Dietetic Internship Week 14: Nutrition Care II (Diabetes)

I walked into the waiting room of the New Westminster iConnect Diabetes Centre and introduced myself to the receptionist. “Oh good, we’re expecting you.” A few minutes later, I met with the dietitian who will be one of my preceptors for the upcoming weeks.

The outpatient setting is quite different from inpatient, I really appreciated the one-on-one time we got to spend with each patient and in-depth conversations about food and nutrition. The clinic helps adults with pre-diabetes, type I diabetes, and type II diabetes to manage their disease and prevent long-term complications. Nurses and dietitians work closely in this setting, and patients often see both healthcare providers during the same visit, either back to back, or simultaneously. The dietitian’s role is to assess dietary intake and physical activity levels, provide appropriate feedback to the client, and encourage the client to adopt lifestyle management strategies as appropriate.

The cornerstone of dietary management seems to consist of:

  1. Appropriate timing of meals and snacks: breakfast within 1-2 hours of waking, a meal every 4-6 hours, and a nighttime snack if needed.
  2. Appropriate carbohydrate intake at mealtimes: 45-60 g of carbohydrates per meal for most patients.
  3. Choosing appropriate carbohydrate containing foods: we like high fibre, moderate protein, and low sodium, sugar, and fat.

Common co-morbidities of type 2 diabetes include: coronary artery disease, dyslipidemia, hypertension, and chronic kidney failure, so it’s important to be aware if a patient has any of these conditions and counsel appropriately.

One question I’ve been pondering is how to build trust with clients and create a therapeutic relationship within the allotted time. I think there are a few techniques that might be helpful:

  • Clearly state the overall goal at the beginning, and get client on board. For example: The goal of this session is to help you better control your blood sugars through your diet. Does that sound good to you?
  • Set an agenda for the meeting: reduce uncertainty by outlining what will be discussed before starting.
  • Ask permission: would it be okay if I weigh you today? Would you be willing to try _____________?
  • Inspire self-efficacy: Make sure the client feels capable of achieving success (what that means is individualized). Work with the client to brainstorm ways to reduce barriers or increase incentives to achieve the goal.
  • Respect the client: listen actively, use empathy when appropriate, understand that they may not be ready for change, and work with their identified concerns.

A few clinical pieces I’ve picked up:

  • Urine Albumin:Creatinine Ratio (UACR, or ACR) is used to estimate the progression of renal disease. The ACR is proportional to the amount of albumin excreted in the urine. Increased excretion of albumin is a sensitive marker for chronic kidney disease due to diabetes, glomerular disease, and hypertension. Higher ACR is associated with increased risk of end stage renal disease (JASN (2009) 20(5), 1069-1077; doi:10.1681/ASN.2008070730). Similarly, a reduction in ACR may be associated with improved cardiovascular and renal outcomes (Kidney International (2005) 68, S25–S29; doi:10.1111/j.1523-1755.2005.09805.x).
  • Insulin should be injected into subcutaneous fat to ensure consistent results each time. Recommended sites include the abdomen, outer thighs, and tricep area. Insulin delivered into the abdomen works the fastest and most consistently, it’s also a convenient self-injection location. Sites should be rotated every time (do not inject into the same 2-3 inch area).
  • Angiotensin II Receptor Blockers (ARBs) and Angiotensin Converting Enzyme (ACE) Inhibitors both lower the risks for diabetic nephropathy and hypertension (Kidney International (2005) 67, 799–812; doi:10.1111/j.1523-1755.2005.00145.x).
  • Fish oils and fish (cod) liver oils are not the same. Both are good sources of omega-3s, but fish liver oils also contain vitamins A and D, which are not found in fish oils. Pregnant women should take caution with fish liver oil due to risks of birth defects with excessive vitamin A intake. However, fish liver oil may be a good choice for those with insufficient vitamin D intake (JABFM (2005) 18(5), 445-446; doi:10.3122/jabfm.18.5.445b). Fish do not synthesize these omega-3 fats, instead, they get them from the microalgae they eat. So microalgae supplements may be an option for vegetarians and vegans, although the health benefits of omega-3 supplements are unclear.
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