Setting the Agenda
Before you begin your assessment or any interaction with a client, make sure to:
- Start out by greeting them and introducing yourself.
- Describe the role of a registered dietitian relevant of their diabetes care.
- Invite them into the conversation to build rapport and be an active participant in their health care.
- Set the agenda for the appointment by asking about what brings them in and how you can help with the management of their diabetes.
Gathering Data for an Assessment
When gathering data for your assessment make sure to collect information on the patient’s:
- Clinical Data (both Medical history and Social history)
- Anthropometric Data
- Biochemical Data
- Dietary Data
You are playing the role of Katie, a dietitian in a diabetes program at a Community Health Centre outside of Toronto. You have received a referral from Dr. Darlington to see a client. Your client Penelope Kelly, is a 50 year old woman living in Barrie with her husband and 2 children. The reason for referral is related to her hypertension, recent diagnosis of Type 2 diabetes, and interest in losing weight. She has coverage for her medication, and has used the food bank in the past because she couldn’t afford food. She feels too tired to exercise and walks 15 minutes to the grocery store once a week. She wants to lose weight because she would like to have more energy and be healthier. The client is meeting with you this afternoon.
When gathering clinical data, consider:
- Diagnosis: Do they have prediabetes, type 2 diabetes, or gestational diabetes? Are they at risk of developing diabetes? How long have they had diabetes?
- Past Medical History: Do they have other medical conditions (e.g. hypertension, dyslipidemia, cardiovascular disease, schizophrenia, depression, bipolar disorder, polycystic ovary syndrome, sleep apnea)?
- Family History: Did members of their family have diabetes or other medical conditions?
- Symptoms: Do they experience any complications of poor diabetes management (e.g. polydipsia, polyuria, neuropathy, nephropathy, sexual dysfunction, or problems with their vision, feet, or gums)?
- Interdisciplinary team: Do they regularly see an endocrinologist, chiropodist, dentist, optometrist, or nephrologist?
- Medications: Are they on any oral anti-hyperglycemic agents, non-insulin injectables, and/or insulin? Blood pressure or cholesterol medications? Are they taking any supplements?
- Insulin is a very effective medication in managing all types of diabetes. To learn more, read Diabetes Canada’s resources on insulin.
When gathering medications as part of the nutrition assessment, refer to the Diabetes Medication Chart as this summarizes the various types of oral hypoglycemic agents and any medications used for lowering blood pressure and cholesterol, and their side effects, nutrition interactions, and the parts of the body they act on to help control blood sugar.
- Diagnosis: Type 2 diabetes (diagnosed 2 weeks ago)
- Past Medical History: Hypertension
- Medications: Dr. Darlington has discussed with Penelope that rather than start her on medications for diabetes or blood pressure, he would like to follow up with her in 2 months to see if her blood pressure and blood glucose can be controlled with changes in her diet and weight.
- 500 mg calcium
- 1000 vitamin D
- 60 mg Diamicron (once daily with breakfast)
It’s also important to gather information on the client’s social history, which will help you to tailor your nutrition plan later on. When gathering social history, consider:
- Housing: What is their living situation? Do they live with others? Do they have a support system? Do they have access to a kitchen?
- Income: Are they currently working? What is their main source of income?
- Insurance: Do they have medical coverage?
- Substance use: Smoking? Alcohol? Any other substances?
- Food security: Has anyone in their household gone without food in the past month because they couldn’t afford it? Do they ever have to use the food bank or skip meals because they do not have enough money for food?
- Physical activity: Do they have any mobility issues (short or long-term)? Are there barriers preventing them from getting physically active (e.g. living in an unsafe area makes it difficult to get outside to exercise)?
- Housing: Lives in Barrie with her husband and 2 children.
- Income: Not currently working (laid off), living off savings, has not qualified for social assistance.
- Insurance: Has medical coverage.
- Food security: Occasionally uses food bank, does not skip meals.
- Physical activity: Sedentary most days due to fatigue, walks 15 minutes to the grocery store and back once a week.
When gathering anthropometric data from the client, consider:
- Weight: Current body weight in kilograms. If the client is open to having this taken, it can be valuable to know as part of their weight history.
- Weight History: Do they have an interest in weight loss? Have they tried to lose weight before? Has their weight recently fluctuated? What was their highest and lowest adult body weight?
- Waist Circumference: Current waist circumference in cm. If the client is open to having this taken, it can be a valuable screening measurement.
- Height: Current height in centimetres.
- BMI: Body Mass Index.
It’s important to ask if the client is comfortable having these measurements taken as this may trigger stress for some clients. If the client states that weight loss is a goal for them, it can be helpful to know:
- Why that goal is important for them.
- If they have tried to lose weight before.
- Any diets they have tried in the past.
- How their weight has fluctuated over the years.
- Weight: 76.5 kg (Usual Body Weight for the past several years)
- Height = 162.5 cm
- BMI = 29 kg/m2
- Weight History
- Lowest adult body weight = 67 kg (15 years ago)
- Has tried many diets in the past; some weight cycling
- She would like to lose weight to feel healthier and have more energy
You may need to interpret Oral Glucose Tolerance Test (OGTT), Fasting Blood Glucose (FBG), and Random Blood Glucose (RBG) values for a client to see if they are at risk of diabetes, have pre-diabetes, or are newly diagnosed with diabetes. The most common lab value you will use is Glycated Hemoglobin (HbA1C or A1C), as this can tell you how well their diabetes and blood sugars have been managed over the past 3 months.
|Lab Test||Definition||Normal||Pre-DM||Type 2 DM|
|OGTT||Oral glucose tolerance test:
Challenge body with 75g glucose load. Test PG pre and 2 hrs post (mmol/L)
|< 7.8||7.8 – 11.0||≥ 11.1|
|FPG/FBG||Fasting plasma/blood glucose:
At least 8 hrs of fasting (mmol/L)
|4.0 – 6.0||6.1 – 6.9||≥ 7.0|
|Random PG/BG||Plasma/blood glucose:
Tested at anytime (mmol/L)
|< 11.1||_||≥ 11.1|
3 month average plasma glucose concentration
|< 6.0%||6.1% – 6.4%||≥ 6.5%|
The target ranges for A1C and blood sugars vary depending on age. When assessing blood sugar values with a client, you’ll want to gather information about their self-monitoring of blood glucose (SMBG). It’s important to ask them:
- Do you use a glucose meter to check your blood sugars?
