1. Grace Neal (RD) Diabetes Dietitian
Diet & Diabetes
Grace Neal (RD)
Diabetes Dietitian

2. Nutritional Intervention
Help patient to make appropriate food choices to:
- reduce risk
- Improve glycaemic control
- quality of life.
Advice needs to be based on scientific evidence and then tailored specifically for the individual, taking into account their personal and cultural preferences, beliefs, lifestyle and the change that the individual is willing and able to make.
Reduce risk – complications associated with diabetes
Improve glycaemic control – decrease symptoms
Role of dietitian is to translate scientific knowledge into layman terms
*Negotiating*

3. No magic wand
However, regardless of how much input and energy you give we do not have a magic wand – a patient will only make changes if they are will to make changes

4. Guidance Used
Evidence-based nutrition guidelines for the prevention and management of diabetes – May 2011, Diabetes UK
Hertfordshire Diabetes Clinical Guidelines – July 2010
NICE Guidance GC66 – Type 2 Diabetes
NICE Guidance GC15 – Type 1 Diabetes
Diabetes UK
So, I mentioned that the advice is based on scientific knowledge, where does the science come from?
Replace the 2003 guidance – this is the first evidence based nutritional guidance produced (obtain on Diabetes UK)
Hertfordshire guidance (found on the trust website- will provide at the end of presentation)

5. Management & Models
Everyone with diabetes should receive individual, ongoing nutritional advice from a registered dietitian (A)
All people with diabetes should be offered structured education at the time of diagnosis with an annual follow-up (A)
Education should involve a person-centred approach & a variety of learning styles (A)
– means evidence is based on meta analysis or at least one RCT
DESMOND or DAFNE
*Negotiating* - person centred. Some may be willing to make huge changes & others won’t. Working with the pt and negotiating change – and encouraging them to set their own goals for change, they need to believe they can achieve them. Would you want to receive the exact same dietary advice to everyone else in the waiting room (different cultures, backgrounds, sizes & dietary requirements etc.)

6. TYPE 1
Foods that have a direct impact on BGL’s and how to identify them (carbohydrate is the main nutritional consideration for glycaemic control)
Carbohydrate awareness and/or counting
Count the carbs to either match the insulin (fixed dose) OR adjust the insulin to match the carbs (basal bolus/MDI)
Awareness of: Exercise, Sickness, Alcohol and snacking etc.
General healthy eating advice in line with the population
DAFNE course (Dose Adjusting For Normal Eating)
Imperative that they see a dietitian, as they need to have a good awareness/understanding of how & what foods impact on their diabetes, if not it could be very dangerous e.g. eating a ‘fry up’ & going hypo.
Pt who thought steak would increase BGL’s (been type 1 for 15 years)
DAFNE: 5 day course

7. Type 2 – Glycaemic control
Weight management should be the primary nutritional strategy in managing blood glucose (BG) in people who are overweight or obese
Focus should be on total energy intake rather than the source of the energy in the diet
The total amount of carbohydrate consumed is a strong predictor of glycaemic response & monitoring total carb intake is a key strategy in achieving glycaemic control
Physical activity!! & ?Lower GI food choices
The remainder of this talk will focus on type 2.
Weight management – Often refer to CBT for confidence
Mostly our one-one consultations are with
90% of pt with type 2 diabetes are overweight and 80% of those are obese
?GI – limited time available in consultation d/c the obvious low/high GI choices but more important is amount of carb
PA - One of the cheapest, most effective medicines in diabetes 

8. Type 2 – CVD (blood lipids & blood pressure)
Saturated Fats & Trans fats
Plant sterols & stanols
Reduce sodium
Mediterranean style diet
Oily fish
Weight loss
Exercise (aerobic)

9. Type 2 – Practical 2 Pronged Approach
Educate about food/ food groups that have a direct impact on blood glucose levels
Identifying carbs & understanding their relationship to glucose
- Menus, diet history
- Food & carb diary
- Food pictures & models
- Games
Educate about foods/ diet types that will have a long term impact on BGL’s (abdominal obesity)
Identifying high calorie & high fat foods/drinks
- Diet history
- Calorie counting
- Food portion pictures
- Games

10. Carbohydrate Awareness
Menu 1
Breakfast
2 x slices of thick wholemeal toast
2 heaped tsp jam
Lunch
250 gram jacket potato
½ can of baked beans
125ml of low fat yogurt
Snack
1 digestive biscuit
Large green apple
Dinner
150 gram chips
2 scoops of vanilla ice cream
Menu 2
Breakfast
Bowl of muesli
Semi skimmed milk
150mls fresh orange juice
Lunch
Baguette
Packet of baked crisps
Snack
Hot buttered scone
Dinner
225g cooked spagetti
2 cream crackers
Small pots of raisins

