[0:44] Shireen: In today’s episode, we are privileged to feature Dr. Daria Igudesman, a dynamic expert in the field of nutrition with a focus on diabetes management. Dr. Igudesman’s research findings and her continued work will provide valuable insights into blood sugar and weight management for individuals with Type 1 Diabetes. We explore the practical strategies she offers to enhance the lives of those living with Type 1. Stay tuned. Dr. Daria Igudesman is a postdoctoral fellow at the Advent Health Translational Research Institute. She earned a PhD in Nutrition and is credentialed as a registered dietitian. Her research focuses on Nutrition and the gut microbiome in Type 1 Diabetes management. Welcome, Dr. Igudesman.

[1:28] Daria Igudesman: Thank you so much, Shireen. It’s a pleasure to be here.

[1:30] Shireen: It’s such a pleasure having you on. I do want to start out by first just understanding a little bit about your journey and what really inspired your transition from in the Communications field all the way to, sort of, looking at nutrition and specifically focusing on Diabetes management. What was about it?

[1:50] Daria: Yeah, absolutely. It was a relatively long journey, but I’ll try to keep it brief. So, my first sort of career after graduating with my undergraduate degree in Communication Studies was working on a health and wellness website as part of a Marketing job. And I was relying very heavily on blogs and sort of people who were not nutrition experts to find information that I could then disseminate to our audience. So, we were essentially trying to drive web traffic to this website through enticing nutritional content. Well, I became deeply interested in the topic of Nutrition through this job, not realizing that most of the things I had learned up until that point were just flat out false. One of the things in particular that I tried was following a juice cleanse and even a leek soup cleanse to try and lose a little bit of weight during the Summer months. But once I started formally studying Nutrition, I had a huge mind shift away from trying to use Nutrition in a very sort of acute and more extreme way to promote quick outcomes to using nutrition in a very suitable and sensible way to prevent disease and promote disease management. So I’ll kind of skip through my journey because again, it was kind of a long one, but in my master’s program. So, I went to go and do a master’s in Human Nutrition. After having obtained this Communications degree, I learned a lot about diabetes management, both pharmacotherapies and different kinds of nutrition therapies. And this got me really interested in furthering my education in Nutrition and Diabetes management. So, I went on to earn a PhD, knowing that I wanted to do research in this space. So, when I was looking for universities where I would do my PhD, Type 1 Diabetes actually was never really on my radar. I didn’t know much about it all, but I knew there was a Diabetes researcher at the University of North Carolina by the name of Dr. Elizabeth Mayer Davis and she convinced me that Type 1 Diabetes is actually a really important disease in which to study not only blood glucose management, but also weight management. And we can talk more about what Type 1 Diabetes is, how it develops, and why weight management is important, but often understudied in this specific disease state. So, that’s a really brief snapshot of my journey.

[4:23] Shireen: That’s very interesting. And, you know, you talked about type one diabetes management and your focus being there. I would like for our listeners to first learn about the prevalence of type one diabetes, because the most common one we hear about, like I think it’s 90 percent of diabetes is type two. Can you help us understand what are some of the basic differences between type two and type one? And then from there, I want to understand some of the unique challenges that individuals with type two, type one diabetes face in managing their blood sugars.

[4:56] Daria: Absolutely. So you hit the nail on the head when you said that about 90 percent of people with diabetes have type two diabetes, which we often think of as being lifestyle related, but I do want to point out that type two diabetes, as far as we know now, actually has a greater genetic component in terms of susceptibility to disease development than type one diabetes has. So type one diabetes is caused by type two diabetes. The autoimmune destruction of the insulin producing beta cells of the pancreas. We’re not entirely sure what triggers that autoimmune response. We think it’s a combination of genetic risk as sort of the background. And then on top of that, there being some sort of environmental trigger, like perhaps a viral infection, although shh We’re still really trying to sort that out. And type one diabetes typically develops much younger or much earlier than type two diabetes does. Although that’s not always the case. Unfortunately, we’re seeing higher prevalences of type two diabetes in the pediatric population now. And over time, type one and type two can look more and more similar in terms of disease management, particularly as type two diabetes progresses to require insulin administration in some people, but really the primary difference is the cause. Um, so again, autoimmune in type 1 diabetes. And because all of your insulin production is essentially lost within the first year or two after diagnosis, you must take insulin to survive, essentially. That’s an absolute must. So, you know, really from early on in disease onset. And I’m sorry, the second part of your question was Around blood sugar management, right? Yeah, just really managing the blood sugar. Right. Yeah, so this is actually where it gets really interesting because,  as I said, insulin is required for survival in type 1 diabetes. It’s also required to cover the carbohydrates in your diet. And actually, fat and protein also contribute to how much insulin and how you’re dosing your insulin to cover the various macronutrients that you’re consuming. So, because people with type 1 diabetes have to dose insulin for essentially every meal they eat, unless it’s extremely low carb or, you know, a very, very small meal or snack, there’s always the potential to misdose your insulin. If you misdose your insulin, you can do it in two ways. You can give too little insulin, which will cause your blood sugar to go high.And then maybe you’ll have to give a little bit more insulin to correct that high blood sugar. If you provide too much insulin for a given meal, your blood sugar will drop low. And that’s what we consider to be really acutely dangerous in type 1 diabetes. And it’s something that a lot of people really fear, rightfully so, because it can be fatal in some cases. Although new diabetes technologies are really increasing the safety of insulin dosing. So we’ll get into this, I’m sure, but because there’s always the potential for hypo or low blood sugar to occur, if you give yourself too much insulin, what ends up happening is that now you’re having to consume extra simple carbohydrates to correct that low blood sugar, which can, be perceived as countering weight management efforts for a lot of people. And meanwhile, people with type two diabetes have lots of different kinds of oral medications that they typically start with or injectable medications like GLP 1 receptor agonists. So insulin is not required for all people with type two diabetes.

[8:33] Shireen: You know, your research also is looking at gut microbes. I do want to understand that a little bit. One, can you help us explain how the metabolites Produced in the gut, microbes are linked to blood sugar fluctuation. So what is that relationship there? And weight changes again, specifically for people with type one diabetes. 

[8:54] Daria: Yeah, absolutely. So the evidence that we have is mostly from animal models, so I just wanna preface. This response with that caveat because we’re not quite at the place yet in our scientific understanding where we can make recommendations based on how we think someone’s dietary changes are going to influence the microbiome and therefore blood sugar management. There are these really interesting molecules called short chain fatty acids, which are metabolites that are produced by the gut microbiome. So, to take a step even further back, I think most people have some basic understanding of what the gut microbiome is, but just as a brief primer, they are the bacterial and non bacterial microbes living around, on, and inside of our bodies. I specifically will be talking about the gut microbiome, which is in the colon. And so they consist of bacteria, fungi, viruses, protozoa, archaea, lots of different types of microorganisms, but the bacteria are the best studied. So that’s kind of what I’ll be referring to.  So what bacteria do when we consume a meal is they try to kind of pick up the scraps of everything that we weren’t able to absorb in our small intestines. So things like dietary fiber, because we lack the enzymes to digest dietary fiber. So it reaches the colon. The microbes can use that fiber for energy for their own needs. And then they kind of spit out little molecules that they don’t need. So kind of by products of their fermentation, which we can then absorb across our colon lining into our bloodstream and those metabolites primarily consist of short chain fatty acids. These metabolites are lauded in the literature as having myriad health benefits, but truthfully, Their effects in humans are not rigorously studied. Based on animal models, we think short chain fatty acids might be able to help with blood sugar management by acting on the liver and other tissues, but there are also some studies that suggest the opposite. Short chain fatty acids can also signal to the brain via GLP 1, which is this molecule that is now a pharmacotherapy, like, you know, included in drugs like Ozempic and Wigobi. So really fascinating. The short chain fatty acids can stimulate the production of these molecules that then tell the brain, I’m not hungry anymore. So they can act in various ways, directly on the liver. They can act on the brain. The thing is that we don’t know how big those effects are and we don’t know how they vary between people with and without type 1 diabetes. So those are major gaps that we need to fill before we can start to make clinical recommendations. And we also need to know how to specifically change the gut microbiome to produce the ideal amount and types of short chain fatty acids that could be beneficial for metabolism.

