Patient Rights and Diabetic Diets - page 5

Nursing staff on my unit have been having a debate lately about where the line is with diabetic patients on MD-ordered ADA or carb control diets and patient rights. In particular, a diabetic pt on... Read More

  1. by   GardenDove
    Did I say always ? No I did not. I'm pointing out, however, that the pts described in the opening post probably already have a lifelong relationship with food that is deeply imbedded and most likely contributed to their condition in the first place. Therefore, I believe the nurse should be tolerant.

    Also, our national weight problem is a big health threat, we all know that. Is this too touchy of a subject for us to broach just because weight is a sensitive subject for many? And, I have no doubt that the Western diet, high in sugar, contributes to type 2 diabetes even when the sufferer isn't overweight.

    Did you know that people today eat more than twice the amount of processed sugar than they did 40 years ago? Our national diet has deteriorated.
  2. by   GardenDove
    And yes, it's even more important for non-Caucasians to heed this advise. Did you know about the diabetes rates in the Native American population is through the roof? The Navahos have rates greater that 50% I believe. Latin Americans also have large amounts of indiginous ancestry and are being hit hard by our sugar laden diet.
  3. by   Myxel67
    I think the >50% number applies to the Pima tribe. And they don't even have to be obese!
  4. by   GardenDove
    I think it's because their bodies didn't have generations to adapt to our processed diet like Europeans. When I went to Scotland we did a tour of an ancient castle in Sterling, and they had one section that gave information on the rations of your average serf who lived in the castle. They were granted a huge allotment of ale each day, basically these guys drank enormous amounts of alcohol as a part of their daily diet. I'm sure that weeded out a few from the genetic pool.
  5. by   Myxel67
    Quote from GardenDove
    Did I say always ? No I did not. I'm pointing out, however, that the pts described in the opening post probably already have a lifelong relationship with food that is deeply imbedded and most likely contributed to their condition in the first place. Therefore, I believe the nurse should be tolerant.

    Also, our national weight problem is a big health threat, we all know that. Is this too touchy of a subject for us to broach just because weight is a sensitive subject for many? And, I have no doubt that the Western diet, high in sugar, contributes to type 2 diabetes even when the sufferer isn't overweight.

    Did you know that people today eat more than twice the amount of processed sugar than they did 40 years ago? Our national diet has deteriorated.
    All of us have a lifelong relationship with food--otherwise we wouldn't live very long.

    Eating sugar does not cause diabetes--DM is an endocrine disorder of insulin resistence and insulin production.

    We as nurses should be less judgmental. We should also be more aware of the pathophysiology of a disease before we subscribe to popular misconceptions and attempt to spread them to others
  6. by   GardenDove
    Type 2 diabetes is universally recognized today to be associated with diet. Obviously, certain people have a genetic predisposition to respond to our western diet with this disorder, no different than those who get high cholesterol and heart disease from our rich diet. Type 2 diabetes is the most common form of diabetes, I'm sure we all know.

    Why is mentioning this fact assumed to be judgemental? If you'll read my posts here, I argue in favor of pt rights and a non-judgemnetal approach.
  7. by   SassyRedhead
    Offtopic, but in keeping with the above. I think there are multiple factors for diabetes. The attached, for example could be a factor.

    (I would have just linked it but it was in the middle of a longer article.)

    By ANDR PICARD, from the July 6. 2002 issue of the Globe and Mail, with a report from Avis Favaro, CTV News - Copyright 2002 Bell Globemedia Interactive Inc. All Rights Reserved

    SHARP DECLINE OF NUTRIENTS IN OUR DAILY FOOD

    Today's Foods Lack Yesterday's Nutrition

    Fruits and vegetables sold in Canadian supermarkets today contain far fewer nutrients than they did 50 years ago, according to an analysis conducted by The Globe and Mail and CTV News.

    Vital vitamins and minerals have dramatically declined in some of our most popular foods, including potatoes, tomatoes, bananas and apples, the analysis reveals. Take the potato, by far the most consumed food in Canada. The average spud has lost 100 per cent of its vitamin A, which is important for good eyesight; 57 per cent of its vitamin C and iron, a key component of healthy blood; and 28 per cent of its calcium, essential for building healthy bones and teeth. It also lost 50 per cent of its riboflavin and 18 per cent of its thiamine. Of the seven key nutrients measured, only niacin levels have increased.

