How do you educate people with type 1 and type 2 diabetes about the effect of carbohydrates on their glycaemic control?


#1

Nutritional advice for people with diabetes has changed over the last decades, from ‘avoid carbohydrates’ to ‘calculate the precise intake’ and ‘follow personal nutrition plan’.

For people with type 1 diabetes, carbohydrate counting education is seen as the first objective. Many studies have shown that intensive insulin therapy (which includes injections of rapid-acting insulin before each meal in an amount proportional to the carbohydrates) improves glycaemic control.

For people with type 2 diabetes, studies associate glycaemic index of carbohydrates with an improved glycaemic control, improved lipid serum concentrations and feelings of satiety, supporting weight loss in people with type 2 diabetes. However, recent studies have shown that the amount of carbohydrate in a food is a stronger predictor of glucose response than glycaemic index.

In addition, the objectives of a nutrition plans should take into account personal preferences in order to improve glycaemic control and lifestyle of the person with diabetes.

We would like to know about your experiences and daily practices. Do you think that carbohydrate counting and the glycaemic index are of interest to both people with type 1 or type 2 diabetes? Do you use specific techniques to develop nutrition plans for specific populations, like children or pregnant women?
How do you educate people with type 1 and type 2 diabetes about the effect of carbohydrates on their glycaemic control?


#2

Most authorities agree that knowledge about the effects of
carbohydrates on blood glucose levels can support self-managment in
people with both type 1 and type 2 diabetes, and the American Diabetes
Association (ADA), Diabetes UK, the Canadian Diabetes Association (CDA)
and the European Association for the Study of Diabetes (EASD) have all
published guidelines and recommendations addressing this [1-4]. However,
the main challenge for people with diabetes and for health
professionals is translating the theory into practice. Studies have
shown that people with type 1 diabetes who adopt carbohydrate counting
and insulin adjustment on a meal-by-meal basis can improve glycaemic
control and quality of life without increasing hypoglycaemia, body
weight or cardiovascular risk. In most high-income countries, this
strategy for management of type 1 diabetes is now common place, but it
does require resources that may be beyond many low and middle-income
countries (LMIC), including investment in structured education, an
organised health service, trained educators and people with diabetes who
are numerate, literate and have access to basal-bolus insulin regimens
(or SCII therapy) and blood testing equipment. For many in LMIC, the
only available dietary intervention may be that of carbohydrate control
or management.For those with type 2 diabetes, the picture is
different. There is evidence to suggest that carbohydrate management
improves glycaemic control [5-7], and one small study indicating that
carbohydrate counting is effective (but not more so than intensive
insulin management) [8]. So how do we facilitate carbohydrate
counting and management in practice? Most authorities would agree that
carbohydrate counting and insulin adjustment for those with type 1 are
best facilitated through face-to-face education and experiential
learning, although there are a vareity of books, on-line resources and
apps available (see below for reputable examples). Unfortunately, not
all tools rely on evidence-based advice and are unable to provide the
necessary professional support and back-up.For those with type 2,
carbohydrate management is recommended, and this begins with developing
carbohydrate awareness (identifying foods that contain carbohydrate).
This can be achieved in a variety of ways, although engaging the person
with diabetes is essential. Using visual aids supports learning - for
example as a quiz with food models, actual foods or pictures and
photographs of commonly eaten local foods where people are asked to
identify those that contain carbohydrate and those that don’t. This
process can be supported by hand-outs, either a written list or pictures
of carbohydrate-containing foods. Once people with diabets are
familiar with the source of carbohydrate in their diet, carbohydrate
management moves into place. There is no evidence for the ‘right’ amount
of carbohydrate for people with type 2 diabetes and much depends on
weight management in those who are overweight or obese, as weight loss
will improve glycaemic control, cardiovascular risk and quality of life.
Carbohydrate management can be faciltated in a variety of ways,
including using plate models, carbohydrate budgets or exchanges and
using the hand as a portion guide.In terms of the glycaemic
index, in practice this is a confusing concept for many people, although
the evidence suggests that there is some advantage to using it as an
adjunct to carbohydrate management. With the recent publicity about
sugar, refined starches and low carbohydrate diets, practical advice
about carbohydrate should probably discourage high intakes of refined
carbohydrates (sugar, many breads, white rice and potatoes) and
encourage carbohydrates from wholegrains, vegetables, legumes and fruit,
most of which are low GI.