by Linda Omichinski, RD

Working in a Diabetes Education Centre for the past 12 years has given me an opportunity to see clients over the long term with diabetes. Initially, I used a traditional approach, with exchanges, as I had been taught. But, in time, I moved ahead to the nondiet approach as described in Part I of this article (see Healtby Weight journal 1998; 12: 9-1 1) because of the damaging and unhappy cycles of behavior I was seeing.

The example below of Barb, who has type 2 diabetes, shows how this approach can be put Into action.

Practical application of the nondiet approach

In real life...

Barb (not her real name) Is a 65-year-old woman who came to see the dietitian after being diagnosed with elevated blood sugars. The dietitian used a life-style, nondieting approach to educate the client about her diabetes. Barb was introduced to the new skills she would need in the following way...

Assessment of client's nutritional knowledge: what you already know, builds up confidence

Barb was asked to divide food models into two groups -identifying foods that did and did not contain natural sugar.

Education: what you need to know, simple, easy to understand and remember guidelines

The dietitian expanded on the concept of balanced meals using nondiet nutrition concepts. Food models assisted in illustrating the purpose of carbohydrates for energy and protein for slower release of energy to stabi-lize blood glucose levels. Barb was advised about the 2/3 to 3/4 carbohydrate and 1/3 to 1/4 protein combination.

Verification of concept: assimilating the known and the unknown using familiar examples

Barb was asked to describe the types of meals she might eat using her existing knowledge about the content of food and the new concepts she had been shown.

Portion control

Barb was told how to tune into her body by recognizing the natural signals of hunger and satiety to determine the amount she could eat. She was encouraged to be experimental and note how she felt before and after eating.

New health choices

Barb was advised that she would learn how to gradually make changes in her cooking techniques, eating, and activity patterns. Her desire to make these changes was supported with the guidance that lifestyle change is a skill building process that takes time.

Barb left feeling positive and began to gradually make the suggested changes in her lifestyle. A short time later though, the dietitian received a phone call from Barb's daughter. She was indignant that her mother had not received a diet instruction sheet. She wanted the dietitian to administer a diet as soon as pos-sible. The dietitian advised Barb's daughter that her mother's scheduled 1 month follow-up was the following week at which time her progress would be assessed.

How could this situation be handled using the empowerment model (i.e., the nondiet approach)?

If the dietitian was new to the nondiet approach, the reaction of Barb's daughter might be intimidating. It could be tempting to yield to her request, rationalizing that the nondiet approach is not for everyone, and perhaps the client's wishes should be considered. We know that people are used to getting diet sheets and being weighed to indicate progress and success.

In actual practice, here is what did happen. Barb reviewed her meals in detail with the dietitian, revealing that she had an excellent grasp of the concepts of bal-anced meals and hunger and satiety signals. The dietitian maintained her new role, focusing on building the client's confidence level and affirming her ability to make healthy choices about her lifestyle. The dietitian told Barb that she did not need the restrictions of a diabetic diet per se. In addition, Barb had an improved blood glucose level, further indicating her ability to handle the concepts.

Barb was encouraged to continue with her present course since she was doing just fine. Suggestions about fine tuning her cooking techniques also were provided at this time. In keeping with the client empowerment ideal, Barb was advised to let her family know how well she was managing her new health condition-the dietitian did not take responsibility for contact with the daughter!

As a cautionary note, sometimes clients will follow a strict diet before having a blood test to ensure a good reading. A total health profile and HbAiC levels may be a more accurate indicator of the client's true under-standing of the disease. (HBA1C is a test that measures the average blood sugar over the previous 3 months).

In this way, there is a shift in the model for diabetes education. Client education is at the top of the pyramid. The empowerment of the individual, through recognition of the complexity of their personal needs when faced with their health condition, stimulates the desire to learn what they need to know to take care of themselves-the choice for permanent healthy living. They are then sup-plied with the tools, techniques, and facts that enable the client's choices to occur. An integrated program may be needed to cover all aspects of lifestyle change.

A number of years ago, when I began working with the nondiet approach, I took the time to follow some clients, their weight loss, and blood sugar levels, and I found some interesting results (Table 1).