    The story is similar for 25 fruits and vegetables that were analyzed. But Health Canada refused to comment on the findings, saying the debate was an academic one. The academics, for their part, are intrigued, but not alarmed. Modern farming methods, long-haul transportation and crop-breeding practices are all believed to be contributing to the drop in vitamins and minerals.

    Phil Warman, an agronomist and professor of agricultural sciences at Nova Scotia Agricultural College, said there is no doubt the nutritional content of food is different today, due to the emphasis on producing cheap food. "The emphasis is on appearance, storability and transportability, and there has been much less emphasis on the nutritional value of fruits and vegetables," he said. Dr. Warman said crops are bred to produce higher yields, to be resistant to disease and to produce more visually attractive fruits and vegetables, but little or no emphasis is placed on their vitamin or mineral content.

    While there is little evidence, anecdotal or otherwise, that the changes are resulting in major nutritional deficiencies in the general population, Dr. Warman said consumers should care about the issue because it is the nutrients, not the appearance, that give food value. "I care because I want to eat a product that is as high in nutritional value as possible. Otherwise, I would eat sawdust with nitrogen fertilizer," he said.

    Tim Lang, a professor at the Centre for Food Policy in London, England, agreed. "It's an issue of consumer rights," he said. "We think of an orange as a constant, but the reality is it isn't." In fact, you would have to eat eight oranges today to get the same amount of vitamin A your grandparents got from a single orange. And you would need to eat five to get the same level of iron. However, the amount of vitamin C has increased slightly.

    Dr. Lang said declining nutrient levels may prove to be a health issue because we are only beginning to understand how important micro nutrients are to disease prevention. "The argument that it doesn't matter because we overconsume is complacent. ... Nutrient density might also be important."

    Alison Stephen, director of research at the Heart and Stroke Foundation of Canada, said the biggest nutritional problem is that most Canadians do not eat anywhere near the recommended five to 10 servings of fruits and vegetables daily. But she is not unduly worried about today's consumers failing to get their required vitamins and minerals. "A lot of our foods today are fortified — milk, bread, apple juice, cereal," she said.

    In other words, grains and dairy products are far more important sources of essential nutrients than they were in the past. To conduct the analysis, The Globe and Mail and CTV examined food tables that were prepared by government researchers in 1951, 1972 and 1999, and compared the nutrients available from 100 grams of the given food.

    The results were almost identical to similar research conducted in the United States and Britain. The U.K. research was published in the British Food Journal, a peer-reviewed, scientific publication, while the U.S. data have been published only in alternative-health journals. According to the Canadian data, almost 80 per cent of foods tested showed drops in calcium and iron; three-quarters saw drops in vitamin A, and half lost vitamin C and riboflavin; one-third lost thiamine and 12 per cent lost niacin. But some experts said the explanation for the decline might be found in testing and sampling methods.

    Len Pich, an associate professor of nutrition at Brescia College in London, Ont., questioned the accuracy of the numbers, saying testing methods were not great in 1951, so we may only now be getting a true idea of the nutrients in fruits and vegetables. "Did they really go down, or do we just have better techniques for analyzing those nutrients?" he wondered. However, Dr. Pich said the issue is one Health Canada should examine. "If there's a problem, I'm confident the government will take it seriously and do the necessary research to address it," he said.

    In the analysis, the biggest loser was broccoli, a food that epitomizes the dictates of healthy eating. All seven of its measurable nutrients declined, notably calcium, which fell 63 per cent, and iron, which dropped 34 per cent. Broccoli is often cited as an excellent source of calcium and iron.

    Cathy Bakker, a graduate student in vegetable physiology at the University of Guelph, has done research showing that the more fertilizer used, the lower the vitamin C content of broccoli. She was not surprised by the drop in nutrients but said food growers are catering to public demand. In her study, the vegetables grown with less fertilizer contained more vitamin C, but they were less firm and green, making them less attractive to consumers. "Consumers want a broccoli that's all nice and green and firm, not one that's all wilty," she said.

    -------

    I now return you to the regularly scheduled topic. :chuckle
  8. by   gdbn
    Just wanted to say how much I appreciated your insight and discussion. It applies to many areas - the concepts you cover.
  9. by   RN BSN 2009
    Quote from rn/writer
    Rather than judge the person or even offer education they've probably heard a thousand times before, it might be more effective to talk to them, person to person, and ask how things look to them. Don't come in with preconceived notions, but rather offer a genuine listening ear.