[11:59] Shireen: So what you’re saying is a lot of that research is still pending to be done to really understand and what it looks like within humans.

[12:06] Daria: Exactly. That’s right.

[12:07] Shireen: And, you know, you mentioned just a minute ago, dietary fiber. Could you explain how the metabolites produced by gut microbes are linked to blood sugar fluctuations and weight changes specifically for those people with type 1 diabetes, but then how does various diet really influence the makeup of what the gut microbiome really looks like?

[12:31] Daria: Yeah, so major changes in someone’s diet can impact the composition and the function of the gut microbiome. So if you were to go from consuming a very low fiber diet, which is actually what most people in the United States are consuming, to consuming a diet that is replete in fiber, providing, you know, those great substrates for our intestinal microbes. Those are their preferred substrates that we think help beneficial gut microbes flourish and proliferate. So fiber is really the number one thing that we can consume more of to, we think, grow beneficial gut microbes.  So the gut microbes, again, They can take that fiber, produce short chain fatty acids. I mentioned that short chain fatty acids can act on the liver. We think they stop liver production of glucose, but some studies, again, have suggested that they increase liver production of glucose. So that’s one way in which they could lead to blood glucose fluctuations. It could be variable from one person to another. We know every person has a very individualized gut microbiome. So it’s probably really dependent on, you know, the specific context of the given individual.  The other way that short chain fatty acids can influence blood glucose management is by impacting gut permeability. So in our colonic lining, The cells that make up that lining have proteins in between them called tight junctions, which prevent little pieces of microbial cell walls and other antigens from entering our bloodstream. But if those tight junctions get damaged because not enough short chain fatty acids are around to feed those intestinal cells, for example, some of those microbial antigens can start passing through those cells and that can actually trigger an inflammatory response.  And we know that inflammation can then cause insulin to work less optimally, which may lead to greater hyperglycemia or high blood glucose. But again, this is very much a theory that’s been described quite a lot in the literature, but not very well tested empirically yet. So we still have a lot of work left to do to confirm those hypotheses.

[14:55] Shireen: You know, you mentioned it a little while ago around the impact of lifestyle change, type 2 diabetes, and we hear that all the time. You’re saying a lot of it is also rooted in genetics, especially when we’re talking about type 2 diabetes. Are there any practical tips or lifestyle changes that you recommend for individuals with type 1 diabetes looking to achieve better blood sugar control?

[15:19] Daria: Yeah, absolutely. So, we have a fair amount of evidence to suggest that a variety of diet approaches can be effective and helpful for blood glucose management specifically in people with type 1 diabetes. Whether that be a low glycemic index diet, a lower carbohydrate diet, a Mediterranean diet that’s rich in fiber, and all of these types of diet patterns can and should be adapted to someone’s personal preferences, to their cultural preferences. So that’s really the beauty of the state of the evidence, in my opinion, is that there’s no one diet that fits all. We still have a lot of work left to do to personalize diets. In other words, to predict which diet might work better for one person or another based on their genes, based on the composition of their gut microbiome, again, based on their personal and cultural preferences. So. Again, we can really individualize these diets and I think the next step will be to generate empirical evidence of which diet is most likely to work best in which person.

[16:28] Shireen: And you know, you talked about a little while ago also about publishing the first dietary trial to focus explicitly on weight management for people with type 1 diabetes. Can you tell us a little bit more about that? What can one even expect from some of this research and where it is headed?

