Overview

• The emphasis of modern diabetes care is on self-management, which is appropriate for the majority of patients

• People living with diabetes vary enormously in their individual needs and expectations

• Patients and clinicians should work together to set priorities, define targets, and overcome barriers to quality of life diet, but in so doing risks the impression that no therapeutic intervention has been offered at all at diagnosis. This must be avoided through dietary assessment and education, including written materials, and not simply brief verbal 'eat a healthy diet' advice.

Box 10.1 What does this mean in practice?

• Use complex carbohydrate as the main energy source rather than fat or protein

• Avoid 'filling up' with fatty foods such as cheese or meat containing high saturated fat levels

• Eat fish, especially oily fish, once or twice a week

• Use olive oil or rapeseed oil in cooking

• Keep sugar to a minimum especially if overweight, although it does not need to be excluded entirely

• Artificial sweeteners are recommended for the overweight and those with hypertriglyceridaemia

• Eat five portions of fruit or vegetables daily

• Restrict salt, which is often present in processed foods

Introduction

The clinic consultation is a valuable but very brief window of opportunity for advice and reflection on progress towards treatment targets. New technologies have increased the availability of clinician advice to patients in ways not foreseen a generation ago. But for the majority of the time patients make their own hour by hour decisions about what to eat, how much insulin to take, and how to adapt this to immediate needs including exercise requirements. Clinicians need to encourage patients to learn self-management skills.

Important issues for the individual include: What should I eat? How should I self-monitor andhow frequently? How can I interpret and act on the results of my blood tests to improve control? How can I exercise effectively and safely, to encourage weight loss and improve my health?

What should I eat?

Advice on diet has undergone several significant revisions in the past thirty years. The most recent consensus document was published in Diabetic Medicine in 2003 by Connor et al. By and large people with diabetes should be encouraged to eat a similar healthy diet as recommended to the general population. However, many patients are unclear about what this actually means in practice (Box 10.1). Patients may believe that they are already eating a healthy diet despite being seriously overweight. The modern approach aims to induce sustainable life-style changes, and avoids the term 'diabetic

Recommended dietary management for people with diabetes (adapted from Connor, see also Box 10.1)

• Less than 35% of overall energy intake should be made up of fat

• Saturated and trans-unsaturated fat should make up <10% of energy intake

• Daily protein intake should be <1 g/kg of body weight

• 60-70% of total energy intake should consist of carbohydrate and cis-monounsaturated fat

• Up to 10% of overall energy can be in the form of simple carbohydrate (including sucrose) but only in the context of a healthy diet and in the overweight this may prevent weight reduction

• Soluble fibre has beneficial effects on glycaemia and lipids

• Insoluble fibre does not affect glycaemia or lipids but may improve satiety and thereby assist in weight loss

• Encourage foods naturally rich in vitamins and antioxidants -supplements are not usually necessary and in some situations might be harmful

• No more than 6 g sodium chloride daily

Glycaemic index

Patients may have heard about 'Low GI' diets and wish to try this approach. The glycaemic index (GI) is a measure of how quickly the blood glucose will rise in response to an ingested carbohydrate source. Complex carbohydrate sources have a lower GI than simple sugars. Lists are available of the GI of several hundred foods. There is some evidence that such diets can assist in glycaemic control by smoothing blood glucose fluctuations and improving satiety, assisting in weight loss. However, the measurement of glycaemic index is problematic, and foods may affect glycaemia inconsistently, depending for instance on the other foods consumed. Patients may develop misconceptions about the best food options, and avoid potentially healthy food rich in nutrients such as root vegetables. Low GI diets are therefore not recommended for general adoption, as they do not add much to the standard advice, which also recommends complex carbohydrate as the major energy staple.

Modern nutritional management

The modern focus is on encouraging an interesting, varied diet with regular intake of complex carbohydrate (CHO). Even though such CHO is calorific, it is much less so than an equivalent weight of fat, and tends to satisfy the appetite more effectively as it will be absorbed over a longer period of time. Simple sugars should be kept to a minimum, as they should in the health conscious individual who is aiming to avoid getting diabetes in the first place, but are not completely disallowed and they may in small amounts make the diet more appealing.

