juice at mealtimes to ‘make up’ my set exchanges because I couldn’t fit another mouthful in.
I was repeatedly forced to snack when not hungry to avoid hypos, often unable to eat with everyone else because it wasn’t the right time for my set diabetes regime.
Cakes, chocolates, biscuits, etc. were of course strictly forbidden, as was any food containing added sugar, including baked beans!
This made parties, sleepovers and canteen lunches difficult and, although allowed the indulgence of ice cream, it was only once a week and if my blood glucose levels were well controlled.
Thankfully things have now changed.
As a dietitian I have lived and worked in Australia, the USA and the UK and have noted variations in the nutritional recommendations given by dietitians and diabetes specialist nurses in their everyday practice.
Essentially, the same dietary information is given, but the emphasis varies considerably.
Speaking in very general terms, the nutritional focus in the UK is on very good but quite general ‘healthy eating’ advice using the plate model, such as reducing saturated fats, increasing fruit and vegetable intake, increasing fibre, moderating refined sugar and salt, and so on.
Only small consideration is given to the carbohydrate content of foods, at least from the patient’s perspective.
In Australia, similar approaches are taken to healthy eating using the food pyramid, but with a much greater emphasis on glycaemic index.
In many centres in the USA, more time is devoted to estimating the carbohydrate content of foods/carbohydrate exchanges and how this relates to the need for varying insulin doses at meal times.
Although ‘healthy eating’ concepts are discussed, there is a much smaller emphasis given to the glycaemic index.
Although we are all clear on many aspects of diabetes nutrition guidelines, such as the need to reduce fat intake in relation to heart disease, there are still many aspects upon which the jury is still deliberating.
For example, should we be teaching patients in depth about how to estimate the carbohydrate content of foods and hence deliver variable amounts of insulin based on what and how much is eaten.
Here in the UK, the development of new insulins and insulin delivery systems such as pens and infusion pumps is fuelling a returned interest in the need to teach patients about the carbohydrate content of foods.
An ongoing interest in the glycaemic index is also being seen, and how it can be applied in a practical way to the nutritional management of all types of diabetes.
Further discussion of these issues is included elsewhere in this book.
The best way of course to achieve consistency in diabetes nutrition recommendations is to carry out research.
I believe it is important to remember that demonstrating the effectiveness of nutritional advice by assessing improvements in diabetes outcomes is not enough.
We need to go further and ask ourselves whether or not people with diabetes are willing and able to follow our recommendations in the long term.
This is a subject which continues to fascinate me, as I know that I did not always follow the advice given to me when I was growing up with diabetes.
Why?
A scientifically proven approach may well deliver the desired outcomes in a controlled clinical
50 NUTRITIONAL MANAGEMENT OF DIABETES MELLITUS
environment, but is it simple to apply in the real world and does it make a notable difference to diabetes control and perhaps more importantly quality of life? Assuming that you do not have either the time or resources to carry out your own clinical research, the time-tested approach of talking and listening to your patients can provide you with valuable information. The point here is that dietary advice is not a ‘one size fits all’ approach. The type and complexity of information given, how and when it is delivered will depend on the individual, the resources available to you and your professional judgement.
. Don’t rattle off the same piece of information to all of us, based on your own agenda. Make sure it is relevant to us, otherwise we see little point in following your advice or returning to see you. . Dietitians are often not very realistic or practical. Talk to us about our everyday foods and how we can still eat the things we enjoy every now and again while maintaining our diabetes control. . Remember to listen. . Question tradition.
As a dietitian who also has diabetes, what nutritional guidelines do I now use to manage my own diabetes?
I believe I have taken the best from all I have learnt about food and diabetes over the years.
I have not always followed ‘current thinking’ on nutritional guidelines, but rather I have used what works for me.
I started insulin pump therapy five years ago to improve my glycaemic control and introduce greater flexibility to my daily life.
I have therefore moved away from the strict ‘sugar-free’ diet that I followed on diagnosis, to what I think is a much more healthy and balanced approach to food and nutrition.
I generally follow ‘healthy eating’ guidelines but occasionally have a sugar and fat-loaded treat.
I estimate the carbohydrate content of foods, which allows me to adjust my insulin doses according to what and how much I feel like eating.
