Taking Control of Diabetes: Expert Strategies for Prevention and Management with Dr. Alex McDonald

Diabetes affects nearly 40 million Americans, yet millions remain unaware of their diagnosis. It’s a condition that knows no boundaries, touching lives across all ages, sizes, and socioeconomic backgrounds. With its growing prevalence, especially among younger generations, understanding how to prevent, manage, and thrive despite diabetes has never been more critical.

Joining us today is Dr. Alex McDonald, a Southern California Kaiser Permanente Medical Group physician specializing in Family and Sports Medicine. A dedicated advocate for health and wellness, Dr. McDonald brings insights from his experience as a member of the American Academy of Family Physicians, the American College of Sports Medicine, and other esteemed organizations. Tune in to discover practical strategies for taking control of your health, whether you’re managing diabetes or striving to prevent it.

Transcript

Erin Brinker: 0:06

Erin, welcome everyone. I'm Erin Brinker, and this is the making hope happen radio show, the holidays are in full swing, and I hope yours are off to a great start. Thanksgiving is the biggest feast day of the year here in the United States, which can be both wonderful and problematic. My guest today is an expert in diabetes care. Yes, that skirts that hit so many people from so many walks of life. It is a serious diagnosis, but it doesn't have to be scary. And Dr Alex McDonald from Kaiser Permanente is going to demystify the topic and tell us how to live well, here we go. I am absolutely thrilled to welcome to the show another wonderful medical health professional, medical professional from Kaiser Permanente, Dr Alex McDonald. He is core faculty and in family residency, a KP at kp Fontana Medical Center. He's an assistant clinical professor at the School of Medicine. And Dr McDonald is well, he's an expert on diabetes. Dr McDonald, welcome to the show.

Dr. Alex McDonald: 1:05

Thank you so much for having me. I appreciate the time.

Erin Brinker: 1:08

So first tell us about your background, kind of who you are, and then what led you into specializing in, among other things, diabetes.

Dr. Alex McDonald: 1:16

Absolutely. Thanks so much for having me here. So I practice family medicine, and I also did an extra year of training in sports medicine. And so I'm very passionate about lifestyle and exercise. Obviously, I was an athlete myself before getting into the sports medicine world. And then as doing primary care and family medicine, I take care of a little bit of everything. I tell people that I take care of everyone from newborn babies all the way to Grandma's and grandpa's at all, all ages and stages of life, if you will. And at this point, about about 15% of the population has diabetes, or it's estimated about 15% of the population of the United States has diabetes. And so this is something that I see every single day in primary care and family medicine. And used to be historically, treated more with within the special sub specialties with endocrinology, but there are just so many people who have type two diabetes in particular that this is something now that family medicine and primary care takes care of on a daily basis. And so that's a little bit about my background. You know, I get bored easily, and so I do a little bit of everything within with my family medicine hat on, I work in the hospital, where I take care of patients in the hospital who are very sick, often with multiple comorbidities and often complications due to diabetes. But then I also work in the in the clinic, taking care of patients on an outpatient basis, and then also putting my sports medicine hat on, I take care of kind of athletes of all ages and stages. I think of not just sports medicine as sort of athletes, but but people who do who use their body for a living. I have a lot of patients who are work in construction or law enforcement, who do a lot of physical labor as part of their job, which directly impacts their health. Many of those patients have diabetes as well, and we talk about how physical activity is a big piece of that, but we I get ahead of myself.

Erin Brinker: 3:11

So so, you know, I had never thought it makes perfect sense. I'd never thought of somebody who works with their body for a living being needing to see a sports medicine doctor, but I'm sure that, I mean, that makes complete sense now that I think about it. Because they have repetitive injuries, they're using their muscles and tendons and all of that every day, as opposed to sitting like I do in a chair all day long, which is also not good,

Dr. Alex McDonald: 3:36

exactly. It's a balance, right? We know that. We know sitting all day for even they've done good studies showing people who are physically active and healthy and do exercise. But then if they sit at it, at a desk for eight hours a day, they have a much higher incidence of all kinds of medical conditions versus people who who move around a little bit all day long. But then there's also the other extreme, where people who do who do too much. You know stone masons is, I have a couple patients who have horrible arthritis in their knees and backs and hip from from doing stone masonry work for for 30 years, and so everything's a bit of a balance.

Erin Brinker: 4:10

Wow. So you mentioned that 15% of, I assume, is that adults, children, or both of the population, has diabetes. So that's,

Dr. Alex McDonald: 4:19

that's a recent estimate for the entire United States. Now, the key, obviously, is, is there's only about the estimate is all ages and stages, but, but only about 10% of those people actually know that they have diabetes. It's an estimated about 5% of the United States has diabetes but doesn't even know it, which is an even scarier fact.

Erin Brinker: 4:39

So, and are you defining diabetes as an A 1c of six, one, 6.0 and higher? Are you also including people who are would be classified as pre diabetic?

Dr. Alex McDonald: 4:50

So that's just people who have an average blood sugar the the three month, a 1c of 6.5

Erin Brinker: 4:56

or higher? Oh, 6.5 or higher. Yeah. Which

Dr. Alex McDonald: 4:58

is the which is the diet? COVID range. So the pre diabetes range is 5.6 to 6.4 and then the diabetes range is 6.5 or higher. And so that's only people who have formal diabetes 6.5 or higher on on two or more blood tests. We don't, we don't diagnose diabetes based on a single blood test. It requires, you know, a couple, at least two different blood tests separated by a period of time.

Erin Brinker: 5:23

Okay, so how many of these people? There's so many things that impact diabetes, and you know, it's your weight, it's your lifestyle, if you're a smoker, it's the food that you eat, but it's also genetics. And I'll use myself as an example. I'm a diabetic, and so is everybody on my dad's side of the family, and my I have a brother who is like, Mr. Keto, Mr. CrossFit. He does Spartan Races. He's, you know, eats nails for breakfast, kind of guy, but he has diabetes. He has to, if he has any carbs at all, he gets a spike. But my dad was, but has battled with his weight his whole life, but he's gone on a low carb diet that he's been on for five years, and he's 80 years old and is at a healthy weight, but he has to fight it every day. I mean, any carbs at all? And then there's me. I tried being a vegan, which I really liked. Being a vegan, my blood sugar, however, did not right, and I found that rice to me, I might as well have six cupcakes if I'm going to have a bowl of rice. So, you know, it can hit any family and any person, even when they seem to be doing the right things.

