Transcript: Nutritional Counseling for Diabetes Patients - What You Need to Know

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‚ÄčLiz Rohr:
My understanding is it's really most appropriate for patients who have type 1 diabetes, but what are like... Tell me if I'm wrong there or what your general thoughts are from that dietician perspective about carb counting for patients.

Well, hey there, it's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.


This week's episode is an interview with Meghan Kavanaugh. We've had her on the channel before. She is a nurse practitioner in diabetes care as a specialist, however, before she became a nurse practitioner, she was a registered dietician nutritionist, RDN. And so in this interview, we're focusing on the diabetes nutrition counseling that comes along with the diagnosis of diabetes and the care of the patients who have diabetes in our primary care practices. I really, really love this interview because I got to see behind the scenes of what it's really like when we send patients for nutrition support.


And also, we talked about the ways that we can and cannot support patients in primary care as nurse practitioners, right? There's no replacement for a nutritionist, however, there are some things that we can do, either keep doing what we're doing or improve, but it was such a beautiful interview and an eye-opening interview for even myself coming in from this perspective of holistic care. It was really, really special. So if you are taking care of patients in primary care with diabetes and you're trying to approach dietary counseling, this episode is just going to be the best. So without further ado, here's my interview with Meghan Kavanaugh.


Awesome. Thank you so much for being here with us again. So can you introduce yourself to anybody who hasn't heard from you before?

Meghan Kavanaugh:
Yeah, sure. So I'm Meghan Kavanaugh. I live in north Louisiana. I'm a family nurse practitioner, but I'm also a registered dietician. So I started my career as an RND and then eventually decided to go back to nursing school and then NP school. So I currently practice as a nurse practitioner, but I maintain all my credentials for RD.

Liz Rohr:
That's awesome. Yeah. So we did an interview, you and I did an interview for the channel before for the channel as a podcast on YouTube, and we really focused on the diabetes care, most common questions from a nurse practitioner perspective. And so even though you're not practicing as an RDN, RD right now, I'd love to talk about with so much experience that you have and so much passion that you have. I think the context of the conversation, like you and I just touched on before we started recording was that so many people, some people have a resource with a nutritionist in their clinics, some people have nothing and they don't even have somebody to refer to. And so a lot, basically what we're going on of the questions from the Real World NP community. And a lot of people are asking questions like, "Oh my gosh, what do I do for patients who have diabetes and who need support on the nutrition side?" Because it's a really holistic approach to diabetes.

It's not just about medications, right? So thank you so much for joining us for this. So I think a place to start would be in your experience as a nutritionist, and you can obviously add in your thoughts now being a nurse practitioner, where do you start with somebody who has a new diagnosis? So for example, if I have somebody with a new diagnosis of diabetes and I refer them to your office and you are working as a dietician, where do you even start with a person in that situation?

Meghan Kavanaugh:
That is a great question because it also has-

Liz Rohr:
It's a big question. A big answer.

Meghan Kavanaugh:
... it is a big question because probably one of the biggest questions the patient has is what am I supposed to eat? What can I eat? What can I eat? That's one of the number one things that's asked, whether it be provider in RD or whatever. And the answer is, you can eat a lot, you can eat all kinds of things. And where it's hard to think of it now as an RD because typically, when you refer out one of the things, you have a lot more time, okay? So if you have, as an NP, you're in clinic and you have somebody that's newly diagnosed and you are trying to start medications, start some initial education, and then of course, nutrition is on the focal point for a lot of people's brains. And what time of a time slot, what like 10, 15, 20 minutes? So there's not a lot of time.

So encouraging of course to refer out, I really, when people especially say, "Well, what can I eat?" I like to say, "What do you like to eat?" I started giving some ideas there. And one of also from the get-go is just always reiterating that you're not going to learn everything all at one time. There's a lot that's going on with a new diagnosis with diabetes, there's a lot that goes on with nutrition along with it, and it's a huge learning curve. I mean, you might have somebody that's 60 years old and they've had 60-year old habits and now that we're going to have to transition. So it's a lot of motivational interviewing, a lot of feedback, not just talking at the person, but getting their feedback and building on that and then knowing, hopefully if the resource is there, that they have multiple visits to build on things and not having to change everything all at one time. So that's a broad question, but [inaudible 00:05:29] answer, but-

Liz Rohr:
Yeah. No, totally. I think that's a great place to start and I think it's so important to reiterate, especially for whether people are experienced clinicians, providers listening, or if they're students who are going into practice. I don't know, that's my philosophy of practice, too. You and I share that of we just meet the patient where they're at. And honestly, I think I feel like research supports that too, especially when it comes to motivational interviewing. Even if you don't feel super confident with that skillset, if you starting with where the patient is and doing an assessment first, I think applies to not only nutrition, but also just our approach as nurse practitioners in general where it's like, "Okay, well where are we starting off from?" Right?

Meghan Kavanaugh:
Right.

Liz Rohr:
So that's really cool. So I guess the speaking from experience as a nurse practitioner working in a clinic, having worked in clinics where there's no resource in-house and we have to refer out and some people have access and some people don't, I think I can sum up with the understanding that I have of the gist of what people do when they're in that situation.

So I think that there's a couple things that people do and one is like, okay, and we also heard this from the questions from the community. It's like, okay, so where do we go? So if we've done an assessment with somebody, do we go straight to a recommendation? Because clearly, you have a very sophisticated nuance level of knowledge, right? And so if we're talking about a moment like starter place one, is do I... A lot of people want to do, "Okay, do I do the plate method?" "Do I do the Mediterranean diet?" A lot of people wrote in and say, "I'm tired of saying just eat less carbohydrates."

Meghan Kavanaugh:
Oh yeah, I love that part. Yeah.

Liz Rohr:
And so where would you go in terms of a first step, thinking about those potential three options of do you use the MyPlate method? Do you talk about carb counting? Do you talk about "less carbohydrates"? Whatever that means. What's a first place to start, potentially, for a beginner 101?

