Freedom From Counting for People with Diabetes, Part I

Used with permission from the Healthy Weight Journal, Jan/Feb/98

by Linda Omichinski, RD
One of the main health issues for people with diabetes is to develop and sustain a long-term plan that ensures stabilized blood sugars within an acceptable lifestyle. When one considers the destruction caused by chronic dieting syndrome behaviors and the inconclusiveness of weight loss benefits, the questions have to be asked: Why utilize weight loss as a goal and treatment plan? Why prescribe the diet lifestyle (food and exercise have-to's) for people with diabetes?

The traditional medical approach of restrictive diet often leads to damaging and unhappy cycles of behavior and attitude.

With diabetes, the changes made need to be maintained for the rest of one's life. The person with diabetes requires an integrated, flexible, and lifelong plan for total health that accommodates lifestyle choices. However, the traditional medical approach of restrictive diet and restrained lifestyle often leads to damaging and unhappy cycles of behavior and attitude that mimic chronic dieting syndrome.

In contrast, the special needs of the person with diabetes can be uniquely met through a genuine nondiet approach utilizing empowerment techniques. This model puts the client in charge of building individual health parameters in consultation with a facilitative health professional.

Slow, gradual, and supported experimentation with different types of food and levels of activity combine with positive attitude-building methods to instill the necessary confidence for healthy decision making. Optimum glycemic levels are attainable and retainable within this setting of client choice and responsibility. For both the person with diabetes and the health professional team, there are exciting new roles to learn about "letting go" and empowerment. The result of self-stimulated lifestyle choices is increased health potential.

People who have diabetes go through issues similar to people who have weight problems. This is particularly evident with type 2 diabetes, 80 to 90 percent of the diabetes population. These issues are:
1.   frequent feelings of hunger
2.   feelings of restriction and deprivation due to elimination of some favorite foods
3.   feelings of awkwardness at mealtimes because of the need to eat differently from family and friends, or forcing sudden changes in eating habits on the family
4.   feelings of guilt when "cheating" inevitably occurs, which often leads to going off the diet
5.   feeling of total dependence on the diet sheet resulting in total preoccupation.
The failure of the medical model is identified with four characteristics of this traditional method of treatment.
·   Disease is the focus-the treatment course prescribed often is weight loss to achieve an ideal body weight or body mass index within the norms.
·   Health practitioners are in control.
·   Information is given to clients according to arbitrary judgments on "what you feel" they need to know.
·   Success is measured by external goals such as weight loss, following a diet.

As practitioners, we need to examine the effectiveness of this treatment in stabilizing blood sugars over an extended period of time. Despite the initial benefits of the "Improved" diet and exercise programs prescribed for people with diabetes in the past, estimates suggest that one third to one half of the people with diabetes have difficulty following these programs for any length of time. Once blood sugars have been brought under control, former eating and exercise habits often return, along with the former lifestyle. Diet and exercise programs treat diabetes but make little attempt to address the individual's emotional response regarding food.

Success is measured on intrinsic motivation and internal goals-feeling better, improved well-being.

The alternative is the health promotion model based on a nondieting lifestyle:
-   The individual client is the focus of treatment.
-   The individual is in control and takes charge.
·   Information is given so individuals can make choices.
·   Success is measured on intrinsic motivation and internal goals (i.e., feeling better, improved well-being).
The application of the nondiet approach to the lifestyle issues of the person with diabetes works because the emotional power of food is accommodated through client choice. Weight loss focus is removed from the client concerns.

Research supports this approach. Increasing evidence points to the inconclusive benefits or actual risk with weight loss regimens. For example, fluctuations in body weight are less healthy than if one stabilizes at a higher weight. Yo-yo dieting where weight is lost and then regained seems to be associated with more fat being distributed around the stomach area.

Increased risk of obesity-related diabetes has been associated with fat in the stomach area rather than fat in the hips and thighs.

So how can we use the nondiet approach with this group of people? (Continued in Part II.)

Using the nondiet approach in diabetes treatment
Concept	Rationale	Contrast With
1. Regular eating including snacks according to physical hunger.	Overeating is less likely to occur, there-fore pancreas is less stressed due to a decreased sugar load at any one meal.	Eating according to the diet sheet.
2. Carbohydrate/protein balance as nondiet nutrition concepts: visual aid of one third to three fourths carbohydrates and one third to one quarter protein-gradual shift in balance.	Protein slows down the release of sugar (from carbohydrates) into the blood-stream, and helps to stabilize blood sugar and maintain longer satiety value. In addition, protein is distributed to all meals instead of having a high protein load at the evening meal. The lower protein also poses less stress on the kidney (kidney disease is one of the complications of diabetes).	Calculating exchanges or counting carbohydrates and robbing one of the enjoyments of food and causing a preoccupation with food.
3. Tune in to taste and texture by gradually increasing fiber content of meals	Allows tastes to change gradually and body to adjust to different foods	Sudden increase in fiber, person feels bloated and constipated, and says it is not for them and drops the fiber.
4. Eat when hungry, stop when full	Internal regulator of portion control, listen to one's body, taking care of body's needs	Portion control according to exchanges and diet
5. Tailor your tastes for gradual approach to change in tastes	Small changes allow one to change one's taste resulting in eating healthier by preference rather than because one "should"	Eat low fat, low sugar, and high fiber foods resulting in drastic changes of eating habits that is likely to be abandoned early because tastes don't change. Diet temporarily changes because one feels one should eat this way.
6. Build activity into one's lifestyle.	So it becomes integrated into a person's lifestyle. Encouraging research indicates that physical training, even without weight loss, seems to increase the body's sensitivity to insulin, making the available insulin work better.	Do a certain amount of exercise daily. It becomes an "add on" that one may never get to.
7. Use a blood glucose monitor to test the effect of food on one's blood sugar (i.e., try eating a fruit in the middle of the afternoon and then test your blood sugar a couple of hours later). For many people with diabetes, this type of food has a great effect on blood sugar level. If this is the case, try adding a little bit of protein like a small amount of cheese with the fruit or try a more complex carbohydrate that releases the sugar more slowly (e.g., a whole grain bun). When Ann tried this, she discovered that with a fasting blood sugar of 6 (1 1 0), her blood sugar increased to 12 (215) or 13 (235) when she ate a fruit in the middle of the afternoon. She tried adding a small piece of cheese and her blood sugar only increased to 8 (145) or 9 (165).	One can test out the concepts and learn how to work diabetes and foods into the daily way of life	Take your blood sugar every day or several times a day and record it. This method doesn't allow you to determine how food and activity affect your blood sugar.
8. Add water to unsweetened juices (which contain natural sugar) and/or have them at the end of a meal	Adding water to juices which are naturally highly sweetened allows you to begin to appreciate tastes that are less sweet tasting and will quench your taste better. Having them at the end of a meal means that there is food in your stomach so it will take longer for the sugar to get into your bloodstream.	Drink diet drinks, and diet juices.... This will still cause the individual to have cravings for sugar as they still will like sweet tasting foods. Diet drinks have their place in the eating pattern of a person with diabetes, but relying on them heavily by switching from regular to diet food or drinks does not allow one to begin to enjoy foods lower in sugar, the true measure of permanent change.
9. Make small changes gradually and accept where your weight stabilizes	Due to genetic predisposition or history of chronic dieting, one's weight may not change very much even though lifestyle changes are made. Even a small amount of weight loss, as little as 5 to 10 pounds, results in improved glycemic values. By losing even a modest amount of weight (as little as 10 pounds), these patients may lower their insulin resistance to the point where the insulin their pancreas produces is sufficient to keep blood sugars down. Even if weight is not lost, in many cases blood glucose improves with a nondieting lifestyle.	Losing weight to reach your ideal body weight or body mass index is the main focus when individuals lose weight bv following a rigid diabetic diet only to go off the diet once the weight is lost and inevitably regain the weight.

Linda Omichinski, RD, is president of HUGS International Inc., developer and marketer of nondiet programs and products for adults and teens, author of You Count, Calories Don't and co-author of Tailoring Your Taste book and workshop tour on which this article is based. HUGS International Inc., Box 102A, RR#3, Portage la Prairie, Manitoba, Canada RlN 3A3 (565-4847; fax 204-428-5072; email linda@hugs.com; website: (www.hugs.com)

Suggested Reading

• Meredith S, Leiter LA.
• Shumak SL. Deterioration of glucose control in NIDDM. Can Diabet 1991; 4:2.
• Coopan S. Special report on type 11 diabetes. joslin Magazine, Fall, 1986
• Meredith S, Leiter L.A. "Commercial weight loss clinics in the co- treatment of obese patients with diabetes: Are they safe?", Can Diabet 1991; 4:1.

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).

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)