    "I know you've heard the scare stories and the shoulds and shouldn'ts a million times. I'm wondering what those ideas mean to you and if there's a way we can work together on some of this."

    Go beyond the physical assessment. Is the person newly diagnosed and still in denial? Have they been struggling and do they now feel defeated because they ended up hospitalized anyway? Are the bad habits such a part of their familial culture that they feel helpless to even try to break away? Have they reached a point where they have given up and want the pleasurable things for whatever time they have left?

    Each of these requires a different acknowledgment and a different approach to have any chance of success.

    We look at the situation from a nursing/medical point of view. It's an entirely altered perspective when it's your LIFE. Especially when you know the people who are supposed to be helping you are looking at you with judgment and maybe even contempt. Even kind-hearted nurses sometimes come across like they're dealing with naughty children.

    This tends to evoke an oppositional response, not because the patient is diabetic, but because they're human.

    The word "non-compliant" is in itself a judgment of sorts. Someone in another thread said she preferred to use the word "non-participating" as it acknowledges that the patient really DOES have a choice, whether that sits well with us or not. This isn't just touchy-feely sentimental sludge. People care about showing up in the equation as more than just an evaluation of how well they are cooperating. Diabetics can end up feeling like what matters most to health care staff is how many gold stars they earn instead of their overall quality of life.

    The primary goal should be connection first, then adaptation.

    I know that time is precious, but redundant education that falls on deaf ears takes time, too. Often, diabetics know the what and the why. "I should control my blood sugar so I can live longer and avoid complications." What they sometimes lack is the how. "How do I interact with my family and still try to maintain some kind of healthy eating?" "How do I get through a day when eating has been such a high point all my life? What do I put in its place?" "How do I separate the emotional satisfaction of eating from the physical needs?" This is where many practitioners miss the boat. Yes, a percentage of "non-compliance" stems from lack of information, but I'd be willing to bet that far more comes from having no clue how to make that information matter on a personal level and lacking the ability to find practical ways to live. Even when such facts are presented, there is sometimes little regard for readiness to hear. It's like answering questions that haven't yet been asked. Without an apparent use, the knowledge is discarded or filed away for a future that never quite arrives.

    A typical defense mechanism is for diabetic patients to engage caregivers in a tug-of-war. One reason is that it's often an unconscious expression of anger about an ongoing loss of control. Another is that if you can prevail in such a contest, it can substitute for the victory you wish you had elsewhere. In other words, if you can't win over your blood sugar, at least you can show that darn nurse that you're in charge of what you eat.

    As clinicians, we often come in with tug-of-war ropes of our own. It can be infuriating to see someone have repeated admissions for conditions which are somewhat controllable when it seems like they won't lift a finger to change their life-threatening ways. It's like watching someone smack themselves in the head with a hammer and then moan and whine about having a headache. Hard to keep from saying, "Well, if you'd just quit hurting yourself, you might quit hurting." An understandable reaction, but ineffective for both sides.

    The trick is to recognize the patient's autonomy and then actually use it to their advantage. You can't EVER make the choices that belong to your patient for them. What you can do is get them talking about how THEY make their choices and what they are thinking. For many, that would be a first--to have someone asking them for their thoughts instead of dumping more information on them or scolding them.

    It would also be a first for many to put their own thoughts into words. And some of them might be surprised at their true motivation or lack thereof. Once you know what matters to them--their currency--you can meet them where they are and try to find something that will satisfy the emotional/psychological appetite while stiking a balance with their limitations.

    For example, you could meet the big male patient mentioned above--the one whose family brought in all kinds of food--by connecting with him at a time when the others aren't around. Get him talking about his brothers and the food and the feelings. Then, having entered into that warm and delicious picture, you can bring up the concerns about blood sugar and the rest. You can ask if he is interested in finding balance between his wants and his needs and tell him you might have a couple of ideas if he is.

    If he says no, leave the door open to further discussion by saying that you'll be happy to talk again if he changes his mind. He might be testing you to see if you really are that rare medical bird who can see past the diagnosis to the real person and respect his choices even when you disagree. Could be the beginning of trust.

