Shireen Abdullah  0:00  
From national committees to frontline care. Sarah Hormachea, a registered dietitian and Diabetes Care and Education Specialist, brings the latest on type 1 diabetes nutrition therapy. Hear how guidance has evolved, what it means for daily decisions, and where research is headed next. Stay tuned.

Shireen Abdullah  0:22  
Podcasting from Dallas, Texas. I am Shireen, and this is the Yumlish Podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Shireen Abdullah  0:54  
Sarah Hormachea is a Diabetes Care and Education Specialist who believes nutrition and therapy should honor both culture and science. Drawing on 10+ years in clinical and community settings, she helps make diabetes care more personal, inclusive, and effective. Welcome, Sarah.

Sarah Hormachea  1:16  
Thank you for having me.

Shireen Abdullah  1:17
An absolute pleasure having you on, so I’m really interested in diving into this topic around type 1 diabetes. We don’t do a lot of type 1. We don’t have a lot of type 1 conversations here on the podcast. I’m really excited to dive into it. Again, thank you for being here, and we’d love to start out by learning a little bit more about your background. Of course, you’re doing this amazing work in this space, but tell us a little bit more about what led you to focus on diabetes care and education. Where did it all begin?

Sarah Hormachea  1:43  
Yes, I started my career in the field of nutrition, specifically with the Indian Health Service here in Denver, Colorado. So I started working for an urban Indian health center that served the tribal communities living in the area. And Denver really is a central hub for a lot of the different tribes coming from this Northwest and the Four Corners area. There is such a need for cultural competent care that serves the cultural needs, including food, nutrition, health, and wellness of the community. And Denver is a really good place to sort of foster that cultural specific care. There is a high prevalence of diabetes, specifically type 2, though we’re seeing more of the onset and prevalence of type 1 in this community. And there are very specific needs, so to have and work in a program that caters to this community is very important.

Sarah Hormachea  2:50  
I found that after a while, I needed to develop my clinical competencies, and so ended up transitioning into a big teaching hospital in an endocrinology center, where I got to do more hands-on training and teaching with diabetes devices, insulin pumps, CGMS, and a lot of different medication therapy that isn’t quite used in that primary care setting. And then recently transitioned into contract consulting and private practice as an opportunity to serve in a variety of different environments. So I do some work now, still with the Indian Health Service, with the different medical device companies, and it’s been a pleasure to really work across the spectrum and scope of different care modalities for individuals with both type 1 and type 2 diabetes.

Shireen Abdullah  3:47 
Thank you for that background and that overview, which actually leads me into the next question, which is, what role does a Diabetes Care and Education Specialist really play in supporting someone who has specifically type 1 diabetes?

Sarah Hormachea  4:04  
Yeah, the answer is a pretty significant role. Diabetes Care and Education specialists were formerly known as diabetes educators, and in the last few years, the profession rebranded. Largely because Diabetes Care and Education specialists are doing so much more than just education. It’s care coordination. It’s higher levels of education on medical devices. It’s refilling or helping to coordinate refills on prescriptions. So a much broader scope in care. Diabetes Care and Education specialists come from a variety of different backgrounds. The leaders are generally nurses, dietitians, and pharmacists. Though we’re seeing a lot of public health professionals join the team, social workers join the team, specifically with type 1 diabetes.

Sarah Hormachea  4:55  
We’re helping folks navigate the realities of a new diagnosis, what that might mean for someone in the immediate and the long term. The experience of type 1 diabetes is just as varied and unique as someone with type 2 or any other type, and we’re seeing this especially play out in adult-onset type 1. We used to think that type 1 only presented in childhood. We called it juvenile onset. Now we’re realizing that over half of our individuals diagnosed with type 1 actually present after the age of 18, and their experience is quite different. So Diabetes Care and Education specialists are stepping in, helping folks understand and navigate those diagnoses, depending on where they are, and sort of their spectrum of life and the spectrum with their diagnosis.

Shireen Abdullah  5:47  
Very helpful. Now you were recently involved in updating a chapter on M&T Medical Nutrition Therapy for type 1 diabetes. What were some of the most significant updates or takeaways from that work?

