Managing Clinical Problems in Diabetes, Case Study #16: Nutritional Management and Physical Activity

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

Mr. WC self-referred to a diabetes centre at a tertiary hospital. “I am confused about the recommendations for diet, especially the GI. As a veteran of 27 years of type 1 diabetes, I am also a veteran of a number of treatment schedules, various insulins and diets. The ‘one-size-fits-all’ approach is inappropriate at best and downright dangerous in some circumstances. I control my blood glucose with long-acting insulin at midnight and rapid-acting insulin before each meal and eating a low GI diet. However, eating low GI foods send my blood glucose down after I eat. When I correct my blood glucose it goes the other way and I get hyperglycemic because the GI kicks in and so do my recovery hormones. What can I do?”…

Dietitian 

I would seek extra information from his GP about his clinical results (HbA1c, lipid profile, blood pressure, BMI) and whether he has any long-term complications such as gastroparesis. In addition, I would clarify the following issues with Mr. WC: 

• What are his actual blood glucose levels around specific meals and the dietary and medication adjustments he makes to interpret his statement that: ‘eating low GI foods sends my blood glucose down after I eat’? Some people feel ‘hypo’ when their blood glucose levels are above 4 mmol/L. I also need to clarify whether the blood glucose drops after every meal or specific meals or at certain times of the day. 
• Does he count carbohydrates? If he does, clarify whether he includes very low GI foods such as pulses and only eats low GI carbohydrates or includes some medium and high GI carbohydrates as well. 
• Does he adjust his insulin according to the carbohydrate content of the meal? 
• Has he attended any structured/self-management education programs? 

Once those issues are clarified I would provide the following advice: 

• Inform him that the quantity of carbohydrate consumed is the key strategy for optimal glycemic control and that the quality or GI may only offer additional benefits if the quantity of carbohydrate is considered (Sheard et al. 2004). 
• If he is only eating low GI foods, I would advise him that his diet may be more nutritionally balanced if he incorporates some medium/high GI carbohydrates into his eating plan. 
• I would recommend that he does not count the carbohydrate content of very low GI foods such as pulses. 

• Suggest that when he consumes a low GI meal, he experiments with injecting the rapid-acting insulin with the meal or after the meal rather than before it. Carbohydrate digestion and the resultant rise in blood glucose will have commenced before the insulin begins to work. 
• If available, offer him the opportunity to attend a structured/self-management education program to develop the knowledge, skills, and confidence to adjust insulin according to the quantity of carbohydrate consumed. 

Diabetes educator

I agree with all the dietitian’s strategies, but I would clarify how soon after a meal he tests his blood glucose. He needs to test at least 2 hours after to determine postprandial glucose levels. If he tests sooner he may detect the rise in blood glucose that occurs in the post-absorptive state. 

I would also ascertain what long-acting insulin he is using and why he is injecting it at midnight. The type of insulin and injection time may account for some of the variability. I would also check his blood glucose testing equipment and technique and insulin administration technique and injection sites to determine whether they could be a factor. He may be unnecessarily treating hypoglycemia. 

It is not clear whether he exercises and what effect that has on his insulin requirements and timing of meals. Alcohol intake also needs to be considered.    

American Diabetes Association (2006) Nutrition recommendations and interventions for diabetes – 2006. A position statement. DiabetesCare 29(9): 2140–2157.

Baines S, Roberts D (2001) Undernutrition in the community.Australian Prescriber 24(5): 113–115.

Bouchard L, Drapeau V, Provencher V et al. (2004) Neuromedin beta: a strong candidate gene linking eating behaviours and susceptibility to obesity. American Journal of Clinical Nutrition 80(6): 1478–1486.

Brand-Miller J, Foster-Powell K, Colagiuri S et al. (1998) The GI Factor. Hodder, Sydney.

Chagnon YC, Perusse L, Weisnagel SJ et al. (2000) The human obesity gene map: the 1999 update. Obesity Research 8: 89–117.

Conn V, Hafdahl A (2007) Metabolic effects of interventions to increase exercise in adults with type 2 diabetes. Diabetologia 50: 913–921.

Egger G (2007) An interview with Professor Gary Egger. Part 1.Weight Management in Review 5: 1–4.

Howe M (2007) Weighty issue. Australian Doctor 16 March: 43. International Diabetes Federation (IDF) (2006) Incidence of diabetes. Diabetes Atlas 2 (www.eatlas.idf.org/Incidence/). Knowler WC, Barrett-Connor E, Fowler SE et al. (Diabetes Prevention Program Research Group) (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention and metformin. New England Journal of Medicine 346: 393–403.

Lindström J, Louheranta A, Mannelin M et al. (Finnish Diabetes Prevention Study) (2003) Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 26(12): 3230–3236.

Marks S (2000) Obesity management. Current Therapeutics 41: 6.

Mooradian A, Failla M, Hoogwerf B et al. (1994) Selected vitamins and minerals in diabetes care. Diabetes Care 17: 464–479.

Moyad M (2007) Fad diets and obesity. Part 1: measuring weight in a clinical setting. Urology Nursing 24(2): 114–119.

National Health and Medical Research Council (NHMR.C) (1999) Dietary Guidelines for Older Australians. NHMR.C, Canberra.

Pan XR, Li GW, Hu YH et al. (1997) Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 20: 537–544.

Peterson D, Govindji A (1988) Giving dietary advice to Asian diabetic patients. Practical Diabetes 5(7): 683–686.

Powers M (1996) Handbook of Diabetes Medical Nutrition Therapy, Chapter 3. Aspen Publishers, Gaithersburg.

Sheard NF, Clark NG, Brand-Miller JC et al. (2004) Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the American Diabetes Association. DiabetesCare 27 (9): 2266–2271.

Tomkin G, Hadden D, Weaver J et al. (1971) Vitamin B12 status of patients on long-term metformin therapy. British Medical Journal 2: 685–687.

Tuomilehto J, Lindström S, Laakso M et al. (2001) Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine 344: 1343–1350.

West D (2007) Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care 30: 1081–1087.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion #17

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath