Diabetes in Hospital: A Practical Approach for Healthcare Professionals


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Dietary advice is fundamental to the management of diabetes. Although ideally such advice should be delivered by a state-registered dietitian, it is more usually delivered by other health professionals. The primary focus for those with type 1 diabetes is carbohydrate counting and insulin adjustment and for the majority of people with type 2 diabetes, weight management is key. Patient-centred care is emphasised for the delivery of dietary advice.

It is widely recognised that knowledge alone is not sufficient to induce behaviour change and practical approaches to a variety of behavioural interventions are discussed. There is a wealth of evidence demonstrating that dietary interventions are effective for the management of both type 1 and type 2 diabetes, for the prevention of type 2 diabetes, and there is now emerging evidence for the remission of type 2 diabetes [ 1 — 5 ].

Traditionally, it is recommended that nutritional advice is delivered by registered dietitians, and although there is evidence that dietitian-led interventions are more effective than those without input from dietitians [ 6 ], both the American Diabetes Association ADA and Diabetes UK recognise that other health professionals have a role in delivering dietary advice, ideally guided by a registered dietitian [ 1 , 2 ]. The current recommended gold standard of care is to deliver dietary advice as part of intensive multicomponent lifestyle programmes, and this is endorsed by both international and national bodies [ 8 — 11 ].

In many areas of the world, there are no dietitians or education programmes available, and where there are, limited uptake and restricted access to these facilities mean that people with diabetes rely on their primary healthcare provider for dietary advice. Unfortunately, primary healthcare professionals have little training in delivering dietary advice to people with diabetes. Nurses are often required to deliver dietary advice, but there is evidence that they have inadequate knowledge and skills to improve outcomes [ 14 ].

This article aims to offer a practical guide for health professionals who deliver dietary information to people with diabetes. Evidence-based guidelines for dietary advice are widely available and differ slightly for type 1 and type 2 diabetes [ 1 , 2 ]. The primary strategy for glycaemic control is widely accepted as carbohydrate counting with insulin dose adjustment on a meal-by-meal basis, and two recent meta-analyses have confirmed the efficacy of this approach [ 16 , 17 ].

It is recommended that carbohydrate counting and insulin adjustment are included in structured education programmes and referral to a local, validated programme is advocated. There is online, web-based information available for those with no access to structured education, for example from Diabetes UK and the Royal Bournemouth Hospital [ 18 , 19 ], but these approaches have not been tested for efficacy and safety in randomised controlled trials.

The key question is what dietary strategy should be used to support weight loss in people with type 2 diabetes.

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At present, it is unlikely that this would be readily translated to general practice, but discussion is ongoing. For general weight management in those with established type 2 diabetes there is evidence that most dietary interventions are effective [ 20 ], that differences in outcomes between different strategies are small and insignificant [ 21 — 23 ], and that behavioural interventions increase efficacy [ 24 , 25 ]. One aspect of weight management that is often overlooked is that of personal choice and despite recommendations that dietary advice should be culturally acceptable, affordable and tailored to the individual, the personal view of the health professionals commonly underpins advice.

This can be illustrated by the recent controversy about low carbohydrate diets, where academics and health professionals alike have opposing views; some are recommending healthy eating [ 26 ] and others are proposing that low carbohydrate diets should be the default strategy for those with type 2 diabetes [ 27 ]. In these debates, the views of the person with diabetes are rarely heard, despite calls for patient-centred care PCC [ 28 ].


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Medical care for those with diabetes traditionally mirrored the acute care model, where clinicians collect information and dispense advice based on observed clinical parameters. Management guidelines for long-term conditions such as diabetes now emphasise the role of patient centred care [ 28 ] and empathy [ 30 ] while acknowledging that people with diabetes make daily self-management decisions that have greater impact on their health than those made by health professionals [ 31 ].