Sarah Hormachea  6:03  
Yes, so nutrition is ever evolving in this discipline. It’s very personal, it’s very individualized, but it can have immense benefits if implemented and used in a very customized way. So, traditional nutrition therapy, limited carbohydrates. It was very prescriptive. It was very biased. It did not leave a lot of room for cultural eating traditions, and we have since evolved and taken a more nuanced and inclusive approach to the type of nutrition that can really benefit in a type 1 diagnosis. Some of the big takeaways or the big updates we’re seeing in more recent guidelines are a very customized approach. We don’t give specific carbohydrate recommendations anymore. We look at someone’s preference or cultural eating patterns.

Sarah Hormachea  7:03  
In my experience working at Indian Health Service, we have some tribal eating patterns that eat up to 70% carbohydrate. We have other tribal eating patterns that might eat 10% carbohydrate, right, depending on their ancestral lands and what types of foods they had access to, and they ate traditionally. So a much more inclusive look on carbohydrates. We’re also looking now at the very real, lived experience of type 1 in adulthood, and how they may be impacted by processed foods, by an environment that is conducive to overweight and obesity, and we’re finding that a lot of the same guidelines we would give in type 2 are actually appropriate in type 1 as well, because there are folks with that condition are exposed to many of the same risk factors.

Sarah Hormachea  7:57  
So we’re starting to see diabetes more on a continuum that individuals with type 1 may also have overweight and obesity, and maybe trying to eat in a way that’s mindful of that. We’re recognizing that individuals with type 2 may not be obese or even be overweight, right? That their reason for type 2 diabetes is rooted in something else, so much more customization, much more discussion and nuance, especially around cultural eating patterns and how those can be incorporated and implemented in a very sustainable way.

Shireen Abdullah  8:34  
That takes me then to the next question. You know, you mentioned like it being on this continuum. How do these updates then impact how dietitians, Diabetes Care and Education specialists like yourself really work with patients on a day-to-day basis? What would that look like differently then?

Sarah Hormachea  8:52  
Yes, we’re seeing a lot more guided discussion. We’re seeing more coaching, more counseling, and less of this prescriptive meal plan. Gone are the days where dietitians give you this handout from a tearpad that says, with specificity, the exact amount of carbohydrates you can have and the exact types of foods you can have, and how those fit in the exchange system. We’re looking much more holistically, synergistically, right? How different foods play in with one another and impact what you might experience or see in your glucose levels, right? If you’re someone and you’re tracking your blood sugars, we’re looking at other macronutrients. We now have an understanding of how things like fat and protein, alcohol and caffeine affect our glycemic experience.

Sarah Hormachea  9:44  
So much more customized. It should be a guided discussion and not a prescriptive set of instructions. And even more importantly, there should be a follow-up. There should be 2,3,4, sessions  that occur after that initial assessment to ask you: “How are things going? What’s working well?” We have amazing diabetes technology now to give us more real-time feedback, we don’t have to guess. We don’t have to lean into the old dogma of “eat something before you go to bed,” right? So you don’t have a low, when you can look specifically at your glucose monitoring device and say, “Oh, you are having a low.” Let’s talk about that, or “your blood sugars look great overnight. You don’t need to have a bedtime snack.” So we’re really challenging some of that old dogma in nutrition counseling around diabetes.

Shireen Abdullah  10:36  
How is that nutrition therapy integrated into care plans immediately, especially right after diagnosis?

Sarah Hormachea  10:43  
Yes, so depending on someone’s experience with the diagnosis. The hope is that there are some level of nutrition crash course 101. For folks that  present to the emergency department and have a very traumatic diagnosis, they’re probably going to receive some bedtime education. They may go home on a medication like insulin, at which point there needs to be some education on what is the purpose of insulin, right to match the foods that you eat, specifically the carbohydrates. So there will likely be some education on: what is a carb, which of your foods contain carbs, and how can you appropriately match your insulin to those carbs?

Sarah Hormachea  11:26  
For someone who might have a more slow onset of diagnosis, we might talk more specifically just about healthy eating patterns in adult-onset type 1; they may not need insulin right away, right? It’s a very common experience, or becoming more common, that there’s a bit more of this runway in the honeymoon period where the need for insulin is delayed, and so we can lean into more healthful eating strategies, and perhaps not necessarily jump right into carb counting 101, per se. So takeaway, being very highly individualized on the person, the diagnosis, the diagnostic experience, and then sort of what medications end up being used or prescribed to manage that new diagnosis.

