks long. 

[00:59:16] There's supporting that you get to meet with me weekly for laser coaching so we can design those specific small goals, attainable goals, so you build the confidence that self reliance. And so if you want more information about it send me a message on Instagram. My Instagram handle is John Massingale Nutrition on Instagram send me an email at johngmass17at@gmail.com or probably the two easiest ways to contact me. And then from there my plan is to do a ten week course, probably three to four times a year on different topics. 

[01:00:05] Hope to do one that's more diabetes related and then l hope to do one more lifestyle related. Just planning to attend the conference later on in the year, the Academy of Lifestyle Medicine Conference that hopefully you guys are going in Orlando in November. I'm really excited to be my first time to go. So that's the plan. Because I have people that I've worked within different areas of the state that maybe don'thave a plant-based dietitian. 

[01:00:43] So, I think that that's part of one of the things I want to work within the Dallas for work there as well, is making dieticians healthcare professionals more accessible. So that way, because I just happened to be just starting with Baylor, Scott and White, and I didn't know it but it's a great benefit partof their wellness packages, being able to meet with the dietitian. But not every company not everybody has that option so that is the concept around telemedicine and being able to be more accessible to individuals in online learning which I think is part of the future of medicine. Absolutely. 

[01:01:31] It's super comfortable to be able to do this to see your physician or your practitioner or your health coach, whoever may be, by zoom in the comforts of your own home. And we're very lucky to have you and to know you and that you're nearby here in the Dallas Fort Worth area, because we're often approached and asked if we know of a plan-based, cardiologistand plant-based physician. And the truth of the matters is that we still lack a lot of specialists, but we always know and I always feel the need to clarify those individuals those healthcare professionals are probably going to direct you towards a dietitian because that's really how it works. And so I really want to drive that message that yes, while you may have a cardiologist who's on board with eating plant-based and all that they don't really dedicate that much time when it comes to actually guiding you. They usually direct you to someone else. 

[01:02:28] They partner with like a dietitian. And so the fact that you're able to offer these resources probably continually throughout the year online is great. And also that you offer it via telehealth and that you're at  Baylor Scott. I'm actuallyon an outpatient basis, so I'm not in a hospital. I'll be workingat a couple of different clinics here in Fort Worth.

[01:02:50] I'm going to be a clinic in Saginaw, which is a suburb of Fort Worth north Fort Worth butalso mainly at a clinic that's near downtown Fort Worth. So there'll be primary care physicians. And that's what I found is that there's lot of primary care physicians that have to manage their patients diabetes and some of them maybe that may not be their specialist just like I experienced at the Dialysis clinic the endocrinologist that specializes with kidneys was also managing their patients diabetes. And they're not sometimes a diabetes expert so a lot of times the dietitian and they're very taxed for time meaning that they only have maybe five to ten minutes a lot of times with patients. So, the behavior change part of really going through the diet part and the behavior change takes a lot of time. 

[01:03:55] So I'll be supporting primary care physicians that are Baylor Scott White physicians in Fort Worth at a couple of different clinics. Yeah. Awesome It sounds like you're finallyin a place where you're really happy and you feel like you're really contributing to the health of the patients unlike the other missed opportunities at you saw somewhere else. Is there anything else you'd like to share with our listeners if you have a final message or anything else I didn'task about. 

[01:04:24] Yeah, so I think that when we look at chronic disease, the last statistics shown was that the Centers for Disease Control 86% of healthcare dollars are spent on treating chronic disease. And really that's more of a sick care model. And so what I'm seeing with patients is that patients are living longer, but a lot of those years they're living with increased disability. And so really the focus needs to be on preventative early detection working with your primary care physician so he can have that talk like I got when I was in my mid thirtys. And then from there working in stepping maybe outside of your comfort zone and working on with a healthcare professional whether it's a health coach ora registered dietitian. 

[01:05:34] And then from there it's taking, I think those small steps because I think a lot of times what causes a lot of people to not make lifestyle changes is that they think it's an all or nothing or it's a really big change in their life. I know personally it was just small changes, but it was small, consistent changes over timeis what has helped me get to my ideal weight to and thrive. I've done an Iron Man, I've done the Cowtown Marathon and if you want to get off medications, if you want to get off of insulin, if you want to get off of blood pressure medications, if you want to not have to go to physicians offices there is a choice. And the Danish Twin study says that 20% of our future health can be dictated upon our genes and our genetics, and 80% is based on our lifestyle. So much of this is in your hands and in your control so it's really implementing few small steps, and there is no one size fits all solution. 

[01:07:07] And that's what l always try and tell patients. It's really finding what fits for you that helps you thrive and live a long life.

[01:07:17] And you don'thave to be a vegan. But I believe in the more you move toward incorporating more whole foods more plants the weight takes care of itself. Weight loss takes care of itself. Your health takes care of itself. Wonderful. 