The challenge for most health professionals is using a patient-centred approach when they have little access to training in behavioural therapy or support from clinical psychologists. Patient-centred care PCC has been defined as encompassing the management of biophysical markers, alongside the human experience of disease [ 32 ]. Limited evidence suggests that a variety of behavioural approaches can improve interactions between health professionals and patients, and that some result in improvements in health outcomes, but many studies do not fully report specific details of successful interactions and the underpinning theories [ 32 , 33 ].

A variety of behavioural and psychosocial strategies have been tested in studies and all appear to improve outcomes in people with diabetes when compared with no intervention [ 35 , 36 ]. Some examples of useful practical strategies in practice include the 5C intervention [ 35 ] and solution focused therapy SFT [ 36 ]. The 5C intervention consists of five concepts: constructing a problem definition, collaborative goal-setting, collaborative problem-solving, contracting for change and continuing support.

There are a number of practical steps, outlined below, that can be useful when facilitating health behaviour change [ 38 ]. Typically, most health professionals have a strong righting reflex where they try to persuade or convince individuals to change their behaviour in order to improve their health, but without first gaining their permission.

The most persuasive and influential voice in any interaction is the person with diabetes; the locus of control rests firmly with them and they are best placed to set the agenda. Some examples of useful phrases to set the agenda and elicit specific issues around weight management include:. What do you think? Once the person with diabetes has identified a specific issue this can be further defined using simple techniques to assess importance and confidence [ 39 ].

In order to assess importance the following question can be asked:. On a scale of 1 to 10, where 1 is not at all important, and 10 is very important, what number would you give yourself? Many people are already aware of the link between health and body weight and will allocate a high score in answer to this question. A high score denotes that weight loss is of consequence to the individual, and no further time or effort is needed to convince them. If a low score is volunteered by the person with diabetes, indicating that weight loss is not important, this can be explored by a follow-up question:.

Once importance has been established and addressed, confidence can be assessed in a similar fashion by asking:. How confident are you about actually losing weight? On a scale of 1 to 10, where 1 is not at all confident, and 10 is very confident, what number would you give yourself? A high score denotes confidence that the individual feels able to achieve weight loss and can begin the process of goal-setting and defining the dietary intervention that they would like to adopt. In practice, many people with type 2 diabetes recognise the importance of weight loss, but report low confidence.

This frequently creates resistance and, as a result, the person with diabetes often refuses to engage and will ignore, deny or question any recommendations made. This can be addressed by simply noting the confidence number given by the individual and asking them for their opinion about the next step by saying:. What would need to change in your life to move the score up to a 7 or 8? Techniques such as cognitive behavioural therapy CBT and motivational interviewing MI are useful techniques for supporting discussion about barriers to behaviour change.

CBT is a structured talking therapy designed to support problem-solving by facilitating and supporting skills to challenge negative thoughts and modify dysfunctional behaviour. It helps people understand the links between thoughts, feelings and behaviour and although there is evidence of its effectiveness for depression and anxiety, there are equivocal results for glycaemic control and quality of life [ 40 ]. MI is a style of counselling that explores and supports resolution of the ambivalence that prevents people achieving their personal health goals and operates through five guiding principles: expressing empathy through reflective listening, developing discrepancy between goals and behaviour, avoiding arguments and confrontation, adjusting to rather than opposing resistance and supporting self-efficacy.

MI has been widely applied to diabetes and evidence shows that it has the potential to facilitate behaviour change [ 41 ] and that it is effective for weight loss in people with type 2 diabetes [ 42 ]. Applying these strategies supports the individual in identifying specific issues which can then be addressed through collaborative goal-setting. Setting specific and realistic goals is key for successful behaviour change, together with regular self-reflection and feedback.

Feedback is integral to health behaviour change [ 45 ], and it is generally accepted that self-monitoring is effective for improving glycaemic control and weight loss in people with type 1 diabetes. There is also a significant association between self-monitoring by diet or physical activity diaries or self-weighing and weight loss [ 48 ], with evidence suggesting that daily or weekly self-weighing improves outcomes [ 49 ]. There are a wide variety of strategies to support self-monitoring including paper diaries and technology-enabled self-management solutions using mobile phones, secure messaging and digital feedback from personal devices tracking physical activity, energy expenditure and food intake, and there is evidence of efficacy for these technology-enabled self-management devices [ 50 ].

Delivering effective dietary advice for people with diabetes goes beyond supplying information and addresses the behavioural and psychosocial determinants of health behaviour change. Adopting new skills and changing their own behaviour is challenging for many healthcare professionals, and there are few education programmes available that specifically address effective consultation skills rather then increasing clinical expertise.

Despite these challenges, there are practical strategies that can be incorporated into general practice and most of these strategies are not more time-consuming than standard approaches and are more effective if used appropriately. No funding or sponsorship was received for this study or publication of this article. All named authors meet the International Committee of Medical Journal Editors ICMJE criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Pamela Dyson has no conflict of interest to declare for this manuscript, she receives no personal remuneration from any private company. This article is based on previously conducted treatments and does not contain any studies with human participants or animals performed by any of the authors.


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Enhanced Digital Features. To view enhanced digital features for this article go to Change history. In the original publication, part of acknowledgement text was missing and it should read. National Center for Biotechnology Information , U. Journal List Diabetes Ther v. Diabetes Ther. Published online Jan Pamela A. Author information Article notes Copyright and License information Disclaimer. Dyson, Email: ku. Corresponding author. Received Nov This article has been corrected. See Diabetes Ther. This article has been cited by other articles in PMC.

Abstract Dietary advice is fundamental to the management of diabetes. Keywords: Diabetes, Diet, Person-centred.

Introduction

Introduction There is a wealth of evidence demonstrating that dietary interventions are effective for the management of both type 1 and type 2 diabetes, for the prevention of type 2 diabetes, and there is now emerging evidence for the remission of type 2 diabetes [ 1 — 5 ]. Components of Dietary Advice Evidence-based guidelines for dietary advice are widely available and differ slightly for type 1 and type 2 diabetes [ 1 , 2 ].

Delivering Dietary Advice Medical care for those with diabetes traditionally mirrored the acute care model, where clinicians collect information and dispense advice based on observed clinical parameters.

Main Article Content

Patient-Centred Care Patient-centred care PCC has been defined as encompassing the management of biophysical markers, alongside the human experience of disease [ 32 ]. Medical care for those with diabetes traditionally mirrored the acute care model, where clinicians collect information and dispense advice based on observed clinical parameters. Management guidelines for long-term conditions such as diabetes now emphasise the role of patient centred care [ 28 ] and empathy [ 30 ] while acknowledging that people with diabetes make daily self-management decisions that have greater impact on their health than those made by health professionals [ 31 ].

The challenge for most health professionals is using a patient-centred approach when they have little access to training in behavioural therapy or support from clinical psychologists. Patient-centred care PCC has been defined as encompassing the management of biophysical markers, alongside the human experience of disease [ 32 ]. Limited evidence suggests that a variety of behavioural approaches can improve interactions between health professionals and patients, and that some result in improvements in health outcomes, but many studies do not fully report specific details of successful interactions and the underpinning theories [ 32 , 33 ].

A variety of behavioural and psychosocial strategies have been tested in studies and all appear to improve outcomes in people with diabetes when compared with no intervention [ 35 , 36 ]. Some examples of useful practical strategies in practice include the 5C intervention [ 35 ] and solution focused therapy SFT [ 36 ]. The 5C intervention consists of five concepts: constructing a problem definition, collaborative goal-setting, collaborative problem-solving, contracting for change and continuing support.


