Lifestyle management (1): Nutrition
Raising the issue of healthy eating
Introduction
Healthy eating is of fundamental importance as part of diabetes health care behaviour and has beneficial effects on weight, metabolic control and general wellbeing. In particular weight control in those who are overweight is associated with improved glycaemic control, reduced blood pressure, improved lipid profile and reduced mortality. Several studies have identified that the more intensive the support for implementing dietary change the more significant the improvement in lipid levels, blood glucose levels and HbA1c.
There has been a move away from prescriptive diets given in an authoritarian manner. Interventions are more likely to be successful if a psychological (behavioural) approach is taken. It is essential to assess an individual's readiness to change dietary behaviour at the initial consultation, with the aim being to motivate and educate individuals to a level in which they can achieve the necessary dietary and lifestyle changes. The use of the behavioural approach to dietary interventions with people with diabetes has shown clinically significant benefits in terms of weight loss, lipids, HbA1c and self care.
Dietary goals
• Eat regular meals
• Include starchy foods at each meal e.g. potatoes, rice pasta etc.
• Eat more high fibre foods e.g. wholegrain breads and cereals, pulses and more fruit & vegetables (these foods tend to have a lower G.I)
• Eat less fried and fatty foods
• Limit sugary foods and drinks
• Try to include oily fish (at least once a week)
• Reduce salt and salty foods
• Try to achieve weight loss if BMI > 25kg/m2
• Keep within the recommended limits of alcohol (refer alcohol section)
• DO NOT encourage special "Diabetic" products
Stages of behaviour change
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Whilst the following is useful for targeting brief health promotion interventions in primary care, it is worth remembering that people's lifestyle choices are dependent on many factors including economic circumstances, gender, level of knowledge, education, social and family circumstances, available choices, time etc. When doing an assessment these broader determinants of health need to be taken into account.
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The approach, information and support that you provide to patients will depend upon the stage of change of each individual. Below is a guide to working with patients at various stages of the change cycle:
Stage of change |
Characteristics |
Aims |
Not interested in change (pre-contemplation) |
• The person may not have considered change or be aware of the risks their current behaviour carries • Others may understand risk but are not interested in changing behaviour at this time • Trying to coerce someone who is clearly not ready to attempt change is often counter-productive and may result in resistance or hostility |
• Raise awareness of the issue, particularly health risks • Offer information about the likely benefits of change • Offer support if the person wants to consider change in the future • Maintain an open door policy |
Thinking about change (contemplation) |
• People sometimes feel ready to think about change but are not yet able to make a decision or commitment to change- perhaps because they are unsure of their ability to succeed, or they need more information to help them to decide |
• Help them to consider the pros and cons of changing or not changing • Offer information, as required • Encourage individuals to explore feelings about change- acknowledging problems and difficulties they perceive • Offer support for those people who decide that they are unable to attempt change at this time-they may want to try in the future |
Preparing to change (preparation) |
• An individual may make a commitment to attempt change when they believe the benefits of change outweigh the costs, that change is worthwhile and that they are likely to succeed |
• Explore different options for change • Explore barriers to successful change • Explore skills and support needed for success • Offer information, as appropriate • Negotiate and agree an action plan |
Making changes (maintenance) |
• People are actively changing chosen aspects of their behaviour |
• Offer support and encouragement |
Maintaining change (maintenance) |
• People are adapting to their new behaviour • For some this remains a struggle for some time |
• Offer support and encouragement to maintain change • Offer support to cope with relapse |
Relapse |
• The new behaviour becomes too difficult to maintain • The person reverts back to previous behaviour |
• Point out the valuable learning about which strategies help or hinder change • Provide support and encouragement to try again |
Raising the issue of healthy eating
Ask about eating habits
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Conduct using the following questions, dietary assessment form 1 (returned by patient), dietary assessment form 2 and "Balance of Good Health"
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Assess the patient's current diet in terms of the F requency, A mount and T ypes of food, from each of the five food groups (see dietary assessment form 1 and "Balance of Good Health"):
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Assess "portions per day" of each food group
"portion size" of each food group
"portion type" for each food group:-
Food item |
Examples |
| Bread | white/wholemeal/grained |
| Cereal | sugary/wholegrain/wholewheat |
| Fruit/vegetables | boiled/steamed/roasted/with butter tinned/fresh/in juice/ in syrup |
| Milk/dairy | full fat/semi skimmed/skimmed full fat/reduced fat cheese full fat/reduced fat/low sugar yoghurt |
| Meat/fish | fatty/lean meat/fish/oily fish |
| Fats/sugary | cakes/biscuits/ sweets crisps/fried foods/take away food |
| Sodium | tinned products i.e. soups, cup a soups tinned savoury snacks tinned smoked, processed meats, stock cubes salted savoury snacks - nuts and crisp added salt at the table - yes/no |
Assess motivation to change
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In what ways do you think what you eat affects your health?
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Have you thought about changing what you eat?
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How important is it for you to change your eating behaviour/habits?
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What good things might you find if you did change?
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What might you lose if you decided to change?
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What help/information might you need to achieve changes
Advise about healthy eating
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For those patients that are eating healthily, encourage them to continue behaviour and review at next appointment
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For those who are not currently motivated to change:
- highlight the key dietary messages
- encourage the patient to think about change
- arrange to see again
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For those who are interested and are thinking of eating more healthily, clear advice should be provided on:
- the benefits of a healthy balanced diet
- the risks associated with an unhealthy diet
- changes in proportion
- changes in frequency
- changes in amounts
- changes in type
- helping to identify potential barriers
- benefits of physical activity
Assist to make the change
For specific modifiable risk factors, diet sheets are provided (see diet sheet section and protocol diagram below). Key issues will include:
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healthy food choices (focusing on "Healthy Eating with Diabetes" advice)
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benefits of healthy eating/weight reduction
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reviewing past experiences What helped, what hindered? Consider issues such as cost, access, availability, likes/dislikes, lifestyle etc
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planning/identifying likely problems and making a plan to deal with them. E mphasise the importance of partner, family and friend support
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identifying other areas/sources of support, help and information
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benefits of physical activity
Problem |
Action |
| BMI <25 | Provide 1st Line Diabetes diet sheet |
BMI >25 |
Refer to dietitian |
| BP <140/80 | Provide 1st Line Diabetes diet sheet |
BP >140/80 |
Focus on reduced sugar and fat, weight reduction and sensible drinking Refer to dietitian |
Abnormal lipid levels |
Provide lipid lowering diet sheet Refer to dietitian |
| Newly diagnosed diabetes | Provide 1st Line Diabetes diet sheet Refer to dietitian
|
Poorly controlled diabetes |
Provide 1st Line Diabetes diet sheet Refer to dietitian
|
Regular follow-up and support is an important factor in maintaining successful change. Check the patient's progress with their change in eating behaviour at follow-up and review appointments: Are they succeeding to make changes for the better? Do they feel a difference in themselves?
If Yes:
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Continue to encourage and support the patient
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Amend action plan changes if necessary
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Re-do measurements i.e. BMI , BP, Lipid Levels, Blood Sugar, HbA1c, Weight etc
If No:
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Relapse is common; habits of a lifetime are not changeable overnight.
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Support and encourage the patient in making sense of their relapse and in trying again.
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It is also important that they understand that they can allow themselves a treat now and again. If they try and deprive themselves and over restrict their diet they will be less likely to change.