Dr. Alex McDonald: 6:32

Yeah. I mean, you hit the nail on the head there with those examples, is there are so many factors involved, right? There's, there's there's age, there's your diet, there's your metabolism, there's your genetics, there's your lifestyle, there's your physical activity. There's so many different factors which impact someone's kind of health, but also their their blood sugar and their way their body responds to to carbohydrates and spikes and insulin release and insulin sensitivity. And there's many, many different factors, and that's why it's such a difficult you know, there's not a one size fits all approach. It really requires individual sort of attention and details for for, you know, the care team with with nurses and physicians and pharmacists and physical therapists and athletic coaches and nutritionists to figure out what works for each individual patient. And unfortunately, there's a lot of trial and error. You know, some people it's really easy. They just sort of follow the routine guidelines put out by the American diabetic Association, and they're, they they're doing really well. Other people really struggle. And there's, there's multiple different there's multiple different factors which which go into the diagnosis and in creating patients risk and elevated blood sugars. But then there are also multiple ways to treat it, so it really becomes very, very complex very, very quickly.

Erin Brinker: 7:50

So what do you do? Let's, let's say that I'm, I'm gained some weight, I'm really thirsty and I'm really tired, and I come to you saying, you know, what's going on with me? How, What? What? How would you treat me?

Dr. Alex McDonald: 8:05

Yeah. I mean, I think the first, the first step is, you know, meeting with your your family medicine and your primary care physician, and just doing kind of a, getting a good history and a good physical exam. That's always the most important piece. A lot of people you know like to turn to Dr Google, which is a can be a good first step, but also can go down the rabbit hole very, very quickly, and before you know it, you know you have, you know something terrible with you and you're dying, which is not always the case. So I always encourage people to, you know, make an appointment with their primary care physician. If you don't have a primary care physician, find a primary care physician who you who you know and you trust. That relationship is so important between the patient and your primary care doctor. In this day and age, a lot of people just sort of, you know, want to get care, you know, through an app or just through an urgent care, which is, which is fine when there's there's an emergency or there's an acute issue, but for something like diabetes or any chronic medical condition, it really trust and time, and that continuity of relationship between a doctor and a patient is so important. So that's my first pieces. Is find a primary care doctor who you like, who you trust, who fits your fits with your personality and with your needs. And you know not every physician is going to match with every patient, and that's okay. So so don't be afraid to meet with different different physicians to find the right person for you. So that's, that's the first step. The second step is obviously just getting getting some blood work. You know, oftentimes we'll look at kidney function, we'll look at liver function, we'll look at the average blood sugar, or the the a 1c which is a three month average. Sometimes we'll even look at, like, instantaneous blood sugar, like, what's your blood sugar right at that moment? And then we'll also look at other factors, such as your cholesterol, your your lipid panel will look at your weight, your height, your body mass index. There's multiple factors which we kind of all put together, but But getting that good history and then some blood work is sort of the first step in the in the in the journey.

Erin Brinker: 9:56

So we, I. Uh, how long have we seen these high numbers? Is it that people back in this, 50s, 60s, 70s, 80s, were not tested appropriately, or because as I'm as I'm processed, thinking about what's changed and why these numbers are as high as they are. You know, maybe it's that we're eating more processed food, maybe that were more sedentary. You know, kids are playing one on playing video games instead of being outside and playing all the video games have been around for 30 years or 40 years. So you know, what has changed about United States, our diets, our culture that has caused this spike in diabetes?

Dr. Alex McDonald: 10:39

You know, I think you hit the nail the head on most of those factors. So, so there's no one one thing, I think, and there's multiple probably, theories which, which lead to this or potential conflicting variables. I mean, the first thing, like you said, the the highly processed foods, the vast majority of the the American diet, is this, highly processed foods with a lot of added, salt and sugar and other factors, which are just terrible for our health. That's number one. Number two is Americans are getting larger. The amount of individuals in this country who are either obese or even morbidly obese is significant, and it continues to grow and climb every single day. And then lastly, the sedentary lifestyles. You know, a lot of us, you know, we have technology, which is, has innovated physical activity out of our lives. You know, imagine, you know, 1000s of years ago, and when we were Hunter Hunter gatherers, we would would walk around or or hunt animals all day long and have, like, maybe one meal a day, if that even and so obviously that wasn't healthy for us either, but we were designed to take any calories and any nutrition we have and really store store that as much as possible for you know, we didn't know when our next meal was coming. Now, fast forward. Today, we have just sedentary lifestyles. Our technology has has made it even easier to be less physically active. You know, great example, I send a, I send a message down the hallway to one of my colleagues, through the through the computer system, versus walking down the hallway and talking to them, you know, just something as simple, simple as that, not to, not to mention a lot of the the machines, which now do a lot of the manual labor for us. So I think it's a combination of all those factors. As we, as we get larger, we the population is overweight or obese or morbidly obese, that results in what's called insulin insensitivity, where our bodies just don't respond to the insulin in the same way, and so our blood sugars just go up and up and up. And it's a, it's a multi factorial problem, but I think those are probably the three biggest, biggest contributors.

Erin Brinker: 12:42

So I have a question about insulin insensitivity. So you know, if you are a type two diabetic, and just say, for say, your BMI is 39 I'm just making this up. And you know you're trying to create, uh, create a more healthy lifestyle. But clearly your body isn't using the insulin correctly. Because, you know, you're diabetic. How is giving insulin to that patient if your body can't use the insulin correctly, how is giving insulin to that patient helping them reduce their blood sugar?