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There are a number of practical steps, outlined below, that can be useful when facilitating health behaviour change [ 38 ]. Typically, most health professionals have a strong righting reflex where they try to persuade or convince individuals to change their behaviour in order to improve their health, but without first gaining their permission. The most persuasive and influential voice in any interaction is the person with diabetes; the locus of control rests firmly with them and they are best placed to set the agenda. Some examples of useful phrases to set the agenda and elicit specific issues around weight management include:.

What do you think? Once the person with diabetes has identified a specific issue this can be further defined using simple techniques to assess importance and confidence [ 39 ]. In order to assess importance the following question can be asked:. On a scale of 1 to 10, where 1 is not at all important, and 10 is very important, what number would you give yourself? Many people are already aware of the link between health and body weight and will allocate a high score in answer to this question. A high score denotes that weight loss is of consequence to the individual, and no further time or effort is needed to convince them.

If a low score is volunteered by the person with diabetes, indicating that weight loss is not important, this can be explored by a follow-up question:. Once importance has been established and addressed, confidence can be assessed in a similar fashion by asking:. How confident are you about actually losing weight? On a scale of 1 to 10, where 1 is not at all confident, and 10 is very confident, what number would you give yourself?

A high score denotes confidence that the individual feels able to achieve weight loss and can begin the process of goal-setting and defining the dietary intervention that they would like to adopt. In practice, many people with type 2 diabetes recognise the importance of weight loss, but report low confidence. This frequently creates resistance and, as a result, the person with diabetes often refuses to engage and will ignore, deny or question any recommendations made. This can be addressed by simply noting the confidence number given by the individual and asking them for their opinion about the next step by saying:.

What would need to change in your life to move the score up to a 7 or 8? Techniques such as cognitive behavioural therapy CBT and motivational interviewing MI are useful techniques for supporting discussion about barriers to behaviour change. CBT is a structured talking therapy designed to support problem-solving by facilitating and supporting skills to challenge negative thoughts and modify dysfunctional behaviour. It helps people understand the links between thoughts, feelings and behaviour and although there is evidence of its effectiveness for depression and anxiety, there are equivocal results for glycaemic control and quality of life [ 40 ].

MI is a style of counselling that explores and supports resolution of the ambivalence that prevents people achieving their personal health goals and operates through five guiding principles: expressing empathy through reflective listening, developing discrepancy between goals and behaviour, avoiding arguments and confrontation, adjusting to rather than opposing resistance and supporting self-efficacy.

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MI has been widely applied to diabetes and evidence shows that it has the potential to facilitate behaviour change [ 41 ] and that it is effective for weight loss in people with type 2 diabetes [ 42 ]. Applying these strategies supports the individual in identifying specific issues which can then be addressed through collaborative goal-setting.

Setting specific and realistic goals is key for successful behaviour change, together with regular self-reflection and feedback. Feedback is integral to health behaviour change [ 45 ], and it is generally accepted that self-monitoring is effective for improving glycaemic control and weight loss in people with type 1 diabetes. There is also a significant association between self-monitoring by diet or physical activity diaries or self-weighing and weight loss [ 48 ], with evidence suggesting that daily or weekly self-weighing improves outcomes [ 49 ].

There are a wide variety of strategies to support self-monitoring including paper diaries and technology-enabled self-management solutions using mobile phones, secure messaging and digital feedback from personal devices tracking physical activity, energy expenditure and food intake, and there is evidence of efficacy for these technology-enabled self-management devices [ 50 ]. Delivering effective dietary advice for people with diabetes goes beyond supplying information and addresses the behavioural and psychosocial determinants of health behaviour change.

Adopting new skills and changing their own behaviour is challenging for many healthcare professionals, and there are few education programmes available that specifically address effective consultation skills rather then increasing clinical expertise. Despite these challenges, there are practical strategies that can be incorporated into general practice and most of these strategies are not more time-consuming than standard approaches and are more effective if used appropriately.

