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Dietary advice in type 2 diabetes

Obesity is the strongest risk factor for type 2 diabetes, and 80–90% of people with this condition are overweight. While weight loss is an important aspect of diabetes management, it has many barriers to success. Here I discuss weight management, commonly held beliefs and attitudes, and some recommendations that can be used to support and encourage the people we see in the clinic.

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In 2013, figures in the UK showed that 3.2 million people had diabetes, of whom 90% (2 880 000) had type 2 diabetes (Diabetes UK, 2014). Between 80% and 90% of people with diabetes are overweight, and approximately 60–90% of type 2 diabetes is obesity-related (Chan et al, 1994; Anderson et al, 2003). Obesity is the most potent risk factor for type 2 diabetes (Diabetes UK, 2014), and for this reason I focus on weight management as I share some thoughts, ideas and encouragement. We all have our role to play in supporting patients.

“Weight loss is important in people with type 2 diabetes who are overweight or obese and should be the primary management strategy” (Dyson et al, 2011).

My clinic appointments
Before meeting my patients, I ask them to complete a 4-day food diary, and 90% make the effort, which allows us more time to talk about their diet. A key question to ask is whether they learned anything from completing the diary – telling me they ate fewer biscuits because they didn’t want to write it down is a good thing. It is easy to identify regular eating patterns, fruit and vegetable consumption, whether the person opts for lower-glycaemic-index carbohydrates and so on. There is always a concern about whether a food diary is accurate, but working with an individual’s food likes and dislikes will get us further. A key question is what people may have already changed in their diet – cutting out six biscuits per day or not snacking on a daily chocolate bar will have resulted in weight loss. I find it helps to be excited about any weight loss that has been achieved. Also, although we have to record weight in kilograms, we must tell people their weight in a language they understand – 85 kg (“dooberries” as they have been referred to in my clinic) means nothing, but 13 st 5 lb does.

Find out whether individuals recognise their own strengths and weaknesses when it comes to eating – have they gone “cold turkey” with their food choices? A discussion about treats or dealing with offers of tempting foods is helpful.

“Encourage high-fibre, low-glycaemic-index sources of carbohydrate in the diet, such as fruit, vegetables, wholegrains and pulses; include low-fat dairy products and oily fish; and control the intake of foods containing saturated fat” (NICE, 2009).

Common quotes from clinics
“I don’t eat anything sugary.”
We need to talk about total carbohydrate in the diet and the fact that this group of foods gets digested into blood glucose. Historically, we have told people to eat plenty of carbohydrates but, realistically, they need to eat a suitable amount for their energy needs. A resource to help with portion control and teaching about carbohydrates is available at www.carbsandcals.com (accessed 27.11.14). There is room for some limited substitution of sucrose-containing foods for other carbohydrates in the meal plan, but care should be taken to avoid excess energy intake (NICE, 2009). Generally, toasting carbohydrates will attract butter, so having breakfast cereals more often will help to reduce fat intake.

“I want a diet sheet.”
Diabetes UK provide a menu planner that, after input of gender, age, activity levels and current weight, gives guidance on portion sizes and suggested menu plans. This is an excellent starting point and can be found at www.storetour.co.uk/MenuPlanner.aspx (accessed 27.11.14).

“I have been told I am obese.”
Considering the aims of engaging with patients when they are ready for change, people arriving at the clinic who have already been told they are obese may already have switched off – the time for engagement has already passed. An open-ended question along the lines of “what’s happening with your weight at the moment?” may take you to a more positive place to discuss weight loss. In my experience, many individuals, especially women, have been perpetual dieters since school age, so we must be sensitive. Indeed, a survey of 2000 women found that, by 45 years of age, the average woman has been on 61 diets since the age of 16 (Huffington Post, 2012).

“I have to finish everything on my plate.”
The figures are shocking for the amount of food that we do waste, and the average family in Surrey has been found to throw away almost £60 of food per week (Surrey Waste Partnership, 2013); however, some people who have lived through rationing cannot stop eating until their plates are clear. We do not want people to waste food, but cooking the correct amount is a life saver. A packet of eight sausages is enough for four meals, and so splitting and freezing portions makes better sense. Batch cooking and freezing suitable portions makes life easier, stews being ideal examples.

“I want to follow this diet my neighbour recommended.”
Encouraging people with a plan that they have an interest in is surely going to be more successful than poo-pooing the idea and dishing out advice that they do not want to follow and have heard before. We of course need people to be safe when losing weight, but, in terms of an “ideal plan”, perhaps we can be more flexible in supporting the people we see.

Conclusion
Despite time constraints, helping people focus on the good dietary or lifestyle changes they have made is a good place to start. If you have ever tried any kind of behaviour change, you will know it is not easy, so getting exasperated or telling people off does not pay any beneficial dividend. Supporting individuals by offering weekly weigh-ins at the surgery may be helpful. Referring them to patient education groups in your locality will be beneficial. Hopefully, signposting people to suitable information and having resources to hand will help to encourage them and impart the positive role that diet can play in their diabetes.

Questions to test your knowledge

The answers are not necessarily found in this article.

1. How many calories are in 1 lb (0.5 kg) of body weight?
a) 1500 calories
b) 2500 calories
c) 3500 calories

2. Consuming fruit and vegetables and low-fat dairy products helps to reduce your blood pressure.
Is this true or false?

3. A portion of fruit or vegetables weighs 80 g (approximately 3 oz)
Is this true or false?

4. A 40-g portion of oats provides half of the beta-glucan soluble fibre suggested per day to help lower cholesterol.
Is this true or false?

5. Our daily energy needs remain constant throughout our adult lives.
Is this true or false?

Answers are at the bottom of the page.

Useful resources
Diabetes UK’s Evidence-based nutrition guidelines for the prevention and management of diabeteshttp://bit.ly/1oL7h27

British Dietetic Association fact sheets: www.bda.uk.com/foodfacts/home

The Type 2 Diabetes Companion Guide (Code 6955) and the Eating Well With Diabetes guide (Code 6958) – both available for the price of postage from the Diabetes UK online shop:
https://shop.diabetes.org.uk

Carbs & Cals: www.carbsandcals.com

Menu planner: www.storetour.co.uk/MenuPlanner.aspx

Answers: 1 – [c]; 2 – true; 3 – true; 4 – true (40 g of oats provides 47% of the recommended 3 g of beta-glucan); 5 – false (our daily energy needs generally start to decrease from the age of 50 onwards).

Anderson JW, Kendall CW, Jenkins DJ (2003) Importance of weight management in type 2 diabetes: review with meta-analysis of clinical studies. J Am Coll Nutr 22: 331–9
Chan JM, Rimm EB, Colditz GA et al (1994) Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 17: 961–9
Diabetes UK (2014) Diabetes: facts and stats (version 3). Diabetes UK, London. Available at: http://bit.ly/1ugR891 (accessed 27.11.14)
Dyson PA, Kelly T, Deakin T et al (2011) Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet Med 28: 1282–8
Huffington Post (2012) The average woman has been on 61 diets by age 45, reveals poll. Huffington Post UK, London. Available at: http://huff.to/1rqliYS (accessed 27.11.14)
NICE (2009) Type 2 diabetes: the management of type 2 diabetes (CG87). NICE, London. Available at: www.nice.org.uk/cg87 (accessed 27.11.14)
Surrey Waste Partnership (2013) Food waste facts. Surrey Waste Partnership, Kingston upon Thames

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