Dr. Alex McDonald: 13:12

Yeah, great question. So let's, let's take, actually, take a step back. So we have type one diabetics and type two diabetics. And let me just kind of explain the difference there just for listeners. So type one diabetics do not produce enough insulin their their pancreas, which is a kind of a an organ near the stomach, kind of in the middle of your stomach, releases insulin when you eat sugar. And what that insulin does is it's kind of the key to help the blood, the sugar, go from the blood into the cells, where it can be used as fuel, essentially. And so type one diabetics, they don't have the insulin, they don't have the key, which can kind of unlock that trans transporter from the sugar in the blood to the sugar in the cell where it needs to be used. So, you know, hundreds of years ago, you know, type one diabetic, children would actually be starving. They would be emaciated, and they would die of malnutrition, because basically, they couldn't get the sugar from the blood into the cell where it was used as as fuel for the machine, so to speak. So that's type one diabetic. Type two diabetic is probably a much more complicated illness, and it has to do with insulin resistance. Whereas your body produces the insulin. However, for whatever reason, a multitude of reasons, the insulin isn't as effective. And so the the body can get the sugar from the from the blood into the cell, but it doesn't work as well. Typically, when people who are who are overweight, that really results in insulin resistance, just by a myriad of sort of metabolic factors which, which causes that. So the the giving somebody who's type two diabetic, giving them more insulin, you basically are kind of giving a higher dose so that, that way you can get enough of the. Blood from the assuming enough of the sugar from the blood into the working cells. Now there are multiple other different medications and multiple other kind of pathways where we can impact the blood sugar production in folks who have type two diabetes, but insulin is just sort of one, one tool in our medication toolbox.

Erin Brinker: 15:20

So then that's Metformin, which impacts the liver, and then the ozempic and mugovi, which impact your society, so you're eating less correct. Can you talk about those two, those GLP one drugs, and kind of what they do, and you know, long term, what the impact is, if we even know yet?

Dr. Alex McDonald: 15:38

Yeah, that's a great question. So, so the GLP one receptor agonist medications like, you know, ozempic or wegovy or Victoza or semaglutide or lyraglutide or there are multiple different different types of medications out there, both brand name and generic, and they work in multiple different ways. And honestly, we don't know exactly how they work, but they work in multiple different aspects. The first, first piece they do is they, they, they help prevent the stomach from emptying. Right? Your stomach is sort of a storage pouch, and there's muscles in the stomach and and we know that they prevent the stomach from emptying as quickly, and so people just a smaller amount of food make people feel more full, which is part of the reason why one of the side effects of those medications is sort of nausea or heartburn or things like that, where the food just doesn't leave the stomach quite as quickly. The second aspect is it helps to people talk about sort of the food noise, if you will. It helps suppress something in the brain about just that desire to eat or to be hungry or think about food on a on a regular basis. That's the second piece. And then the third piece also it helps impact the pancreas and how the pancreas produces insulin. And so there's multiple different sort of factors where these medications work. There are several others, but those are kind of the big ones that I've noticed overall in terms of how these medications work for diabetes control, but then also, now this new indication for weight loss,

Erin Brinker: 17:08

is it an effective weight loss drug long term? And then I'll ask you the same question, if it's an effective diabetes drug long term, but first of all, because there's so many people who are using it essentially, off label to lose weight, right? Is, is that? Is that effective long term? Are they going to put it on as soon as they get off the drugs?

Dr. Alex McDonald: 17:26

Yeah, that's a great question, actually, and I think we don't know the answer, honestly. So the there's no question that some folks who have started some of these GLP one receptor agonist medications have lost a significant amount of weight. We're talking, you know, 50, 100 pounds, the the studies really don't look out more than a year or two, honestly, and so we really don't know kind of the long term benefits. There's some, there's some people that think there's a school of thought that once you're on these medications, you need to be on these medications forever. However, I'm not a big fan of that school of thought. Personally. I think, you know, once you, once you kind of achieve your weight loss goals, trying to, trying to titrate down off these medications is is probably a better long term solution, and and part of the issue also is it's not just about medication, right? It's about diet, it's about exercise, it's about lifestyle. And medications can be part of a comprehensive diabetes or weight loss approach. But it's not the only piece I have. Some patients who said, I kid you not, they sent me an email that says, I don't have time to exercise. Can you prescribe me weight loss medications? That's no, that's not. That's not how this works. It has to be part of a comprehensive approach now. Now, once you achieve, achieve your weight loss goals, you you basically you're giving your body a second chance to sort of reset its metabolism, to reset that those lifestyle factors. So I've had a lot of patients who've lost weight and maintain their weight loss without medications, just with diet and exercise alone. Same thing with bariatric surgery. We're talking about weight losses. It helps people lose a tremendous amount of weight, but it doesn't do the hard work for you, the diet, the exercise and the lifestyle pieces are so critical to maintaining that weight loss. What the medications or the bariatric surgery help you do is they help you sort of get a second chance to help reset your metal metabolism. Because when we know when folks become obese or morbidly obese, their their metabolism changes, and it can be very, very hard to to reset that system. But I think medication, surgery can help give people sort of a second chance. But again, it's not a replacement or, or, or in lieu of diet, exercise and the hard, the hard work of his daily, consistent healthy choices. So that's for weight loss, for for diabetes. You know, it's very reasonable to be on these medications, but if people can lose enough weight, they can reduce their insulin sensitivity. If they can develop these good healthy lifestyles, they can reduce their insulin sensitivity. I've had a lot of patients who are diabetes, who, excuse me, who have diabetes. They've started some of these GLP one receptor agonists. They've lost a bunch of weight, and their blood sugar has normalized. And then they maintain their blood sugar without the medication. I think one important factor is, once you have diabetes, you always have diabetes is just well controlled. And again, these medications can be, can be part of a comprehensive approach to address multiple factors.

Erin Brinker: 20:26

Stuff. What popped into my mind is that, you know, once you're an alcoholic, you're always an alcoholic, and you know, you maybe need a meeting and so sorry, as somebody who struggles with my weight, that's how I'm thinking about it, yeah, and that's, I think

Dr. Alex McDonald: 20:38

that's a really important point, is, again, there's multiple different avenues here, and we cannot ignore the the mental health and the psychological component of having a chronic illness or obesity or blood pressure or diabetes or you name it. So finding, finding kind of support, be it within the family or professional help or support groups online, however, whatever, whatever it is that works for you, finding that support group is critical to long term success.