No funding or sponsorship was received for this study or publication of this article. All named authors meet the International Committee of Medical Journal Editors ICMJE criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Pamela Dyson has no conflict of interest to declare for this manuscript, she receives no personal remuneration from any private company. This article is based on previously conducted treatments and does not contain any studies with human participants or animals performed by any of the authors. Enhanced Digital Features.

To view enhanced digital features for this article go to Change history. In the original publication, part of acknowledgement text was missing and it should read. National Center for Biotechnology Information , U. Journal List Diabetes Ther v. Diabetes Ther. Published online Jan Pamela A. Author information Article notes Copyright and License information Disclaimer. Dyson, Email: ku. Corresponding author.

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Received Nov This article has been corrected. See Diabetes Ther. This article has been cited by other articles in PMC. Abstract Dietary advice is fundamental to the management of diabetes. Keywords: Diabetes, Diet, Person-centred. Introduction There is a wealth of evidence demonstrating that dietary interventions are effective for the management of both type 1 and type 2 diabetes, for the prevention of type 2 diabetes, and there is now emerging evidence for the remission of type 2 diabetes [ 1 — 5 ].

Components of Dietary Advice Evidence-based guidelines for dietary advice are widely available and differ slightly for type 1 and type 2 diabetes [ 1 , 2 ]. Delivering Dietary Advice Medical care for those with diabetes traditionally mirrored the acute care model, where clinicians collect information and dispense advice based on observed clinical parameters.

Patient-Centred Care Patient-centred care PCC has been defined as encompassing the management of biophysical markers, alongside the human experience of disease [ 32 ]. Applying PCC to Weight Management in Diabetes A variety of behavioural and psychosocial strategies have been tested in studies and all appear to improve outcomes in people with diabetes when compared with no intervention [ 35 , 36 ]. Agenda Setting Typically, most health professionals have a strong righting reflex where they try to persuade or convince individuals to change their behaviour in order to improve their health, but without first gaining their permission.

Self-Monitoring, Self-Reflection and Feedback Feedback is integral to health behaviour change [ 45 ], and it is generally accepted that self-monitoring is effective for improving glycaemic control and weight loss in people with type 1 diabetes. Conclusions Delivering effective dietary advice for people with diabetes goes beyond supplying information and addresses the behavioural and psychosocial determinants of health behaviour change. Acknowledgements Funding No funding or sponsorship was received for this study or publication of this article.

Authorship All named authors meet the International Committee of Medical Journal Editors ICMJE criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. Disclosures Pamela Dyson has no conflict of interest to declare for this manuscript, she receives no personal remuneration from any private company.

Compliance with Ethics Guidelines This article is based on previously conducted treatments and does not contain any studies with human participants or animals performed by any of the authors. Footnotes Enhanced Digital Features To view enhanced digital features for this article go to References 1. Diabet Med. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults.

J Am Diet Assoc. Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: a systematic review and economic evaluation. Health Technol Assess. Briggs Early K, Stanley K.

Bell's Palsy - causes, symptoms, diagnosis, treatment, pathology

J Acad Nutr Diet. Dietetic services and nutritional issues. International Diabetes Federation. International charter of rights and responsibilities of people with diabetes.

Diabetes in Hospital: A Practical Approach for Healthcare Professionals Diabetes in Hospital: A Practical Approach for Healthcare Professionals
Diabetes in Hospital: A Practical Approach for Healthcare Professionals Diabetes in Hospital: A Practical Approach for Healthcare Professionals
Diabetes in Hospital: A Practical Approach for Healthcare Professionals Diabetes in Hospital: A Practical Approach for Healthcare Professionals
Diabetes in Hospital: A Practical Approach for Healthcare Professionals Diabetes in Hospital: A Practical Approach for Healthcare Professionals
Diabetes in Hospital: A Practical Approach for Healthcare Professionals Diabetes in Hospital: A Practical Approach for Healthcare Professionals
Diabetes in Hospital: A Practical Approach for Healthcare Professionals Diabetes in Hospital: A Practical Approach for Healthcare Professionals

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