[16:44] Daria: Absolutely. So I mentioned that there’s A fair amount of literature looking at dietary approaches for managing blood sugar in type 1 diabetes. What there is much less of, in fact, almost none of, is literature supporting  which diets can help people with type 1 diabetes manage their weight. Effectively and safely and safety is a key concern because as I mentioned, when you are making dietary changes, you’ve got to make changes to your insulin dosing appropriately to prevent hypoglycemia while also, of course, trying to prevent spikes in blood sugar. So we and actually 1 other group published 2 papers on the topic of weight management and type 1 diabetes fairly close together in time. One was in 2018, one was in 2020, I think. And the first study that was published tested a Mediterranean diet against a low fat diet, I believe,  and again, found no differences overall in the ability of these two diets to produce weight loss in people with type 1 diabetes. What they did not do was they did not measure blood glucose objectively. They had people self report their blood sugar levels, which we know could have some level of bias. So I think what our study really added a couple of years later was to show objectively that a low fat diet, a low carbohydrate diet and a Mediterranean diet, and the Mediterranean diet, by the way, did not have calorie restriction while the low carb and the low fat did. Again, all three diet approaches produced similar weight loss across people, and we showed objectively that people’s blood sugar did not worsen in response to the weight loss, because sometimes you’ll see that happen actually, and that can be a concern. is that blood sugar management kind of goes haywire while people with type one are trying to manage their weight.So we really took the first step, which is to dispel that notion because there is evidence to suggest that clinical providers avoid the topic of weight management in people with type one diabetes and obesity. to a much greater extent than they would address the topic in people with type two diabetes and obesity. And I think a big part of the reason for that is because the evidence base just isn’t there and we need to generate the evidence to get it into clinical practice. So the only other thing I’ll say about that is that even though the three diets produced relatively equivalent weight loss in our study participants with type 1 diabetes. There was a lot of variability in response across those three diets. Some people lost a lot of weight. Some people lost a little bit of weight. Some people even gained weight. So again, we need to understand what those characteristics are that lead to success or less optimal success for some people versus others? Is it as simple as preference so that greater adherence facilitates greater weight loss or is it more complex? Do some people really have something metabolically different about them that makes a certain diet more optimal than another?

[19:53] Shireen: Fascinating question, and, you know, you mentioned dispelling notions, which takes me to my next question around what are some of those common misconceptions around this relationship between blood sugar management, weight management in type one diabetes, and then how are you working to really dispel some of these misconceptions?

[20:12] Daria: Yeah, that’s a great question. So, I think the first misconception that’s really important to address is that insulin in and of itself makes people with type 1 diabetes gain weight. That is an absolute misnomer. First of all, people with type 1, as we know, need to take insulin to survive. That false notion can lead some people to restrict or omit insulin for weight loss, which can be incredibly detrimental to their health.So that’s the first thing that we want people to understand. You’ve gotta take the insulin that you need to meet your mealtime needs.  So the thing about that that I think can be shifted slightly in people’s minds is that it’s not the insulin, it’s the insulin Um, in the context of consuming too many calories over a sustained period of time, which is actually not that much different than it would be for someone without type 1 diabetes. If I consumed more calories than I need to maintain my current weight over a sustained period of time, my insulin levels would increase endogenously because my pancreas is making more insulin, which would promote weight gain, right? Because insulin promotes fat storage. Same thing in a person with type 1 diabetes, except they’re administering their insulin exogenously via injection or pump. So that I think is the very first myth that’s so important to dispel.

[21:37] Shireen: Interesting. So it’s not the insulin, it’s what the insulin is doing. You just have to learn to manage, sort of that, insulin level. Absolutely. Okay. That’s helpful. In your research, are there specific dietary or nutritional strategies that you found to be particularly effective in helping people with type one diabetes manage their blood sugar levels?