Erin Brinker: 21:06

So do you see, as people are wanting this kind of long term weight loss, being able to stick to it, long term management of their diabetes? Do you see that there'll be micro dosing in these GLP one so that maybe they don't need quite as much, just a little, because they're not that for whatever reason, they're not successful when they're off the medication. Yeah,

Dr. Alex McDonald: 21:27

you know. And I get think that's where the the individual, the individual, you know, features of that person and that patient, really need to come into factors. Again, like I said, there's no, there's no one size fits all approach. My preference is if we can minimize medications, that's, you know, I always tell patients when I first meet them that diet, sleep, exercise and stress relief are going to do more for you than any medication in the world. But there is a role for medications, and sometimes we can maximize those lifestyle factors and we can eliminate the need for medications. My favorite thing to do is stop medications. But everyone's different, and some people, some people, they're not able to stop their medications or or they can go to a lower dose of medication, or they can go to a a easier, less risky medication that will better control their diabetes. And so, like I said at the beginning, there's no one size fits all, which is where you know, developing a relationship with with your family physician or your primary care doctor, who you who you know, who, who you trust, and they know you is absolutely critical.

Erin Brinker: 22:32

So let's say that I'm 22 years old. I'm getting married. I know I have a family history of of diabetes, and I don't want that for my future kids, you know, fast, you know, I try to do my best to eat right, but sometimes I drink Diet Coke or, you know, have I slip up a little bit? How do I and maybe it's just, it's just a consistent, healthy lifestyle over time. But how do I protect my kids? Because kids are out there at friends houses, and they eat whatever they're eating, school lunches, you know, how do I protect my children?

Dr. Alex McDonald: 23:05

Yeah, that's, that's a great question. And actually funny. You should mention that I actually had a patient. I had a seven year old who I took, was taken care of last week, who's, who's, you know, at the 98th percentile of their body mass index. So they're at the higher end of of a healthy weight and height, and one of the issues is her parents are divorced, and when she goes to her dad's house, sorry, Dad's it's always the dad's fault. When she goes to her dad's house, she eats a bunch of junk, versus when she's at her mom's house, her mom cooks at home and has a healthier, healthier diet for so you know, there are definitely kind of external factors involved when it comes to controlling your weight and your diet. But again, it you don't have to be perfect. I think a lot of times I have patients who are who are aiming for a perfect meal, exercising, you know, seven days a week, eating perfectly, never having, you know, a soda or, you know, I don't know, Thanksgiving is coming up this week. So Right? Christmas, the holidays coming up here. So, you know, it's, it's not, it's not possible for us to be perfect. And so when we psychologically set ourselves up to be perfect, we fail, and then we feel like failure is and we just give up. And so what I tell patients is, I want you to adhere to the 9010 rule, 90% of the time you eat, right? You exercise, you do all the stuff you're supposed to, and 10% of the time you can, I don't know, have some pumpkin pie or a candy cane or whatever it is you want, because we can't be perfect. And if we try to be perfect, we're only setting ourselves up for for failure. And that's where that kind of psychology comes in, and giving yourself a little bit of grace to to indulge, because we're all human, but also knowing that there are sort of ramifications of

Erin Brinker: 24:46

that. So what do they say? Perfect is the enemy of the good, absolutely. So there are also the philosophy. So I have a I have some relatives who are they have children who are type one diabetic, and they all. Have the monitors that hook up to the phone so you know exactly what's going on with the child's because they have children, the child's blood sugar and but they essentially take the attitude that, well, my kid can eat whatever he wants. I'll just adjust his blood sugar accordingly. It used to be before we had all this monitoring. You were just had to be very, very rigid about what your child ate. Is, how do you feel about that kind of philosophy, and, you know, What should parents do? Yeah,

Dr. Alex McDonald: 25:26

I mean, I think so that's a bit of a more nuanced approach. I think, you know, definitely this technology helps us to, you know, better control our blood sugars. And for type one diabetics, you know, when you have this instantaneous blood sugar reading, you can adjust insulin to keep blood sugars in the correct range. Now, does that mean that there are kind of long term problems over time with that health Absolutely, just like, you know, a normal, healthy kid who doesn't have diabetes, I wouldn't tell them it's okay to eat a bunch of junk food, there are there impacts on our health overall long term. And so it's not a it's not an excuse to eat whatever you want and do whatever you want. You know, again, like I said, medication is part of a comprehensive lifestyle approach where you know whether you have a chronic disease or not, you maybe need to be a little bit more mindful of diet, sleep, exercise, stress relief if you have a chronic health condition, but it, but if, even if you don't, doesn't mean you can just ignore that entirely, because eventually you will develop a long term health condition if you don't, kind of stay on top of those good habits of lifestyle medicine, as we call it.

Erin Brinker: 26:33

So back to the 9010 Yep. So let's talk a little bit about, you know, on a policy level, if you were, if you had a magic wand, and you could, we could talk about about food policy and food availability, and, you know, and I'm thinking about the how ubiquitous sweeteners like corn syrup and sugar and others are in our food. And you know what that? Because I think it absolutely what do we all as human beings in this country have in common? Well, we are all subject to the same food system, so that has to have played a role in this, in what's happening, you know, what would you say? You know, if you were to advise a member of Congress, and this is a little bit outside the scope, but if you were to advise a member of Congress about that, what would you say? Oh,

Dr. Alex McDonald: 27:22

wow. How much time do we have? No, I think you know when it comes to to, like, you know, food labels and nutrition, basically, I tell people when the most important thing when it comes to reading food labels and understanding nutrition is you should each eat foods which don't have food labels on them. Yeah. So really, really focusing on sort of naturally, minimally or not at all processed foods, right? We can, we can drink some apple juice, or we can eat an apple. Apple has a lot more fiber. It has more more nutrients, has more nutrition in it, versus apple juice has been highly processed and often, you know, they added sugar and other things like that and preservatives. And so, you know, if I had my if I had my dream, people would only eat, you know, minimally or non processed foods. I tell people the most, anything that comes in a box, a bag or a package probably has added salt, sugar and chemicals. And so really eliminating those from our diet as much as possible, I think, is the important piece. Now, the trade off with that is it takes, it's more expensive, it takes a lot more time, oftentimes, to prepare those foods. And so I tell people, you know, try to try to do meal prep on the weekends. And so that way, you know, you make a big salad, you make a big something on the weekend, and then you eat that throughout the throughout the week, because with our busy lives, the time for for healthy cooking and eating and even just sitting down and having a family meal, which is good for our mental health and eating more slowly and not feeling rushed, which are all important things For our satiety, are are very, very hard to come by in this day and age. So there are multiple factors involved. But I think my biggest thing is avoid anything which comes in a box, a bag or a package,

Erin Brinker: 29:12

yeah, and maybe as as we're thinking about farm policy and what subsidize and what isn't, taking a look at the at the systems that that cause the processed food to be so harmful. Now, we've heard a lot of and I'm not sure if you'd be an expert in this or not. I've heard a lot of brouhaha and the internet. So it may not be true. Probably isn't. Is seed oil safe, like the oils and things that people eat, just vegetable oil?

Dr. Alex McDonald: 29:41

Yeah, I mean, I think there are multiple different types of oils, you know, I'm not an expert in that, so I don't want to kind of speak out of line. But again, a lot of the the least processed foods are probably better for you. We know that, you know, olive oil is probably one of the best that you can use for yourself in terms of just, you know. Heart healthy oils versus things which are more processed, like the grape seed oils or like coconut oil, has a lot higher saturated fat in it. I'm not an expert in those overall, and so I don't want to, I don't want to shake out a turn or give our listeners a false information.

Erin Brinker: 30:16

Well, so it will be, it will be a rarity on the internet. We're going to only have true information.

Dr. Alex McDonald: 30:22

Well, we'll do what we can.

Erin Brinker: 30:24

Now, I'm just kidding. I you talked about Dr Google, Google, and I think that people are they know that they're not well. And you know, metabolic syndrome is so common, and metabolic issues and hormonal issues are so common, people are desperate to and they'll, they'll define what the answers are, and they'll, they'll follow whatever rabbit down the hole that they can. And I think it's important that they be given, that people hear the solid, correct information. Yeah,

Dr. Alex McDonald: 30:52

well, and I talk to people about this all the time, is, is I definitely want my patients engaged in their health, and I want them to learn more and to be interested, but I want them to make sure that they're getting their information from from good, credible resources. And so I often will tell patients, hey, if you if you hear something or read something which sounds too good to be true. It one, it probably is. But two, come like, like, send me an email, or come see me or ask me about it. So we can put it into context. Maybe there was a study that showed this one small population benefited from from this one intervention. But maybe that doesn't necessarily apply to you, and so I think that's really where, where physicians can be extremely helpful in terms of helping a patient understand information and putting into context for them and their individual individual body, because you can find anything you want on the internet. These days you can and so I think it's really important to make sure that you you have a trusted individual who you can kind of rely on to help vet some of this information and understanding how it, how it, how it, put it, put it within context with your individual lifestyle.

Erin Brinker: 31:59

So we've talked about the kinds of foods and having, you know, basically shopping the perimeter, the perimeter of the store. You know, you go to the butcher, you go to the produce section, you go to the dairy section. Do you have a preference personally about keto diets versus Mediterranean, versus plant based? Or are you kind of agnostic about that?

Dr. Alex McDonald: 32:22

Yeah, you know, that's a great question. And I think part of the issue is we have this sort of phase diet mentality that, like, you know, it was the Atkins diet, and now it's a keto diet, and then it's the South Beach diet, and they're all just, there's the blueberry diet and the ice cream died. And, like, literally, you name it, there's an ice cream diet. No, I'm just using. I'm just teasing. But, like, the point is, there's so many different sort of, quote, unquote diets out there, sure that you need to sort of think about it. There's anything that's, again, sounds too good to be true, or that has sort of, you know, a flash in a pan, I think, is not as beneficial or as much more suspect. So what I tell patients is, look, you shouldn't be be going on to sort of a quote, unquote, you know, diet with a with a big D. You should have a lifestyle change. Now, if that means you want to have a low carb diet and eat mostly, you know, protein. And if that works for you, and that is sustainable for you know, the long term, then I'm okay with you trying that. But we, what we can't do is every six weeks being trying something new and different. And so I tell people that if you want to try a certain, you know, quote, unquote, diet, I'm okay with that, we just have to make sure that one, it's sustainable, and two, that we kind of check, you know, these sort of metabolic profiles, you know, from time to time, every, every six months or so when you're on that new lifestyle. Because there can be, there can be trade offs, you know, maybe if you're on the keto diet, you're losing weight, except your cholesterol is going through the roof, which puts you at higher risk of heart disease and strokes and heart attacks and things like that. So again, it needs to be taken within context. So that's the first piece. The second piece is the diet that I recommend is actually kind of, what's called a whole food, plant based diet, right? So it doesn't necessarily have to be vegetarian, but it should be mostly, again, mostly Whole Foods, non processed, and mostly plants. I tell people that about half your plate should be fresh fruits and vegetables, a quarter of it should be some kind of healthy lean protein, and then a quarter of it should be some kind of whole grain carbohydrate. So the Mediterranean diet is sort of a very common one which is very well studied and very evidence based that balances sort of those risks and trade offs for most people, but there's more and more evidence showing that eliminating animal proteins from your diet can really improve your overall health, not just for sort of cholesterol and heart attack and stroke risk, but also for some people with diabetes. You know, they followed the very traditional sort of diabetic. Diets are doing all the right stuff, but when they when they move to a whole food plant based or even vegetarian diet, they find their blood sugar improved significantly. But again, it's really individualized. So, you know, it's

Erin Brinker: 35:12

interesting because, you know, I said that, I mentioned that I had been a vegan, and I did. I liked being a vegan, and I didn't do it for I did for health reasons. I didn't do it for, you know, spiritual reasons, or, you know, I mean, I love animals, but animals eat animals, and so I don't have a problem eating animals, but I found that there were that my blood sugar would spike tremendously. And for me, it was just rice. And I didn't know it at that time, but it was just rice. So had I not eaten rice, then I probably would still be on that diet. And I think that, you know, we as diabetics being proactive and and kind of owning your disease is you, you have to pay attention to what spikes your blood sugar and what what impact. And even if somebody else is saying that shouldn't do, that doesn't really matter what should or shouldn't, that's what your body's doing. So that's what you have to listen to.

Dr. Alex McDonald: 36:02

Yep, exactly. I have a lot of patients who come see me, and we're working through, sort of their their nutrition, and we're making recommendations. And they say, well, but I met with the nutritionist, and they said something different. And I said, Well, that's again, that's the hard part. Is it's not a one size fits all when it comes to sort of, you know, dietary guidelines, the their recent guidelines that came out a couple years ago that really put, really emphasize sort of personal preferences, like what foods you like. I mean, if, if the recommendations are, you eat nothing but brussels sprouts all day long, but you hate eating brussels sprouts. By the way, I love Brussels sprouts, but you hate eating brussels sprouts, then that's not really going to be a good diet for you. So really, for you. So really personal preference and what foods you like are really important. Cultural and religious traditions are really important to make sure eating foods which kind of fit with your culture and the traditions. And then, thirdly, those foods which are not going to impact your health or will minimize the impacts to blood sugar, cholesterol, you name it. So again, highly individualized. There's no one size fits all, and unfortunately, there's a lot of trial and error, which needs to go into that work to figure out what's going to work for you and your individual body. And that's why having a team with nutritionists and physicians and nurses that can be really beneficial for you. So

Erin Brinker: 37:21

is type type two diabetes an autoimmune disease?

Dr. Alex McDonald: 37:27

Not technically no. So type one diabetes, diabetes can be associated with an autoimmune disease. It depends typically, but type two diabetes, I believe, is not so someone out there who maybe was smarter than me might be able to correct me, but my understanding is there, there may be some implications, but not directly, an autoimmune disease for type two diabetes.

Erin Brinker: 37:47

So, and I asked that I have, I'm just being very open. I have, I have Hashimotos. And so this, this kind of hormonal imbalance that I'm trying to walk a tightrope. And sometimes it's great. My blood sugar's just dynamite. And then then it's not, and it's frustrating, because there's, it's, it's this kind of up and down, and up and down. Is that rare? Is that, you know, do other people have the same experience?

Dr. Alex McDonald: 38:14

Yeah, you know, I think a lot of people have, you know, when it comes to any chronic disease, there is not a sort of set it. And for good mentality, you know, if you have high blood pressure, oftentimes you can take a medic blood pressure medication, and then, you know, within reason that's pretty well controlled your blood pressures, but it needs to be adjusted from time to time. For diabetes, there is so many more factors involved. And so we know, for example, if somebody is really stressed at work, and they're not sleeping as as well recently, because they have all this other stuff going on. It causes your cortisol, your your blood blood stress hormone, to spike, which causes your blood sugar to go up. And so there's multiple different impacts. And so there really is not a there's not a one size fits all approach. So if things are going well, I tell my patients who have diabetes, hey, I want to see you about once every six months, just to sort of touch base and make sure you're doing okay. Do blood work every six months just to make sure you're doing okay. However, people who are not well controlled, I want to see them much more regularly to help get them under better control, because we can't just sort of rest on our laurels. You know what? Worked last year may not work this year, unfortunately,

Erin Brinker: 39:20

well, you brought up sleep, which is huge. I mean, I know so many people who are not getting they're getting, you know, six hours or less a night because of stress, because of, you know, maybe they're caring for an elder, aging parent. Maybe they have stress at work, you know, all kinds of stuff. You know, how do you, from what it sounds like, that plays a huge role.

Dr. Alex McDonald: 39:40

Oh, absolutely. And like I said before, diet, sleep, exercise and stress relief, those four things are absolutely critical to maintaining and improving your health. And even if those are not the sole features and you need medication on top of that, they have a huge and a disproportional impact. So. Sleep is absolutely foundational. There is most people, the vast majority of Americans, need about eight hours of sleep a night. Now, if we get by at seven on average, that's probably enough. When we start getting less than seven on a regular basis, there are definitely metabolic and cognitive impacts. They did a good study showing people who had got less than seven hours of sleep on a regular basis, they just their brains were slower. They would literally think slower than people who got more than seven hours on a regular basis. And so that's just kind of one kind of cognitive example. But we know there's a whole bunch of factors involved with with metabolics and cortisol and stress, and you name it. So if you're not sleeping, you're not like recharging your phone overnight, essentially, and eventually, the battery's going to run dry and you're going to damage the phone and have all kinds of other issues and and you can't use the phone, right? So I tell people, sleep is just like you. You charge your your battery on your phone every night so that it works better the next day.

Erin Brinker: 41:00

Yeah, yeah, you do have to, you have to reboot. You know, you you talked about cognitive issues from a lack of sleep, and in long term, you have to think that, that, you know, all of these play into how well your brain works as you age. I've heard some people, and I don't know if this is true or not, but I've heard some people describe Alzheimer's, for example, as type three diabetes. And I don't know if that link has actually been made, or people are just kind of watching things and making that assumption. What do you think?

Dr. Alex McDonald: 41:31

Yeah, you know. I don't know exactly. We know for a fact that elevated blood sugar, or just sugar in general, causes inflammation in the body, which can make multiple other factors worse. And so if you already have inflammation or narrowing of the blood vessels in the brain, and your blood sugar goes up, that can cause inflammation of the blood vessels, which can cause, you know, increase the risks of strokes and heart attacks or even even what we call vascular dementia, right? The blood vessels just are not able to provide enough blood, and the brain stops working as well, because the just the chronic inflammation that happens within those arteries throughout the entire body, right? One of the biggest side effects of uncontrolled diabetes is vision loss, because the small, sensitive blood vessels in the back of the eyeball get damaged from the chronic blood sugar. Same thing with the kidneys. The lot of folks who have uncontrolled diabetes end up going on hemodialysis because their kidneys stopped working, because those little, tiny, sensitive blood vessels in the kidneys stop working from the from the inflammation and the sugar over time. And so the same thing happens in our brain, whether we can make a direct correlation or not, you know, I couldn't say but, but there's no question that elevated blood sugar significantly increase increases your risk of multiple conditions, dementia being one of them.

Erin Brinker: 42:49

So we've talked about people who have diabetes, and certainly there are a lot of people who don't know they're diabetic. I would imagine there's even more who don't know that they're pre diabetic. Can you talk about pre diabetes, and kind of what, what that looks like in it, and what might be the hint that somebody's blood sugar is not where it should be.