The challenge is to reduce calorie intake in a sustainable way, and avoid 'yo-yoing' - as discussed in Chapter 3. For some patients, there is no risk of yo-yoing as the weight simply does not alter following the initial advice. For such patients, a review of the dietary regimen and the written advice provided is necessary. Referral to a dietician may be beneficial (see Box 10.2) and is recommended for all patients at diagnosis.

• Fruit is recommended on a regular basis, but fruit juice is surprisingly high in carbohydrate and calories as it is often made from concentrate

• Muesli is generally considered a healthy food, but often contains a lot of sugar and raisins that are a very concentrated form of carbohydrate, and unlike some other foods that may be taken occasionally, muesli is eaten every morning by some patients. A bowl of shredded wheat or some wholegrain toast are preferable as regular alternatives

• Patients sometimes take away with the 'healthy eating' message an assumption that drinks such as cola and lemonade are 'healthier' than their low calorie equivalents, as they are less likely to contain artificial ingredients. In fact such drinks are loaded with simple carbohydrate and their exclusion may help very significantly in reducing calorie intake, and blood sugar levels. Some patients may have been self-treating the thirst of hyperglycaemia with these drinks prior to diagnosis. Low calorie alternatives containing no carbohydrate at all are now widely available and generally safe. (The exception is that people with phenylketonuria should avoid aspartame, which contains phenylalanine)

• Food should remain interesting. A simple piece of advice is to encourage patients to ensure their plate contains foods of several different colours (a 'rainbow', see Chapter 20)

• Salad foods are available all the year round, and should not be viewed as exclusively a summer option

• Whilst most foods can be taken at least 'occasionally', there is a danger that patients may consume a different 'occasional treat' item on each day of the week, believing (correctly, in a sense) that they have followed the advice. This may be one reason why a patient fails to lose weight

• Processed foods including sauces often contain a lot of added salt, which manufacturers know will make them more likely to sell. The 6 g/day limit is on sodium chloride, and this equates to 2.4 g of sodium, as salt is only 40% sodium. This is important, as manufacturers often give the content simply as sodium, which does not sound as high

Box 10.2 The need for all to understand basic dietary principles

Dieticians have an important role to play in the team management of diabetes, including the education of patients requiring accurate carbohydrate counting, and for patients with renal failure, coeliac disease, and other conditions often associated with diabetes. However, for many uncomplicated type 2 patients this need not be regarded as a specialist area of dietetics. Doctors, nurses and other professionals must feel able to reinforce the recommended advice. Familiarity with the principles of a healthy diet and the ability to translate this into practical meal suggestions should be within the toolkit of all health professionals. The entire team should have access to the same printable educational material so that a consistent message can be provided repeatedly if needed. Online resources have helped a lot in facilitating this (see Chapter 20)

A few additional points of advice may be helpful to supplement the 'healthy eating' message:

Alcohol

Alcohol is not excluded in diabetes, and in moderation carries some cardiovascular benefits, but the following issues are very important:

• Many alcoholic drinks are highly calorific, partly because the alcohol itself is so, even when not combined with sweet ingredients

• Sweet alcoholic drinks include sherries and liqueurs, which not only contain calories but also sugar that is likely to raise blood glucose levels

• The same applies to beers, even 'bitters', particularly the darker ones

• Lagers, or dry wines in strict moderation are therefore preferable

• Intoxication with alcohol may impair an individual's ability to control their diabetes, for instance through their decision making over carbohydrate intake and insulin doses

• Alcohol may mask the symptoms of hypoglycaemia - the patient who is actually hypo may not receive assistance as it is clear they are intoxicated

Figure 10.1 Alcohol should be taken only with awareness of the risks, which are higher in those with diabetes. Reproduced with permission from Getty Images.