[21:57] Daria: Yeah, that’s a great question. So one interesting thing to point out is that people with type one diabetes tend to eat a little bit lower carb on average than their counterparts without. Type 1 diabetes. And I’m talking about on a population level. That may not be true for all individuals, but on a population level, epidemiologic evidence suggests that people with Type 1 diabetes consume about 40 percent of their calories from carbohydrate. In someone without Type 1, that might be closer to 50 percent or so. And some of that might just be, you know, messaging that people receive around low carb, potentially making it a little bit easier for diabetes management. That might be true for some people. But it’s certainly not true for all. And again, this really gets back to the idea of individualization of diet, but also taking some of the general principles from the dietary guidelines for Americans that we know just work and make sense for blood glucose management, like getting enough dietary fiber. In your diet, which, you know, slows the digestion and absorption of food carbohydrate in particular minimizes blood glucose spikes and can also have health benefits for blood lipids and cardiovascular risk down the road. But really, for any person with type 1 diabetes, the most unique thing will be. Making sure that one’s insulin dosing is well suited for the way in which they’re eating. And that’s something that’s really important to work on with one’s healthcare provider.

[23:24] Shireen: That’s helpful. And we are toward the end of the episode, but I do want to try to sneak in one more question in here. What are some key takeaways or What advice that you would offer to individuals with type one diabetes who are listening to this episode here today or caregivers for someone who has type one diabetes, really to be able to strike a balance between again, managing their blood sugar effectively, maintaining that healthy weight. What advice would you provide to them?

[23:50] Daria: Yeah, absolutely. So I would just say don’t give up. I think there are a lot of challenges that people face and sometimes people can just feel, and we know this from qualitative work that we’ve done in focus groups with both adolescents and adults with type 1 diabetes, is that this futility people feel around Exercising and then having a low blood sugar and then having to consume more carbohydrate sort of these cyclical hypoglycemia related factors really challenging weight management, not only weight loss, but also sort of maintaining one’s weight, but I would really just say don’t give up and also do everything you can to educate yourself about all of the different diabetes related treatment options that are available because the new technologies are really doing a wonderful job at helping, again, to prevent hypoglycemia, prevent hyperglycemia in sort of predictive ways, you know, linking someone’s continuous glucose monitor to their insulin pumps, they’re talking to each other and sort of acting as a bionic pancreas in a sense, can really take a lot of the onus off the individual to sort of have to. Micromanage their diabetes, and so I think that’s one big takeaway is not to give up. And also just to mention that there are lots of different types of weight management therapies that are out there, including pharmacotherapies, which can be a compliment potentially to dietary therapies. So there are options out there. I would just encourage everyone to keep searching for what works for them. It’s okay to take a break sometimes and say, you know, I needed step back and take a breather and just focus on my blood glucose management because diabetes is a chronic disease that requires day to day management. But yeah, essentially not to give up and to reach out for help when needed.

[25:38] Shireen: Absolutely. And to stay on top of the research that some of the incredible research work that you are doing. So I really appreciate that. I do have one last to last, last promise. This is the last question. How can our listeners connect with you and just learn more about your work and stay connected?

[23:53] Daria: Yeah, absolutely. I can easily be found on LinkedIn. If you Google my name, you can also probably find an Instagram page, which I don’t monitor super frequently. So I would say LinkedIn is probably the best way to reach me. And I’m more than happy to speak with anyone about my work.

[26:08] Shireen: Lovely. Lovely. We appreciate your time, Dr. Igudesman. This has been a very valuable and insightful episode for us here at the Yumlish podcast. Thank you so much for joining us and to our listeners. Thank you for tuning into another episode of the Yumlish podcast. You know what time it is, head over to social media. And answer this quick question. How can you be more proactive in raising awareness among individuals with type one diabetes about the importance of healthful diet patterns? So again, head over to our social media again, go to Facebook at Yumlish or go to Instagram at Yumlish. Find us there. Find this podcast post comment below to tell us how can you be more proactive and just really raising awareness among individuals with type one diabetes about the importance of healthful diet patterns. We will continue the conversation there. And with that, Dr. Daria Igudesman, thank you very much again.

[26:57] Daria: Thank you very much for having me. It’s been a pleasure.

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