Dr. Alex McDonald: 43:08

Yeah. So, you know, the kind of the medical industry has kind of developed these kind of terms, you know, there's, there's pre diabetes, and there's, there's pre this, and there's pre that, and I'm not a huge fan of that. So everything is a spectrum, and we have to sort of draw the line at some point. And so for average blood sugar, the A, 1c or the three month average blood sugar, the line for when you're technically have diabetes or not, is 6.5 with at least two different blood blood, blood measures over time. And so that's kind of where we draw the line normal blood sugar, as I said before, is is 5.6 or less, or 5.5 or less. So that middle range between those two is what we call that, that pre diabetes range. So what do we do with that? There's some people who are in the pre diabetes range who never go in and develop diabetes, about five to 10% percent of people per year who have pre diabetes will go on to develop full blown diabetes. However, we know for a fact that people who have pre diabetes, you know, are often higher risk of high blood sugar, high cholesterol, strokes, heart attacks, you name it. So it is sort of a, I sort of use it as a as a learning opportunity to change your lifestyle, to help reduce your risk of going on to further conditions. And so I'm not a huge fan of the term pre diabetes. I often don't start with medication. When someone has pre diabetes, I start with diet, sleep, exercise, stress relief. I feel like a broken record, but I start with those lifestyle pieces first, and it's sort of a point to have a conversation about, hey, what are we going to do here? Let's, let's focus on on keeping you healthy and preventing disease, because ultimately, my job as a family physician is to prevent disease, rather than just treat it. And so I think, sort of having somebody. They get their their blood sugar checked on a regular or routine basis based on the risk factors. Is, is just sort of a point to have that conversation to prevent future issues down the road.

Erin Brinker: 45:12

You know, it just it drives home the need for a medical home to have a primary care physician that you work with who gets to know you and your lifestyle and your family, and can really be a partner and so much of what we you know, people show up in the emergency room when something is reaching a critical level and they've never seen a doctor to mitigate the problem from way back, yep,

Dr. Alex McDonald: 45:37

exactly, exactly. You know, an ounce of ounce of prevention is worth a pound of cure, and there's no difference when it comes to health conditions. And like I said before, the top of this conversation is when I work in the hospital, I see all these downstream consequences of poorly controlled diabetes and blood pressure and cholesterol and you name it. But a number of those patients either didn't have access to a primary care physician or didn't have access to medical coverage. And how can we how can we help prevent this? Unfortunately, in this day and age, our our healthcare system is really not a healthcare system. It's a disease care system. We are sort of set up to treat things once they've already occurred, versus versus preventing them. And that's, I mean, I'm a little bit biased, but that's one of the reasons I love being a part of Kaiser Permanente, is we are set up to prevent illness. We really value prevention. We really value community outreach in ways that a lot of other medical systems and a lot of medical organizations just will treat you once you're sick, versus here at kp, we invest a huge amount of time and energy to help people stay healthy or get healthy, versus just treating them once they're

Erin Brinker: 46:52

already sick. So I know that you all have classes in weight loss and diabetes management and asthma, in quitting smoking, all kinds of stuff. Can you talk about what that you know, the about those classes, whatever you know about those classes and and what a benefit that has been in your practice? Absolutely.

Dr. Alex McDonald: 47:10

So I have the the average patient sees their their family doctor for 20 minutes, maybe once or twice a year, right? And how much education can I really do in that time? So that's where I the KP Center for Healthy Living is so important, because knowledge is power. If I can help someone learn what to do or not do, what to eat, what not to eat, how to exercise, that is so much more valuable than just simply prescribing them a medication. Now, like I said, medication has a role, but if we can educate our patients regarding diet, sleep, exercise, stress relief, and help them build those healthy lifestyles and healthy foundations, and not just the individual, but the entire family, oftentimes, I use the example of smoking, if one person in the family is trying to quit smoking and the other one is not, that's, that's, you know, not as beneficial as both. They're trying to quit together. And so that's where the Center for Health Living is so critical, because it can really educate couples and families together to all work and improve their health. There. There's no way that I can do enough education when my in my 20 or 40 minutes per year with all of my patients, but being being there to support them, sort of being their coach. You know, sometimes patients will send me emails being like, Hey, Dr McDonald, I just went to the gym six days this week, right? And just knowing those things and giving them some positive reinforcement, and being that, that accountability for partner, partner with some patients is just so valuable, and that's where I think our organization, with the Center for Healthy Living, is just so so well set up to help people help themselves, versus just give them a pill or give them a medication or give them a procedure, which is not a good long term fix.

Erin Brinker: 48:56

You know, I use an app called glucose. What's it called? Oh my gosh, I just forgot the name of it. It is the gluco glucose partner. Anyway, you can add in all of every time I check my blood sugar, I can add it and every time I eat something, I can add it in. There's a place for notes and all of that. And when I was first diagnosed, I actually my brother had been diagnosed, and I thought, well, I hadn't been I knew I was pre diabetic, and so I just bought a meter, and I started tracking it myself, and I was able to send, send her a report glucose buddy, that's what's called, send her my primary care physician a report. And said, this is all the things that I'm doing. This is all these are all the things that I'm eating. And together, we had a really informed conversation about what I could do or what I should be doing. And it has been, it has been tremendously helpful. Now it takes some discipline to be able to enter all of that stuff, and there are times where I'm more disciplined than not, or less disciplined than before, but it's, it's been very helpful, and certainly gives her information to help me make. The right decisions.

Dr. Alex McDonald: 50:01

I think that is such a valuable tool. There are so many different apps out there that where you can kind of keep track and keep food logs, and it can tell you, you know, not only just kind of calories, but but you know micronutrients and you know, see how it responds and how your body responds to those individual pieces. I agree, keeping a keeping a food journal or a food diary is exceptionally challenging, but I tell people, if you can just do it for three days, just do a food diary for three days. Write down everything you eat, how much it is. If you can put it into an app, which will tell you kind of nutritional and caloric value, even better. But just do it for three days, and you will you will be blown away by by what you are or not eating. Maybe people, people often will say, Oh, I'm having I eat a healthy diet, and I have them do a three day food journal, and they're like, oh, geez, I'm not eating a healthy diet at all

Erin Brinker: 50:51

that happened to me. Like, oh, oh geez. I shouldn't have had this, or I shouldn't have had that. And maybe I wouldn't. I shouldn't get the coffee, the fruit, coffee drink. I should just get the regular coffee drink

Dr. Alex McDonald: 51:02

Exactly. So I think we have, you know, in this day and age, we have sort of, you know, portion distortion, right? We all go to Cheesecake Factory, and we have, like, you know, a week's worth of calorie, caloric in a heavy cream laden pasta dish. And we just don't even have any concept of that, because that's how much we eat. And so sometimes, if you if you measure how much a serving of cereal is, you know, often a half or three quarters of a cup. No one has one serving of cereal. We always have, like, two or three minimum, right? Because that's the sort of what we're used to seeing. So I think learning, learning what actually a portion size is, is really, really valuable. And then also the next level, that is how your body responds to that, and it's a tremendous amount of work, but I encourage my patients, just do it for three days, and you will be be blown away. So

Erin Brinker: 51:49

we have just a couple of minutes left. Talk to me about getting started on an exercise project, because we think, you know, I have, you look at those super toned bodies on TV and think, Okay, I have to get out there and and run a marathon. But it doesn't have to be all that you can just get up and take a walk. Correct?

