If you did not already know – November is Diabetes Awareness Month. There are now an estimated 11 million Canadians already living with diabetes or prediabetes and an additional 1.5 million Canadians who are undiagnosed. Given that approximately 30 percent of the Canadian population has or are prediabetes the Canadian Diabetes Association (CDA) believes the disease has now reached epidemic proportions. Observing November as diabetes month helps bring attention on the impact this disease has on millions of people but it also brings awareness about what can be done to manage diabetes and prevent its progression.
This month The Salvation Army Toronto Grace Health Centre (TGHC) is doing its part in promoting diabetes awareness by discussing how our health care facility provides treatment to patients with diabetes in addition to their other complex healthcare needs. To help us understand the complexities of providing care to a diabetic patient at the TGHC, we enlisted the expertise of our Registered Dietitian Brent Martin.
I think we should begin by asking what a Registered Dietitian (RD) is.
BM: A registered dietitian is a regulated health professional who can provide advice on nutrition, food and healthy eating to make it easier for you to make daily food choices and plan healthy meals. Registered Dietitians take complex medical and nutrition research and translate the science into practical advice. Here at the TGHC, I assess nutritional risk and develop nutritional care plans for all patients in the Complex Continuing Care (CCC) and Post Acute Care Rehabilitation (PACR) programs. In the palliative unit, I will see patients only with a medical doctor’s (MD) consult as the focus is on comfort care.
Can you elaborate on your responsibilities and the type of nutritional care you provide for the patients at the TGHC?
BM: I’ll just talk about a few of my core duties. Upon admission I will prepare a comprehensive initial nutritional assessment for all new patients on all floors, except as I said, palliative care. Patients that have an enteral feeding tube (tube feed) are seen immediately on admission, and the enteral nutrition order written within hours of admission. Any changes to the enteral nutrition care plan are communicated to our pharmacy and health care team. On admission I will also screen patients on oral intake within 24 hours of admission to start the initial assessment and confirm correct therapeutic diet and diet texture. My other duties include completing quarterly and annual nutritional assessments, attending weekly team rehabilitation rounds, as well as weekly rounds with the wound care team. I attend all admission family team meetings, quarterly patient care meetings and discharge planning meetings as needed. In addition, some patients and/or their caregivers will receive one to one nutrition counseling if a patient is being discharged back to the community. Part of my duties include conducting nutrition in-services for our hospital staff. I take an active role and participate in committees: Interdisciplinary Professional Practice, wound care, as well as quality improvement projects that involve research on improving patient outcomes. My duties also extend to evaluating the therapeutic menu and recommending changes or improvements to the menu items. In addition, to increase efficiency and the quality of the nutritional care we provide, I evaluate and develop nutritional assessment tools.
On admission you stated that a patient receives a nutritional assessment, what’s involved in a nutritional assessment?
BM: When we do a nutritional assessment with new patient admissions we review the current medical condition, any therapeutic diets the patient is receiving, their current appetite, eating pattern, and average daily fluid and food intake. The patient’s current weight, weight history is assessed, and from there we determine their goal weight with patient and family input. We review both nutritionally pertinent medications and lab work, and determine if nutrition intervention would help. Based on these parameters we make an assessment of the patient’s nutritional risk and status. At that point we develop a nutrition care plan and a therapeutic diet to improve the nutritional status or stabilize and monitor the patient’s outcome. We have eight main therapeutic diets, which includes a diabetic diet.
Let’s talk about patients at the TGHC that have diabetes and their nutritional care. I believe there are three different types of diabetes but all the patients at the TGHC with diabetes are Type 2 is that correct?
BM: Yes, the statistic is that 90% of people with diabetes have Type 2. Type 2 diabetes occurs when the body cannot properly use insulin that is released (called insulin insensitivity) or does not make enough insulin. As a result, sugar builds up in the blood instead of being used as energy. However, its not just about managing the patient’s sugar levels, there are other factors. Patients that are admitted to the TGHC with diabetes could be on medication like insulin, pills, or a combination of both. Many diabetics have comorbidities (other complex healthcare issues) like heart disease, hypertension or obesity making their care difficult to manage. During admission the MD and Pharmacist determines the patient’s medication and after a nutritional assessment the patient will be placed on a diabetic menu and evening snack to prevent fasting hypoglycemia (low blood sugar).
What you’re saying is that managing the patient’s diet is a team effort?
BM: It’s an interprofessional health care team effort. During the patient’s stay the RD will collaborate with the MD and pharmacist making suggestions informing the team on patient food and fluid intake, which may lead to using more or less medications to control the diabetes. Medication and diet, work together to control a patient’s blood glucose levels.
Are there patients that are strictly “diet controlled” with no medications?
BM: Yes, there are patients who are fortunate to be able to maintain their sugar levels by maintaining a consistent healthy diabetic diet. But this can also happen for patients who are on low dose oral medications. By maintaining proper dietary eating patterns and portion control some patients while they’re receiving treatment at the TGHC can improve to being strictly “diet controlled.”
