Review Articles

Diabetic diet education - a team approach Joan Munro SRD District Dietitian, St Mary's Hospital, Milton Road, Portsmouth, Hants PO3 6AD

Introduction As the trend for treating diabetics in

the community increases, dietitians will inevitably see fewer patients at diagnosis and the onus for accurate and consistent dietary advice at this stage will rest increasingly with other health profes- sionals such as practice nurses, district and community nurses, health visitors and general practitioners as well as diabetic nurse specialists. The success of later dietary education depends on the foundations laid in this important first stage.

This article looks at the dietary changes diabetics need to be able to make at different stages and, drawing on experience gained in teaching on the ENB 928 course in Portsmouth, pro- poses a structured approach to dietary education.

Responsibility for detailed individual dietary advice remains with the dietitian, but the complementary role of other health professionals in providing 'first aid' diet advice and reinforcement is acknowledged and suggestions are made for ensuring clear and consistent dietary messages for patients.

This system was devised for adults and, without modfication, it would not be suitable for children. Nor should it be used for diabetics with other dietary restrictions eg in renal disease.

It is not within the scope of this article to discuss the effectiveness of dietary education in improving diabetic control. It simply takes current dietary recom- mendations for diabetics and looks at how best they may br: conveyed to the patient.

What does the diabetic need to be able to do? Expectations

Just what do we expect our diabetic patients to know, understand or be able to do following their dietary education? Do we expect them to be able to scan labels in the supermarket and choose nutritionally balanced meals with the requisite proportions of fibre, fat and carbohydrate within a defined energy allowance, or do we set them targets like eating roughly the right food at roughly the right times at home and at work over the next two or three weeks?

The majority of the general popula- tion (including dietitians) are unable to perform the first task consistently, yet

some of us probably have the fond. hope that we can teach our diabetic patients to be able to do this. Recent government guidelines for a healthier diet for the gen- eral population suggested a ten year period of gradual change, yet we often expect diabetics to make essentially simi- lar changes within two or three weeks.

Realistic expectations are essential to avoid our own and our patients feelings of failure. The diabetic patient needs to be able to make differing levels of diet- ary change according to the stage of his condition and his diabetes education. Diet teaching and information should therefore be strictly limited to the amount necessary to enable the patient to make the dietary changes required at each stage. Understanding andlor com- pliance should be checked before pro- ceeding to the next stage. Although we may be anxious to provide as much infor- mation as possible, we need to remind ourselves that information is likelier to be retained if it is reinforced by use.

Table 1 looks at the changes our patients need to be able to make and suggests three levels or stages of dietary

change. The three stages are not rigidly defined. Different patients will reach a slightly different level at each stage according to their needs and their abilities. Thus a patient with non-insulin dependent diabetes needs only to reach number seven in the first stage while a patient with insulin-dependent diabetes needs to reach number nine. Stage I First aid dietary advice

- can be undertaken by members of the diabetic care team suitably trained and delegated with this task.

Stage I1 & 111 Detailed individual diet advice should be under- taken by the dietitian. Other members of the team have a role to play in reinforcement and feed back.

Stage I - first-aid dietary advice Reducing refined carbohydrate

The major sources are sucrose, some fructose eg in fruit juices and some glu-

Table 1

What the diabetic needs to be able to do

7. 2. 3. 4. 5.

6.

7.

8. 9.

70. 17.

72.

1.3. 14.

75. 16.

7 7. 18.

19.

Acknowledge the need for dieta measures

Substitutesome fibre rich CHO forrefined Avoid majorsources of fat Substitute selected dietproducts for some of the refined CHO Adapt shopping and cooking to comply with the above Select meals and snacks for everyday routine adaptedas above Counteractlavoid hypos (if on insulin) Avoid irregular eatin pattern (if on insulin)

Make more detailed changes in proportion and and type of CHO Make more detailed changes in proportion and

!&$%Lppingand cooking to comply with above Select meals andsnacks for varying cirrumstances (eg s

Select alcoholic drinks as appropriate Use exchan e system to vary food intake within prescribedlfmits Use CHO Countdown to select 'gdexchanges Using specialrecipes, prepare diabetic dishes and include in diet Use information on foodlabels to aid food selection