Dr. Alex McDonald: 52:07

Correct? I tell people, you know, oftentimes we, you know, doctors will tell people to to to go exercise, right? But, but how often do you do? Do doctors tell patients, oh, here's, here's a pill of metformin, just take some here and there, right? Like, we don't actually do that, yeah. So no, I am. I'm a huge advocate of what's called the exercise or the physical activity prescription. Sometimes when you say the word exercise, people think of like sweating and being uncomfortable, and that's not, it's really about being physically active. And so I often will give people what's called a physical activity prescription, and it will say on there, it will say on a piece of paper, walk five minutes three times a day, right? There have been good studies showing people who have diabetes. In particular, if you walk for five minutes after breakfast, five minutes after lunch and five minutes after dinner, you have better blood sugar control than if you walked for 15 minutes once a day. Seriously doing, yep, doing it even, even as little as two minutes of physical activity or walking after you eat can significantly lower your blood sugar. And the reason for this is that, remember, we talked about insulin being the key to help sugar go from the blood into the cells. Exercise bypasses that that need for the insulin key, it uses a different pathway. And so by being physically active, we are actually lowering our blood sugar, whether whether we're diabetic or not, which will often help us be, you know, get those blood sugars under better control, regardless. And not only that, it's good for our hearts, our lungs, our muscles, you name it, our mental health. If I had one medicine, of all the medicines in the world, if I had just one medicine, it would be 30 minutes of physical activity, five days a week, right? It doesn't have to be all at once. It can be five minutes here. It can be taking the stairs instead of the elevator at work. It can be parking at the far end of the parking lot instead of right next to the door. Every step we take, all helps build stronger muscles, bones, our lungs, our improve our blood sugar, improve our mental health. And so I'm this is kind of how I got into sort of the lifestyle medicine world is through sports medicine and through exercise. Because, you know, physical activity is not just for athletes. It's for everybody. It's for everyone. If we, if we had a, if we had a better understanding of how we can make sure we stay more physically active, and that can just be more steps throughout the day that is going to overall make us a much, much healthier population as a whole.

Erin Brinker: 54:35

Well, Dr Alex McDonald, this has been such a great conversation as I diabetes hits every family. It's it is it hits every every race, every demographic, every you know, rich, poor and everybody in between and and so I know that this is really helpful, especially right before the holidays, when food is everywhere. So thank you so much. How do people find and follow you on social media? Or are you on social media and learn more about Kaiser Permanente,

Dr. Alex McDonald: 55:04

yeah, absolutely. I'm so glad, glad to be here, and I'm grateful for the opportunity to share some of my my insights. So I'm on Instagram at Alex Z McDonald. You can, you can follow me there. I do a lot of social media work in terms of just try to educating, educating my patients. You know, collectively, as opposed to individually, check out the Kaiser Permanente Center for healthy living. You can just Google it, and there's tons of information and ways to get involved there. So I hope everyone takes a little bit away from this, and especially heading into the holidays, we don't be perfect. We just have to do something. And then you know that 9010 rule is so important, and I encourage my patients just to stick to that as much as they can.

Erin Brinker: 55:44

Well, thank you so much. Sorry. My alarm, my we're right on time. My alarm just went off. So thank you so much for joining me today. You have been a delight. Happy holidays to you and and I'm going to recommit to being healthy.

Dr. Alex McDonald: 55:58

Awesome. Well, thank you so much. I appreciate the time, and I appreciate everyone out there listening.

Erin Brinker: 56:03

Well, that is all we have time for today. The glucose buddy app that we mentioned, or that was mentioned in the conversation with Dr McDonald, can be found in the Apple App Store or the Google Play Store. It's not free, but it's very helpful while you're learning about how to best manage your blood sugar, and then you can export reports that you can give to your doctor, which are very helpful for your physician, so you can learn how to manage your blood sugar. They're not a sponsor. I'm just a user. And it was helpful for me as I was learning to navigate this so it helped a lot. So for more information about the making hope happen Foundation, please visit Making hope.org. That's making hope.or. O R G, got a great idea for a show topic. Email me at show at making hope.org. That's S, H, O, W at making hope. Dot O R G, have a great week, everyone.

Unknown: 57:02

Hi. My name is Nora Lee signs, and I am Program Coordinator at uplift San Bernardino, a collective impact initiative at the making hope happen Foundation. And this is my story. In November of 2017 my husband, our four young sons and I moved away from our families to San Bernardino with the hope of reaching our goal of home ownership in 2018 as our oldest son started kindergarten, I connected with the school district and learned about making hope happens. Kids program with my oldest in kindergarten and my twins at preschool. I had the opportunity to tote my youngest to the kids parenting classes in January of 2020, my husband and our family's breadwinner unexpectedly passed away. I found myself in a pandemic with my sons in an uncertain future. It was then that that oasis that I found at kids turned into my support system, as the staff and friends rallied around me while my sons and I struggled to find our new normal. In October of 2020 after seven years as a homemaker, I joined the making hope happen foundation as a program coordinator for uplift San Bernardino. This career opportunity reignited my family's dream of home ownership in November of 2022 through the mutual support of the uplift San Bernardino Housing Network, my family was able to buy our first home. In my role as program coordinator, and as I connect with other families in our community, I can wholeheartedly attest to the opportunities that the foundation is bringing to our community and truly making hope happen. For more

Erin Brinker: 58:33

information about the making hope happen foundation and to make a donation, please visit www dot Making hope.org. That's www.makinghope.org your donations make our work possible. You.