I also use the glycaemic index to fine tune the way I deliver my food bolus, such as split or extended boluses and during exercise.
I remember very clearly during my dietetic training an eight-year-old boy, Josh, who was admitted to the children’s ward with ketoacidosis.
I spoke in great detail with Josh and his mum about juggling diet and insulin doses and answered their many questions about what he would be able to eat.
After spending some time with them, his mum became quite upset.
I told her that I had diabetes and her attitude seemed to change.
The next day, I returned to the ward to review what we had spoken about.
As I walked onto the ward, I remember hearing Josh’s mum say to her friend, proudly and with enthusiasm, ‘There is Josh’s dietitian , she also has diabetes’.
I don’t routinely tell all the patients I see that I have diabetes, but for many patients it can be beneficial.
Having diabetes has allowed me to
DIETITIAN AND DIABETIC: THOUGHTS ON DIABETES 51
Gain a greater understanding and acceptance of patients when they do not follow the advice I give them, e.g. testing blood sugars or following dietary advice.
This makes it less frustrating for me, and the patient usually feels less judged and better understood. .
Recognise in patients what they do not always recognise in themselves, e.g. denial, fear, anger, etc. .
Empower and inspire patients, ‘If you can do it, then I can too’ (you don’t need diabetes to prove this, try following your own dietary guidelines coupled with saline injections for a week). .
Address, in small and subtle ways when appropriate, the emotional aspects of living with diabetes. .
Do not forget that there are many aspects involved in managing diabetes and that for many patients food and nutrition is not always the first priority. .
Realise that patients not only need information, they also need support, even if they don’t admit or show it.
I firmly believe that all health professionals without diabetes can achieve this kind of empathy by working towards understanding their patients and believing that they can make a valuable contribution to the quality of life of people with diabetes.
As someone who has lived with and cared for people with diabetes, I would encourage you to teach them the necessary knowledge and skills to manage their own diabetes on a day-to-day basis, so that they take responsibility for their own health.
Consider all aspects of diabetes not just the nutritional issues, so that you give your patients the best possible care.
Ask questions and listen.
I have tried to share with you some of my ideas and I realise that my experience is not that of all people with diabetes, but I hope this has enhanced your understanding and inspired you to give your patients the information and care they need to live a long and healthy life with, not despite, their diabetes.
I wish you all the best in educating and caring for people with diabetes.
The Nutritional Management of Children’s Diabetes SHERIDAN WALDRON,1 PETER SWIFT,2 LINDSEY OLIVER3 AND DEBORAH FOOTE4 1Leicestershire Nutrition and Dietetic Service, Leicestershire, UK 2Leicester Royal Infirmary Children’s Hospital, Leicester, Leicestershire, UK 3NorthTyneside General Hospital, NorthTyneside, UK 4Royal Prince Alfred Hospital, Camperdown, NSW, Australia
INTRODUCTION
There is considerable consensus on the nutritional management of children and adolescents with diabetes, which has been brought together in the ISPAD Consensus Guidelines 2000 (1), having initially evolved from adult nutritional recommendations (2,3).
Effective nutritional management for children and adolescents with diabetes is important not only for glycaemic control but also for long-term cardiovascular risk prevention in a group particularly susceptible to future heart disease (4,5).
To achieve these nutritional objectives paediatrically trained dietitians with experience in diabetes are essential (1,6).
The assessment and management of the nutritional needs of diabetic children is both skilled and complex, requiring an understanding of childhood and adolescent psychology and family dynamics alongside a detailed knowledge of diabetes care.
Simply transferring knowledge is not enough as effective management requires motivating behavioural changes, which is more difficult in the young than other age groups, especially in adolescence, when adherence to all aspects of their diabetic care is poor (7).
This makes negotiation and compromise essential tools.
Nutritional Management of Diabetes Mellitus. Edited by G. Frost, A. Dornhorst and R. Moses & 2003 John Wiley & Sons, Ltd. ISBN 0 471 49751 7
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The safety and quality of life of children and adolescents with diabetes must not be compromised while trying to achieve the nutritional objectives outlined above. Consideration therefore needs to be given to an individual’s:
. age . lifestyle . culture and beliefs . food preference . eating patterns . food availability . financial circumstances