11. Example of a patients ‘Food, Carb & BG’ diary

12. Example of a patients ‘Food, Carb & BG’ diary
Day One: Thursday
Day Two : Friday
Day Three : Saturday
Time
6.45 am
8.30 am
BG levels
8.0
6.6
7.3
Breakfast
1 slice toast (16,) 1 Weetabix
(13), bran flakes (20), O.juice (20)
Total Carbohydrate: grams
1 slice toast (16), 1 Weetabix (13), bran flakes (20), milk (10)
Total Carbohydrate: 59 grams
1 wholemeal bagel (40). 1 Weetabix
(13), bran flakes (20), milk (10)
Total Carbohydrate: 83 grams
12.30 pm
12.15 pm
BG Levels
9.0
6.9
11.6
Lunch
Ham sandwich (wholemeal
bread) (32) Satsuma (10)
Total Carbohydrate: 42 grams
Cheese sandwich (wholemeal bread)
(32) Apple (16)
At about 5 pm 2 ginger biscuits (14)
Total Carbohydrate: grams
Ham sandwich (wholemeal bread) (32)
Satsuma (10)
Total Carbohydrate: grams
6 pm
6.30 pm
6.15 pm
7.0
7.4
Evening
Meal
Faggots (24), rice (45),
Apple (16)
Total Carbohydrate: 85 grams
Pasta bake (40), sauce (9),
Total Carbohydrate: 59 grams
Chicken & mushroom pie (30), potato
(40), Satsuma (10)
Total Carbohydrate: grams
B4 bed
10 pm
11.0
10.15 pm
Bedtime
2 digestive biscuits
Total Carbohydrate 20 grams
Total Carbohydrate 20 grams

13. It’s a way of finding out more about type 2 diabetes
- Understanding the nature of their diabetes
- The possible risks associated with having diabetes
- What they can do to manage their diabetes and minimise any risks
- Answers to most of the questions about their diabetes with which they may have
It’s a resource to help people manage the changes diabetes will bring to their life
It’s an opportunity to meet & share experiences with others
Different approach to education the patients are expected to be very much involved e.g.
- They are asked lots of questions, they are encouraged to explore the answers themselves, often their questions will not be answered directly instead they are guided to work out the answer themselves OR to know how to find the answer
The only newly diagnosed type 2’s we will see are on the DESMOND programme.

14. Newly diagnosed Type 2 diabetes (6/12) 10 people in the group
2 x ½ day sessions
Newly diagnosed Type 2 diabetes (6/12)
10 people in the group
2 local DESMOND educators
Evidence based information about the causes, effects and options for managing diabetes
Currently is West Hertfordshire the courses are run by a DSN and DSD

15. Summary Type 1 - Carbohydrate & Insulin education (1-1 or DAFNE)
- Food in relation to: hypo’s (tx), exercise etc
Type 2
- Weight Loss (if overweight or abdo obese)
- Carbohydrate awareness (food & BGLs)
- Healthy eating i.e. ↑vegetables, ↓ fat, moderate carb portions & opt for starchy carbs.
- CVD: ↑oily fish, ↓ fat & opt for mono fats, ↑ lentils pulses, ↑ grains
- ↑ Activity

16. What can you do? Don’t try to be too specific!! Why?
Be careful of ‘rigid’ blanket advice!! Why?
? Eating to prevent hypoglycaemia? Valid??
Diabetes UK – “10 Steps to Healthy Eating”
↑Activity e.g. GP referral scheme, local walk
↓Sat Fat, ↓Sugary foods ↑Vegetables
Eat Well Plate OR Weight Loss Plate
Specific – Elderly lady who was told to stop eating ‘ready brek & special K’ due to GI. However, these were the only 2 cereal types she liked so she started eating ryvita and marmalade with butter. Outcome = Sat fat intake increased, Kcals increased, Ca+ decreased as well as some important minerals and vitamins due to fortification of cereal
Blanket advice – Don’t have sugar, or crisps etc.. Under weight elderly or type 1 patient
Pt may mention that they have evening snacks and have to “eat to prevent them from going too low”

17. What can you do?
Eat Well Plate
Weight Loss Plate

18. Contacts & Referrals Ask GP to refer OR refer directly to service by:
- Type “SPOC Form” into search box (top left of page)

19. Contact & Referrals Diabetes Service:
Potters Bar Community Hospital Barnet Road Potters Bar Hertfordshire EN6 2RY Tel: Fax:  
Dietitians direct: