Blog — Clinical Spanish

Explaining type 2 diabetes management in Spanish: the A1c number the patient has heard for three years without understanding what it measures, the insulin the patient is not taking correctly because the scale at home is in pounds, and the dietary conversation that works in a household where the food that is available is not the food in the handout

Carmen Villalobos is 61. She has had type 2 diabetes for nine years. She brings a folder to every quarterly visit. Inside the folder: the printout from every A1c blood draw she has had since the diagnosis. She has organized them chronologically, with the dates written in her own hand on the top corner of each page. Today’s reading is 9.1. Three months ago it was 8.4. Six months ago it was 7.8. Eighteen months ago it was 7.2, and the doctor said she was “doing well.” She has not been told anything different since. She has been told that 9.1 is “muy alta” and needs to come down below 7. She has been told this at four consecutive visits. She is not in denial. She is trying. She cannot explain why the number went up after she gave up bread for six weeks, or why it keeps going up when she is eating “better.” She does not know what A1c measures. She has never been told. Three failure modes that repeat in every diabetes management encounter where the nurse’s clinical information is not connecting to the patient’s actual life.

Failure mode 1: The A1c explanation that doesn’t explain what A1c measures

Carmen knows her number. She has had this number explained to her at every quarterly visit for nine years. The explanation she has received, in various forms, is: “Su A1c está en nueve punto uno — necesita estar por debajo de siete.” (Your A1c is 9.1 — it needs to be below seven.) This is true. It is not an explanation.

What Carmen understands from this explanation: “alta” is bad, “baja” is better, below 7 is the target, hers is not there. What Carmen does not understand: what A1c is measuring, why it went up when she ate well last month, why it didn’t go down after the six weeks she gave up bread, or what specifically she would need to do consistently over time to change it.

The nurse who inherits this patient at today’s visit asks the question that surfaces the gap: “¿Sabe usted qué mide el A1c exactamente — no que está alta o baja, sino qué es lo que está midiendo en su sangre?” (Do you know what A1c measures exactly — not that it’s high or low, but what it is measuring in your blood?)

Carmen: “El azúcar. Que está alta.” (The sugar. That it’s high.)

She is not wrong. She is also not able to use this information to change her daily behavior, because she does not understand the mechanism that connects her daily choices to this quarterly number.

The ninety-day average explanation. The metaphor that works in patient Spanish:

“Los glóbulos rojos — las células rojas de la sangre — llevan el azúcar pegada en su superficie durante los noventa días que viven. Cuando medimos el A1c, no estamos midiendo el azúcar de hoy ni la de ayer — estamos midiendo cuánto azúcar ha estado pegada en sus glóbulos rojos durante los últimos tres meses. Un número de nueve punto uno — como el suyo hoy — significa que el promedio de azúcar en su sangre durante estos tres meses estuvo muy alto, no solo en algunos días, sino en la mayoría de los días.”

(The red blood cells carry sugar stuck to their surface for the ninety days they live. When we measure A1c, we are not measuring today’s sugar or yesterday’s — we are measuring how much sugar has been stuck to your red blood cells over the last three months. A number of 9.1 — like yours today — means the average sugar in your blood over these three months was very high, not just on some days, but on most days.)

Two things this explanation does that “el A1c mide el azúcar” does not do: it explains why “eating well last week” does not change the number at today’s visit — because the three months before last week still count in the average; and it explains why a single bad day is not catastrophic — because the number reflects most days, not all days. Both of these are changes to the patient’s mental model that change what kind of effort feels worth making.

The notebbook analogy that makes the average concrete: “Imágínese que tiene un cuaderno donde anota el azúcar después de cada comida, cada día, durante tres meses. El A1c es como el promedio de ese cuaderno. Si en la mayoría de los días el azúcar después de comer fue alta — aunque no hubiera un solo día muy malo — el promedio sube. Si en la mayoría de los días el azúcar estuvo razonablemente controlada — aunque hubiera algún día difícil — el promedio baja.”

(Imagine that you have a notebook where you write down your blood sugar after each meal, every day, for three months. The A1c is like the average of that notebook. If on most days the blood sugar after eating was high — even if there was not a single very bad day — the average goes up. If on most days the sugar was reasonably controlled — even if there was a difficult day here and there — the average goes down.)

The trend question that opens the behavioral history: “Veo que su número ha subido — de 7.2 a 7.8 a 8.4 a 9.1 — en dieciocho meses. ¿Qué cambio en esos dieciocho meses en su vida?” (I see that your number has gone up — from 7.2 to 7.8 to 8.4 to 9.1 — in eighteen months. What changed in your life during those eighteen months?)

Carmen is quiet for a moment. Then: her son and daughter-in-law moved in two years ago with her three grandchildren. The daughter-in-law is a good cook. She makes rice the way her mother makes it — a stickier variety, cooked in chicken broth with more oil than Carmen used to use. The grandchildren drink Jarritos and there are always twelve-packs in the refrigerator. Carmen started drinking one with dinner because it was there. She had not connected either of these to her A1c. She has been focused on not eating bread.

The trend question, asked correctly, surfaces these changes in under three minutes. A clinical history that asks only “what are you eating” would have produced a food log of what Carmen thinks of as her diet — the planned meals, the things she controls — not the ambient changes that came in with her son’s family.

The teach-back question that establishes understanding, and cannot be answered with “sí”: “¿Cómo le explicaría a su esposo esta noche qué mide el A1c — si él le preguntara?” (How would you explain to your husband tonight what A1c measures — if he asked you?)

A patient who can describe the three-month average in her own words has understood it in a way that will inform daily decisions. A patient who says “sí, ya entendí” after the nurse finishes the explanation may have understood only that the nurse’s turn is done. The distinction matters, because the patient who does not understand the 90-day average will continue making episodic heroic corrections — giving up bread for six weeks, stopping the tortillas for a month — and wondering why the number doesn’t move. The patient who understands it will make smaller, sustained changes and expect results at the next quarterly visit rather than the next day.

For the broader vocabulary of lab result explanation with Spanish-speaking patients, see the explaining lab results in Spanish reference page. The how to explain a new diagnosis in Spanish post covers the polite-yes trap and the teach-back method for any diagnosis, including the three-question teach-back that no patient can answer with “sí.” A1c education is a variant of that same problem: the patient who says “ya entendí” has not necessarily understood anything. The test is always whether they can explain it back.

Failure mode 2: The insulin that’s not being taken correctly because the scale at home is in pounds

Carmen is on metformin 1000 milligrams twice daily, which she takes consistently. She is also on two insulins: glargine (Lantus) 22 units at bedtime as a basal dose, and lispro (Humalog) on a carbohydrate ratio of one unit per fifteen grams of carbohydrate at each meal, plus a correction sliding scale for pre-meal glucose readings above 150. She has been on this regimen for fourteen months. Her A1c has gone from 7.8 to 9.1 in that period.

The nurse who asks today’s first diagnostic question — “¿Cuántos tipos de insulina tiene usted en casa?” (How many types of insulin do you have at home?) — gets an answer that reframes the entire chart note.

Carmen: “Dos. El plúmón gris y el azul. Me pongo el azul con la comida y el gris… a veces.” (Two. The gray pen and the blue one. I take the blue one with meals and the gray one… sometimes.)

“¿Para qué es el gris?” (What is the gray one for?)

Carmen: “Para cuando el azúcar está alta. O para la noche. No estoy segura — la enfermera me dijo que era para las noches pero me lo pongo cuando siento que el azúcar subió.” (For when the blood sugar is high. Or for the night. I’m not sure — the nurse told me it was for the nights but I take it when I feel like my sugar went up.)

She has been using the basal insulin as a sliding-scale rescue dose rather than as a continuous background dose. This is not a compliance failure. It is a teaching failure: she was not taught the functional difference between the two insulins in language that distinguished them by mechanism rather than by administration time.

The two-insulin explanation that does not use the words “basal” or “bolus.”

“Las dos insulinas hacen cosas diferentes — y necesitan las dos para que el tratamiento funcione. La del plúmón gris se llama insulina de fondo. No tiene que sentir el azúcar alta para tomarla — trabaja veinticuatro horas seguidas, despacio, para que el azúcar en su sangre no suba mientras duerme o está sentada sin comer. El cuerpo siempre produce algo de azúcar — incluso de noche, cuando no está comiendo — y la insulina de fondo es la que maneja ese azúcar constante. Si la olvida, aunque no coma nada, el azúcar sube solo. La del plúmón azul se llama insulina de comida. Solo trabaja por tres o cuatro horas, y su único trabajo es manejar el azúcar que llega cuando come. Si la toma sin comer, el azúcar puede bajar peligrosamente. Si come sin tomarla, el azúcar del desayuno, del almuerzo, y de la cena se queda en la sangre sin que nadie la maneje.”

(The two insulins do different things — and you need both for the treatment to work. The gray pen is called background insulin. You don’t need to feel your sugar is high to take it — it works twenty-four hours continuously, slowly, so that your blood sugar doesn’t rise while you sleep or sit without eating. The body always produces some sugar — even at night, when you are not eating — and the background insulin is what manages that constant sugar. If you skip it, even if you eat nothing, the sugar rises on its own. The blue pen is called meal insulin. It only works for three or four hours, and its only job is to manage the sugar that arrives when you eat. If you take it without eating, the sugar can drop dangerously. If you eat without taking it, the sugar from breakfast, from lunch, and from dinner stays in the blood with nothing managing it.)

The water pump analogy that makes the basal function concrete: “La insulina de fondo es como la bomba de agua de una casa — tiene que estar funcionando todo el tiempo, aunque nadie esté usando el agua. Si la apaga cuando nadie abre la llave, cuando alguien llega y abre la llave, no hay presión. La bomba no sabe si hay alguien en la casa o no — solo sabe que tiene que estar funcionando.”

(Background insulin is like the water pump in a house — it has to be running all the time, even when nobody is using the water. If you turn it off when nobody is using the water, when someone comes and opens the tap, there is no pressure. The pump doesn’t know if someone is in the house or not — it just knows it has to be running.)

The dosing question that uncovers the pounds-vs.-grams problem: “¿Cómo decide cuántas unidades se pone del plúmón azul antes de comer?” (How do you decide how many units to take from the blue pen before eating?)

Carmen: “Según lo que voy a comer — si es mucho, más; si es poco, menos. A veces peso la comida.” (According to what I am going to eat — if it’s a lot, more; if it’s a little, less. Sometimes I weigh the food.)

“¿La receta dice una unidad por cada quince gramos de carbohidratos — cuando pesa la comida, en qué medida sale su báscula, en gramos o en libras?” (The prescription says one unit per fifteen grams of carbohydrates — when you weigh the food, does your scale read in grams or in pounds?)

Carmen: “En libras, creo. Hay números pequeños.” (In pounds, I think. There are small numbers.)

This is the problem. One pound is approximately 454 grams. A cup of cooked rice that weighs 0.4 pounds on a household scale — which Carmen may read as “point four” or may mentally interpret as a small number — is approximately 180 grams of cooked rice, which contains roughly 40 grams of carbohydrate. At a 1:15 ratio, that is a little under 3 units of insulin. But the calculation Carmen is performing, if she is using the display number directly, is producing a number that bears no relationship to her actual carbohydrate load.

The practical fix is not to teach the conversion. It is to build a reference card in household measures that bypasses the scale entirely:

“En vez de pesar la comida y convertir, vamos a hacer algo más fácil — voy a escribirle cuántas unidades le corresponden a los platos que usted prepara. Una taza de arroz cocinado: tres unidades. Una tortilla de harina grande: dos unidades. Una tortilla de maíz chica: una unidad. Una taza de frijoles: dos unidades. Si come un plato normal — arroz, frijoles, y una tortilla grande de harina — eso son generalmente siete unidades antes de contar la corrección.”

(Instead of weighing the food and converting, let’s do something simpler — I am going to write you how many units correspond to the dishes you make. One cup of cooked rice: three units. One large flour tortilla: two units. One small corn tortilla: one unit. One cup of beans: two units. If you eat a normal plate — rice, beans, and one large flour tortilla — that is generally seven units before counting the correction.)

Most patients who are trying to use a carbohydrate ratio are better served by a four-line reference card in their actual foods than by mastering the arithmetic of a gram-based calculation on a scale that reads the wrong unit.

The insulin storage problem. The fifth diagnostic question: “¿Dónde guarda la insulina del plúmón azul después de abrirlo?” (Where do you store the blue pen after opening it?)

Carmen: “En el refrigerador. Cada mañana la saco para desayunar y después la regreso.” (In the refrigerator. Every morning I take it out for breakfast and then I put it back.)

The storage explanation: “La insulina que ya abrió puede quedarse fuera del refrigerador — a temperatura normal del cuarto, lejos del sol — por hasta treinta días. Sacarla y regresarla todos los días — el cambio de temperatura constante — puede hacer que la insulina pierda fuerza antes de esos treinta días. Los frascos o plumones que no ha abierto todavía, esos sí en el refrigerador. Pero el que ya está abierto, déjelo fuera en un lugar fresco, no en el sol.”

(The insulin you already opened can stay out of the refrigerator — at normal room temperature, away from the sun — for up to thirty days. Taking it out and putting it back every day — the constant temperature change — can cause the insulin to lose strength before those thirty days are up. Pens and vials you haven’t opened yet — those go in the refrigerator. But the one already opened — leave it out in a cool place, not in the sun.)

Carmen’s insulin management has three simultaneous problems: a basal that she is taking as a rescue dose, a bolus carbohydrate ratio she cannot calculate in the unit system her scale uses, and a storage pattern that degrades the medication’s effectiveness. None of these are visible in the chart note that says “patient on glargine 22u QHS and lispro per carb ratio, teaching provided.” All three are visible in a five-question diagnostic conversation that takes less time than re-explaining the regimen without knowing what the patient actually understands.

For the broader vocabulary of medication history, brown-bag review, and the polypharmacy conversation with Spanish-speaking patients, see the medication reconciliation in Spanish post. For the acute context — the hypoglycemic patient who says “me siento que me voy” and the DKA patient whose insulin history reveals access failure rather than noncompliance — see the diabetic emergency in Spanish post.

Failure mode 3: The dietary conversation that works when the nurse cannot change what the family cooks

The standard ADA-aligned handout Carmen received at her last visit: reduce rice portions to half a cup, substitute brown rice for white, limit tortillas to one per meal, avoid white bread, limit beans to half a cup per serving, eliminate sugary drinks, fill half the plate with non-starchy vegetables.

The nurse who reads Carmen’s A1c trend and prescribes the handout is not wrong about the nutrition science. She is wrong about the implementation context. Carmen is not the primary cook. Her daughter-in-law cooks for a household of seven. Brown rice is not sold at the discount grocery where the family shops. Limiting to one tortilla means eating less than the rest of the family — which her husband and daughter-in-law will notice, comment on, and eventually push back against. Filling half the plate with non-starchy vegetables requires buying vegetables that are not in the regular grocery run. “Avoid sugary drinks” is advice directed at someone who chooses what to buy; Carmen lives in a house where the Jarritos are in the refrigerator because her grandchildren live in the house.