• Alcohol directly impairs the metabolic response to falling blood glucose

• Alcohol interacts with sulphonylureas to increase the risk of hypoglycaemia

• A combination of hypoglycaemia and alcohol intoxication puts the patient at risk of a seizure

Individuals who wish to take alcohol need to be aware of all of these issues. A particularly dangerous situation is where insulin is taken at a social event, as well as alcohol, followed by delay in the arrival of the meal, leading to severe hypoglycaemia that is not recognised early enough by the intoxicated patient or his/her companions. It is often at social events where the individual loses control of meal arrangements (content and timing), and at the same events alcohol is frequently on offer (Figure 10.1).

Should I self-monitor?

In the UK, there is a national funding issue over self-monitoring, as testing strips are still quite expensive and are prescribed under the NHS. Most patients with diabetes get free prescriptions, and the cost of this activity is therefore borne largely by the state. In countries without such a system, the cost is likely to fall on the individual, and any benefits may then add to health inequalities between socio-economic groups.

In selecting patients likely to benefit from self-monitoring, the following issues should be considered:

Treatment regimen: Those taking insulin (particularly type 1 patients) are far more likely to benefit than patients treated with life-style measures alone or oral medication, for reasons discussed below. Type 1 patients are generally recommended to monitor at least twice a day. The DiGEM study (Farmer etal. 2007) found that self-monitoring in people with non-insulin treated type 2 diabetes not only failed to improve glycaemic control, but also failed to improve psychological parameters such as quality of life

Symptom awareness: Some patients are better than others at predicting their current blood glucose level without monitoring, and may be able to predict whether it is likely to be rising, falling or static. Those who have lost hypoglycaemia awareness are particularly dependent on frequent monitoring. Others may tend to mistake normal symptoms (e.g. of hunger or anxiety) for hypoglycaemia

The need for flexibility: For some patients, flexibility in carbohydrate intake and exercise is required for their life-style, which might include frequent international travel, night-shifts, or unpredictable delays in mealtimes. Such influences should not be encouraged as they are likely to be disruptive, but if they are unavoidable then frequent monitoring combined with appropriate adjustments may maintain stability. Patients driving for long distances and at any risk of hypoglycaemia should generally monitor before setting off and every 90 minutes during the journey. For patients wishing to fast during Ramadan, self-monitoring is often recommended during this period

Response to abnormal results: It is part of the personality of some patients to 'over-react' to abnormal results. Such individuals, unless they can 'retrain' this tendency, are at risk of 'tampering,' i.e. of worsening rather than improving control as a result of the monitoring. It is sometimes possible to identify such a predisposition among the behaviours of the patient in other areas of their life

Other psychological issues: 'Learned helplessness' is a potential psychological effect of self-monitoring in the patient who has not been taught (or is unable to learn) to respond appropriately to self-monitored results. It is in a sense the opposite of self-efficacy. Unexpected fluctuations become perplexing and demoralising. This may reduce quality of life and can easily result if self-monitoring is recommended with no training in responding behaviourally to the results

Continuous glucose monitoring devices

Figures 10.2 and 10.3 represents a profile from a type 2 and a type 1 patient respectively, using a continuous glucose monitoring device taking subcutaneous glucose measurements every 5 minutes for 72 hours. A subcutaneous probe is inserted under the skin. Such devices are now available to allow patients and clinicians to explore underlying patterns in blood glucose profiles, but the technology is still quite expensive for routine use.

How should I use my blood glucose results to improve control?

Chapter 3 discussed the now established principle ofpatient autonomy, in succession to the more paternalistic approach of the past. This paternalism arose at a time when self-monitoring at home was not a practical proposition - the technology had simply not been invented. Patients depended much more on a doctor's advice to achieve glycaemic control, and might need admission to hospital to

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Figure 10.2 Profile from a patient with type 2 diabetes treated with metformin only. Fluctuations are relatively small and the fasting level is very similar on each of the days sampled. Reproduced from Medtronic.

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Figure 10.2 Profile from a patient with type 2 diabetes treated with metformin only. Fluctuations are relatively small and the fasting level is very similar on each of the days sampled. Reproduced from Medtronic.

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