Meghan Kavanaugh:
And a beginner 101 might start with does the patient even know what a carbohydrate is? So they might not realize that fruit can raise blood sugar, certain vegetables can raise blood sugars. I mean, we don't want to go in, in any situation just with that assumption that somebody has a baseline knowledge. So it's like, tell me about foods that you like, your habits. Are you a snacker? Do you work night shift and you snack throughout the night to stay awake? Do you have any different religious beliefs, cultural beliefs, just things like that because everything that you read about nutrition is right, that it's not one size fits all. So if you do say, "Okay, let's start with the plate method", well, it's a good starter, it's a good visual for a lot of people, it's very easy and it's adaptable for a lot of different situations and meals, but Mediterranean diet, it's very, very healthy.

That might work for some people versus just explaining what carbohydrates are and the focus at the beginning of reduction in carbohydrates. So you do have to get a little bit more of a history at first to figure out where they're at because if they're newly diagnosed, for instance, for me, if they see primary care, they're newly diagnosed and then they see us soon after that, well, they've already probably been on Google and looking at things and they might have a family member that is teaching them some things. So by the time they've seen us, sometimes really good changes have already been made. They've started a walking regimen, maybe they're drinking a lot of sodas and sweet tea and juices, and they cut that out and they've had a significant improvement already. So again, it's just meeting them where they're at. But it is when you're limited in that time, it is very like, "Okay, I'm just going to do the plate method and just start with some education there."


But it might need to start with, okay, let's just focus at first, "Are you drinking any sugary drinks?" Okay, that's I say, easy. It's difficult for people to do, but-

Liz Rohr:
It is.

Meghan Kavanaugh:
... right out of the gate, it's like, "Hey, look. Even if you are still having some higher carb meals, but if you're having sodas with it or drinking tons of juice or even large quantities of milk, let's work on reducing that because you're going to see an improvement pretty quickly". So that's a good starting point for a lot of people. And even if you have the ability to have a regular follow-up with somebody, they can keep track with even little food logs or use something on their phone, their notes app or an app where they can log some things so you can look at it. But again, that's where ideally you would have a registered dietician doing that, but of course, not everybody has that resource.

So really just, I hate to say it depends, but it really just depends on where that person is.

Liz Rohr:
It's true.

Meghan Kavanaugh:
And then a lot of, there's good resources online, good starting places where it's like even if you say, "Okay, I'm going to get you in with an RD, but here's a good resource that can be printed off from American Diabetes Association". AADE has a good ones. DiaTribe, which I can give you the links for those, and of course the MyPlate, but something that's a good visual that's basic, just to start getting some education for that patient.

Liz Rohr:
Totally. Oh, I love that. Do you feel, is this... My intuition is that it's also a patient-dependent thing, but do you feel, are there any standards that you follow as a dietician or the dieticians follow where it's like, here's the ideal amount of protein, ideal amount of carbs, ideal amount of... Does it ever break down like that, or when you come and you do a follow-up with a patient and you've started at that place with them, when you do their follow-up and their blood sugar maybe has improved, but it's not at goal yet, where are your places to go for that? What is leading your thought process there? Are you looking...

It sounds like you're probably going to assess what their meals are, but are you simply targeting carbohydrates at that point, or tell me a little bit about that when it comes to the, if you've started... So for example, in the primary care clinic, you start with reducing milk, which actually has a lot more sugar than I think a lot of people realize, and juice and sweet tea and stuff like that and sodas. So say they've made that change and they're not at goal, where's that next place that you're going with that person? Is there an ideal or is it really targeted based on that person and their specific A1C? For example.

Meghan Kavanaugh:
There are different targets, and it depends on the guidelines that you read for different percentages of calories that come from the different macronutrients, fat protein and carbohydrates. Used to, I mean, even when I was finishing RD school, the amount of carbohydrates that were recommended were just like, wow, I mean wow-

Liz Rohr:
A lot?

Meghan Kavanaugh:
Yes, it was a lot. And so finally, it was like, I don't know, it might be a year or two ago, they finally said, "Hey, a very low carbohydrate diet can be appropriate for certain patients and populations". And with your question about certain percentages, for there, I also just assess with the patient how detailed they want to be because when you start getting into macro counting and if you're wanting them to count every gram of everything, it's a big job and not everybody wants that amount of data. And it's also very, very time-consuming to teach. But yeah, there are depends on the patient, their goals, if they need weight reduction as well and percentages of each macronutrient, then going from there and you can convert it into the number of recommended carbohydrates like per meal. So that's a good starting point, especially when you're getting into carbohydrate counting.

Liz Rohr:
And carbohydrate counting, my understanding is it's really most appropriate for patients who have type 1 diabetes, but tell me if I'm wrong there or what your general thoughts are from that dietician perspective about carb counting for patients.

Meghan Kavanaugh:
Yes. For type 1, for sure, because ideally with the carbohydrate counting, knowing how many grams are consumed at the meal, whether it'd be 12, 26 or 64, it's converted ideally with the math for an insulin to carbohydrate ratio so that patient is dosing their insulin based off the carbohydrates that are consumed. But we also do carbohydrate counting for people who have pre-diabetes, type 2 diabetes because it's not even to be so precise for that insulin dosing part of it, but also to be cognizant of foods that can potentially raise the blood sugar and at any amounts consumed it at that time.

So we do with that, we'll teach that, but maybe not as to a precise amount where if you have somebody that has type 1 or type 2, that dose is for an insulin to carbohydrate ratio, and let's say they're very insulin-resistant and they need one unit, for example, for every four grams of carbohydrates, which is pretty strong, that's two saltine crackers. So you say, "Okay, well if you eat two saltine crackers, that's one unit of insulin". So that precision, the carbohydrate counting is very, very important and ideally done in the most accurate way possible for correct insulin dosing.

Liz Rohr:
Yeah, so that's pretty involved for most patients though.

Meghan Kavanaugh:
Yeah.

