When implementing your nutrition care plan, you may have to liaise with other members of the care team. You’ll want to discuss if you think a client might benefit from increasing their insulin dose, to consider starting a statin if dietary changes have not been effective in managing their cholesterol, or if your client needs a requisition for updated bloodwork. This may include liaising with the endocrinologist, physician or nurse practitioner, diabetes nurse educator, social worker, physiotherapist, and chiropodist.
In this case, you have consulted with Penelope’s physician regarding her current pharmacotherapy and concern over recurrent hypoglycemia with her medication regimen. The physician has considered this and has discontinued Diamicron and will replace it with either an SGLT2i or GLP1-RA (depending on which one they can secure compassionate coverage for). You can refer to the Diabetes Medication Chart for a refresher on these medications.
When educating clients, try to:
- Individualize the education as much as possible: Discuss high-risk topics (like hypoglycemia) first since they are priority, connect the client’s goals to your plan, and focus on what they want to learn.
- Find out if client has had previous education: Ask the client if any one else has talked to them about their diet and diabetes, and adjust your education accordingly.
- Focus on a few key messages: If the client is newly diagnosed or doesn’t know much about diabetes, try not to overwhelm them with too much information during your first couple of interactions. Use visuals, like props and resources, to convey your message whenever possible.
Pause here and think of some key messages you might want to speak to Penelope about when providing education. Continue when you are ready.
Based on your assessment Penelope has a basic understanding of diabetes pathophysiology, but she does not know how to properly treat hypoglycemia. It is important to start your education by reviewing hypoglycemia treatment and then moving on to the key dietary changes that will improve her diabetes management.
Penelope tells you that she gets confused sometimes when trying to plan a meal and thought she was spreading her carbs out throughout the day. She doesn’t understand why her BGs are low in the morning and high in the evening. To keep it simple you can focus on a these 3 key messages, asking questions throughout:
- Carbohydrates come from plants (found in grains, legumes, starchy vegetables, fruit, milk, nuts, seeds) and give us energy by being digested into sugar/glucose for use by our cells. Can Penelope identify the carbs she currently includes in her diet?
- Hypoglycemia (or low BG) is dangerous because it can lead to fainting and falling. If you feel low, check your BG and follow the 15:15 rule if it is below 4.0 mmol/L.
- Penelope’s breakfast contains mostly protein and fat (from the eggs, bacon, and mayo) with very little carbs – this may have caused a low BG and made her feel shaky and hungry before lunch. Her dinner contained mostly carbs (from the potatoes, corn, and apple juice) which may have caused a high BG reading after dinner. Review the Plate Method with Penelope to portion carbs at each meal by filling her plate with ½ vegetables, ¼ starch, and ¼ protein.
It’s also important to ask your client questions throughout. For example, when helping Penelope understand why her blood sugars were low in the morning, ask Penelope to put her breakfast foods on the plate and see if it is balanced. What is she missing? What could she add next time to make sure she is getting enough carbs in the morning?
Pause here and practice explaining the key messages above in plain language.
It can also be helpful to use simple analogies. For example, insulin is like a “key” that unlocks the “door” to our cells, allowing sugar in to provide us energy. In using this analogy to help educate a client about diabetes, you could say:
Ongoing management of a chronic disease can lead to burnout, and making dietary changes may be difficult for some patients. To help support them in making these changes, you may want to try:
- Motivational interviewing: collect their story, listen reflectively, collaborate rather than convince.
- setting: help to identify barriers to change as part of creating a nutrition care plan with the client.
- Referral to social worker: consider referring them to a social worker if they need someone to talk to about coping with the burden of managing a chronic disease.
Pause here and think about some SMART goals that you could set in collaboration with Penelope. Continue when you are ready.
Here are some SMART goals Penelope could work on based on her diet history and our nutrition care plan. As a part of making the goals SMART, you can discuss with her when she plans on making these changes and come up with ways to support her if or when she encounters barriers.
- Use the 15:15 rule to treat hypoglycemia
- Use the Plate Method to create balanced meals, with high fibre CHO at each snack and meal, like whole grain bread or brown rice
- Choose a no-sugar beverage instead of apple juice at dinner time
- Include CHO and protein at HS snack if BGs below 7 mmol/L
- Continue to test BGs twice per day (FBG in the morning and BG at HS) using a glucometer
Goals that are Specific, Measurable, Achievable, Relevant, and Time-bound.