Avoid majorsources of refined C 3; 0

Regulate energy inta Q e as necessary

cialoccasions, illness, sportlactivit)5 shift- wor R" )

270 Practical Diabetes November/December 1987 vbl4 No 6

Review Art ides Diabetic diet education

Table 2

First-aid diet advice checklist

RefinedCHO

Addedsugar: in tea, in coffee, on breakfast cereals Softdrinks: squashes, minerals, sweetened fruit juices, Lucozade, tonics, cough syrups Sweets & chocolates: boiledsweets, mints, fruit jellies, toffees, cough sweets, chocolates, chocolate bars Sweet biscuits: cream biscuits, chocolate biscuits, shortbread, wafers etc Cakes: cream cakes, pastries, iced buns, doughnuts etc Desserts: fmit pies, sponges, milk puddings, jellies, ice cream, packet and tinned desserts, condensedmilk, fruit in syrup Fruit juice: pure fmit juices

Alternative

Tablet or liquid sweetener or cut out

Low calorie or diabetic squashes, low calorie minerals

Fresh fruit

Plain biscuits e Digestive, Rich Tea, Crackers, Gisp%reads

Scone, plain bun, extra bread

Fresh fruit, tinned fruit without sugar, stewed fruit without sugar, low calorie yogurt

Limit to 1 smallglass daily

High Fat Foods Alternative Fried foods, foods cooked in oil or fat

Chips, friedpotatoes, crisps

Fat on meat Butte6 margarine, cheese

Grill, use non-stick pan or other cooking methods without fat or oil Boiled orjacket potatoes, mashed potato. reduce crisps to2 to 3 packets per week Trim excess fat from meat Spread orslice thinlb reduce quantity

High Fibre foods Choice

White and brown breads

Breakfast cereals

Vegetables

Wholemeal bread, granary bread, high fibre white bread Weetabix, Shredded wheat, Puffed Wheat, muesli, bran cereals, porridge Pulses eg. baked beans, peas, potatoes in jacket

lick or circle the foods eaten and the alternatives suggested. File in patient‘s notes.

cose. Table 2 above shows a checklist of refined carbohydrate foods and alterna- tives to be used in the-first instance. This checklist would need to be adapted for regional and ethnic differences in food consumption.

Note that Stage I dietary advice, basic though it is. contains 15 categories of food with sublists, which the patient may possibly have to change.

DO NOT TELL THE PATIENT TO HAVE A SUGAR FREE DIET! The conscientious patient told to follow a sugar free diet goes to the supermarket and scans labels despairingly for foods without sugar. As a great many staple foods such as breakfast cereals contain sugar the choice is very limited. Our aim is to reduce the amount of sugar con-

sumed, not to eliminate it. The patient has encountered his first grey area: sugar is not banned - foods which contain small amounts of sugar are allowed but food labels show only that a food con- tains sugar not how much sugar it con- tains. Watch out for pick-me-ups and tonics the pafient may have been taking if feeling under par eg Lucozade, and for cough sweets and cough syrups. Exces- sive amounts of lemonade and soft drinks may have been taken to counter- act thirst. The pure fruit juices, now widely available, are also a source of rapidly absorbed carbohydrate.

If the patient is overweight then alter- natives to biscuits, cakes and desserts may not be necessary, they can simply be cut out.

Special diet products Diabetic cakes, biscuits and sweets

should not be recommended at this stage even if the patient is slim. The most valu- able advice you can give is to reassure the patient and his family that it is not necessary to rush off and buy special diabetic foods, many of which are expen- sive. It is unnecessary, especially since the nutritional advantage is so slight, to put the patient at such economic disad- vantage. Some diabetic products are use- ful for special occasions, but the dietitian will advise on this later in the light of other constituents of the diet.

Some of the most useful special pro- ducts are the low calorie drinks and fruits tinned without sugar which can be bought in most supermarkets.

Sweeteners Tablet and liquid sweetenes can be

recommended for drinks and for break- fast cereals (liquid sweetener can be added to the milk) but it is too early to go into the relative merits of bulk or nutri- tive sweeteners for use in cakes and bak- ing. Cakes and baked goods, even if they are made with sugar substitutes, are high in fat and energy and their intake may need to be limited.

Recipes Recipes and cookery books abound.

