August 2022 Drop-In Q&A with MCT2D Health Educator and Dietitian, Rina

Find the most recent Drop-In Q&A session with MCT2D Dietitian and Health Educator, Rina Hisamatsu, recorded August 12. Rina presented alongside program co-director and lead pharmacist Heidi Diez.
Q&A from the Session

Are there any online sources of information on diet for diabetes you would refer patients to?
3. CDC’s Living with Diabetes homepage https://www.cdc.gov/diabetes/managing/eat-well.html (English and Spanish handouts available)
For those interested in low-carb resources:

Tips on discussing obesity in children/teens?
There is no one right way to discussing overweight and obesity with children/adolescents. For children in particular, it may be beneficial to approach weight from a family-based approach to weight management, because health promoting behaviors such as diet and exercise are often influenced by family life. It is important to keep in mind that the language we use can greatly impact their response and determine their level of engagement. We encourage language that is non-stigmatizing and non-judgmental as that can further affect individuals who may already be receiving negative messages through their family, friends, social media outlets etc.
We encourage using tools that do not put the blame on the individual, nor shame them into thinking it is due to a lack of will power, but rather focus on tangible strategies to instill healthy behaviors in the pediatric population.
Conversations with individuals of this population may include topics such as the impact of reducing intake of highly processed and addictive foods including sugar-sweetened beverages, chips, cakes, cookies etc.; focusing on tangible ways to increase intake of vegetables, fruit, protein, healthy fats, complex carbohydrates; benefits of movement and activity for a healthy body and mind; how to get kids and teens involved in the cooking process; and learning about where food comes from.
The American Psychological Association Discussing Weight (apa.org) has additional resources for healthcare professionals around the discussion of overweight obesity within the pediatric population.

The Low Carb on a Budget Handout - if a patient is not on KETO, but is doing low carb 50-100g per day, should they still do higher fat?
Short answer is yes. Although the level of fat intake is not as high on a low-carb meal plan compared to a very-low carb (keto) meal plan, you may likely need to increase fat intake to some extent if you are lowering your carbohydrate intake to 50-100g/day.
In general, we encourage individuals to follow the 3 step or 4 step process to making a balanced meal. It starts with 1) prioritizing adequate protein intake from quality sources like fish, seafood, meat, poultry, tofu etc.; 2) abundance of non-starchy vegetables; and 3) include some fats to add flavor and satiety to a meal. The 4th step of adding some complex carbohydrates depends on the individual’s carbohydrate goals and their level of carbohydrate restriction.
We recommend choosing fats/oils from whole food sources (avocados, nuts/seeds, olive/olive oil, oils, butter, dairy, fatty cuts of fish and meat etc.) and to start with 1-2 sources per meal. It should be noted that fats/oils are used for flavor and satiety and should be modified depending on the individual’s hunger cues throughout the day.

Since we’re new to MCT2D, interested in joining. We do not have a dietician at Answer Health.
Welcome and thank you for joining us in this initiative! Please let us know how we can best support you going forward, particularly in relation to providing nutrition education for your site. As a start, we have many provider and patient facing resources available through the MCT2D resource library linked here.

How to bill for time spent training patient on diet if you are not a dietician
We are not aware of any specific codes for nutrition counseling outside of what is used at Michigan Medicine. Within the Ambulatory Care Unit of Michigan Medicine, nutrition visits are billed under Care Management codes (Provider Delivered Care Management “PDCM codes” or “G-codes”). It is a Blue Cross Blue Shield of Michigan (BCBSM) Program and these codes are recognized throughout the state of Michigan for care managers including RDNs, pharmacists, social workers, and Care Navigators (RNs).

For people interested in weight loss recommendations for patients with diabetes. What can they do? High protein,  intermittent fasting,  etc.
Low or very low carbohydrate meal plans can be an effective strategy for weight loss and improving metabolic outcomes (1). What we suggest is to start a conversation with 1-2 patients who you have identified as potential candidates interested in this approach. Review what the meal plan entails, collect diet history and baseline carbohydrate intake, and other pertinent information regarding medical history/medications. Depending on your patient’s experience and level of comfort, you may decide to set an initial carbohydrate goal with them (for example <130g/day) and commit to 2-3 weeks before follow-up. For each meal, prioritize protein intake, non-starchy vegetables, some fats, and +/- complex carbohydrates.
Intermittent fasting has certainly become a growing trend in the recent years. One non-randomized study (2) showed improvements in weight loss, blood sugars, and lipids using time-restricted eating with no change in their baseline diet. Another systematic review concluded that intermittent fasting energy restriction can be an effective strategy for treatment of overweight and obesity (3). However, there is currently insufficient evidence to support a certain eating pattern over another for intermittent fasting. Intermittent fasting, particularly time-restricted eating, will naturally limit the hours an individual eats, and therefore it can reduce their overall eating window and caloric intake. It is important to note that individuals who are interested to pursue this strategy be mindful to maintain adequate hydration and consume meals that are nutrient-dense with adequate protein to manage satiety.

