How to: counsel Type 2 diabetics
Nutritional counselling is an integral part of your role. Dietitian Anne Myers offers a checklist of patient ‘to-dos’ on World Diabetes Day…
The benefits of improved nutrition can directly affect treatment outcomes. Poor dietary practices can increase the risk of developing dental caries, increase risk of periodontal disease and delay tissue healing. This can be particularly so if the patient suffers from chronic diseases such as Type 2 diabetes.
Dietary counselling in a dental practice traditionally includes discussions on the role of sugars, the frequency and types of foods eaten and discussing the length of time that foods and beverages are retained in the mouth. When faced with a patient with Type 2 diabetes, however, do hygienists and therapists feel confident to discuss dietary recommendations for good diabetes control? And why should you be concerned?
The World Health Organization defines diabetes as a chronic disease that occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and, over time, leads to serious damage to many of the body’s systems, especially the nerves and blood vessels.
Diabetes is a common lifelong health condition. Given that the numbers of people with Type 2 diabetes are increasing across the nation, we can be sure that the proportions of patients in dental clinics will also be on the rise.
Impact on dental health
It has been demonstrated that having Type 2 diabetes brings implications for oral health. Periodontitis is more prevalent and severe in diabetes and the risk of alveolar bone loss is higher. Statistically, significant relationships have been shown between diabetes and periodontitis in large-scale meta-analyses with the risk related to the duration and degree of diabetic control. Poor control of diabetes and the consequential hyperglycaemia can aggravate periodontitis significantly.
Advice to patients with Type 2 diabetes
• Aim for weight loss if overweight or obese
• Eat three meals a day (a regular meal pattern can help glycaemic control)
• Include some carbohydrate at each meal (this does not need to be excessive amounts, especially when considering weight control. Low GI choices preferable)
• Cut down on fats (especially saturated fats)
• Eat more fruit and vegetables
• Include pulses/lentils/beans in the diet
• Aim for two portions a week oily fish (for cardiovascular health)
• Reduce salt
• Alcohol in moderation
• Limit sugar and sugary foods (these don’t have to be avoided for glycaemic control but should be limited if trying to lose weight)
• Don’t use ‘diabetic’ foods
Often, poor control of Type 2 diabetes can be associated with poor dietary practices. Improving diet has been shown to have an impact on glycaemic control. This may, in turn, have an impact on dental health outcomes.
Everyone with diabetes should receive individual, ongoing nutritional advice from a registered dietitian. On the frontline, however, therapists and hygienists should be armed with sufficient ‘stop gap’ knowledge when offering dietary advice for these patients.
There have been many changes to the nutritional recommendations for people with Type 2 diabetes since 1982, when Diabetes UK, (as the British Diabetic Association), released its first policy statement on the issue. More recent guidelines have made quite sweeping changes and the old sugarfree diet with compulsory frequent snacks to manage blood sugars has well and truly gone. The newer diabetes recommendations also include a liberalisation in the consumption of sucrose and consideration of the glycaemic index (GI) *(a measure which ranks carbohydrates according to their effect on blood glucose levels). In fact, carbohydrates overall are now considered, rather than sugar alone, with an understanding that total amount of carbohydrate has much greater influence on glycaemia than source and type. This shouldn’t be a cause for concern when considering dental health, however, as a reduction in sucrose consumption is recommended for weight reduction. In current guidelines, a large emphasis is now placed on weight and lipid management. As a result, previous suggestions that all people with Type 2 diabetes require frequent snacks have been refuted. This is in line with dietary recommendations for dental health.
So, when faced with a patient with poor diabetes control and impacting periodontitis, what practical advice should you be able to offer when discussing dietary recommendations for diabetes control? Firstly, dietary recommendations should be in line with the Department of Health’s Eat Well Plate guide for healthy eating. This includes a variety of food every day from the four main food groups – bread/rice/potatoes and starchy foods, fruit and vegetables, milk and dairy foods and meat, fish and protein alternatives – with very occasional treats from the fifth – foods high in fat and sugar.
Consideration should also be given to the new recommendations. Being armed with the knowledge of the most current guidelines for the dietary management of Type 2 diabetes will benefit both practitioner and patient in the dental practice. With current trends and projections for the prevalence of diabetes in the future, dietary counselling for Type 2 diabetes will no doubt be a vital part of the extended role of the hygienist and therapist.
• References available on request
About the author
Anne Myers is a dietitian and nutritionist who qualified in Australia in 1994 and now lives and works in England. She has extensive experience in many clinical areas and more recently as an advanced practitioner in diabetes, working in the NHS for seven years. Anne now works as a freelance consultant and as a lecturer in Nutrition and Dietetics and Diabetes Management.