There has been over a hundred years of research on diabetes and diet. From starvation diets to carbohydrate controlled, the portion or exchange system, low glyceamic index, glyceamic load, low carb. low fat, functional/flexible insulin therapy (DAFNE is one version of this I believe) and the normal healthy diet (whatever that is). It‘s hard not to be cynical about dietary advice when you’ve watched the advice change over 40 years. The latest position statement from the ADA is an admirable attempt to acknowledge the overwhelming lack of evidence on diabetes and diet and to recommend an individualised approach to dietary recommendations for people with diabetes.
“There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals, personal and cultural preferences, health literacy and numeracy, access to healthful choices, and readiness, willingness, and ability to change. Nutrition interventions should … provide the individual with diabetes practical tools for day-to-day food plan and behavior change that can be maintained over the long term.” ADA Position Statement, Nutrition Therapy Recommendations for the Management of Adults with Diabetes.
What struck me about this was the emphasis on the need for every person with diabetes to change. Rereading the statement, they seem to be saying we can’t tell you exactly what you should be doing, but nevertheless, what you’re doing now is wrong and needs to be changed. Sure, most people in the world could improve their diet whether they have diabetes or not but this isn’t what the ADA statement is about. They are making an assertion here that behaviour change is at the heart of “nutrition therapy” for diabetes and that “nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan.”
From the perspective of the patient I dislike the assumption that because I have an autoimmune disease that destroyed my islet cells at the age of 16 months, my behaviour needs to change. Rather than acknowledging that it’s my pancreas that’s the problem and I need to learn skills to compensate for its failure, the blame is put on my behaviour. Furthermore, the health care professional is called upon to make a lot of judgements about my literacy and numeracy and desire to change before coming up with an individualised plan to modify my behaviour.
Frankly, I’d prefer a less subjective approach. What’s wrong with a skills based approach to nutrition? Surely if health care professionals are called to deliver education in the skills necessary to make informed choices about nutrition, this respects the patient’s individual preferences and desires and equips them with the skills they need to manage a lifetime of diabetes and to respond to the latest evidence or fads as appropriate. Instead of focusing on behaviour change, why not focus on skills such as carbohydrate counting, kilojoule counting, understanding of nutrition content of foods? Knowledge will not guarantee healthy choices but neither does vague talk about “behaviour change”. People with type 1 need specific skills in carbohydrate counting in order to manage their diabetes, how they choose to exercise those skills is up to them.
What do you think? Would you prefer diabetes education to be skills or behaviour based? Have health care consultations helped you change your behaviour for better or worse?Tweet