Shireen Abdullah  12:18  
Keeping the conversation going around this initial diagnosis, like this first year of diagnosis, are there lifestyle or self-care strategies, approaches that you’ve seen work especially well in this period of time?

Sarah Hormachea  12:32  
Yeah, this is a really challenging time for folks.  What I see more often than not is that diagnoses come on very abruptly and suddenly, and at the least opportune time. And so one of the most important things that someone can do is acknowledge and accept and come to some sense of understanding of a new diagnosis. Denial and ignoring things and hoping that they’ll go away certainly is, while a common coping tool is not an effective coping tool. So you know, some level of acknowledgement and acceptance is important. Connecting with support, coaching, and guidance is key as well. There are many diabetes nonprofit groups that seek to connect folks with resources and tools.

Sarah Hormachea  13:28  
Connecting with a Diabetes Care and Education Specialist to get some coaching and some guidance is really helpful. Centering on your values and where you see health as part of your life is really important, too. Sometimes it takes these diagnoses for people to stop and reflect and recognize that health is wealth, right? And if you have, if you don’t have your health, what? What do you have? So, taking time to focus on those self-care behaviors. There are clear outlined health care behaviors we know have been very effective, and this is across any diagnosis of diabetes, whether it’s type 1, type 2, gestational, these are largely focused on healthful eating, movement monitoring medication, so on and so forth, but I would say really accepting and understanding a new diagnosis is key.

Shireen Abdullah  14:25  
The reason really being because I would assume so it’s like, a huge lifestyle change that you have to quickly adopt to, like, almost overnight and in doing so, there’s like, not only the physical like, managing that on a day to day basis, but there’s that emotional change in that, in the way that you’re thinking about managing it as well, like that in itself, is a huge lift as well.

Sarah Hormachea  14:46  
Yeah, it’s a huge lift. And often, the discussion around prognosis with type 1 is that we don’t have a cure. And it tends to be progressive. So it  is largely dependent on management and risk reduction. Now we have some phenomenal treatments coming down the pipeline and some great investigational research around stem cell therapy and transplant, but we’re still not really at a widespread implementation phase yet, where you know someone can feel that their type 1 is going to be cured or treated, and even words like remission are not something we use with type 1. Those are largely used in the type 2 community.

Shireen Abdullah  15:34  
What are some common, perhaps, misconceptions that you have seen patients have about nutrition and type 1 diabetes, and then also, how do you go about addressing such misconceptions?

Sarah Hormachea  15:47  
Yeah, I think one of the biggest misconceptions that I hear often is no carbs, no sugar, no fruit, no bread, no rice, no pasta. And I think that this is grounded in some truth. Right before the invention of insulin, about 100 years ago, we had no other treatment but to withhold carbohydrates. But that was 100 years ago, and treatment has come a long way. And so I would argue that bread, rice, pasta, starchy foods, Halloween, candy, right? There’s a place for all of it, so long as you have the tools and the confidence to navigate it using the other therapies and modalities that you have on hand.

Sarah Hormachea  16:35  
So, anyone who says no this and never that, I would question, I would really question that misconception, because I think there is space for many of the foods that we enjoy to work those in. I think there is a lot of misconceptions too around, like whether sugar worsens or causes diabetes, and could type 1 have been prevented? Could type 2 have been prevented? But I don’t know that we quite have a consensus, scientific consensus on that yet. But really, the no-carbs is the biggest one that I see for someone who’s newly diagnosed.

Shireen Abdullah  17:12  
This is a question I’m really excited about, and you know, you almost tapped into it just a second ago. But looking ahead, what emerging research, trends in M&T medical nutrition therapy do you think will shape the way type 1 diabetes care comes around in the next few years? Sort of help us understand what’s in our line of sight here?

