Dietary advice will form the backbone of a diabetic's future management and it is therefore crucial to get the right message across from the outset. Poor information delivered early in management can have adverse short, and long-term effects, and should be avoided. The aims of dietary advice should be to minimize symptoms of hyperglycaemia, minimize the risk of hypoglycaemia, and to promote weight loss, while ensuring that any proposed changes are tolerable and sustainable (Frost et al., 1991). Remember that in encouraging the patient to make (possibly) substantial changes to their dietary intake you will be asking them to change life-long habits, to stop doing things they enjoy (and perhaps replace with less-well-received alternatives) and will at first appear to be asking them to make changes that will diminish their ability to socialize with family and friends at the dinner table and on special occasions. For most new diabetics, but depending on the severity of their glycaemia, it is perhaps best to keep the message simple at first, to avoid alienation or confusion.
Dietary changes should modify, rather than totally change the patient's eating pattern. Total calorie intake should be restricted to that needed to achieve and maintain an agreed target weight. At least half the energy intake should be made up of carbohydrate, and from mainly complex carbohydrates, with a high fibre content. At least five portions, and preferably more, of fruit and vegetables should be consumed every day (a portion is 80 g but is most simply measured as one handful), refined carbohydrates in the form of sugary food and drinks should be reduced. Total fat intake should be reduced, and saturated (animal) fats replaced with monounsaturated and polyunsaturated fats commonly found in oily fish and green leafy vegetables (Royal College of General Practitioners, 1994). Dietary salt should be reduced, alcohol intake should be in moderation, and special 'diabetic' products which are high in calories are not to be recommended. Much can be achieved from a few simple dietetic changes.
Over the next few appointments, and depending on the symptomatic and glycaemic response, advice can begin to specifically promote weight loss, to include detailed information on reducing portion sizes, reducing calorific intake by 600 kcal (or 20 per cent) daily, calorie calculations for specific and favourite foods, and steps to maximize the potential for a daily intake of at least five portions of fruit and vegetables, an increase in dietary protein and fibre, a reduction of fat intake to less than 10 per cent, and moderation of carbohydrate intake to 50 per cent of calorific intake. Although it may sound rather simplistic, asking the patient to complete a 'food diary' for 1 week can provide both the clinician and the patient with invaluable information. In the absence of a pre-printed diary form, a simple A4 piece of paper, marked off into days of the week will suffice. By the end of the week the patient will usually have begun to make some changes as they confront their previously unrecognized, or unacknowledged habits. Comments such as 'I never realized I ate so much between meals', or 'I wasn't aware that I used so much sugar in my tea over the course of the day' are not unusual when the patient presents the diary. For those patients whose diaries are awash with high sugar, high fat foods, and frequent snacking, it is best to select only a few possible changes to suggest to the patient, the ultimate choice of what to alter resting with the patient. A repeat food diary after a few weeks will present further opportunity assist the patient in refining their intake even further. Some patients will want to become expert in managing their diet, to facilitate weight loss, and to exert maximum control of the diabetes. The general practitioner and nurse can be a useful source of information material to aid patient education, by using published healthy eating leaflets and manuals.
For those general practitioners or nurses who lack experience or confidence to advise new diabetics on dietary matters, referral to a community based dietitian is essential. An experienced dietitian is ideally placed to provide detailed, but pragmatic dietary advice to facilitate an immediate improvement in symptomatology, but also to promote long-term dietary control of diabetes. Community dietitians are unfortunately an uncommon commodity in practice but when available to the primary care team the value of their contribution can be immense.
The role of the practice receptionist is all too often overlooked. Whilst not directly involved in patient care, they are usually closely involved in administering practice-based diabetic clinics and administering annual examination recall systems and encouraging patients to attend. An informed and enthusiastic receptionist can play a significant role in ensuring patients receive the clinical care they require, by being alert to previous non-attendance and under-use of regular diabetic medication, and responding positively to requests for consultations by the patient. The receptionist team can also play a significant part in developing obesity management services in primary care. The National Obesity Forum's annual Award for Excellence in Obesity Management in Primary Care (Lean et al., 1991) receives entries from many excellent practice-based weight-loss programmes (incorporating diabetic management) which have been initiated, and run, by the receptionists, who have then gone on to enthuse and involve the rest of the primary care team in the practice.
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