The question that replaces the handout:

“No le voy a dar una lista de lo que debe comer y lo que no debe comer. Lo que voy a hacer es preguntarle qué comió ayer — empezando por el desayuno — porque eso me dice lo que realmente es posible cambiar en su casa. Y de ahí encontramos uno o dos cambios pequeños que no van a cambiar lo que come su familia, solo el efecto que la comida tiene en su azúcar.”

(I am not going to give you a list of what you should eat and what you should not eat. What I am going to do is ask you what you ate yesterday — starting with breakfast — because that tells me what is actually possible to change in your house. And from there we find one or two small changes that will not change what your family eats, only the effect the food has on your blood sugar.)

The word “yesterday” is not interchangeable with “what are you eating.” “What are you eating” produces the patient’s mental model of her diet — the planned meals, the controlled days, the things she is proud of. “What did you eat yesterday” produces the actual diet: the Jumex with breakfast, the agua de tamarindo with lunch, the Jarrito her granddaughter left on the table. Starting with breakfast forces the chronological order: the patient cannot curate the narrative when she is being asked to reconstruct a specific day in sequence.

What Carmen ate yesterday:

Desayuno. Two eggs scrambled with tomato and chile, two large flour tortillas, black coffee with one spoonful of sugar, and a six-ounce can of Jumex mango nectar that her granddaughter had left open on the counter. Carmen drank it because she did not want to waste it. The Jumex contained approximately 28 grams of sugar.

Almuerzo. A plate of arroz rojo made by her daughter-in-law (approximately one cup cooked, in chicken broth with added oil), a serving of frijoles de la olla, a piece of boiled chicken, two corn tortillas, and a twelve-ounce glass of agua de tamarindo made with piloncillo. Approximately 35 grams of sugar in the tamarindo.

Cena. Caldo de pollo with potatoes, chayote, and carrots, one large flour tortilla, and a grapefruit Jarrito left in the refrigerator from the twelve-pack. Approximately 27 grams of sugar in the Jarrito.

Total sugar from drinks: approximately 90 grams. At a one-to-fifteen carbohydrate ratio, that is six units of insulin required just for the drinks — drinks that produced no satiety, no nutritional benefit beyond hydration, and which Carmen did not think to mention when she was asked about her diet, because she does not think of drinks as food.

The drink intervention.

“De las cosas que comió ayer, los jugos y el refresco y el agua de tamarindo son los que más suben el azúcar sin llenarlo. Un Jarrito de toronja sube el azúcar casi tanto como un plato de arroz — pero el arroz la llena y el Jarrito no. El Jumex del desayuno, el agua de tamarindo del almuerzo, y el Jarrito de la cena le dieron ayer casi noventa gramos de azúcar que el cuerpo tuvo que manejar, sin que usted se llenara con ninguno de ellos. Si cambiamos solo eso — agua simple, agua con limón, o agua de jamaica sin o con muy poca azúcar — y no cambia nada más de lo que come, el promedio de azúcar que mide el A1c puede bajar un punto o más.”

(Of the things you ate yesterday, the juices and the soda and the tamarindo water are the ones that raise blood sugar the most without filling you up. A grapefruit Jarrito raises blood sugar almost as much as a plate of rice — but the rice fills you up and the Jarrito does not. The Jumex at breakfast, the tamarindo water at lunch, and the Jarrito at dinner gave you yesterday almost ninety grams of sugar that your body had to manage, without filling you up on any of them. If we change only that — plain water, water with lime, or agua de jamaica with little or no sugar — and you change nothing else about what you eat, the sugar average that the A1c measures can go down one point or more.)

The agua de jamaica substitution: hibiscus flowers steeped in water with little or no added sugar is culturally familiar, inexpensive, available at any Latin American market, and contains essentially zero sugar when prepared without sweetener. It can be made in a large pot and kept in the refrigerator alongside the Jarritos. The household switch — replacing the family’s sodas with a pitcher of agua de jamaica — does not require Carmen to eat differently from the rest of the household at the table, does not single her out as the sick person who cannot have what everyone else is having, and often extends the benefit to other household members.