Sarah Hormachea  17:36  
Yeah, I’m excited for some of the ideas and therapies, and strategic plans that we’ll see in the next few years. Again, historically, the nutrition, the eating patterns, or “diets”. And in nutrition therapy, for type 1, was very prescriptive; it left very little wiggle room for cultural eating patterns or joy foods. We then saw sort of this transition into strict carbohydrate-counting amounts, right? We’d say 45 to 60 grams per meal. We’re now seeing, starting to see new approaches to nutrition therapy that look at plant-based eating. We’re looking at ketogenic eating patterns. So ketogenic was a hard no for individuals with type 1 for the risk of diabetic ketoacidosis. Well, we’re starting to revisit some of that evidence and say perhaps not right. Perhaps there is some utility in doing very low-carbohydrate, high-fat eating patterns.

Sarah Hormachea  18:42  
We’re now looking at nutrition in a type 1 diabetes community for the cardiovascular benefit. We’re seeing the use of some of those incretin-based therapies, right? So, semaglutide, or tricepatide, more commonly known as Ozempic, Wegovy, so on and so forth, not indicated in type 1, but we are seeing anecdotal use and sort of off-label use for folks that are recognizing the benefit to them in their unique situation. So I would not be surprised if in the next few years, we start to see more medication therapy available that will impact and affect our nutrition therapy that we provide alongside it. So I think those are very promising. We’re looking more at gut health, probiotics, and prebiotics, right? What is the gut glucose connection?

Sarah Hormachea  19:42  
For folks with other co-existing autoantibodies or autoimmune disorders like Hashimoto’s or celiacs, we’re looking then at different nutrition strategies that might benefit autoimmune disorders. So we’ve had for a while the auto-immune protocol diet, where we kind of tease out some of those triggering foods that may exacerbate autoimmune-related conditions, but we’re starting to see more exploration down that pathway and see if there’s something we can recommend more widely. So lots of new research and studies are coming down the pipeline to kind of help shape and guide our nutrition therapy recommendations.

Shireen Abdullah  20:23  
How fascinating. I’m curious to see how all of this shapes up, especially in the space itself. We are toward the end of the episode, unfortunately, Sarah, at this point, but I’d love for our listeners to know and understand, like, how they can stay on top of some of this research that’s coming out. Do you talk about it? How can our listeners connect with you and stay in touch with your work?

Sarah Hormachea  20:44  
Yes, I love to connect with clients and patients and different community organizations that need more guidance and support in this area. There are many amazing nonprofits working to support research and education in the area. I mean, some of my go-tos are Breakthrough T1D, American Diabetes Association, the Association for Diabetes Care and Education specialists. So whether you’re an individual living with type 1, or you’re a practitioner working in the field, there really, is a lot out there, and it’s growing as far as ongoing support and education. But certainly for me at an individual level, I’m on many of the social media platforms to stay engaged, and I do try to get the word out where I can, as far as writing and publishing with the different organizations.

Shireen Abdullah  21:44  
Any particular social media channel here that you’d like to tag, so that we can go find you on there?

Sarah Hormachea  21:52 
Sure, I’m on Facebook and Instagram under my name: Sarah Hormachea.

Shireen Abdullah  21:58  
Perfect. Thanks so much for that, Sarah, and again, thank you so much for this conversation. Truly appreciate it. To our listeners: thank you for tuning in to another episode of the Yumlish podcast. We’re hoping you found this podcast interesting. This episode is interesting, and if you did, head over to our social media @Yumlish, either on Facebook or on Instagram, find this podcast post, and comment below for this question, which is: How has nutrition played a role in how you or a loved one manages or navigates their type 1 diabetes? Again, head over to @Yumlish on Facebook, on Instagram, find this podcast below, and comment to tell us: How has nutrition played a role in how you or a loved one manages or navigates their type 1 diabetes? We’ll continue the conversation there. Sarah, it was an absolute pleasure. Thank you so much for coming on.

Sarah Hormachea  22:48  
Thanks for having me.

Shireen Abdullah  22:50  
Thank you for listening to the Yumlish podcast. Make sure to follow us on social media, @Yumlish_ on Instagram and Twitter, and @Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions, and to chat and connect with us about your journey and perspective. You can also visit our website, Yumlish.com, for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week’s show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we’ll see you next time. Remember, your health always comes first. Stay well.

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Website URL: www.sarahhormachea.com 
Instagram URL: https://www.instagram.com/sarah.hormachea/ 
Facebook URL: https://www.facebook.com/sarahhormachea.diabetescare 
LinkedIn URL: https://www.linkedin.com/in/sarahhormachea/