Type 2 diabetes: First messages in diet and lifestyle

Many GP practice teams have concerns that the initial dietary advice that they provide is accurate, consistent and evidence based. Similarly, a common concern of individuals with diabetes is that they feel they are given conflicting information on diet (Diabetes UK, 2001). 

A competence- and skills-based approach
Providing information alone is insufficient without the means to put knowledge into practice. New approaches using behavioural change skills, motivational interviewing skills and competence-based practice to address ambivalence to change and to provide information exchange, rather than advice giving, are suggested by recent meta-analysis (Hettema et al, 2005) to be more effective.

Phase I of the Diabetes Competence Framework (Skills for Health, 2005) was launched in October 2004. Included in this framework is a competence for first messages in diet entitled Help an individual understand the effect of food, drink and exercise on their diabetes. The competence includes the four key elements of delivering first messages: gathering information, assessment, providing education and agreeing a dietary plan.  

Preliminary assessments
The provision of first messages is an educational process. According to Parkin (2001):

‘Many initial educational strategies rely on health professionals’ perceptions of what patients with diabetes need to know.’ 

However, in the author’s experience, people are more interested in the ‘nitty-gritty’ of living with diabetes at this time and may not be ready to focus on more complex health issues.

A six-step approach to providing these first messages is outlined below and elaborated upon in Table 1.

• Step 1: Assess the individual’s first concerns regarding diet and lifestyle.
• Step 2: Assess the individual’s preconceived ideas about diet and diabetes.
• Step 3: Recognise the importance of health beliefs and other psychosocial issues.
• Step 4: Assess the individual’s readiness to change.
• Step 5: Assess the individual’s ability to self-manage and the support system.
• Step 6: Assess the individual’s levels of literacy for written information.

Essential first messages for a basic dietary plan
First messages on food should, in the author’s opinion, always start with a focus on enjoyment and be delivered in a positive way rather than the language of ‘should not’ and ‘avoid’.

A healthy way to eat
The Balance of Good Health (Wired for Health, 2005) provides a food group and portions approach to learning about food and can be easily adapted to show healthy eating for people with type 2 diabetes. The model is about food choice and not about food exclusion. The food groups and portions approach to diet (Figure 1) covers the amount of dairy products, fruit and vegetables, carbohydrate, protein and fat needed daily to provide good nutrition as the basis of a healthy way to eat. First messages need to emphasise that starchy foods are not fattening and have less than half the calories of fat (Food Standards Agency, 2005c). Foods high in monounsaturated fats, such as olive, rapeseed and vegetables oils and spreads, can replace foods rich in saturated or polyunsaturated fats. Not adding extra salt to food is of benefit. Furthermore, drinking sufficient fluid is essential; individuals should be aiming to drink between six and eight glasses a day (1.2 litres; Food Standards Agency, 2005b). Finally, it is best to cook food from fresh ingredients if possible.

Although healthy eating is a good starting point, first messages in diet for type 2 diabetes need to also cover the meal pattern, such as the importance of eating regular meals to spread the carbohydrate load over the day and thus reduce peaks and troughs of blood glucose (Thomas, 2003).

Are there any foods to avoid?
Biscuits, cakes and chocolate products marketed specifically for people with diabetes are often still high in fat and calories, and, as such, are not suitable for them (Connor et al, 2003).

In addition, there are quite a few functional foods on the market that claim either to reduce cholesterol or blood pressure or to make people feel well. Reliance on these products is not advised and they should not take the place of healthy food and lifestyle choices or drugs.

Shopping and food labels
Eating well for type 2 diabetes starts with shopping for food. People regularly request help with understanding food labels, and Diabetes UK (2005) has designed a credit card-sized, fold-out pamphlet to do this (Figure 2; the free guide is available by calling Diabetes UK’s distribution department on 0800 585 088 and quoting 7402 as a product code). Table 2 also provides a useful guide to interpreting food labels.

Weight management
The most important message on weight is the benefits that weight loss of 10 kg or a 10 % reduction from current weight has for glucose control, blood pressure and risk of heart disease (Connor et al, 2003). For some people, however, the appropriate first message may be avoiding further weight gain.

