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

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*

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

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)

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.)

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

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 

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)

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

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

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

Example of a patients ‘Food, Carb & BG’ diary Day One: Thursday 12.1.2012 Day Two : Friday 13.1.201 Day Three : Saturday 14.1.2012 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: 69 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: 48 +14 grams Ham sandwich (wholemeal bread) (32) Satsuma (10) Total Carbohydrate: 42+14 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: 70 grams B4 bed 10 pm 11.0 10.15 pm Bedtime 2 digestive biscuits Total Carbohydrate 20 grams Total Carbohydrate 20 grams

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.

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

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

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”

What can you do? Eat Well Plate Weight Loss Plate

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

Contact & Referrals Diabetes Service: Potters Bar Community Hospital Barnet Road Potters Bar Hertfordshire EN6 2RY Tel: 01707 621152 Fax: 01707 621178  Email: Hertscommunitydiabetes@nhs.net Dietitians direct: 01727 866600