Patient Rights and Diabetic Diets

[SassyRedhead]

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 our unit had a big bag of candy in her belongings and went postal about being allowed to have it, even though she was ordered QID accuchecks with PO antidiabetic meds and sliding scale insulin.

My comment was that I am the licensed personnel in the situation responsible for carrying out MD orders (carb control diet in this case), and the pt was insisting on NOT exchanging anything off the tray for some of the candy but, rather, that she have it ad lib at the bedside. I feel that in allowing her to have the candy, I would be going against MD orders and could be held liable for any adverse consequences if she ate herself into a huge BS.

Now, I am not going to ever rip something out of someone's hands, but this was tucked into belongings and I would not get it for her after reminding her of the order and how this would impact her BS. If a pts family brought in a milkshake, for example, and the pt was consuming it and refused to give it up, I would just document the heck out of it after also informing the visitors that the MD has not given orders for such food and that this goes against the pts plan of care. For what it's worth, this pt also has known psych issues.

Am I right? Wrong? Completely off base?

[Myxel67]

I disagree. Overweight is a huge risk factor for type 2 diabetes. I've seen it countless times. These types of lifestyle changes are extremely difficult to make, and food is often a comfort to people, just like a cigarette is to a smoker, or a drink is to an alcoholic. People don't always have free will when it comes to addictions.

The distribution of body fat is a huge factor in determining risk for type 2 DM. Higher risk is associated with abdominal (or central body) obesity--arms and legs may be quite trim, but bulk of weight is concentrated in abdominal area. Those who have fat distributed more evenly have a lower risk. The second person might even have a higher % of body fat as well. Heredity and ethnic background also play a large part in risk for type 2 DM.

[SCRN1]

I'm not doing that, I'm just stating a fact. Obviously the people who are the subject of this thread are those who aren't willing or able to control their eating. Re-read the opening post. It's about a diabetic who is 'noncompliant' with her diet and gorges on candy while in the hospital.

I know what the opening post says. I was referring to your following statement:

Originally Posted by GardenDove

Lets face it, most people who get diabetes already have problems with their weight. That's what got them in trouble in the first place, their food addictions.

[GardenDove]

http://www.eatlas.idf.org/Obesity_and_type_2_diabetes/

Analyses by the International Obesity Task Force (IOTF), undertaken for the World Health Report 2002 and associated WHO Global Burden of Disease research, indicate that approximately 58% of diabetes mellitus globally can be attributed to BMI above 21 kg/m2. However in western countries, around 90% of type 2 diabetes cases are attributable to weight gain, as shown in the figure below,and childhood overweight and obesity are now leading to an unusual pattern of premature type 2 diabetes, which is particularly difficult to manage once established

[SCRN1]

http://www.eatlas.idf.org/Obesity_and_type_2_diabetes/

Analyses by the International Obesity Task Force (IOTF), undertaken for the World Health Report 2002 and associated WHO Global Burden of Disease research, indicate that approximately 58% of diabetes mellitus globally can be attributed to BMI above 21 kg/m2. However in western countries, around 90% of type 2 diabetes cases are attributable to weight gain, as shown in the figure below,and childhood overweight and obesity are now leading to an unusual pattern of premature type 2 diabetes, which is particularly difficult to manage once established

Note on the same link you quoted from it says...

Type 2 diabetes is often, but not always, associated with obesity, which itself can cause insulin resistance and lead to elevated blood sugar levels. It is strongly familial, but major susceptibility genes have not yet been identified.

[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.

[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.

[Myxel67]

I think the >50% number applies to the Pima tribe. And they don't even have to be obese!

[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.

[Myxel67]

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

[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.

[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 ANDRÉ 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 Piché, 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. Piché 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.

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I now return you to the regularly scheduled topic. :chuckle

[gdbn]

Just wanted to say how much I appreciated your insight and discussion. It applies to many areas - the concepts you cover.