During my 2 weeks at the iConnect Diabetes Education Centre, I got to spend lots of one-on-one time with clients to talk about food choices, and I hope I was able to better support them in managing their chronic health conditions.
One thing that struck me was the variety of clients who visit the diabetes centre in terms of demographic differences, disease severity, and in attitudes towards diabetes management. One of the first clients I observed was a young person with type I diabetes who wanted to start insulin pump therapy. I felt their nervous excitement as they decided on the technology that could help improve their quality of life. Older clients are more common, although they varied widely in their cultural and socioeconomic background. From this clientele, I learned about the diets of Indian and Iranian cultures, such as sabji (Indian dish– vegetables in curry), ganthia (Indian dish– fried snacks made from gram flour), and the fact that some people from Iran enjoy feta cheese and walnuts with bread for breakfast. In terms of disease severity– the first few days I met clients whose blood sugars were regularly in the high- teens to mid- twenties (mmol/L)– and that really shocked me. As I met more clients, I learned those numbers are relatively uncommon for this diabetes clinic, which was a relief. There are also people who have A1C levels of 6.3% or 7.0%, and we see those clients too (although less frequently).
The theme of diabetes care in the outpatient setting can be described as self-management. I think one client summed it up when they said “At the end of the day, you’re the one who’s going to go home with the disease.” After this rotation ended, I stumbled upon an interesting talk by an UBC pharmacy professor about his vision towards using evidence-based medicine to provide patient-centered diabetes care (I recommend starting at 34 min if you don’t want to watch whole 56 minutes, but the lecture is very informative).
According to his lecture, the role of the healthcare provider should be to: encourage activity and healthy eating (watch the lecture to find out what those mean according to him), use lab values to estimate risks of adverse outcomes (heart attacks, strokes, amputations, blindness, etc.), explain to the patient the treatments available, the effectiveness of treatment in reducing risk for adverse outcomes, and the side effects, costs and inconvenience of diabetes management (going for tests, medical appointments, self-monitoring). Finally, after the client understands the treatment as well as the potential risks and benefits, they make the decision about how they want to manage their diabetes, and the healthcare provider would support that decision. One of the major benefits of this approach is the medical management of a client’s chronic condition can be better aligned with the client’s personal health beliefs.
The talk was mostly centered on pharmacological approaches to managing diabetes. And there are differences between prescribing drugs and suggesting dietary changes, so not everything he said can be applied to dietetic practice. For example, the risks of harm associated with drugs are much more acute compared to that of a poor diet. And compliance is lower when it comes to lifestyle changes compared with taking medications.
Working in the realm of lifestyle change, here’s what I think is applicable:
- Sharing with clients up-to-date evidence about the effects of dietary management of diabetes in terms of reducing disease risk
- Asking clients about their desired outcome — what are their health beliefs and how does nutrition fit in?
- Working towards their goals of nutritional management of diabetes
In a real-life setting, not every nutrition intervention has clear-cut benefits and drawbacks; it may take a long time to reap the benefits, or the magnitude of change in disease outcome could be insignificant. Add to that the fact that clients themselves need to be motivated enough to make and sustain the change. These are the challenges dietitians are working with with when it comes to nutritional management of chronic diseases.
If I ever work in the area of chronic disease management, I would like to:
- Effectively communicate to the client current evidence regarding the effectiveness of lifestyle interventions on disease outcome
- Conduct effective patient interviews to understand their values about health and well-being
- Motivate clients to a) set appropriate goals based on 1. and 2. above; and b)achieve these goals
So this rotation wrapped up the first 4 months of my dietetic internship. I’m excited to spend 2 weeks with my family and friends in Ontario to enjoy some time off and prepare for the next 5.5 months! And who knows, maybe I’ll even get a chance to blog about non-internship topics!