The University for business and the professions Empowering patients with Diabetes- Nurse’s Role in promoting healthy diets

The University for business and the professions

Empowering patients with Diabetes- Nurse’s Role in promoting healthy diets.


Guided Poster presentation at the International Conference for Health Promoting Hospitals.

(Dublin May 17-20, 2005)

Victoria Oladimeji (PhD, MA, MBA, BA, RGN, RM)Lecturer in Nursing Studies with specialty in Health Promotion

City UniversitySt Bartholomew School of Nursing and MidwiferyPhilpot StreetWhitechapelLondonEC1 2EAEngland

Tel: 020 7040 5800Direct Line: 020 7040 5887Fax: 020 7040 5811Email [email protected]


Introduction

Education about diet is essential to delay the onset, or even prevent diabetes in those at risk of Type 2 diabetes and for the effective management of the condition in those with Types 1 and 2 diabetes.


Nurses, in collaboration with doctors and dietitians are uniquely placed to provide this input and to ensure the integration of accurate and consistent dietary messages throughout hospital and community care teams. The aim is to empower patients living with diabetes by providing them with the information required to make appropriate choices on the type and quantity of the food which they eat as well as their lifestyles.


The advice must take account of the individual's personal and cultural preferences, beliefs and lifestyle, and must aspect the individual's wishes and willingness to change. The nurse should aim to facilitate self-care and help the patient acquire new knowledge and skills to make informed choices and facilitate behaviour change. Written information summarizing the key messages which the patient can take home and refer to later is usually essential. Partners, carers and parents must be involved where appropriate.


Health Belief Model (HBM)

According to Becker (1974) the rationale behind the Health Belief Model is that even though an individual recognizes the consequences of certain health behaviours, his or her decision to take action will be based on certain criteria such as:


HBM

Susceptibility- the individuals’ belief that the disease will occur or re-occur.

Severity of the risk or illness

The benefits to be gained from complying with therapy.

Cues to action - i.e. stimuli that trigger appropriate health behaviour. They can be internal (how the patient feels) or external (interpersonal interactions and advice from the nurse). Diverse factors- Demographic, cultural, social and personality factors that may influence health behaviour. These link into the patient’s social and family circumstances.


Dietary EducationDietary education should be a resource for life, an on-

going interactive process between patient and professional,

Not a standard package that can be delivered to a patient in a single session.

In the initial stages after diagnosis, people may only be able to assimilate a very limited amount of

information.

The process of dietary assessment provides an opportunity to explain the types of dietary changes

needed and to explore how these may be met. Understanding of and compliance with dietary

messages is important for achieving the goals of diabetic education.


Monitoring progressFollow-up and review of progress is essential. The frequency of follow-up depends on thetype of treatment, the patient's ability and confidence, and on diabetic control. The dietary review should consider:1. Meal pattern, compositional balance and food choices.2. The extent to which specific dietary targets have been achieved.3. Reasons why targets have not been met and how barriers to change may be overcome.4. Patient's ability to interpret blood glucose measurements and make the necessary dietary adjustments.5. Acceptability of the dietary changes made and their impact on the patient's cultural beliefs and quality of life.


For many people, including the majority with Type 2 diabetes, the major nutritional consideration is the correction or limitation of obesity. All patients, relatives and carers should be

advised about the principles of healthy eating (Health Education Authority, 1995) which apply to the general population.


Effects of dietary compliance on Blood Glucose and Cholesterol levels.

There is research evidence to show that Diabetic Dietary Outcomes can be improved by patients’ compliance with dietary requirements. Reduction in triglyceride and increase in HDL for example:1. Lowers blood pressure (although blood pressure will rise during exercise) and also reduces mortality in Type 1 diabetes (Ha & Lean, 1998)2. Can reduce HbA1c by 0.7% in Type 2 diabetes (Boule et al., 2001). Many of the studies in patients with Type 2 diabetes have combined dietary intervention with exercise and lifestyle management programmes. A meta-analysis of 89 studies showed that interventions which focussed solely on dietary advice produced the greatest weight loss and the greatest improvements in metabolic control. (Brown et al., 1996).


The Clinical Picture

The clinical picture (e.g. glycaemic control, lipid profiles, weight change, blood pressure) must be reviewed as part of the lifestyle and dietary assessment so that the effectiveness of the changes made can be evaluated. Goals of care can then be reinforced or adjusted if necessary.

The emphasis should be on ensuring greater understanding of the effects of non-compliance with dietary requirements, and empowering patients towards improved self-care.

A multi-professional approach is important in order to ensure that the dietary messages are reinforce during every contact with the patient


Follow-up Sessions

All patients should have at least one follow-up dietary review. This should be flexible to suit each patients' individual need. An Annual Review offers added opportunity for further dietary review, Those with problems such as renal disease, pregnancy and pre-pregnancy, perceived poor practice or poor knowledge should be seen more frequently.


Conclusion

Responsibility for the management of diabetes whether in hospital or in the community should be shared between the person with diabetes and the Multidisciplinary/Primary Care Team. Emphasis should be on collaborative, multi-agency care.

Wherever possible patients should be allowed to make their own food choices, although guidance may be needed from the nurse and the dietician to ensure that meal plans are appropriate to the circumstances of the illness.


Nurses in collaboration with dietitians should ensure that hospital menus contain appropriate choices for meals and snacks and those suitable foods and drinks are available in hospital canteens and shops and on hospital trolleys. This can be more difficult when these services are contracted out to independent suppliers. All wards must stock food and drink for the oral treatment of hypoglycaemia.

In Primary Care, Dietitians should be involved in providing suitable dietary education for patients.


References. Audit Commission (2002) Integrating services for older people.

London: The Stationery Office.

Audit Commission (2000) The way to go home. Oxford: Audit Commission Chiva A. and Stears D. (2001) Promoting the Health of Older People. Buckingham, Open University.

Boule, N.G., Haddad, E., Kenny, G.P., Wells, G.A. & Sigal, R.J. (2001) Effects of exercise on glycaemic control and body mass in Type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 286, 1218–1227.

Brown, S.A., Upchurch, S., Anding, R., Winter, M. & Ramirez, G. (1996) Promoting weight loss in type II diabetes. Diabetes Care 19, 613–624Bryden, K.S., Neil, A., Mayou, R.A., Peveler, R.C., Fairburn, C.G. & Dunger, D.B.

DOH (2001) National Service Framework for Older Adults. London HMSO

DOH (2003) Discharge Handbook. London HMSO.

Grimmer K. Hedges G. Moss J. Staff perceptions of discharge planning: a challenge for quality improvement. [Journal Article, Tables/Charts] Australian Health Review. 1999; 22(3): 95-109. (18 ref)

Ha, T.K.K. & Lean, M.E.J. (1998) Technical Review. Recommendations for the nutritional management of patients with diabetes. Eur. J. Clin. Nutr. 52, 467–481.

Henwood M. (2004) Hospital Discharge Integrating Health and Social Care Health and Social Care in the Community. London HMSO.

Magilvy J. and Congdon J (2000) . The Crisis Nature of Health Care Transitions for rural Older Adults Public Health Nursing Vol. 17(5)Sept. Oct.

Tower Hamlets PCT 2004 Discharge policy statement

Waters K. (2001) Sources of support for older people after discharge from hospital: 10 years on, Journal of Advanced Nursing Vol 33 (5) March.

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The University for business and the professions Empowering patients with Diabetes- Nurse’s Role in promoting healthy diets