Liz Rohr:
So I saw a number of questions and I've heard a number of questions just in among mentees and in regular life and stuff about what different kinds of diets. So I think that there's different levels of health literacy depending on the patient, and some patients might come in and have done all this research and they might come in being like, "I'm going to do a ketogenic diet", or "I'm going to do a paleo diet", or "I'm going to do a plant-based diet". Do you have any thoughts about that when patients come in with that, with those kind of approaches to their diabetes, or what kind of conversations do you have with them when they bring that up with you?

Meghan Kavanaugh:
Right. And it's more, I think of it like more of an eating style maybe instead of diet, but the labels on things where somebody's saying, "Plant-based diet, but I'm going to be vegan but every now and then, I do want to have a little bit of animal-based proteins". Let's just not call it vegan. If it's not more of like a ethical type thing and you're just wanting to do more plant-based, you don't have to call yourself vegan, right? Or because I like the term the flexitarian, just different options. But especially when you start getting into keto and somebody says, "Well, I want to go keto" and I'm thinking, "Okay, do you mean low carb or do you mean true ketosis where it's a very, very high fat, very, very low calorie, sorry, carbohydrate diet?" So sometimes people say, "I want to do keto", they just really mean I want to reduce my carbohydrates. I know I can lose weight doing that.

Liz Rohr:
Yeah.

Meghan Kavanaugh:
And then we'll also put back what their typical eating behaviors are. It's like, do you feel like this is something that you can do long-term? And we have. Of course, there's people out there that are highly motivated that can stick with a style of eating long-term, but I also want to reiterate to them that they're not failing if they don't eat that style seven days a week every week of the year. So with things like keto or low carb, low carbohydrate, I mean generally, especially if somebody is checking their blood sugars and because we want them to minimize hypoglycemia always, but if they have a continuous glucose monitor and they're able to see the effect of carbohydrates, even low, moderate, high on that CGM, a lot of them naturally shift to, "Wow, I had no idea that milk did that to me" or the obvious stuff like cereals, like something that processed carb and be like, "Oh, please, throw it away. Just get it out of the house".

So they can look at that data and get more of an instant feedback, whether it be through finger sticks or through a CGM, and you add some self-motivation that way too.

Liz Rohr:
Oh, I love that. I love that. I almost wonder if you want to do a pretend patient, like if I was your pretend patient.

Meghan Kavanaugh:
Like an interview?

Liz Rohr:
I don't know if I'm [inaudible 00:17:37] I am.

Meghan Kavanaugh:
Like if I was going to be your dietician?

Liz Rohr:
Yeah, just as an example, how it would go to just... I guess because think part of it is also illustrating how complicated it is, right? Because this came up with a physical therapist too, where it was when I did the physical therapy interview, I think everyone's inclination, and I don't know if you feel this way too, is what exercise sheet can I give them to fix this problem? And they're like, "Holy shit. This is way more, it's way more complicated."

Meghan Kavanaugh:
Oh, I know. I mean, just like that question about the MyPlate versus, and I just... It depends. I just feel like I'm saying it depends for everything, but it does. I mean, it does. That's an honest-

Liz Rohr:
Yeah.

Meghan Kavanaugh:
So people want to be like, "Here's a sheet for this", "Here's a sheet for this", "Here's a sheet for this".

Liz Rohr:
Exactly.

Meghan Kavanaugh:
Yeah. When I worked outpatient education, and if it was somebody that came in just for weight management or type 2 diabetes management, I didn't have a many patients at that time with type 1 diabetes. They've probably, it was referral only, okay? So when they came in, they've already seen their primary care. We were education only, no management. And they would see the registered nurse either that visit or on the same day or they would come back another day with some food logs and everything. If somebody just came in and they did not have any food logs, I started with, "Give me a history." Okay?

"What do you typically like?" And I had these sheets and I said, "Okay, what do you typically like for breakfast? Give me some ideas. Do you eat breakfast?" Jotted down, okay? "What do you eat for lunch?" "What's your work schedule like? Tell me about that." "Do you snack?" "What do you snack on?" "What do you have supper?" "Do you skip meals?" "Do you feel low in between meals?" "Are you a stress eater, emotional eater? Are you a stress non-eater?" "And do you snack at night?" Okay? "Do you work nights?" "What do you do?" "How do you stay awake?" "What do you drink? How much? How much water?" You get this huge history. So I would have, because I'm a pen and paper person, okay? So even with all this technology, I'm just writing all these things down.


So then I'll say, "Okay, look. This is your normal routine. Let's make improvements on this, okay?" "So you drive a truck, you drive cross country and you have fast food and restaurants. What are your favorite fast food places? What do you like to get from there?" "Okay, you're not going to pack anything and then we need to do fast food. Here's what to get." I mean, so it was examples based off of their history at that time. So they came out holding something, it says, "Oh, when I go get pizza, this is what I need to look out for." "When I go in, I'm working nights, these are some ideas of things that I can pack based off of the foods that I like". I mean, so it's very history-based and then improvement based off of their current routines. You see what I'm saying? So that's why it's hard to say, "Hey, my plate is great".

It's a good visual, but still, if you have somebody, "Okay, we do half plate vegetables", but the person's over here like, "I don't like any vegetables. What am I supposed to do? I'm not going to eat a single vegetable." "What vegetables do you like?" "Well, I like green beans." "Okay, let's put some green beans on that plate and let's build from there." So you can be talking at that patient or recommending Mediterranean diet and they can be allergic to fish. So it's more like history. That's why I don't even generally recommend saying, I don't say, "Hey, let's do the Mediterranean plan", it's like, "No, let's try to get good, healthy fatty fish and let's get foods that reduce inflammation" instead of calling it something.