“¿Hacen jamaica en su casa?” (Do you make hibiscus water at home?)

Carmen: “Antes sí, pero la nuera no la hace.” (We used to, but my daughter-in-law doesn’t make it.)

“¿La haría usted? Con muy poca o ninguna azúcar — la flor de jamaica en agua, hervida y enfriada — es su bebida, no cambia lo que comen, y la puede tener en el refrigerador al lado del refresco para cuando tenga sed.” (Would you make it? With very little or no sugar — hibiscus flowers in water, boiled and cooled — it’s your drink, it doesn’t change what they eat, and you can have it in the refrigerator alongside the soda for when you are thirsty.)

The tortilla conversation. Not “limit to one tortilla” but a question that makes the choice concrete: “Cuando come tortillas, ¿son de maíz, las chicas, o de harina, las grandes?” (When you eat tortillas, are they corn, the small ones, or flour, the large ones?)

Carmen: “Las dos. Depende. El desayuno generalmente harina, el almuerzo las de maíz.”

“La tortilla de harina grande — la que viene en el paquete grande — tiene unos treinta gramos de carbohidratos. Una sola tortilla de harina tiene casi lo mismo que todo un plato de arroz. La tortilla de maíz chica tiene quince gramos — la mitad. No le estoy pidiendo que deje las tortillas — le estoy pidiendo que en el desayuno, donde tiene más control porque hace usted los huevos, use las de maíz en vez de las de harina. Eso solo en el desayuno ya reduce sesenta gramos de carbohidratos a la semana.”

(The large flour tortilla — the kind that comes in the big package — has about thirty grams of carbohydrates. One flour tortilla has almost the same as an entire plate of rice. The small corn tortilla has fifteen grams — half. I am not asking you to give up tortillas — I am asking you to use corn ones instead of flour ones at breakfast, where you have more control because you make the eggs yourself. That one change at breakfast alone reduces sixty grams of carbohydrates per week.)

The rice portion conversation. Not “reduce rice to half a cup” but: “¿Si en el mismo plato que hace su nuera, usted se sirve menos arroz — como la mitad de lo que normalmente se sirve — y más frijoles, su plato se vería diferente del plato de los demás?” (If in the same dish your daughter-in-law makes, you serve yourself less rice — about half of what you normally take — and more beans, would your plate look different from everyone else’s?)

Carmen: “Pues no mucho — si agrego más frijoles parece igual.” (Not much — if I add more beans it looks the same.)

“Los frijoles tienen carbohidratos también, pero tienen más fibra, y eso hace que el azúcar suba más despacio. Servirse más frijoles y menos arroz — sin cambiar lo que hace su nuera — es un cambio que nadie en su mesa tiene que saber que está haciendo.”

(Beans have carbohydrates too, but they have more fiber, and that makes the sugar rise more slowly. Serving yourself more beans and less rice — without changing what your daughter-in-law cooks — is a change that nobody at your table has to know you are making.)

The three changes Carmen is leaving with today: replace the three sweetened drinks with agua de jamaica she makes herself; use corn tortillas at breakfast instead of flour; serve herself half the rice she normally would and fill the plate with more beans. None of these changes what her daughter-in-law cooks. None of them require a trip to a different grocery store. None of them single her out at the family table. Together, they address roughly 120 grams of carbohydrate per day — which, sustained over three months, is enough to move the A1c.

For the nutrition assessment vocabulary — the systematic food history conversation for patients with multiple dietary restrictions — see the nutrition assessment in Spanish reference page. For discharge teaching that has to survive the parking lot — the teach-back structure that closes the comprehension gap before the patient walks out — see the discharge instructions in Spanish post.

