Module 202.2 20_a_en_0

Editor's Notes

1. The following three presentations deal with Nutrition Therapy- they are divided into three sections: assessment, recommendations and education. Knowing and understanding a person’s nutritional status is the key to individualized dietary advice and to achieving optimal dietary and diabetes outcomes. Nutritional assessment helps to identify: Malnutrition (under and over weight) People at risk of developing malnutrition People at risk of developing other nutrition-related conditions/diseases, thus making it easier to prevent nutritional deficiencies or help people to overcome nutritional problems Eating patterns that result in poor glycaemic control and an increased risk of cardiovascular disease
2. The objective of nutrition therapy is to help people with diabetes learn how to make appropriate lifestyle choices. Once made, these can help people with diabetes achieve optimum metabolic control and prevent diabetes complications. Food choice, methods of preparation, portion sizes, meal timing, physical activity, inter-current illness – such as coeliac disease, delayed gastric emptying – all affect the diabetes treatment plan and play a role in achieving optimal diabetes outcomes. A behavioural approach to change should be used and acceptable quality of life maintained at all times.
3. The following three slides give overviews of large studies that have reported improved glycaemic outcomes and reduction in the complications of diabetes. These studies all discuss the importance of nutrition therapy as integral to diabetes management. This landmark study in type 1 diabetes confirmed that reduced HbA1c levels lead to decreased diabetes complications. Despite employing a variety of dietary methods – carbohydrate counting, weighing foods, exchange lists, etc – the main result of DCCT was to demonstrate that only four behaviour-related factors improved glycaemic control (as measured by HbA1c). These are presented on the slide. Approaches to consultation and communication with people with diabetes also influenced outcomes; participants achieved deeper understanding of the relationship between food and insulin. Relationships between dietitian and participants were strengthened through: Behavioural approaches Regular follow-up (allowing constant review of treatment goals between participant and dietitian) Additional information Total participants = 1441 people with type 1 diabetes; 726 of whom had no complications at baseline (the primary-prevention cohort); 715 of whom had mild retinopathy (the secondary-intervention cohort) and were assigned to either intensive therapy (the experimental group) or conventional therapy (the control group). Participants were followed for an average of 6.5 years, during which time appearance and progression of retinopathy and other complications were assessed regularly. Intensive therapy effectively delayed the onset and slowed the progression of diabetic retinopathy, nephropathy, and neuropathy in people with type 1 diabetes. DCCT Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med, 329(14), 977-86. Delahanty L.M., Halford B.N. (1993). The role of Diet Behaviours in Achieving improved glycaemic control in intensively treated patients in the Diabetes Control and Complications Trial. Diabetes Care, 16(11),1453-58.
4. The UKPDS represents a landmark in the study of type 2 diabetes. Like DCCT, it showed that improved diabetes outcomes could be achieved by improving glycaemic control. The two groups in this trial were given either intensive therapy (using sulphonylurea or insulin) or conventional therapy plus diet. Results of the trial – conducted over a 10-year period – showed that: The intensive group developed improved glycaemic control (HbA1c 6.2-8.2%) compared with the conventionally treated group (HbA1c 6.9-8.8%) Improved control of hypertension – a result of the intensive therapy – led to a reduced risk of long-term diabetes complications. Additional information Total participants = 3867 newly diagnosed people with type 2 diabetes. A pre-trial 3-month period of diet treatment led to a mean fasting plasma glucose concentration of 6.1-15.0 mmol/L. Participants were randomly assigned to either intensive therapy, or conventional therapy (+ diet) groups. UKPDS Group. (1998). Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). [erratum appears in Lancet 1999 Aug 14; 354(9178): 602]. Lancet, 352, 837-53.
5. DASH (Dietary Approaches to Stop Hypertension) showed how dietary intervention could significantly reduce a major cardiovascular risk factor – hypertension. Following a control period (see below), DASH participants were randomly assigned to the following diet regimes over an 8-week period: Control diet (low in fruit, vegetables, and dairy products, with a fat content typical of the average diet in the USA) Diet rich in fruit and vegetables “Combination’” diet rich in fruit, vegetables, low-fat dairy products, and with reduced saturated and total fat Sodium intake and body weight were maintained at constant levels Results: the diet rich in fruit, vegetables, and low-fat dairy foods – and with reduced saturated and total fat – substantially and significantly lowered blood pressure. Additional information Total participants = 459 adults with systolic blood pressures of less than 160 mmHg and diastolic blood pressures of 80 to 95 mmHg. Prior to the test period, all participants were fed, for 3 weeks, a control diet that was low in fruit, vegetables, and dairy products, with a fat content typical of the average diet in the USA. Appel, W., Moore, T.J.,Obarzanek, E., Vollmer,V.M., Svetkey, L.P., Sacks, F.M., et al. DASH collaborative research group. (1997). A clinical trial of the effects of dietary patterns on blood pressure. N Eng J Med, 336, 117-24. Sacks F.M., Svetkey L.P., Vollmer W.M., et al. DASH-Sodium Collaborative Research Group.(2001). Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med, 344(1), 3-10.
6. The information below is presented as a series of recommendations (not guidelines) based on position statements from the following organisations: - American Diabetes Association (ADA) - Canadian Diabetes Association (CDA) - Diabetes Australia (DA) - Diabetes Study Group of the European Association for the Study of Diabetes (EASD) - Diabetes UK (DUK) The main principles of nutrition therapy or management are: To provide energy and nutrients for health, growth and development To preserve people’s social and psychological well-being To reduce the symptoms of diabetes, i.e. to achieve and maintain target blood glucose values and prevent hypoglycaemia and hyperglycaemia
7. To attain and sustain “acceptable’” body weight – no longer referred to as ideal body weight. This refers to a weight which is reasonable and achievable in the short term and can be maintained in the long term. The weight target should be set collaboratively by the person with diabetes and the health team. Nutrition therapy aims at reducing the risk of micro- and macro-vascular complications in people with diabetes. An example of this is the relationship between dietary factors, HbA1c and diabetes complications. It also aims to integrate nutrition therapy with activity patterns and pharmacological treatment (glucose-lowering medicines and/or insulin therapy) of people with diabetes.
8. People with diabetes not only need to understand their condition but also learn various skills, such as assessing food intake, making appropriate food choices, learning how to solve problems, etc. The person-centred approach begins by: Assessing the individual – taking into consideration the social situation (status, family and friends, environment, work, etc) – and doing a nutrition assessment Assessing lifestyle issues – understanding the person’s readiness to change behaviour (if needed) – and negotiating a management plan that will achieve target glycaemic control and reduce the risk of micro- and macro-vascular complications
9. Identify (brainstorm as a group, in pairs or individually) all factors that influence dietary intake and discuss each point in brief. A nutritional assessment forms the basis of the process of nutritional education and its personalised adaptation. An assessment of nutritional status consists of several components: 1. Health status – physical and mental 2. Dietary intake and food availability 3. Physical activity 4. Learning capabilities and current knowledge 5. Lifestyle – work, leisure and daily routine 6. Ethnic/cultural/social/economic background 7. Readiness to change behaviour 8. Oral health (whether they can chew their food)
10. The second assessment is a clinical assessment. If facilities are available, a full blood screen would be useful – laboratory tests, such as blood glucose, lipid levels, haemoglobin, creatinine, for example. This will provide a comprehensive assessment to screen for complications such as cardiovascular and kidney disease. Finally, it is essential to understand and document the effects of the person’s complete treatment plan, including medication – type, dosage, timing, etc – and any nutritional supplements.
11. It is important to assess whether the person’s weight falls within accepted parameters. The anthropometric measurements of body weight and height commonly help to calculate any “deviation’” from the acceptable weight. 1. Recording body weight Weight is the most important anthropometric measurement. Weighing scales should be checked regularly for accuracy. In people with type 2 diabetes, body weight is often higher than it should be; discussions about weight should be conducted with sensitivity. A negative consultation is unlikely to produce positive behavioural changes and weight loss. To provide any meaningful direction, it is important to always consider body weight with height. 2. Recording height Height is best measured using a wall-mounted stadiometer. The person should be standing barefoot, feet together, with the head, shoulders, buttocks and heels touching the wall. The plane of the ear, mid-point of the hipbone and ankle should be in line (i.e. standing to attention). 3. Waist circumference is also an anthropometric measure. Waist measurement can be taken with a tape measure in a horizontal plane midway between the inferior margin of the ribs and the superior border of the iliac crest.
12. Weight and height measurements are used to calculate Body Mass Index (BMI) – also known as the Quetelet Index. This is calculated using the following formula: BMI = weight in kg/(height in m)2 BMI helps to define overweight and obesity using standard nomograms (see slide). The classification of overweight and obesity in terms of BMI varies depending on ethnic origin. In some continents, such as Asia, a BMI of 23 and above is classified as overweight. Guidance on variations around the world can be found on the IDF website at www.idf.org. BMI may overestimate body fat in people who have a muscular build such as athletes. And it may underestimate body fat in older people and those who have lost muscle mass. It is important that you and the person with diabetes agree on what is a desired or acceptable weight for the person.