And that's why it's so hard because again, we want to hand somebody something that's just, "Hey, eat this, this and this", which we have the same handouts, but we've come up with them, we're like, "These are the foods that will raise your blood sugars. These will help keep it steady". And that's still a good point, but it's like the application to real life. You see what I'm saying? That's where-

Liz Rohr:
Wow. Totally. I think that yeah, I mean, I think that's the thing with that physical therapy interview. Everyone wants to give that handout, do this exercise when you have back pain. And it's the hardest part of, I think for a nurse, and I'd love to hear your perspective on this as both an RD and as a nurse practitioner, but for us, I feel like the main challenge sometimes is the diagnosis, for some conditions. And then once you get there, the managements are pretty clear, right? There's nuances and there's choices, especially when it comes to diabetes, right? You have to be a little bit more sophisticated nuance there. But for the most part, I think that the main challenge, at least newer grads and newer grad nurse practitioners have is getting to the diagnosis and then it's like, "Okay, what's the algorithm of management?" Right?

Meghan Kavanaugh:
Absolutely. Yes.

Liz Rohr:
And I think that with physical therapy specifically, I know for a fact from doing all of that stuff and then doing that interview is like, "Oh, that's the easy part", right?

Is it an orthopedic problem or is it not? And if it's an orthopedic problem, here's all of the sophisticated management. So yeah, it really sounds like with RD, that's the same thing. But I love those history questions. I really love how much that illustrates why it is so sophisticated, and I think it's really hard. And I think I really appreciate you coming on and talking about this because this is the huge challenge, and I think it's at least I know I feel this way and I feel this from other people, is this responsibility to take really good care of our patients-

Meghan Kavanaugh:
Yes.

Liz Rohr:
... in a system that is not set up to support patient's optimal wellness. And so it's like, "Okay, how can I be an RD? How can I be a physical therapist? How can I be this specialist?", right? And the reality is we have to draw the line somewhere. And it really sounds like with RD and dietary education, there are places we can go and I think we can get better at of what history questions to take, right? Because I'm not asking things like, "Are you an emotional eater?" Right?

Meghan Kavanaugh:
Yeah.

Liz Rohr:
Because I'm not really prepared, excuse me, to have that conversation of where do I go from there? They answer yes, I'm like, "Okay, what do I do next? Where do we go from there?", right? So yeah, I really appreciate that. It sounds like some places to go though with the knowledge base that we have as nurse practitioners is perhaps getting really comfortable what are the blood sugar-raising medication, or blood sugar-raising foods versus blood sugar-lowering foods?

Meghan Kavanaugh:
Right.

Liz Rohr:
And then how can we get better at the history and how can we develop our knowledge to be more sophisticated such that we can take the fast... That's a beautiful, beautiful example because that's real life of patients who, they're a truck driver across the country and they only get fast food. What other options are there when you're out driving? I don't know. I mean, I've been up on really long trips where there's a lot of truckers and it's like, okay, well here's one option in the next 45 miles, so that's really cool. That's really helpful.

Meghan Kavanaugh:
And that is, I mean, you talk about getting to the diagnosis and where's the algorithm? I mean, if you and I compared schedules, routines, food likes, dislikes, you're going to get two completely different people on paper, right? So right now, my husband's traveling for work and I'm just making an egg sandwich at night for supper because I'm not going to cook a big meal. And right now, just in the season of life, yes, I know vegetables are very, very healthy, but they're also expensive and they go bad. And so right now, I'm focusing on steam bag vegetables that cost a dollar and I throw them in the microwave. They're done in four minutes. Spill a little bit of salt and pepper.

Liz Rohr:
Right here. Same predicament.

Meghan Kavanaugh:
It's fiber. So where you [inaudible 00:25:03] even social media and these beautiful great meals, that always telling that patient, "It doesn't have to be that complicated. It doesn't have to be that expensive food".

I mean, costs of everything obviously are crazy, but it can be make it as simple as you want while as nutritious as you can and doing the best you can in the season of life right now. I mean, it's like that's the takeaway. So we know every year, holiday season, people are going to indulge and have this, okay, if you have your grandma's favorite or the grandma makes your favorite chocolate pie, okay, but you don't really care about pumpkin... Don't eat the pumpkin pie, eat the one that you like, maybe cut your carbs back a little bit, acknowledge it, but make a holiday, not a holimonth, just celebrate the day, don't make it go to a whole month. And you can still see improvement. So even a lot of these patients, they're coming in after the holidays and still have a lot of people that do are having really good, consistent weight loss, they still have decent blood sugar control.


There's some periods of time they get a little wonky, but it's like learning those little mechanisms of what do I do in the situation? What's the best decision I can make right now in the situation, the social environment that I'm in right now? And that might be a reduction in portions. If you can't control the quality of the food, control the quantity of the food, just reduce it a little bit, drink water, try not to over-indulge in alcohol, limit it to maybe one sweet instead of three. Little things like that, just over and over perfection, not perfection, but just improvement. You just want improvement. And then where they can see some success and build on that. And those are the ones that can really long-term have success because they're realizing that, "I don't have to do exact macro counting to get everything right with the meds that I'm on in my routines and other things that we're dealing with". So that's why. Yeah.

Liz Rohr:
No, I love that.

Meghan Kavanaugh:
Nutrition is complicated, and I think this is why when I went back to nursing school and some friends are like, "Oh my gosh, our nutrition classes that I hate nutrition, I hate nutrition", it's really, it's hard and it's a lot of handholding and food is very emotional, it's very easy.

Liz Rohr:
It is. Yeah.

Meghan Kavanaugh:
Yeah. I mean, there's more you say if you don't ask the question of like, are you an emotional eater? Because what do you do with the answer? Yes.

Liz Rohr:
Yeah. Well, it's like that whole depression screening thing is like it's not recommended to do a depression screening unless you have the resources, right? And so unless I'm like, I can think through that and think about how I respond to it, but just hearing you say that in the moment, I'm like, "Oh gosh, I don't even know... I don't think I've asked that of somebody before". And because I think especially, I don't know if this is your experience, but my experience of becoming a nurse practitioner when I was brand new, I was really focused on what is the safest thing that I can do so I don't miss anything. And then as I develop in my practice, I get into those deeper levels of sophistication where one of the things I was going to say in terms of part of it, I think hopefully this is awareness raising in that one individual person, me, myself as an nurse practitioner, cannot fix a system that is not supporting the anti-wellness of our patients basically, right?

Meghan Kavanaugh:
Right.

Liz Rohr:
But what are the things that I can do in my scope, and how can I raise this as an issue and talk about it with other people? We need RDs, we need physical therapists, we need interdisciplinary collaboration for a reason, right?

Meghan Kavanaugh:
Right.

Liz Rohr:
But that's one of the things I was thinking about, is how can we... One of the ways potentially we can do it in primary care, it's not against the rules to have somebody follow up in a week, well, probably not a week depending on how much space you have in your schedule. But in three months, if you follow... How often do you follow-up with people in nutrition, every month or every two months?

Meghan Kavanaugh:
It depends on their insurance because with Medicare guidelines, Medicare will cover reimbursement for registered dietician for nutrition or MNT, medical nutrition therapy, for diabetes and then for renal. So for your patients who go to dialysis, there's an RD on staff and then they get nutrition counseling while at dialysis. So there's a certain amount, you get a certain amount of hours, and I should have looked this up because I don't think it's changed, but certain amount of hours of initial MNT, so the first time that they meet with the registered dietician and then a certain amount of follow-up. There's also each year, they're allowed to get refreshers, so it does depend. So Medicare, keep that in mind. There are also a decent amount of private insurance company, like Blue Cross, that will allow a certain amount of MNT time, of course, subject to deductible and copay and everything.

So it just depends on how much support is needed. And especially at first, when somebody's newly diagnosed and you're trying to teach these things from a RD perspective, if you have the capability to have a pretty close follow-up, even three, four weeks, a month, six weeks, something like that where they keep... I like food logs. I think that's very helpful. It's not only from my perspective of some calls in effect, especially when I look at some more detailed insulin management, but also when the patient is thinking through, I'm going to have to write that down, I have to write down that I had some Oreos for a snack and you present this if you decide to do this with your patient because the data is not just great for you, but it's a really great eyeopener for that person, especially when you catch them when they're motivated. I don't use fear as a scare tactic, but a new diagnosis, I'm going to change all the things, right?

Liz Rohr:
Yeah.

Meghan Kavanaugh:
And so they're motivated and they want some feedback. And as humans, we like positive feedback. But telling that person, "This is not to grade you, this is not to judge you, this is not to grade your papers, I just need to see what's normal for you, like "Hey, you know what? If you go fast food seven days a week, we're going to work on that. We're going to cut it back some and that's going to save you money, too. You'll see a higher account balance at the bank because you're not spending $10 every time". So finding that of it's not something to use against them because again, food being emotional.

Liz Rohr:
Yeah, you're so right. Yeah.

Meghan Kavanaugh:
Yeah. It can be an embarrassing thing, like "Oh wow, I really drank four sodas a day. This is bad. They're going to fuss at me" and so "[inaudible 00:31:38] just to help. Let me help you". [inaudible 00:31:39] but yeah.

Liz Rohr:
Oh my God, I love that you brought that up because in a part that we're not going to include, I was potentially offering to be your example patient. And even I, as a nurse practitioner, try my very best to be healthy. I'm like, "Ooh, I don't know if I want the whole world knowing that my dietary is right". And it feels that same magnitude for a patient in a clinic, especially if they write it down, especially when they have to give it back. Especially if you have that emotional eating components of there's a lot of feels in there, so I love that and I appreciate that.

Meghan Kavanaugh:
A lot of feels, oh yeah. I'm at this desk right now and it's like, I wonder how many people would be like, "Oh my goodness, she's drinking diet coke that has so many chemicals", but it gives me caffeine and I enjoy it and I drink a lot of water. There's worst things.

Liz Rohr:
Oh right.

Meghan Kavanaugh:
And I talk to my patients about that because they'll say, "Well, I don't want to do, I would rather have regular sodas because at least I'm getting real sugar" and then thought having the aspartame or whatever other artificial sweetener. It's like yeah, but if we look at the hierarchy of what's healthy, what's not, it's health-promoting versus health-neutral versus health-harming. Yes, I usually have a diet Coke on my desk, but I'm also flushing them with a lot of water, so I can't say don't drink them if I'm doing it. And so just things of just letting them realize that you're a person too and you're real world too. Yeah.

Liz Rohr:
Absolutely. And I think, especially for newer grads, I remember feeling this way myself of like I felt like such an imposter and I was like, I just I need to prove myself even to the patients where they're going to think I'm an idiot all the time. If you're feeling like that, that's super normal. And also, the more experience that I have, the more comfortable I am with saying things I don't know, the more comfortable I am with sharing my own humanity because it's coming from a place of, I'm just sharing. It's not like you need to... I'm not putting it on my patient, but at the same time, when you share that you're a human too, people are going to feel more comfortable.

Meghan Kavanaugh:
Oh, yeah.

Liz Rohr:
I want to go back to what you said. I guess a couple of what I'm trying to tease out is it sounds like we need to do one thing, one opportunity is that we could do more assessment questions and asking and really getting a sense in a deeper way of how people are actually eating in a regular basis, not having any judgment about it. We can do our own follow-up visits as primary care as a health dietary counseling visit, right? It could be a diabetes related follow-up, for example, and we can have these conversations. I don't have the skill that you do as a registered dietician, but at the same time, I can do my best. And then just another recap, thinking about high glycemic foods and lower glycemic foods and potentially considering substitutions as one "hack".

It's not really a hack, but what is one small change? And what are some of the other, like when you said the making the best choices in the moment, what are some example, or if you can recap what you shared about the best choices in the moment, what are some of the other examples that you give for patients of how to make their best choices? Whether it's a fast food, like here are the healthiest options at this fast food place versus is there a smaller portion size? Do you know what I mean? Can you think of any other examples of patients where you're... What is their guidance of making the best choice in the moment?

