Quality Standards for Diabetes Care Toolkit

Definition

An appropriately trained health care professional is one with specific expertise and competencies in nutrition. In most instances this will be a registered dietitian who delivers nutritional advice on an individual basis or as part of a structured educational programme.

Introduction

Nutrition

All New Zealanders with type 1 diabetes should be referred for personalised dietary advice from a registered dietitian upon diagnosis and on an ongoing basis as required. People with type 2 diabetes should also have access to nutritional advice from an appropriately trained health professional in either a one-to-one or group consultation. Personalised advice on food and nutrition should be tailored and meaningful to the person with diabetes and their family/whānau, provided in a form that is sensitive to the person’s needs, culture and beliefs, and sensitive to their willingness to change, and should have an effect on their quality of life (National Institute for Health and Care Excellence [NICE] CG87 2009).
Evidence is strong that diabetes-specific dietary advice (including medical nutrition therapy) provided by registered dietitians is an effective and essential therapy in the management of diabetes (Andrews et al 2011; Coppell et al 2010; Franz et al 2010). Furthermore, diabetes-specific dietary advice can improve clinical and metabolic outcomes associated with diabetes and cardiovascular risk, such as glycaemic control, dyslipidaemia, hypertension and obesity, as well as overall nutrition status (American Diabetes Association 2008; Evert et al 2013; Franz 2002; Franz et al 2010).
To support people making healthy food choices and positive changes to their diet over the long term, it is important that all health care professionals working with people with diabetes have a thorough understanding of the New Zealand cardioprotective dietary pattern. This is summarised in the Heart Foundation’s ‘Nine Steps for Heart Healthy Eating’:

Enjoy three meals a day, select from dishes that include plant foods and fish, and avoid dairy fat, meat fat or deep fried foods.

Choose fruits and/or vegetables at every meal and for most snacks.

Select whole grains, whole grain breads or high-fibre breakfast cereals in place of white bread and low-fibre varieties at most meals and snacks.

Include fish or dried peas, beans and soy products, or a small serving of lean meat or skinned poultry, at one or two meals each day.

Choose low-fat milk, low-fat milk products, and soy or legume products every day.

Use nuts, seeds, avocado, oils or margarine instead of animal and coconut fats.

Drink plenty of fluids each day, particularly water, and limit sugar-sweetened drinks and alcohol.

Use only small amounts of sugar or salt when cooking and preparing meals, snacks or drinks (if any). Choose ready-prepared foods low in saturated fat, sugar and sodium.

Mostly avoid, or rarely include, butter, deep-fried and fatty foods and only occasionally choose sweet bakery products or pastries.

For further information: www.heartfoundation.org.nz/shop/product_view/891/a-guide-to-heart-healthy-eating-booklet.
Details of the New Zealand cardioprotective dietary pattern are also outlined in the New Zealand Primary Care Handbook 2012, which gives all health care professionals a useful evidence-based guideline when offering dietary advice to people with diabetes. All people with diabetes should receive written resources to support their learning around dietary recommendations, with signposting to evidence-based dietary resources accessible via reputable websites/applications etc.
According to the Scottish Intercollegiate Guidelines Network (SIGN) (2010) and the American Diabetes Association (2014), dietary advice as part of a comprehensive management plan is recommended to improve glycaemic control for all people with type 1 or type 2 diabetes. Furthermore, it is recommended that nutrition therapy is individualised to the person with diabetes to be most effective (Evert et al 2013; Franz et al 2014).
Achieving nutrition-related goals requires a multidisciplinary team approach, with participation by the person with diabetes in planning and agreeing on goals (see Standard 3). Nutrition management has shifted from what was previously a prescriptive one-size-fits-all approach to focus on the person with diabetes and what is pertinent to their needs in the context of their family/whānau environment. With a focus on active patient participation, it puts the person at the centre of their care and enables recommendations to be tailored to their personal preferences and encourages joint decision-making (Dyson et al 2011).
For people with type 2 diabetes, in addition to learning about the New Zealand cardioprotective dietary pattern, specific advice regarding carbohydrate and alcohol intake, meal patterns and weight management are recommended (NICE CG87 2009). In the primary care setting, diabetes specialist dietitians are involved in the following:

supporting primary care teams

advising individuals with prediabetes and newly diagnosed type 2 diabetes

providing assessment prior to insulin transfer for people with type 2 diabetes and offering support during the process, especially with regard to glycaemic control and weight (Diabetes UK Task and Finish Group 2010).

For type 1 diabetes, specialist dietetic advice should be provided by a dietitian with expertise in type 1 diabetes (for young people, see Standard 16) (NICE CG15 2004). Diabetes specialist dietitians have additional training and skills for the following (Diabetes UK Task and Finish Group 2010):

providing education on carbohydrate counting and supporting individuals with type 1 diabetes to adjust their insulin, manage their pump therapy and might include hypoglycaemia awareness therapy

supporting antenatal and postnatal care

working with young people with diabetes who may have significant eating problems or weight and glycaemic control issues

supporting inpatient care, including complex nutritional care such as those who are enterally fed or have pancreatitis

advising people with complex problems such as gastroparesis and renal disease

supporting the assessment of individuals who are considering bariatric surgery and providing follow-up care if appropriate.
Children and adolescents with diabetes (type 1 or type 2) should be seen by a dietitian with specialist skills in both paediatric and diabetes management (ISPAD 2009). Young people with type 2 diabetes are at significant risk of macro- and microvascular complications (Constantino et al 2013) and should be referred to a specialist diabetes team for dietetic input.
Carbohydrate counting is an essential skill to support intensified insulin management in type 1 diabetes (DAFNE Study Group 2002), either by multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). To achieve this, all patients must be able to access such training locally, and ideally, at their own diabetes clinic (SIGN 2010).