13. Body shape has been found to be important when predicting a person’s risk of cardiovascular disease and metabolic conditions. Abdominal fat is an important risk marker for cardiovascular disease and type 2 diabetes. People may be considered to be at high risk when the WHR is ≥0.9 cm in men and ≥0.8 cm in women. The waist-to-hip ratio (WHR) can be used to identify people as either pear- or apple-shaped. People with a pear-shaped body have a low WHR and are at a lower risk from cardiovascular complications, compared to people with an apple-shaped body. WHR is also called Abdominal Gluteal Ratio (AGR). Central obesity is defined by IDF as a waist circumference for Europid men≥94 cm and for Europid women≥80 cm; For South Asians, Chinese, Japanese men > 90cm and women > 80cms IDF. (2006). The IDF consensus worldwide definition of the Metabolic Syndrome. Brussels: IDF
14. It is essential that healthcare providers perform a nutrition assessment so that advice can be tailored to individual needs and lifestyle. If an individual assessment is not carried out, it is unlikely that the guidance provided will meet the needs and goals of the person with diabetes and it is unlikely that it will be followed. Labelling a person as ‘non-compliant’ is never appropriate. When preparing a nutritional plan, the first step is to consider current dietary habits and nutritional requirements. Retrospective methods, for example taking a diet history or 24-hour recall, show a 15%-20% deviation from the person’s actual intake. This method is useful to give an idea of the normal meal pattern and food habits of a person, but it cannot be used to assess nutrients. It is helpful to do a dietary recall for 2 days, a week day and a weekend day, or a work day and a day off work as activities are often very different. Leading questions should be asked to help people recall their food intake during a normal day. The frequency of intake of certain foods and cooking methods should be documented. These simple methods help the healthcare provider to focus their advice based on the person’s actual food intake.
15. Ask for or check: Food pattern on a usual day Size of portions at home Daily/weekly/monthly purchases Eating out and take-away – frequency Food favourites – self and family Food choices, e.g. skimmed or whole milk Hunger patterns Taking a dietary history requires a number of skills and can be very time consuming. A check-list will help to keep the consultation focused and facilitate the preparation of an individual diet plan to suit the person’s needs. As well consider the person’s response to stress, do they binge eat or starve. Counseling for dealing with these situations should be included.
16. Try to think of other issues that need to be considered. For example: Information may be with held (i.e. about certain unhealthy foods) Information about changes in dietary patterns (i.e. holidays) is not included
17. Detailed dietary assessment methods are often used if information on specific nutrients are required or as clinical tools for research. Food frequency questionnaire The person is presented with a list of foods and asked how often each food item is eaten (times per day, per week, per month, etc). The questionnaire may be administered by the interviewer or completed by the person. An assessment of the quantity of each type of food consumed may also be included. 2. Prospective food records There are different types of such records: a record of the food and drink actually consumed or an estimated record. A three-day food record is believed to give a reasonable indication of a person’s intake of energy, protein, carbohydrate and fat. It should be noted that after three days, the accuracy of the food record may decrease. 3. Weighed food records This prospective method of dietary assessment often involves precise weighed records of every food and drink item consumed, including all the ingredients used in the meals, the amount of edible food wasted and the cooked weight of food, etc. However, this method depends on the participation of highly motivated people to complete records accurately. Therefore, seven-day weighed intakes are often used only in research studies. This method is not required for normal clinical practice.
18. Before planning the treatment options, it is important for the healthcare provider to analyse all the collected assessment data and prepare a mutually agreed management plan. The following items should be considered before a treatment plan is finalized: What are the potential nutrition-related problems? Is a long-term dietary change needed? What lifestyle change is required? Is the person ready to change behaviour? What will help motivate the person? Is the person prepared to change if needed? Can the person receive support from family, friends or community services? How to begin the nutrition education process?
19. In addition to the target metabolic outcomes certain additional outcomes need to be considered for children, pregnant women and the geriatric population.
20. Detailed assessment is essential to provide an individualized nutrition care plan. Assessment includes: Health status Dietary intake Culture Socio-economic background Lifestyle Readiness to change There are a variety of dietary assessment methods: Simple: diet history and diet recall Complex: food frequency, food diaries The nutritional needs of special groups must always be considered.