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Discuss with patient triggers and solutions, which might have caused a relapse:
- availability of food
- cost
- knowledge
- lack of family support
- other priorities
- temptation
- boredom
- time
- environment
- peer pressure
- convenience
- emotional state
- food likes/dislikes
Healthy eating advice
Foods to eat more
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Fruit and vegetables - Having more salads, larger and more frequent vegetable servings. Using fruit as a snack food. It is important not to overcook vegetables in order to maintain nutrient levels
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Starchy foods - To fill you up including some soluble fibre i.e. oats and pulses . Try to include potatoes, pasta, rice, bread, noodles, cereals etc. Try also to include some wholegrain versions e.g. multigrain bread/ crackers
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Fish - Eat oily fish (sardines, pilchards, herring, salmon, trout, mackerel) 2 or more times a week as they are a good source of omega 3. These help protect against heart disease. White fish is healthy too, but it doesn't have the added protective benefit
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Fat - Avoid butter, hard margarine, fatty meat, fried food, full fat milk and its products, cakes, biscuits, pastries, pies, crisps and chips. Choose low fat spread, use cooking oil high in monounsaturates sparingly, lean meat, skinned poultry, skimmed or semi-skimmed milk, diet or 'light' yoghurts, low-fat cheeses, plain biscuits, tea cakes, malt loaf etc
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Sugar and sugary foods - Use sweeteners instead of sugar, honey, fructose, glucose etc. Choose sugar free/diet drinks, have fruit instead of cakes, biscuits, sweets and chocolate, or if fresh is not possible have tinned fruit in juice not syrup or even sugar-free jelly, low-sugar custard etc. Occasionally, 1-2 plain biscuits e.g. Rich Tea, Marie, Hob Nob, or a piece of plain sponge cake are allowed
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Salt - Especially if you have high blood pressure. Reduce amount of salt added at the table (try using herbs, pepper or spices instead). Use only a small amount of salt during cooking. Eat less salty manufactured foods such as salted nuts, crisps, stock cubes, soy sauce, tinned or packet soup, tinned meats etc
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Alcohol - See "Alcohol" section
Glycaemic index
- Glycaemic index (GI) is a system of ranking foods based on the effect that they have on blood sugar levels". Foods are ranked according to GI values:
High G.I. Foods that cause a rapid rise in blood sugar level
Intermediate G.I. Foods that cause a moderate rise in blood sugar level
Low G.I. Foods that cause a slow rise in blood sugar level
You may find that including a food with a low glycaemic index at each meal:
• Helps you to achieve better control of your blood sugars
• Reduces the risk of very low blood sugars or 'hypos' (if you take certain tablets for your diabetes and/or insulin)
• Aid weight reduction (by filling you up for longer)
• Helps reduce the risk of developing heart disease
- Glycaemic index values of common foods are as follows:
|
LOW |
INTERMEDIATE |
HIGH |
|
Bread and Potatoes |
Fruit Loaf |
Rye Bread |
Bagel |
Pasta and Rice |
Wholemeal Pasta |
Basmati Rice |
Rice Cakes |
|
Breakfast Cereals |
All Bran |
Weetabix |
Rice Krispies |
Fruit and Vegetables |
Apples |
Raisins |
Watermelon |
Milk and milk |
Milk |
Ice-cream full fat |
|
Snacks and |
Sponge cakes |
Raisins |
Morning Coffee |
Drinks |
Sugar-free Drinks |
|
Sports Drinks |
Type of food |
Recommended daily |
One portion equals |
Bread, cereals, potato |
5 |
1 egg sized potato |
Fruit and vegetables |
5 (8-9 even better) |
1 whole medium sized fruit or vegetable e.g. apple, |
Milk and dairy |
2-3 |
200ml skimmed milk |
Meat, fish and |
2-3 |
2-4oz (50-100g) lean meat, poultry or oily fish |
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The table below gives guidelines on what constitutes "a lot" or "a little" of nutrient contents of food. When looking at a whole meal it is the amount per serving that is important, for snacks and individual foods look at the amount per 100g. Advise patients to choose foods that contain less than 10g sugar per 100g of product
Food Type
A Lot (These amounts or more)
A Little (These amounts or less)
Fat
20g3gSaturated fat
5g1gSodium
0.5g0.1gFibre
3g0.5gSugar
10g2g
Changing eating behaviour
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A change in eating behaviour will need a lot of careful thought and effort. It is not all an uphill battle, there are things that will help make it easier. Planning ahead will help individuals to feel more in control of what they are trying to achieve
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Do nothing else whilst eating, such as watching TV or reading. Taste and enjoy your calories
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Eat at regular times. Eating on the move is bad for the digestion so always try and eat whilst sitting down
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Try not to skip meals
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Use healthier cooking methods such as grilling, baking, steaming, boiling, poaching and microwaving
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Lose weight sensibly. Aim to lose no more than 1-2lb a week. It is a matter of balance, cutting down appropriately on your food intake and becoming more active
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Shop on a full stomach and have a shopping list. Stick to it
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Keep healthy snacks to hand i.e. chopped fruit, salad and vegetables
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Wait at least 30 minutes after finishing your meal before having seconds/desert
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Plan your meals so you know exactly what you are having
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Check that you are really hungry, and not just eating out of habit
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Be aware of triggers, which might lead you to overeat i.e. feelings (upset, angry, anxious), being alone at home
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Keep a food diary to look out for triggers, especially if you comfort eat
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Changes are difficult but tastes do change and changes do become easier
Resources
Healthy eating with diabetes (patient leaflet)
Sensible slimming (patient leaflet)
Healthy eating with diabetes
Click here to view this patient information leaflet
Sensible slimming
Click here to view this patient information leaflet
Recommended slimming groups
Weight Watchers 08457 123000
Ammanford |
Church Hall, Wind Street Pensioners Hall, Quay Street |
Tues Tues |
10.30am 10.30am |
Carmarthen |
Carmarthen Library |
Weds Weds Weds |
10.30am 12.00pm 5.00pm |
Llanelli |
Capel Alf, Marble Hall Road Llanelli Leisure Centre, Park Crescent
Glenalla Community Centre Calsonic Sports and Social Club Dafen Community Centre, Maescannor Road Burry Port Memorial Hall, Parc y Minos |
Weds Tues Thurs Thurs Thurs Mon Weds Mon |
10.00am 5.30pm 9.30am 10.45am 6.30pm 6.00pm 6.00pm 6.30pm |
Kidwelly |
Morfa Vestry, Hillfields Villas |
Tues |
6.00pm |
Tumble |
Neuadd y Tumble, Heol y Neuadd |
Mon |
6.15pm |
Llandybie |
The Old School (library), High Street |
Weds |
6.30pm |
Llandeilo |
Llandeilo Civic Hall |
Thurs |
6.30pm |
Loughor |
Loughor Welfare Hall |
Weds |
6.00pm |
Pontardulais |
St Teilo Church |
Thurs |
6.00pm |
Rosemary Conley 01792 898385
Llanon |
Llanon Centre (phone above number) |
|
|
Loughor |
Loughor & District WMC, Oakleigh Road |
Mon |
6.00pm |
Morriston |
Sacred Heart Church Hall, Pentrepoeth School Road
|
Tues Tues |
6.00pm 7.30pm |
Waunarlwydd |
Waunarlwydd Community Centre, Victoria Road |
Weds |
9.30am |
Gorseinon |
Gorseinon WMC, Brightom Road
|
Weds 7.30pm |
6.00pm 7.30pm |
Felinfoel |
Swiss Valley Community Centre, Heol Nant
|
Thurs Thurs |
6.00pm 7.30pm |
Your local dietetic department
West Wales General Hospital
Carmarthen SA31 2AF
Phone 01267 227067
Prince Philip Hospital
Llanelli SA14 8QF
Phone 01554 783061
e mail zoepg@carmarthen.wales.nhs.uk
Your local public health team
Carmarthenshire local public health team
Thyssen House, Bynea,
Llanelli SA14 9SU
Phone 01554 778583
e mail:
Liz.Newbury-Davies@nphs.wales.nhs.uk
Caroline.Nichols@nphs.wales.nhs.uk
Other sources
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"Weight Creeping Up on You? Diabetes and Weight Management": Available from Diabetes UK website: www.diabetes.org.uk
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Leaflets and booklets for use by Health Professionals and People with Diabetes: Order from BHF - Tel - 020 7935 0185 or on line at www.bhf.org.uk
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Hassle Free Food. A Guide To Cheap, Quick and Healthy Eating - FREE: Download from Chief Medical Officer website at www.cmo.wales.gov.uk