So if they keep to the diabetic diet they could eventually stop taking medications that help control their diabetes?
BM: Although it is rare that patients can become “diet controlled”, some patients who are already on insulin or pills may be able to cut back on their insulin or pill dosage intake, if they continue to follow a diabetic diet.
Can you expand on the type of menu you provide at the TGHC?
BM: On admission, diabetic patients will receive the standardized diabetic menu, which is portion controlled, with a focus on high fibre complex carbohydrates, healthy fats and adequate protein intake. This is what we at the TGHC refer to as a “non select” menu. Patients most often choose this menu, and I will work with the patient on their preferences to set up a suitable menu for them. If patients are on “select menu” they will receive guidelines from me regarding a balanced diet that includes proteins, healthy fats and how many carb choices to make at each meal. In fact to help diabetic patients I have developed a Top Ten Guidelines for the Diabetic Diet.
Was the diabetic menu at the TGHC developed by you?
BM: No, the food service model was designed and implemented by our food company provider with my input. The patients do have limitations to food choices with this menu but I tell them that I can counsel them before they’re discharged to help them expand their choices once they are at home. I also tell them that the menu at the TGHC is strictly designed to keep their blood sugars under control if they follow it and do not cheat.
There’s cheating! How does this happen?
BM: Family members can hinder a patient’s diabetic control by bringing into the hospital inappropriate foods. For example the patient might complain that they’re hungry between meals and a family member will comply by bringing in their favourite food. I know they mean well and think they’re helping but if the patient is hungry in between meals we can provide healthy snacks. However, I find that once I intervene and educate and inform the family towards making better food choices for the patient they adhere to those choices.
Earlier you spoke about patients that have enteral feed, what is an enteral feed and how is their diabetic diet controlled?
BM: (Smiling) No Cheating! I’ll explain, because some patients have problems that prevent them from receiving adequate nutrition by mouth, and enteral feed refers to the delivery of a nutritionally complete feed directly into the stomach by a gastrostomy tube or a g-tube. As a RD I have different formulas for different enteral feedings depending on the patient’s blood sugar control. Some diabetic patients do not need to go on a specialized diabetic formula, perhaps because they have wounds or higher energy requirements (caloric intake). If a patient’s blood sugars are not well controlled then I will change to a specialized diabetic formula. The patient is then receiving a balanced formula with the right amount of carbohydrates, protein and fats. The benefit is that the formula is consistent every single time unlike oral intake where the diet could fluctuate because the patient eats outside their diet or they fluctuate on portion control. Enteral feed patients are the most compliant…like I said no cheating.
With the diversity of ethnic cultures in Toronto I can’t help wonder how does an RD help diabetic patients with different cultures choose the right (grains and starches, fruits, dairy and alternatives) carbohydrate foods.
BM: I use the ‘Diabetic Food Guide to Healthy Eating’ produced by The Community Diabetes Education Program of Ottawa to help guide diabetic patients in making the right choices. It’s an excellent guide but I will admit it was not designed to specifically address different cultural foods. Cultural food preferences are a challenge and as a RD it’s my job to do research on culturally specific foods when providing diabetic counselling. If I can equate a particular ethnic food to a category in the ‘Diabetics Food Guide’ then I will supplement that grain or fruit.
You said that you help guide diabetic patients by making smarter food choices and portion control. Do you meet patients who do not want your dietary advice?
BM: The reality is that many diabetic patients are resistant to accepting or following dietary advice for various reasons. Some feel it’s not worth doing, or it interferes with their favourite foods that they like to eat, others feel it will impact their lifestyle too radically, or it is too late to change, or they simply do not see the immediate benefits. I always try to determine the reason why and discuss the benefits to maintain good control – most patients listen but it does not mean they will comply.
As an RD I guess that can be very frustrating?
BM: You want the patient to make the right choice and I will provide them with education and information to help them make informed decisions about their health. But it’s their right to choose, and if they choose not to comply with a proper diabetic diet…well then yes it becomes frustrating.
What do you do then?
BM: In order to do your best an honest approach should be employed because as a medical professional it is your duty.
What’s an honest approach?
BM: Their future. I have no problem discussing with a diabetic patient the negative outcomes that can occur if they do not follow a proper diabetic diet. I tell them I’m not the one that needs convincing, and that if they choose not to comply with a proper diet, health outcomes that cannot be reversed will occur. Going out for dialysis three times a week because of kidney failure is a negative outcome that is a direct result of poor diabetic control over the long term. Cardiovascular disease, vision loss, nerve damage, amputation, sexual dysfunction are all negative outcomes that will lessen their quality of life. I also tell them because you do not immediately see the result of a poor diet, or have a lack of portion control these relatable diseases slowly become part of your health and occur when it’s too late.
Brent, what would you say is the singular most important point about diabetes that we should remember?
BM: Diabetes is a manageable disease and you can have quality of life if you stick to your diabetic diet.
Thank you for a great interview!
By: Gerry Condotta