How many servings of grains/day should patients aim for if trying to lose weight? Regular vs diet pop? Artificial sweetener vs sugar?
The number of servings of grains/day largely depends on the level of carbohydrate restriction an individual is pursuing. A low carbohydrate meal plan is defined as limiting carbohydrate intake to 50-130g/day. Individuals will need to be familiarized with foods that contain carbohydrates and the amount they contain. Carbohydrates from complex sources are encouraged which include whole grains (quinoa, barley, farro, brown rice, oats etc.), lentils and legumes, starchy vegetables (squash, beets, sweet potato), and fruit. Based on their carbohydrate goal, an individual can add in some carbohydrates (for example ½ cup of beans) to their meal or snack and keep track to stay within their carbohydrate goals. Grains and other complex carbohydrates are to be avoided for the most part on a very-low carbohydrate (keto) meal plan (<50g carbs/day).
In regard to fluid hydration, we recommend water as the main choice of beverage. We do not recommend regular pop or other sugar sweetened beverages due to their carbohydrate content. Diet pop and other foods that are sweetened using nonnutritive sweeteners can be used in moderation, especially in cases where an individual is looking for alternatives to regular pop and/or working on strategies to wean off sugar sweetened beverages. It should be noted that a heavy use of artificial sweeteners may trigger cravings for some individuals and therefore should be enjoyed in moderation.

Do you count net carbs diabetic carbs or total carbs?
We typically use total carbohydrates when counseling low carb and very-low carb meal plans. Please see below for reference ranges:
50-130g total carbohydrates/day for low-carbohydrate meal plan
<50g total carbohydrates/day for very-low carbohydrate meal plan (keto)

I have a question r/t the "Low Carb on a Budget" information provided thru MCT2D. I often refer the patient to the Green, yellow and red food lists. If a patient is not doing keto then should they still do the full fat options like butter?
Yes, patients who are not on keto (<50g carbs/day) but are pursuing a low-carb meal plan (50-130g carbs/day) can include some fats from full-fat options like butter and oils, nuts and seeds, olive/olive oil, avocado/avocado oil, cheeses, and fatty cuts of fish and meat/poultry. We recommend following the “4 step process” to creating a balanced meal which includes 1) prioritizing protein intake (20-30g/meal); 2) abundance of non-starchy vegetables; 3) add in 1-2 types of fats for flavor and satiety (typically that could look like fat already in your protein source, fats to cook your vegetables in, or 1oz nuts/cheese, dressing/sauce); and 4) add in some complex carbohydrates such as lentils/legumes, whole grains, some fruit etc.

How much protein do you recommend and do you calculate based on total weight or lean weight any change in protein recommendations for patients with CKD?
Although there have been attempts to find the optimal range of macronutrient intake for low-carbohydrate meal plans, there is still no ideal range that applies broadly to all and therefore protein recommendations should be individualized. With this in mind, it should be noted that a low/very-low carbohydrate meal plan is not a high protein diet. On average, people consume 15-20% of their daily calories from protein (4), which usually amounts to 1-1.5g per kg body weight. Although this is higher than the RDA of 0.8g/kg body weight, it is still lower than the threshold for a “high protein” diet of greater than 2.0g/kg body weight.
For individuals with overweight/obesity, the clinical guidance suggests using Ideal Body Weight (IBW) and Adjusted Body Weight (AdjBW) to estimate protein needs using the equation of 1.0-1.5g/kg AdjBW. Please see the link for further information CHAPTER 2. Clinical Nutrition Guideline for Overweight and Obese Adults With Type 2 Diabetes (T2D) or Prediabetes, or Those at High Risk for Developing T2D (ajmc.com).
Figuring out protein needs is very much an iterative process. We suggest starting out with 20-25g protein/meal, assuming 3 meals per day +/- snack(s), and adjusting from there based on the individual’s hunger and satiety cues.
A well-formulated low-carb/very-low carb meal plan can be safe for individuals with normal kidney function or early-stage kidney disease. However, individuals with advanced kidney disease should not pursue this meal plan without prior consultation with a nephrologist and their care team before making any changes to one’s dietary plan. Please see this link for further information What You Need to Know About a Low-Carb Diet and Your Kidneys (dietdoctor.com)

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Blue Cross Blue Shield Blue Care Network of Michigan

Support for the Michigan Collaborative on Type 2 Diabetes is provided by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program. BCBSM’s Value Partnerships program provides clinical and executive support for all CQI programs. To learn more about Value Partnerships, visit www.valuepartnerships.com. Although Blue Cross Blue Shield of Michigan and the Michigan Collaborative on Type 2 Diabetes work in partnership, the opinions, beliefs, and viewpoints expressed by MCT2D do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.