Diabetes and dietetics – why refer?

There is currently a crisis in access to dietetic services for diabetes patients. This is having a significant impact on quality of life and outcomes for children and adults living with diabetes in Ireland, and will inevitably lead to increased costs to the health service. 

Dietitians are healthcare professionals with expert nutritional knowledge and skills in translating scientific information into practical approaches that can help patients to self-manage their diabetes. Many dietitians are also trained to employ behaviour change skills to facilitate lifestyle changes in patients which lead to positive outcomes. 

The true prevalence of diabetes in Ireland is not known as there is no register for people with diabetes. The support group Diabetes Ireland estimates that there are 191,000 people living with diabetes in Ireland (with a prevalence of 6.1% in the population). As well as an increase in the prevalence of type 2 diabetes, the prevalence of type 1 is also on the rise; it is estimated that there are approximately 14,000 people with type 1 diabetes in Ireland.

Evidence for dietetic efficiency and effectiveness

Prevention of type 2 diabetes

Intensive lifestyle change is cost-effective in reducing the risk of diabetes by 28-59%. Lifestyle interventions that incorporate energy restriction and a lower fat intake with increased physical activity can effectively reduce the risk of type 2 diabetes in high-risk groups. Weight loss is the most important predictor of risk reduction, and a weight loss of 5-7% is effective. Each kilogramme of weight loss equates to a 16% reduction in the risk of developing diabetes.^1,2

Type 1 diabetes

The efficacy of dietetic interventions has been shown in a number of studies. The DAFNE study in the UK and Ireland set about teaching people to self-manage using advanced carbohydrate counting and insulin dose adjustment with the aim of decreasing HbA1c by 1% in six months.³ The Diabetes Control and Complications Trial⁴ demonstrated that adjusting insulin in response to hyperglycaemia, meal size and meal content led to a decrease in HbA1c of 0.9%.⁴ Carbohydrate counting can achieve approximately 0.5-1% reduction in HbA1c.⁵

Type 2 diabetes

There is evidence to support nutrition management in type 2 diabetes:

• Dietitian-led intervention improved outcomes in type 2 diabetes with HbA1c >7% despite optimised drug treatment⁶
• Dietitian-led intensive lifestyle intervention attenuated weight gain associated with commencing insulin in type 2 diabetes⁷ 
• The most effective treatment for overweight/obesity in type 2 diabetes reduces mortality by 25%, improves glycaemic control and CVD risk factors. Low fat diets are most widely employed. The Look AHEAD trial reduced weight, HbA1c and CVD risk, which was maintained over four years.⁸

Complicated diabetes and diabetes with co-morbidities

Diabetes is the single-leading cause of end stage renal disease worldwide. It accounts for 45% of prevalent kidney failure, up from 18% in 1980. Approximately 30% of patients with type 1 diabetes will develop chronic kidney disease. The role of the dietitian is essential to achieve and maintain optimal metabolic outcomes including:

• Glycaemic control
• Optimal lipid profile that reduces risk of cardiovascular disease. CVD risk is greatly increased in this population group•
• Help achieve blood pressure targets
• Achieve ideal body weight
• Maintain biochemical parameters within acceptable ranges, eg. potassium, phosphate, monitoring and liaising with the multidisciplinary team with regard to anaemia and renal mineral bone disease, helping to control uraemic symptoms and maintain fluid balance
• Ensure a nutritionally balanced diet.

Cystic fibrosis-related diabetes (CFRD) is the most common co-morbidity in people with CF, occurring in approximately 20% of adolescents and 40-50% of adults. The American Diabetes Association (ADA) recommends that CFRD should be managed by a multidisciplinary team of health professionals, including dietitians, with expertise in CF and diabetes. Patients with CFRD should be seen quarterly by this specialised multidisciplinary team.

Diabetes in pregnancy and gestational diabetes

Poor glycaemic control in the first trimester in type 1 and type 2 diabetes is associated with complications such as malformations, congenital defects, cardiomyopathy, miscarriage, intra-uterine death and a need for neonatal care. The Atlantic Dip study used universal screening with a fasting cut-off value of 5.6mmol/L and identified 12.4% of the population had gestational diabetes. 

In one central Dublin maternity hospital the number diagnosed with gestational diabetes doubled in 10 years from 1999-2009 linked to the increase in obesity. Adverse outcomes are associated with gestational diabetes and obesity. 

Diet is the cornerstone of care for diabetes in pregnancy, with strict control of carbohydrate intake to manage glycaemia. All women with type 1 and type 2 diabetes should be offered preconception counselling to optimise glycaemic control prior to conception, including individualised dietary advice from a dietitian skilled in diabetes and pregnancy.

Diabetes and paediatrics 

The current evidence-based guidelines for nutritional management in children with diabetes are the International Society for Paediatric and Adolescent Diabetes (ISPAD).⁹ These consensus guidelines are based on international paediatric position/consensus statements and evidence derived from recommendations for adults with diabetes. 

ISPAD states that dietary advice provided by a paediatric dietitian should be given as soon as possible after diagnosis and that continuation of care, support and review by a dietitian is essential for the optimal care of diabetes management. The NICE 2010 guidelines¹⁰ recommend optimising the effectiveness of diabetes care and reducing the risk of complications. To achieve this, the diabetes care team should include a dietitian with appropriate training in the needs for children and young people with diabetes. 

Carbohydrate counting is an essential component of the dietary education provided by dietitians. Teaching patients to carbohydrate count has been shown to improve glycaemic control while allowing maximum flexibility in the diet. The Diabetes Control and Complications Trial,⁴ which included subjects age 13-39 years, showed 34-76% reductions in complications of type 1 diabetes in the study group, which received both intensive insulin therapy and monthly clinic visits with a dietitian.

Structured education

The Diabetes Expert Advisory Group First Report (April 2008)¹¹ recommended that people with diabetes living in Ireland should be able to access diabetes care expertise and self-management education that is appropriate to their needs and in a location that is convenient to them.

Dietitians are a core member of the team required to deliver structured education programmes for people with diabetes. There are currently three structured education courses being run throughout Ireland these are CODE, DESMOND and X-pert. (See www.indi.ie and www.diabetes.ie for further information on how to access CODE and Xpert).

Diabetes Ireland has recently opened a new care centre in Santry in north Dublin. It has a team of practitioners with the expertise in the needs of people with diabetes. CODE is available to members on the premises and a dietitian and podiatrist are onsite to provide services to members at reduced rates. For further queries contact Diabetes Ireland on Locall 1850 909 909 or visit www.diabetes.ie

References

1. Hamman et al, 2006
2. Evidence-based nutrition guidelines for the prevention and management of diabetes, Diabetes UK, 2012
3. DAFNE Study Group, 2002
4. Diabetes Control and Complications Trial/ Delahanty & Halford, 1993
5. Dias, 2010; Scavone, 2010; Trento, 2010
6. Coppell, 2010
7. Barratt, 2008
8. Look AHEAD trial
9. International Society for Paediatric and Adolescent Diabetes (ISPAD)
10. National Institute for Health and Clinical Excellence (NICE, 2010) Type 1 Diabetes: Diagnosis and management of type 1 diabetes in children, young people and adults. Clinical Guideline 15
11. Diabetes Expert Advisory Group First Report April 2008