[01:07:34] Thank you so much for sharing that with us. And I wish, to g, that the family of that patient suffering with diabetes would all come on board to support the individual because a lot of times we think oh, well, that personis sick, so they have to eat this way as a result. And it's like, no, you may not want to be in their shoes, so you should come on board and support not only that the family member will feel supported if everyone makes this change together. And like you said, it's not that easy. 

[01:08:05] Which is why there are other resources on how you can get on board to incorporate more plantfoods into your life and moving away from the processed foods. But John, this has been great. Thank you so much for supporting my listeners this way and talking to us about diabetes which is such an important topic. You're welcome. Thanks for having me. 

[01:08:23] I really appreciate it. All right I had such a rich conversation with John Massengale, and I thought that we could sort of recap some of those points that he made during the interview. As you know John is a registered dietitian who is certified as a diabetes care and education specialist. We learned that diabetes is the number one chronic condition that can be the most impacted by making dietary changes. 

[01:08:52] As a matter of fact, I'd like to recommend that you visit episode 184 with Mark Ramirez. He came on the show to speak about how he reverses diabetes I think that you'll enjoy that. We also learned what if your hemoglobina one C is between 5.7 and 6.4, meaning you're basically being checked for your blood sugar levels, you are considered prediabetic. You need to start making healthier lifestyle choices, my friends to prevent conditions that it can actually worsen.

[01:09:24] So, if you're not doing your annual checkups, make sure that you do, and also make sure thatyou get your A one C checked. So I asked John, what exactly is happeningin the body when we're diabetic. He says that number one, either the pancreas does not secrete enough insulinand that's considered type one diabetes or we have insulin resistance. This means that the cell does not recognize insulin. This would be considered type two diabetes. 

[01:09:51] He gave us the example that's provided by the team of Mastering Diabetes where he basically says that the insulin is trying to get into the cell, but it cannot get in. What are some of the signs of diabetes? There's fatigue, frequent urination, thirst and weight gain. While the pillars of lifestyle medicine can greatly help with improving diabetes nutritionis the one pillar that most affects diabetes. He says that nutrition is the biggest piece of the puzzle. 

[01:10:21] Like if you think of all the other pillars as being pieces of the puzzle, nutrition is the largest one. So what diet is recommended to improve diabetes? He says a plant-based diet of course, consisting of legumes fruits and vegetables and unrefined grains would be best. And as a matter of fact one of the diets recommended by the American Diabetes Association is a vegan plant-based diet. Experiencing a 7% weight loss can help reduce insulin resistance which then can help improveyour A one C. 

[01:10:53] I asked about the consequences of living with diabetes that is not properly damaged. Well, we learned that can continue to feel tired and fatigued but also over the course of time we can actually develop chronic conditions such as cardiovascular disease, peripheral arterial disease, and even have a stroke. In addition one can develop diabeticretinopathy which damages the back of the eye. That's the retina and can lead to blindness. There's a loss of feeling in the feet also the loss of blood flow to the leg, which can then lead to potential amputations.

[01:11:28] John sees that there's art to being a dietitian as he closely works with patients to discover their values and goals. He uses motivation a interviewing for this process and helps them set smart goals. These are goals which are realistic and doable. Providing diabetes education is key in helping patients take control of their health. Many times primary care physicians and endocrinologists find themselves trying to manage a diabetic patient. 

[01:11:56] A registered dietitian can help to educate the patient towards reversing their diabetes to prevent renal failure. Two of the main causes of chronic renal disease are hypertension and diabetes which both can be improved on a wholefood plant-based diet. Once a patient has advanced chronic renal disease, they require dialysis and at this point a high protein diet is recommended. Again, a wholefood plant-based diet would be more ideal to increase protein intake such as legumes while minimizing phosphorus intake which is found primarily in animal based protein John recommendst he book Plant-Fed Kidney if you're interested in learning more about that. 

[01:12:39] And finally the CDC says that 86% of health care dollars are spent on treating chronic disease. It is a sick care. Model which does not work. We need to focus on prevention and early detection. John references the Danish twins study where it was shown that 20% of future health can be dictated by our genes. 

[01:13:02] However, 80% of our health can actually be based on lifestyle choices. So much of this is in our control. My friends you have more power over your health than what you've been told. Right now you can prevent chronic conditions by simply choosing healthier lifestyle solutions. I hope that this conversation was useful. 

[01:13:26] Again, I provided a sheet on diabetes. Simply go to bitlydiabetesheet to get more information about diabetes and also get some recipes. And I would love to hear from you. Please tell me what you think about this episode. Simply go to Speakpipe.com HLS and these links will be included in the show notes. 

[01:13:48] And again, my friend thank you for listening. You've been listening to the Healthy Lifestyle Solutions Podcast with your host Maya Acosta. If you've enjoyed this podcast do us a favor and share with one friend who can benefit from this episode. Feel free to leave an honest review as well at rate this podcast com hl this helps us to spread our message. And as always, thank you for being a listener. 

[01:14:16] Bye.