Quick reference: the ten phrases that change the encounter

A1c explanation — the ninety-day average

“Los glóbulos rojos llevan el azúcar pegada durante noventa días — el A1c mide el promedio de esos noventa días, no el azúcar de hoy. Por eso no cambia el número comer bien la última semana: las semanas anteriores todavía cuentan.” (Red blood cells carry sugar stuck to them for ninety days — A1c measures the average of those ninety days, not today’s sugar. That is why eating well last week doesn’t change the number: the prior weeks still count.)

Teach-back: “¿Cómo le explicaría a su esposo qué mide el A1c si él le preguntara?” (How would you explain to your husband what A1c measures if he asked you?)

Trend question — opening the behavioral history

“Su A1c ha subido en los últimos dieciocho meses. ¿Qué cambió en esos dieciocho meses en su vida?” (Your A1c has gone up in the last eighteen months. What changed in your life during those eighteen months?)

Two-insulin distinction — basal vs. bolus without the jargon

“La del plúmón gris es insulina de fondo — trabaja veinticuatro horas aunque no coma nada, porque el cuerpo produce azúcar solo. La del plúmón azul es insulina de comida — solo trabaja cuando hay azúcar de comida que manejar.” (The gray pen is background insulin — it works twenty-four hours even if you eat nothing, because the body produces sugar on its own. The blue pen is meal insulin — it only works when there is food sugar to manage.)

Carb ratio — household measures reference card

“Una taza de arroz cocinado: tres unidades. Una tortilla de harina grande: dos unidades. Una tortilla de maíz chica: una unidad. Una taza de frijoles: dos unidades.” (One cup of cooked rice: three units. One large flour tortilla: two units. One small corn tortilla: one unit. One cup of beans: two units.)

Insulin storage — opened vial

“El plumón que ya abrió puede quedarse fuera del refrigerador hasta treinta días — sacarlo y regresarlo todos los días puede hacerlo perder fuerza. Los que no ha abierto, esos sí en el refrigerador.” (The pen you already opened can stay out of the refrigerator for up to thirty days — taking it out and putting it back every day can cause it to lose strength. The ones you haven’t opened yet — those go in the refrigerator.)

Diet history — the actual food question

“¿Qué comió ayer usted — empezando por el desayuno?” (What did you eat yesterday — starting with breakfast?) Then, at each meal: “¿Y qué tomó con eso?” (And what did you drink with that?)

Drink intervention — the most actionable change

“El jugo, el refresco, y el agua con azúcar suben el azúcar casi tanto como una comida — pero sin llenarlo. Si cambia solo las bebidas por agua de jamaica sin azúcar, el A1c puede bajar un punto sin cambiar nada de lo que come su familia.” (Juice, soda, and sweetened water raise blood sugar almost as much as a meal — but without filling you up. If you only change the drinks to unsweetened hibiscus water, the A1c can go down one point without changing anything your family eats.)

Tortilla type — the substitution that doesn’t disrupt the table

“¿Las tortillas que usa son de maíz o de harina? La de harina grande tiene el doble de carbohidratos que la de maíz chica — mismo plato, la mitad del efecto en el azúcar.” (Are the tortillas you use corn or flour? The large flour tortilla has double the carbohydrates of the small corn tortilla — same plate, half the effect on blood sugar.)

Rice and beans — the invisible substitution

“Si se sirve menos arroz y más frijoles en el mismo plato, ¿el plato se vería diferente del de los demás? Si no se nota, nadie en su mesa tiene que saber que está haciendo un cambio.” (If you serve yourself less rice and more beans on the same plate, would the plate look different from everyone else’s? If it doesn’t show, nobody at your table has to know you are making a change.)

Closing the visit — the specific commitment

“Antes de verla en tres meses, me comprometo con tres cambios, no con diez: las bebidas por jamaica, tortilla de maíz en el desayuno, y menos arroz con más frijoles. Solo esos tres. ¿Cuál le parece el más fácil de empezar mañana?” (Before I see you in three months, commit to three changes, not ten: drinks replaced with jamaica, corn tortilla at breakfast, and less rice with more beans. Only those three. Which one seems easiest to start tomorrow?)