- How often do you check your blood sugars?
- Have you noticed any trends or patterns?
- Do you use a logbook to keep track of your levels?
All of this information helps you to get a good picture of how their diabetes is managed.
|Client||A1C||FBG/BG before eating (mmol/L)||BG 2 hours after eating (mmol/L)|
|Type 2 Children||≤ 7.0%||4.0 – 7.0||5.0 – 10.0 *
8.0 if A1C not met
|Type 1 + Type 2 Adults||≤ 7.0%||4.0 – 7.0||5.0 – 10.0 *
8.0 if A1C not met
|Gestational||≤ 6.0%||3.8 – 5.2||5.0 – 6.6|
|Frail Elderly||≤ 8.5%||5.0 – 12.0||Individualize|
You also want to collect and assess any blood work they’ve done for lipids, including total cholesterol, and cholesterol, and triglycerides. Getting a blood pressure measurement is also helpful to see if they are on target; the control target is < 130/80 mmHg.
amount of total cholesterol in blood
|< 5.2 mmol/L||≤ 4.0 mmol/L|
|HDL – Chol||High density lipoprotein “good” cholesterol:
absorbs cholesterol and carries it back to liver
|≥ 1.0 mmol/L||≥ 1.0 mmol/l (for men)
≥ 1.3 mmol/l (for women)
|LDL – Chol||Low density lipoprotein “bad” cholesterol:
leading to plaque build up resulting in heart disease
|< 3.5 mmol/L||≤ 2.0 mmol/L|
fat found in blood used for energy; excess fat storage
|≤ 1.7 mmol/L||≤ 1.7 mmol/L|
Urinalysis and Renal Function
You also want to check lab work for any evidence of diabetic nephropathy and reduced kidney function. Albumin/creatinine ratio, Serum creatinine, and are all tests that are used in screening for renal disease. It is also worth noting any glucose or ketones present in the urine as this may indicate that blood sugars are not well controlled. These are also discussed in more detail in the renal nutrition module.
|Lab test||Normal||Indication of reduced renal function|
|Albumin/creatinine ratio (ACR)||≤ 2.0 mg/mmol||≥ 2.0 mg/mmol|
|Serum Creatinine||–||Will be elevated (>110 mmol/L)|
|eGFR||> 90 mL/min||≤ 60 mL/min|
Lab results: Here are the labs for Penelope. Determine which lab values are within normal limits (WNL) or are elevated. This information will be used when planning the nutrition care plan in the next section.
|Lab Test||Lab Result||Target Range|
|Random BG||11.0 mmol/L||5.0 – 10.0 mmol/L|
|TC||3.6 mmol/L||≤ 4.0 mmol/L|
|LDL||1.45 mmol/L||≤ 2.0 mmol/L|
|HDL||1.9 mmol/L||≥ 1.3 mmol/L|
|TG||1.2 mmol/L||≤ 1.7 mmol/L|
Blood glucose log: Here is a snapshot of Penelope’s blood sugar log. You can see that her fasting blood sugars have been less than 4 most mornings, around 3 before lunch when she is feeling low, and around 10 or higher 2 hours after dinner.
|Day of week||FBG (mmol/L)||AC Lunch (mmol/L)||2 hours after dinner (mmol/L)|
SMBG: Penelope tests her blood sugar twice per day due to cost, but has recently been testing an additional time before lunch because she’s been feeling shaky and very hungry.
BP: 154/94 mmHg
When gathering dietary data, consider the client’s:
- Eating behaviours: How many meals per day? How many hours between their meals and snacks? Eating at home or eating out?
- Food access and food skills: Do they have access to a kitchen? Do they get groceries and/or cook at home, or does someone else do this for them? Previous nutrition education? What do they know about managing their diabetes and BG with diet choices?
- Diet History: 24-hour recall, 3-day food record, and/or food frequency questionnaire (FFQ). Pop, juice, sweets, alcohol, fast food? Have they tried any diets in the past?
- Food access and food skills: Penelope does the majority of the grocery shopping while her husband Bob works. Penelope and Bob want to teach their children healthy habits. They are motivated to make changes as a family. She had accessed the food bank to help supplement the family’s cupboard while Bob was also laid off.
- Diet History (24-Hour Recall):
|Meal||Penelope’s diet recall|
|2 eggs, 2 pieces bacon, lettuce, 1 rice cake, 15 mL mayo|
|2 chicken breasts with skin, 2 cups salad—mostly lettuce, tomato, cucumber, red peppers, 60 mL dressing, 250 mL chocolate milk|
|6 ounces baked fish, 2 cups mashed potatoes, ½ cup corn, 2 tbsp butter, 2 cups unsweetened apple juice|
|HS snack||¼ cup “fat free” baked pita chips|
Simulation Activity: Penelope
Estimated glomerular filtration rate