By all means reassure the patient that they will be able to adapt their favourite dishes and have appetising meals. For reasons stated earlier do not recommend cookery books or recipes at this stage.

Jams These are not usually a major source

of refined carbohydrate. Reduced sugar jams can be suggested as an alternative to diabetic jams. Some patients may be able to have ordinary jam. The dietitian will assess this in the light of other con- stituents of the diet. 0 If intake of refined carbohydrate foods is already low you should go no further on carbohydrates at this stage. You should inform the doctor straight away that dietary measures are unlikely to improve blood glucose levels.

Reducing fat intake Table 2 lists the measures which will

reduce major sources of fat in the diet. Detailed advice on milks, meats, cheeses, cooked breakfasts etc should be left for the dietitian’s interview when the relative proportions of these and other sources of fat in the patient’s diet will be taken into consideration.

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Review Articles Diabetic diet education

0 If the patient akeady has a low intake of the foods on the checklist then you need go no further on fats at this stage.

Increasing fibre intake Fibre is often equated with bran alone

and patients are advised to have lots of bran with no accompanying advice on fibre-containing foods. This could be related to fibre charts which list fibre con- tent of foods in descending order. Bran with 44g fibre per l00g not surprisingly appears at the top of the list. A more realistic listing in terms of portion sizes or quantities that could reasonably be consumed would rank the recommended daily dose of bran (two tablespoons) alongside a helping of baked beans. 2 tablespoons bran ( 15g)=7gfibre 1 serving of baked beans (1OOg)=7g fibre

Bran in its natural state is dry and chafflike, and is very difficult to swallow. It is most palatable added to porridge, yogurt, stewed fruit and foods of similar consistency. Exceeding two tablespoons daily can lead to bowel obstruction especially in elderly patients with a poor fluid intake. Patients with a poor fluid intake should not take bran.

Since fibre intake is linked to con- sumption of carbohydrate it will automatically be easier for a man on 2000kcal (250g carbohydrate) daily to have a better intake than a woman on 1500kcal (185g carbohydrate) unless pulses, dried fruit or bran cereals are consumed. Table 2 (previous page) lists readily available fibre-containing foods. 0 If the patient already eats most of the foods on the checklist you need go no further on fibre at this stage.

Regular meals What exactly do we mean by ‘eat regu-

lar meals’ and what constitutes a meal? National eating patterns are changing. We now eat more fast foods and the trend towards snacking and eating on the move, or as it is called in America ‘grazing’, is on the increase. Our patients’ experience of structured meals may be limited. We have to give our advice on eating regularly and avoiding long gaps without food in such a way that it does not sound like an invitation to non-stop nibbling

Using the checklist This checklist (Table 2 previous page)

covers major sources of refined car- bohydrate, fat and fibre. Use it like a questionnaire, working through the items on the left handside and marking off those the patient eats. You may find it useful to have pictures of selected foods (Ref4). A full dietary assessment is not necessary at this stage.

Now your patient needs advice on alternatives and written advice on what to do, ‘Diet and Diabetes - Just a Beginning’ produced by the BDA and available through your local dietetic department is intended as a first aid diet sheet. As you work through the alterna- tives for your patients on the right hand side of the checklist you may come across extra items to add on to the right hand side of Just a Beginning which makes it more personalised. Just a Beginning contains all the information necessary and the more succinct inform- ation is at this stage, the less likely you are to confuse the patient.

Stage II & 111 - detailed individual advice

The more complex dietary modifica- tions required in Stages I1 and I11 cannot be made without establishing the baseline, ie what the patient usually eats (or what he used to eat before the changes made in Stage I). However, patients diagnosed several weeks pre- viously will be unable to recall previous eating habits in detail. The checklist in Table 2 (previous page) solves this prob- lem by providing an easy method of recording dietary habits. The form can then be used as a vital piece of feedback for the dietitian and should be filed in the patient’s notes.

Detailed dietary assessment often, unfortunately reveals examples of inap- propriate dietary changes. Health pro- fessionals are not entirely to blame for patients’ confusion, but in view of the plethora of dietary advice available

today it is even mom important to ensure that we work together to provide consis- tent and accurate information, espec- ially within local teams.

The complexities at this stage of diet- ary education - the detailed investiga- tion of eating habits, the mopping up of misinformation, the recommendations on long-term change and the practical advice on how to achieve it - should be dealt with by the dietitian.

Dietary assessment In the course of a routine dietary

assessment, the dietitian will investigate aspects of the patient’s circumstances such as’ability to shop, cook and local facilities. The economic, cultural and religious factors affecting food choices are well documented, but it is easy to overlook more immediate practical problems which severely limit the range of foods eaten (Figure). From the house- bound elderly widow whose home help does the shopping, to the young man newly discharged from a psychiatric unit. living in a bedsit with one gas ring, such patients cannot choose foods freely. Health professionals in the community often have access to information on patients’ circumstances which if con- veyed to the dietitian will save time and help complete the picture.

The dietitian having completed the dietary assessment and considered all the factors affecting eating habits and the patient’s age. sex, job, weight etc will decide on the level of dietary change which is practical for the patient and instruct h idhe r accordingly. Patients

Figure Factors limiting food choices

Who does shopping? (Self, familF friends, home help) P

Who does cooking? (Self, family home help, work canteen, eating out)

I‘ Cooking facilities (Ring, grill, oven, cooker)

L

Location of shops W l k , stairs, transport, carrying heavy bags)

-1 Shopping facilities (Supermarkets, markets, small local shops)

r( Food storage

\ FooddMeals delivered (Meals on wheels, + (Cupboard, fridge, milkman) fieezer)

272 Practical Diabetes November/December 1987 MI 4 No 6

Review Articles

will be given a diet sheet with meal ideas and information on quantities of food. The diet sheet should carry the patient’s name, date and the recommended level of intake for the patient eg 150g carbo- hydrate/1200 kcal daily.

Assuming good instruction was received in Stage I, then most patients should have reached Stage I1 after two or three consultations. A few will take longer.

Note that some patients may never reach Stage I11 which deals with exchanges and sophisticated decisions on food choices. Some may not complete all the steps in Stage 111. This means that many patients will not be able to describe their diet in terms of grams of carbohydrate or calories. Nurses and doctors often take this as a sign that patients do not understand their diet. This is completely erroneous. Further questioning on what is eaten at different times of day will often show that the patient eats a careful, sensible diet. It is helpful, therefore, if the dietitian writes on the diet sheet details of the approxi- mate range of carbohydrate that the patient’s diet will contain - in this case for the benefit of other health profession- als. The patient should know that this is technical information about their diet which is useful for the various health pro-

fessionals they will come into contact with.

Exchanges To exchange or not to exchange - It is

often held that carbohydrate exchanges are far too complicated, especially for elderly NIDD’s yet over-simplified ad- vice such as ‘don’t eat too many sugary foods’ can cause just as much distress as poorly understood food lists. The recent introduction of menu coding for dabe- tics in hospitals has proved that many octogenarians can cope with a simplified exchange system. Patients who can’t cope with the carbohydrate exchanges system can usually be taught a simple sys- tem of swops, eg exchanges for one slice of bread. Otherwise they are con- demned to a rigid unchanging meal pattern.

Conclusion For a successful team approach to diet-

ary education it is essential to define the role of each health professional in giving dietary advice at different stages. Discus- sion and training will be necessary to arrive at the formula best suited to local needs. Good communication within diabetic care teams will help fo ensure clear consistent advice and avoid confus-

Diabetic diet education

ing the patient.

Acknowledgement To the Portsmouth team of dietitians

past and present for their contribution to the development of a more struc- tured approach to diabetic diet teaching; to Sue Cradock, Diabetic Nurse Specialist; Dr K M Shaw, Consultant Physician; and to Portsmouth’s ENB 928 course for nurses.

Notice Isle of Wight Conference on Computers in Diabetes Care

Once again the Isle of Wight confer- ence was thoroughly enjoyed by all and in spite of severe hangovers, most of us managed to concentrate on the interest- ing and excellently presented papers and the display of computer systems.

Thanks must go primarily to Dr Arun Baksi and his staff for the success of the conference, but also to Sealink who man- aged to get us all there in spite of hur- ricanes and to the superbly managed Cliff Tops Hotel who put up with us all.

A further report on the conference will be published in a later issue of Practical Diabetes.

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