Meghan Kavanaugh:
So if it's more of a situation that's, let's say social like family gathering and potluck style, something where there's going to be quite a few dishes, I'll encourage, "Hey, you be in charge of something that's healthy that you know that you enjoy, that you get joy from that is going to promote some wellness and not just shoot your sugar". So if you know that, "Hey, this salad that I make with this salad dressing that I enjoy, I like the way it tastes, I enjoy it", other people would benefit from it too. So you know you have a food going into it that's safe for you and not so much become trigger food.

So if there's tons of different types of starches, which a lot of times in those social situations there are, okay, you're going to have some, but what are your favorites, okay? So let's think about Thanksgiving. We just had Thanksgiving a couple months ago. And I love asking the patients that's coming back and say, "How's the holidays? What's going on? What was the best thing you ate? Tell me the best thing you ate". And I do this right now, so not as an RD and I'm in with the [inaudible 00:36:02]-

Liz Rohr:
Oh, I love that.

Meghan Kavanaugh:
So we have our [inaudible 00:36:04].

Liz Rohr:
Bringing some positivity around food instead of just like, "Oh my gosh, I did a bad job over the holidays".

Meghan Kavanaugh:
Yeah, like "How much pumpkin pie did you have?" It's non-judgmental at all. And then you get that comfort level like that from them because it's hard to talk about food. And again, it can be embarrassing for some people because if they don't want to say, "Oh I don't know, I cheated, I was bad" and I don't like when people say they cheat and they're bad, like no, you're human. You are human. So I like dressing, that's my thing. Dressing. I don't care about-

Liz Rohr:
Stuffing for the northern [inaudible 00:36:35]. Yeah.

Meghan Kavanaugh:
... anything else [inaudible 00:36:36]. Yeah. My mom's dressing or my mother-in-law's dressing, like "Give me a pile of that and some Turkey and I'm good". So then they'll say, "Oh yeah, that was my favorite too", and I'll say, because I don't really like, this is me talking about... I'm using myself as a patient, how about that, Liz? Instead of you as the patient. I don't really care for seasonal desserts, like the cotton pie and pumpkin pie and stuff.

So I'll tell the patient, "Yeah, I don't like that stuff, but I'm going to eat some dressing and I'm going to enjoy it because I can only get it this time of the year. What did you like?" And a lot of times, it's like "Oh yeah, it's my aunt's sweet potato casserole and I had that, but I did good because I ate some extra Turkey and I didn't have that". It's an accomplishment.

Liz Rohr:
Yeah, absolutely.

Meghan Kavanaugh:
So those types of things and environments was we are going to have holidays, we're going to have birthdays, we're going to have events at schools, and there's going to be things. So you, is... When we're talking about how difficult it is to say everybody gets the plate method or everybody... That we're going to hand out Mediterranean, hand out keto or whatever, that's not real world a lot of times. So it might be having, "Okay, I really want to enjoy this piece of birthday cake, but I'm not going to have ice cream on top of it".

But that doesn't mean to eat double the cake either, make it that, but when it comes to... That's a long answer for your short question.

Liz Rohr:
No, that's great.

Meghan Kavanaugh:
It's like these little tangible things and they remember that, they remember like, "Oh, I went and saw Meghan and she was just saying, 'If you don't like something or you can get it any other time of the year, why waste something on that?'" Needing like a special food.

Liz Rohr:
Yeah.

Meghan Kavanaugh:
So when it comes to restaurants and fast foods places, now, most chains have their information online, okay? And I used, it's easy, but I know the easy thing to think about is, okay, if you go and you sit down somewhere, think of it as the plate method. And for people who aren't as familiar, half plate vegetable, quarter plate protein, quarter plate starch, okay? So quarter plate of something that could possibly raise blood sugar.

Most places that you sit down at have a lean-ish protein option, a starch, and then a non-starchy vegetable or salad. So it's like if you think of that plate as the platter that they're going to give you in this huge portion, that's a win, just if you usually get a giant plate of pasta, but the healthier option is to get a protein vegetable and a small amount of a carbohydrate, that's a win. That's a great, great improvement with at the same restaurant, somewhere you enjoy if it's date night or whatever. And then the same thing with fast food restaurants. If it's somebody that's traveling and they just didn't pack something or, because that would be this ideal world that we could say, but people would pack all their stuff, but that doesn't happen. And so, okay, if you run through McDonald's, look at the menu, look at the carbohydrates, look at the different amount of carbohydrates in a small cheeseburger versus a quarter pounder with cheese.


There's a difference there. They have, most places now have little side salads or they have apple slices or something. But I always tell them no matter what, no sugary drinks, just don't get a soda. Just reduce it, like a diet Coke does not cancel out or a Coke. You know what I mean? So it's just reduction in portion sizes to kids' meals. That's another good option where it's just automatically tailored down. And most of the times, it's satisfying enough. We're taught over time to not really think about satiety and eat past the point of fullness or don't waste things that are on your plate because you're just pushed if you were that generation, so people don't even really recognize when they're actually satisfied versus stuffed to the brim and then feeling sick.

Liz Rohr:
Totally.

Meghan Kavanaugh:
So just then you start getting into more intuitive eating too, which everything else takes a lot of time, so yeah.

Liz Rohr:
Yeah. Absolutely. It reminds me of when I talk with parents, do you see kids? I can't remember. Are you family?

Meghan Kavanaugh:
Yeah, we do see kids.

Liz Rohr:
You're family. Yeah. But with kids, when I talk with parents about, or the caregivers of young children about picky eating, and it's like... And obviously, I would love your take on this too, but with the way I talk about it with them is like, if there's a lot of drama that gets created between, there's a power dynamic and kids can only control certain things, and that's one of the things as like what comes in and what goes out of their body basically. And so it's like if you can remove, try your best as the grownup to put your patience, work on the patience of letting all the drama be out of it, letting all the feelings be out of it, and also trusting your child to know their...