Referral into a network of support, if one is available, can bring good results. Structured lifestyle programmes which include education, energy reduction, regular physical activity and frequent participant contact can produce long-term weight loss of 5–7 % (Franz et al, 2002). 

Central obesity
The metabolic risk attached to abdominal adiposity is illustrated by the International Diabetes Federation’s (IDF’s) definition of the metabolic syndrome including central obesity as a prerequisite (Alberti, 2005). In addition, the validity of waist circumference as a measure of abdominal adiposity has been shown (Pouliot et al, 1994).

Physical activity
Physical activity has an important role in improving insulin sensitivity (Connor et al, 2003). It can contribute to weight reduction, with energy expenditure through physical activity amounting to up to 20% of total energy intake from food (Thomas, 2001).

For people not currently doing the recommended 30 minutes of moderate daily activity, encourage them to start small amounts of regular activity and build this up to the recommended level.

Walking groups have been shown to work (for women; Williams and Sultan, 1999). Gardening and dancing are among the other appropriate forms of activity.

Innovative approaches may be needed in all population groups. In particular, though, studies have shown that South Asians living in Britain are less active than Caucasians living in Britain, who, in turn, take less exercise than Asians living in India (Dhawan and Bray, 1997). 

Fad diets
The consensus is that fad diets do not work, and there is only limited evidence to use anything but low-fat diets (Mulvihill et al, 2002; Avenell et al, 2004). It has been shown that people generally eat a similar volume of food from one day to another (Prentice and Poppitt, 1996). To achieve a reduced intake of calories, bulking out meals with whole foods is compatible with good diabetes control, increases satiety and maintains the daily volume of food consumed (Prentice and Poppitt, 1996).

To use or not use the glycaemic index?
UK guidance (Connor et al, 2003) advises against reliance on glycaemic index (GI) tables, which are easily misunderstood and detract from the important early messages on fat and portions. Furthermore, a recent systematic review (Kelly et al, 2005) challenged the recommendation to use a low-GI approach for weight management on the basis that there is no good quality evidence to do so.

Should messages be different for men?
The Men’s Health Forum (MHF; 2005) recently reported on gender inequalities in health. The report concluded the following.

• Men have less knowledge about diet than women, with more confusion about what constitutes a fatty food.
• Men are more likely to drink alcohol to excess.
• Men are less likely to notice weight gain and are often in denial of the problem.
• Although men are more physically active than women, they still do not do enough to gain health benefits.

The GutBusters campaign in Australia showed that the biggest barrier to losing weight was a lack of basic knowledge about food and weight reduction (MHF, 2005). Men prefer being given information rather than counselling and are less group orientated (MHF, 2005). The MHF report called for ‘male-sensitive’ approaches, especially in primary care and health promotion. 

Should messages be different for black and minority ethnic communities?
Ethnicity in the context of provision of health education and care is a complex issue, with language being just one of the factors (Department of Health [DoH], 2005b).

First messages for black and minority ethnic communities may need a different approach and emphasis. South Asian people are more prone to high blood pressure and renal disease, so fat and salt intakes need addressing early (DoH, 2005a). These problems are exacerbated by obesity, and the IDF’s definition of central obesity gives a lower cut-off for South Asian men (90 cm) than Caucasian men (94 cm; Alberti, 2005).

Multiple deprivation, poverty and racism strongly influence the determinants and outcomes of health, and this can have an impact on the effect of health interventions and the access to healthcare in black and minority ethnic communities (DoH, 2005a).

Tools for the job
A list of potentially useful ‘tools for the job’ is given in Table 3.

Concluding remarks
The GP practice team is best placed to provide first messages in diet and lifestyle and often already knows the person who is newly diagnosed. As dietetic expertise shifts into specialist and complex care for when problems arise, the onus on comprehensive first messages falls more and more on the GP practice team. First messages in diet and lifestyle need to consider age, gender, culture and socio-economic group. Individualised, tailored care – rather than ‘blanket’ advice – using competence-based skills and educational tools may be the way forward.

Finally, knowledge of the first messages provided in this article could serve as a useful basis for local structured education initiatives on diet; they may also be useful to help people on a one-to-one basis who are unwilling or unable to attend these initiatives.