The team approach to ongoing diabetes management includes individualized health evaluations by an endocrinologist, diabetes nurse practitioner, and certified diabetes educators (including nurses and dietitians.) The diabetes team works with patients' primary care physicians to prepare a plan tailored to their unique circumstances. The comprehensive diabetes management track is flexible based on a patient's changing needs.
Listen as Dr. Devin Steenkamp, endocrinologist at Boston Medical Center, and Liz Brouillard, Registered Dietitian, explain how the endocrinologist and registered dietitian work together to help patients manage their diabetes.
Devin Steenkamp, MD & Liz Brouillard, RD
Originally hailing from South Africa, Dr. Devin Steenkamp is an endocrinologist at Boston Medical Center, specializing in Diabetes & Metabolism and Diabetes.
Liz Brouillard is a registered dietitian and the Nutrition Manager at the Center for Endocrinology, Nutrition and Weight Management at Boston Medical Center.
Melanie Cole (Host): You are the most important member of your healthcare team. However, a team approach to ongoing diabetes management includes individualized care by an Endocrinologist and nutritional counseling with Registered Dieticians. My guests today are Dr. Devin Steenkamp -- he’s an Endocrinologist at Boston Medical Center -- and Liz Brouillard. She’s a Registered Dietician and Certified Diabetes Educator at Boston Medical Center. Welcome to the show. Dr. Steenkamp, I’d like to start with you. Who is at risk for type two diabetes? What are some things that might predispose somebody to this condition?
Dr. Devin Steenkamp (Guest): Sure, so one of the major factors is your underlying genetics and then allied to that is our Western lifestyle, sedentary behavior, and some of our eating habits. Our food is very calorically dense, and we eat a lot of it, and it’s very easy to come by food these days. We tend to be more sedentary, so obesity is very common in folks who have type two diabetes, as well as other features that are associated with obesity, such as high blood pressure, high cholesterol, and abnormalities in the fat compartment in your body. There’s multiple factors that play a role in the development and the risk of developing type two diabetes. There’s not one specific thing, but surely obesity and excess calories are a big part of that.
Melanie: How would somebody know – you’ve mentioned these risk factors – are there some symptoms of prediabetes? Would there be something in their annual physical blood test that they would know that you could say, “You know what? You are starting to head in this direction.”
Dr. Steenkamp: Yeah. As far as symptoms are concerned, it’s usually a silent condition, and often the diagnosis is made many years after you’ve actually developed the disease. That’s one of the real challenges with diabetes is that you may not recognize some of the symptoms and you may feel tired, you may feel lethargic, you may have a craving for sugary beverages and more sweet cravings than usual. You may be losing some weight. You may not put this all down to diabetes, but when you go and see your doctor, you have an annual physical, they can do some lab work. One of them may be an A1c test, which is the test that can be used to diagnose diabetes. It measures the amount of sugar in your blood over a period of time, over a couple of months. Also, just routine lab work may show that your blood sugars are a little bit elevated that is putting you at risk of developing diabetes, even though you may not have it at this stage, but that you may develop it over time.
Melanie: So Liz, when someone is diagnosed with prediabetes or full-on diabetes, what is the first thing as a Registered Dietician you tell them about managing this every day, day-to-day, and the lifestyle – things you really want them to know about dietary needs for diabetes?
Liz Brouillard (Guest): Sure. When someone’s first diagnosed, especially with pre-diabetes, we’re looking at their diet as a whole to start off with, to see what their dietary habits are to start with. A lot of times we can get good glycemic control just by changing their diet, to eat a healthy diet, and promote weight loss. Not necessarily a specific diet just for the fact that they have diabetes, but a generally healthy diet at the beginning works pretty well. If we can get them to lose some weight, we can see a big improvement in their glycemic control.
Melanie: So Liz, how do you and Dr. Steenkamp work together? And for the patient, how is this team approach so beneficial for the patient as they’re going through treatment?
Liz: Dr. Steenkamp is talking to them about their management -- their treatment -- in terms of their medication, their lab work, and that type of thing. I’m working with them in terms of their lifestyle, and how that can improve their glycemic control. A person sometimes they don’t want to necessarily go to medication right away, so that would be someone that I’m going to work with a lot. That way that’s their goal is to not get to the medications, so I’m going to be working with them on lifestyle changes. Me and Dr. Steenkamp do coordinate care. We will discuss our patients and discuss what their treatment goals are in terms of medications versus lifestyle changes.
Melanie: And Dr. Steenkamp, when you are working with somebody, how do you monitor what they’re doing dietarily, with what they do with medicational intervention and how does that work together, as well?
Dr. Steenkamp: I think they’re just seamlessly integrated. I don’t think that you can add medications into the therapeutic realm for diabetes without having a really solid basis of both exercise and dietary adjustments. I think that that’s the foundation of any good diabetes care is that the lifestyle changes have to be in place, and the dietary changes have to be in place, and having a good faith that they’re – what they’re still struggling with and as far as their behavior is really the most important thing that we’re trying to do. Behavior change is really the most important part, I think. The medication is an additive and often necessary and beneficial, but you’re never going to be able to have success no matter how many medications we recommend if the lifestyle part is neglected or if there is an emphasis placed on that throughout the team.
Melanie: So then where does exercise fit into this picture, Dr. Steenkamp?
Dr. Steenkamp: I think it’s a fundamental part of diabetes management in that it doesn’t only improve a general sense of vitality, it doesn’t – overall, it just improves muscle strength. It has an effect on lowering glucose, particularly after meals if you’re exercising and notice that your sugar is lower after that meal -- particularly for exercising within a couple hours of that bigger meal. I think there’s multiple benefits in terms of blood pressure reduction, cholesterol improvement, improvement of sleep, improvement of concentration and just a general overall improvement in well-being . There’s also added benefits with weight loss, and cardiovascular fitness, which is an important part of diabetes is the cardiovascular risk equivalent. People with type two diabetes are at an increased risk of developing cardiovascular disease. Exercise is well-known to mitigate some of that risk. So again, there's multiple factors that play a role.
Melanie: And Liz, people hear carbohydrates bad, proteins good. Explain some of the best diet tips that you have for people that are managing their diabetes.
Liz: A lot of times people – when they first think about diabetes, they're thinking about they need to avoid all carbohydrates, or sometimes people just come in thinking they need to avoid all sugar, not even understanding that carbohydrates when they get broken down, they turn into sugars. It’s definitely -- educate the patients that they do not have to avoid all carbohydrates in their diet – trying to work with them to develop a healthy diet with – definitely, you do need a good source of lean proteins in the diet, but then also having some carbohydrates with each meal as well. With type two diabetes it’s following an overall, healthy diet with a good – usually, it’s about 50% of your calories coming from carbohydrates – about 30% from your protein and about 20% from your fats. With type two diabetes, we’re trying to get an overall, well-balanced, healthy diet. It would be very different for someone with type one diabetes in the sense that we’re looking at and counting carbs a little bit more than we would with someone with type two diabetes. It’s not that you have to avoid that, which is something that people think of right away -- that I can never eat a carbohydrate, or sugar, again -- but trying to help them understand how to follow a healthy diet for overall well-being for weight loss. That usually tends to lead towards improved glycemic control.
Melanie: And while not all carbohydrates are bad – I mean, obviously, fruits and vegetables and the good, healthy carbohydrates are great -- what do you want them to really clearly stay away from?
Liz: More the simple sugars, processed foods, those are the ones that tend to break down quickly and can raise blood sugar quicker. Definitely having them look towards more whole grains -- your fruits and vegetables, which all have carbohydrates in it and avoid eating all of those processed, high-calorie carbohydrates -- are more the ones that we do what them to avoid.
Melanie: And Dr. Steenkamp, what do you want patients to know about monitoring their blood sugar levels throughout the day? Is this something that you encourage?
Dr. Steenkamp: It really depends on the patient. Part of it has got to do with being aware of what different dietary choices, different exercise choices may – how that may play a role in your sugar. Typically, if you’re not on medications that are putting you at risk for lowering your blood sugar, there really isn’t a strict need for you to monitor your blood sugar because a large part of doing that is wanting to make sure that you’re not having a low blood sugar as a result of the medications. For example, if you’re on insulin, then very clearly you need to be keeping an eye, very closely, on your blood sugar and monitoring things multiple times a day, but if you’re in the stage -- or the therapeutic plan was for you to be making lifestyle changes -- there isn’t a real strict indication for you to need to do that. There isn’t great data that supports checking your blood sugar multiple times a day when you’re not on medication that may lower your blood sugar but generally, a lot of patients -- and I do tend to recommend that people do keep an eye on it periodically in that scenario, just so that they can see that they’re meeting their therapeutic goals. Are there blood sugars where we’d like them to be? Are we succeeding with the therapy that we’re implementing? It’s very individualized. It depends on what the patient’s doing, what medications they're taking, and what we decide as a team.
Melanie: So then wrap it up for us, Dr. Steenkamp, if you would, on how Endocrinology and Dietetics can work together to help someone truly manage their diabetes and live a much healthier lifestyle.
Dr. Steenkamp: Yeah, I think it’s just fundamentally the basis of any good diabetes care. I don’t think that you can work successfully as an Endocrinologist without the help of dieticians. It’s so important in both type two and type one diabetes, and in all metabolic health that we have really great opportunity to work with the nutritionists and my practices wouldn’t be able to be as successful without the help of people like Liz and the other nutritionists and dieticians that work with us. They go hand-in-hand. I don’t think you could do one without the other.
Melanie: And Liz, the final goes to you. Tell us about your team at Boston Medical Center.
Liz: We have a great team here for the diabetes program. We have several dietitians. We have several Endocrinologists, nurse practitioners, and a pharmacist as well that all coordinate care for the patients depending on their needs. We also have Nurse CDE’s as well. The patient will see their Endocrinologist. They typically will also see a Nurse Practitioner, a Nurse, a Dietician, as well as a Pharmacist just so that way we’re hitting all aspects of the education that they need in order to be successful in managing their diabetes.
Melanie: Thank you both for being with us today. It’s really great information. You’re listening to Boston Med Talks with Boston Medical Center. And for more information you can go to BMC.org, that’s BMC.org. This is Melanie Cole, thanks so much for listening.