It can be a process since every kid is a little bit different, but it's like the main goal that I talk about with parents is how to encourage your child to be aware of when they're hungry and when they're full and allowing themselves to be done because... And obviously, you have some behavioral stuff in there where somebody will eat a bite of something and then before bedtime, they're like, "I need to eat this whole thing", right? But it's like even with adults, I know that it's easier when kids like that, they start off with that. But even as adults, we can have conversations about that, of thinking through those pieces too, of do you know when you're full? Do you know when you're hungry? What are some things to practice around there, too?

Meghan Kavanaugh:
Yeah. And what does that feel like? You're like, "How quickly are you eating?" "Are you a nurse at the hospital and you have to eat in just a couple minutes just for literally to get calories in your body and get some nutrition?" And yeah, I would say that's very challenging to teach, knowing hunger cues. And then since we're talking about diabetes and with weight management, you know the GLP1s?

Liz Rohr:
Yeah.

Meghan Kavanaugh:
That's one of the things that's so helpful. I mean, when these patients come back and I told you before we started, I was like, "I really don't want to get into weight loss and stuff".

Liz Rohr:
Yeah. Totally.

Meghan Kavanaugh:
But I'm going to dip into it a little bit from the diabetes perspective. When you've had somebody that has struggled with weight management and because obesity is not being treated with, it is just, it's that kind of problem in and of itself with limitations on medications and insurance coverage and everything without diabetes, but we know that it can help prevent diabetes. And so if you have somebody that's been told their whole life that your BMI is too high and you're overweight and all this, and there's such this negative connotation with food, and then you have one of these medications that all of a sudden, when patients come in, they're like "I'm not obsessed about food, it's great", I can go halfway through my meal and I'm like, "I'm good. I've never had that ability to be able to stop or to realize that, 'Wow, I really am not that hungry and I don't need to snack four or five times a day'".

And in that regard, have that... Because the medication makes you full, or makes you feel fuller longer amongst other ways of just how it shifts the brain and creates a lot of positivity emotionally too, because there's not as much of a obsession with snacking and binging and things like that, but that goes totally down another rabbit hole.

Liz Rohr:
Totally. Oh my goodness.

Meghan Kavanaugh:
Yeah.

Liz Rohr:
Oh my goodness, you're so right. One of the questions I really love that was submitted was, what have you counseled patients on that they seem most surprised to hear? Does anything come to mind with that?

Meghan Kavanaugh:
In regards to foods in general, or-

Liz Rohr:
Yeah, just I guess when you were working as an RD and you had a patient come to you and you started counseling them and they were really surprised, are there any themes that came up? I feel like, for example, when I would take care of patients in the hospital with CKD, pretty late stage CKD, and we would be serving meals and we'd be talking about potassium in milk products, and they were like, "Really? And tomato sauce? Wait, I can't have milk and I can't have tomato sauce?" We had more conversations with that, but do you know what I mean?

Meghan Kavanaugh:
Oh, yeah.

Liz Rohr:
And was there anything that currently comes up that people are like, "Really?" Because we probably would feel that way too in primary care being like, "Oh shoot, we should [inaudible 00:45:12]".

Meghan Kavanaugh:
So with diabetes management and where we're talking about, so starting with foods and of course the focal point being carbohydrates, it's really rare that anybody talks about the blood sugar changes that happen with fat and protein.

Liz Rohr:
Yeah.

Meghan Kavanaugh:
Or even low, even very, very low carbohydrate vegetables like green beans, broccoli, cabbage, all that. But really, you don't see that unless somebody's wearing a CGM or they just have to check their blood sugar a little bit more often. So if you have somebody that is still going pretty low carbohydrate, or if they have a lean and green meal and you're watching a CGM and you pointed out to them, and maybe it's a higher fat steak or beef or something, or if there's a lot of oil on something and then it's like this light little rise and it's not an aggressive rise, but what is that? They didn't have any carbohydrate at that meal at where you can see that, where some of the protein and the fat, well, you'll still have a response. It's not an aggressive surge, but I would say that's a big surprise for a lot of people.

And when you look at insulin management with that, especially if somebody's wearing an insulin pump, there's different tricks that we can use to combat that, like a post-meal bolus based off the amount of protein and fats, and they can combat that without just waiting to go high and get a correction to come back down. Another really big surprise for blood sugar spikes for not everybody, but we see a decent amount, especially if they ran a CGM, is coffee, caffeine, anything that's a stimulant. So they'll wake up cruising really good, and then even if they just have a bite cup of coffee and it's a 100 milligrams of caffeine, and that stimulant, you see that go up.


So there's a lot of times that we have to teach that patient, like this is getting into type 1 and insulin dosing or type 2 resistant on insulin where they have to input some carbohydrates for that because we see the response to get ahead of the spike because it's one of those things that even though it might be zero calories, if there's no sugar, no creamer in it, it still can cause a blood sugar response to it.

Liz Rohr:
Oh my God, that's so fascinating.

Meghan Kavanaugh:
Yeah. So some of the non-obvious things that get really interesting with time. Yeah.

Liz Rohr:
Yeah. And do you see that with other caffeine-related products like tea or soda?

Meghan Kavanaugh:
Energy drinks.

Liz Rohr:
Yeah.

Meghan Kavanaugh:
Tea, I don't see quite as much unless it's a really large quantity of like iced tea.

Liz Rohr:
Yeah.

Meghan Kavanaugh:
So I do have some that, even with unsweetened tea and not even putting an artificial sweetener because there's that potential that artificial sweeteners, the body can't distinguish the difference. There might still be a little blood sugar response, so that's... But even unsweetened tea in the large quantities, you can see it. You can also see it with nicotine. So for smokers, I can sometimes be like, "Is your smoke break at 2:30 every afternoon?" And I see this little spike in there, but those-

Liz Rohr:
That's so interesting.