    If he seems interested, get him talking. What is it about the contraband food that matters most to him? The food itself? The camaraderie with his family? The feeling of having some comfort and control in a not-too-friendly place? Try brainstorming with him ways that the two of you could work together to minimize the damage. They bring in a pizza. Would he be willing to eat the toppings and leave most of the crust? Or have you put a single piece on a plate and refrigerate the rest, to be given a slice at a time over the next two days? Chinese food. How about skipping the rice and the egg rolls and concentrating on the meat and veggies? KFC. Okay, more of a challenge, but suggest he divide the meal, start with the coleslaw, remove half the skin and skip the roll. Better yet, ask him how HE thinks he could alter the meal to make it less carbnoxious.

    This model where the two of you are allies fighting on the same side against a problematic situation is so much more effective than the one where you lock horns with one another. It also might be the first time that this person has had an example of how to break away from the "all-or-nothing" approach where if you take one bite, you might as well eat the whole thing.

    If he's open to it, you can speak with his family members and enlist them in the "project." So many people view their offerings of food as a way to say, "Hey, you're still one of us and we still love you." They need to learn how to enlarge their repertoire and understand that they can deliver this same message by scaling back and adapting their offerings. Don't bring in a bucket of KFC. Bring two pieces of chicken and some coleslaw. Get some barbecue meat without the bun. Chicken and pea pods instead of sweet and sour. A box of sugar-free fudge pops rather than premium ice cream.

    Create a vision of participation that seems doable. Spark imaginations that were formerly used to circumvent restrictions. Teach the "buy down" principle of taking a desire--chocolate covered donuts--and seeing if there is something less carbolicious that would still be satisfying--peanut butter on toast.

    Try to find the opportunity to show the patient the difference in his blood sugars. And let him know that he doesn't ever have feel that he's cheating--he's merely making choices. Once that old bugaboo is lifted, it changes the dynamics of the "game" entirely.

    The lady with the candy might see sweets as a kind of self-administered TLC. You'd have to ask her. Apply the same principles with her. Is she really hungry or is she lonely or bored or unsatisfied in some other way? Try to find out if having the bag of candy means one piece an hour (not all that horrible if they're small) or the whole thing within one hour. If she's willing, put your heads together to come up with something safer. Sugar-free Jello and three minutes of your time. A diet soda. A two-minute foot rub. A phone call to a friend.

    Again, I know time is at a premium, but a couple of minutes spent effectively can be more efficient than the usually unproductive dance.

    Even more important is the concept that there is no such thing as cheating. There are choices. Throw the tug of war rope out the window and let the patients start understanding that the real struggle is inside themselves. As long as we get in the way, they can't really internalize this essential concept. In our efforts to do good, we can actually rob the patients of the very autonomy that could save them.

    I know this is long, but "diabetic compliance" is such an ongoing power struggle and is so poorly understood from the emotional/psychological standpoint. Highly educated folks with good intentions pour all kinds of effort into teaching and caring for this population only to leave out the sense of connection that can make the rest of it work.

    Here's a nugget of truth that is sad but at the same time can give you a real advantage: many diabetics are lonely, starved for respect, used to being found substandard in some way, and resigned to feeling invisible except for their disease. Find a way to meet them where they are AND acknowledge their autonomy, and you will find patients who are ready to consider alternatives, even if they can only take small, hesitant steps in the beginning.

    You really can make a difference for these folks. This knowledge can make a difference for you, too.
    :Yeahthat:
  10. by   Quickbeam
    I'm a community health nurse. I deal with drivers with health problems 1:1 and on a global, statewide basis. Our state's #1 health problem behind the wheel is diabetes. When I talk to the drivers after they have gone into a ditch or another car after a hypoglycemic event, the answer is almost always, "but it wasn't me, it was the diabetes".

    I cancel driver's licenses every day over uncontrolled diabetes issues. It is amazing to me how effective license loss is as a tool to get people to own the illness and get on track. Many people call me and say thanks because they just wanted to deny the illness until it cost them their license. For most, loss of a license was far more real that loss of vision/kidney/heart.

    I'm not saying this is the way to go but I thought a different POV would add to the conversation.
  11. by   mohkull
    I cancel driver's licenses every day over uncontrolled diabetes issues. It is amazing to me how effective license loss is as a tool to get people to own the illness and get on track. Many people call me and say thanks because they just wanted to deny the illness until it cost them their license. For most, loss of a license was far more real that loss of vision/kidney/heart.
    this is my opinion
    Last edit by mohkull on Mar 2, '07

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