|
Freedom
From Counting for People with Diabetes, Part 2 |
Used with permission from the Healthy Weight
Journal, March/April/98
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).
|
Table 1 Insights and Discoveries
about blood sugar and weight loss |
|
|
HbA1C |
|
|
|
Client |
Initial |
6 mos later |
Weight Loss |
Comment |
|
Male |
9.1 |
6.9 |
Decrease 4.7 kg (10.4 lb) |
Some weight loss and a good understanding of carbohydrate/protein
balance. |
|
Male |
9.8 |
7.2 |
Decrease 0.7 kg (1.5 lb - 109% of IBW) |
Weight loss was minimal and client is heavier than recommended
weight, yet blood sugars improved considerably. Weight loss was
not a significant factor in decreasing HbAiC |
|
Female |
8.6 |
8.6 |
Decrease 2.3 kg (5 lb |
Preoccupied with weight. Despite a decrease in weight and an
active life-style, this client's blood sugars did not improve.
Note that this client is very weight preoccupied, possibly contributing
to an increased mental stress level that has an effect on blood
sugars to counterbalance the positive effects that physical activity
and weight loss contribute. |
|
Male |
7.7 |
7.2 |
Increase 3.5 kg (7.7 lb - 110% of IBW) |
Very relaxed-handles stress positively. Although client's weight
increased and client is at a higher weight than recommended,
blood sugar levels have improved. This may be attributed to the
fact that he handles stress very positively and has a very relaxed
attitude. |
|
Female |
7.5 |
6.6 |
Decrease 1.2 kg (2.6 lb - maintaining weight 119% of IBW) |
Even though this client is large and has minimal weight loss,
her understanding of the balance between protein and carbohydrate
at mealtime: adding peanut butter to bread and adding more fiber,
such as whole grain bread, may be a contributor to improved blood
sugars. For example, mixing some whole grain pasta with white
pasta, and serving with a meat sauce, introduces fiber and protein
to the pasta meal, which helps slow down the release of
sugar into one's bloodstream. |
This internal study demonstrated to me that long-term maintenance
of blood sugars, as shown by HbAiC measurement, involves several
other factors than weight loss.
It is unfortunate that so much emphasis is placed on weight
loss, when a healthier attitude toward food and activity, regular
eating, a relaxed disposition, weight stabilization, and balanced
eating may be more important factors to consider.
As you too begin to use this approach and ask the right
kinds of questions to determine the patient's total well
being, you may discover similar results.
Linda Omichinski, RD is President of HUGS International
Inc., developer and marketer of nondiet programs and prod-ucts
for adults and teens, author of You Count, Calories Don't and
co-author of Tailoring your Tastes book and work-shop tour on
which this article is based. HUGS International Inc., Box 102A
RR#3, Portage la Prairie, Manitoba, Canada RlN 3A3 (Tel 800 565
4847; Fax 204 428 5072; email linda@hugs.com website: www.hugs.com) |