Meghan Kavanaugh:
... those really high caffeinated, oh, I can't remember some of the brands, but maybe sugar-free, something like a Red Bull, you can see it. Yeah, you can see it there too.

Liz Rohr:
Yeah. Wow.

Meghan Kavanaugh:
Especially because a lot of those people don't sip. It's like a chug.

Liz Rohr:
Chug.

Meghan Kavanaugh:
... get it back, yeah. And then go back to work. Yeah.

Liz Rohr:
Oh my goodness. Well, this has been super, super helpful. And you said that there are some resources that you recommend and you and I can connect about that in terms of, I mean, you have your own custom handouts it sounds like. And I think, sounds like the moral of the story is that it's really not about handouts, it's about more of a history-taking and a customized approach and thinking about what are those lifestyle changes we can make? What are the lower glycemic options? And yeah, any other parting thoughts or pearls or actually, we didn't even touch on the difference between dietician and nutritionist. Do you want to put that in real quick?

Meghan Kavanaugh:
Yeah. Well, let me say one more thing about-

Liz Rohr:
Yeah, go for it.

Meghan Kavanaugh:
... with getting a history. So just to be clear, when we talk about getting a history and everything, those were visits, and I don't know how our RDs are scheduled. In our clinic, the first visit with the dietician baseline is scheduled for one hour.

Liz Rohr:
Yeah. That's true.

Meghan Kavanaugh:
Yeah. So this type of education, this deep dive, the history-taking, the recommendations, talking about it in response to with medications and stuff, this is not a short process, so I'm sure some of their eyes will be like, "I can't do that. I can't even do what I need to do in a 15 or 20-minute slot" and that's where you just give them little bite-sized pieces of, "Hey, at the beginning, we're going to work on no sugary drinks. That's what we're going to work on right now. Then I want you to start looking at carbohydrates, maybe think of them as in serving sizes and start reducing their increase in protein in vegetables". Those can be just little basic things as long as they have a concept of what carbohydrates, fats, and proteins are. So these are concepts and conversations that take long periods of time. There would be some, in my previous placement appointment that would be for more weight management counseling, that would be hour and a half or two hours. So it's huge blocks of time to get the information and have those really deeper conversations.

Liz Rohr:
Totally. Well, I think that also reminds me-

Meghan Kavanaugh:
So just keep in mind. Yeah.

Liz Rohr:
No, I appreciate that reflection because sometimes, I can be overly ambitious and like, "I'm going to start doing that more."

Meghan Kavanaugh:
I know.

Liz Rohr:
It's like, "Well, hold on, hold on". But I think that also reminds me of, at one of the clinics I worked at, we had a diabetes nurse educator and she had a lot of time to work with patients. And so typically, not that it's the best way to run, well, I'm not going to split hairs there, but there are a lot of times where the nurses that I've worked with have been really supportive, whether it's for hypertension care or diabetes care, and potentially, that could be an opportunity to partner with them if we don't have the access to a registered dietician of how can we partner together to have more time with the nurse, get information, and then we can have it be a more time together in general between the two of us type of thing, too.

Meghan Kavanaugh:
Right. And with things that how they change with telemedicine and telehealth and making sure because not, and this goes into that other question that you just asked about with dietician nutritionists. So with our national board, it's registered dietician nutritionist, so it's RDN, but not every State in the US has a licensure. So in Louisiana, we have a state board for licensure, so it's like title protection. So if somebody, even for telemedicine, they have to be licensed in Louisiana, of course, like anything else. So that is another option. If there's one in, and I just did a little bit of quick research, the eatright.org, which is the overarching for registered dieticians, there's a place to search in your area for registered dieticians that do telemedicine, or just locally or telemedicine. And a lot of hospitals also have outpatient programs, so that's another option too, just trying to find somebody that you can refer to just because I would say most places.

Liz Rohr:
Yeah.

Meghan Kavanaugh:
Yeah.

Liz Rohr:
Yeah, definitely.

Meghan Kavanaugh:
And there also might be a class is available as well, but don't forget that if telemed or telehealth is an option as well. Yeah.

Liz Rohr:
Oh, God, I love that. Yeah. I think that was the thing that you and I talked about before we ever worked together the first time, was that there's a difference. There's a dietician, there's nutritionist. Seems like everybody has different preferences for names, but the national one is RDN, and every State by State may or may not have a licensure process, so somebody could be operating as a nutritionist, but not actually have the certification credentials.

Meghan Kavanaugh:
Right. Yeah, because there's a, of course now, a lot of health coaches, and I mean, there's Instagram influencers and stuff, so I mean ideally, you would have that person that has that four or five-year degree in-

Liz Rohr:
Medical. Yeah.

Meghan Kavanaugh:
Yep.

Liz Rohr:
Because yeah, because anyone in complications-

Meghan Kavanaugh:
National credentialing.

Liz Rohr:
... yeah, of comorbidities with CKD, do you want to think about in those situations? For sure.

Meghan Kavanaugh:
Right. Yeah.

Liz Rohr:
And I guess the request that you had was as long as they don't call you a dietary, that would be nice.

Meghan Kavanaugh:
Oh yes, so just don't call me dietary. Yeah. So RD works fine [inaudible 00:53:38].

Liz Rohr:
Yes. Perfect.

Meghan Kavanaugh:
Yeah.

Liz Rohr:
Also, well, any other parting words of wisdom or pearls of practice or requests that you have for primary care?

Meghan Kavanaugh:
Like I said, it's just I feel like the overarching answer for all the questions are just that it depends and it's just, it's okay if it depends and if that's a hard answer to give because it is just so personalized for every person that walks in the door. And just as in healthcare, we're just, we want to fix and we want to fix, and these are things that take a lot of time to help encourage, just changes in everybody's day-to-day life.

Liz Rohr:
Absolutely.

Meghan Kavanaugh:
So yeah.

Liz Rohr:
Cool. Thank you so much. I really appreciate it. You're the best.

Meghan Kavanaugh:
Yeah. Yes. Oh, thanks, Liz.