Nutrition 411: Diabetes and Wounds: Weight Loss as a Preventative Strategy
Self-management of diabetes often is a daunting prospect for patients, particularly when newly diagnosed. Hearing they must test blood sugar, follow a new diet, engage in physical activity, take medications appropriately, and be concerned with comorbidity complications can be overwhelming. Although healthcare professionals (HCPs) are aware of the dangers of uncontrolled diabetes, patients often are not concerned until detrimental symptoms, such as a wound, occur. Diabetes and wounds is a dangerous combination; a wound is never simple for a patient with diabetes. According to the American Diabetes Association,1 25.8 million people in the United States have diabetes; currently, it is the sixth leading cause of death.
Often the simple act of losing extra weight can help with glucose control and in turn, wound healing; however, this is easier said than done. In order to maintain A1C levels below 7%, changes to diet and physical activity are recommended to facilitate weight loss, a challenge for most patients even though weight loss has been proven to improve glycemic control and reduce complications, thus, improving quality of life.2 Discussing the need for weight loss can be difficult for HCPs, but if a patient is at risk for developing further disease complications (eg, amputation), it is imperative that HCPs become comfortable and tackle weight issues head-on.
Stages of Change
Before giving suggestions for lifestyle changes and weight loss, it is important to determine if the individual is ready to make a change. The transtheoretical model of behavior change is a tool that is commonly used to determine a patient’s readiness to change. With this model, an individual is said to progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and relapse.3 An individual in the precontemplation stage is not thinking about the problem and does not intend to make any changes. Often this patient is not aware of the risks regarding his current behavior or lifestyle. This would be the time to simply provide information regarding the negative impact the behavior has on health. The HCP should approach the topic with sincerity and understanding and without judgment. Facts should be provided and subsequent action left to the patient. If the patient is interested or becomes concerned, he/she has moved into the next stage of change: contemplation. In this stage, an individual becomes aware of a desire to change and usually will weigh the pros and cons of changing his behavior. It is most helpful to have an open discussion with the patient and provide support for making a change. Once the individual believes the advantages outweigh the disadvantages of changing, he has entered the preparation stage. In this stage, a commitment to take action in the near future has been made. The HCP should encourage small steps and provide tips or suggestions related to the situation. Creating a plan of action with the patient can be a helpful method to assist the patient into the action stage. This stage marks the beginning of actual change. The HCP needs to be aware that relapse is common in this stage if the individual has not sufficiently prepared for change. Providing encouragement and solutions for any barriers to change is important. Once the individual has maintained the desired behavior change for at least 6 months, he is said to be in the maintenance stage. Relapse is less common is this stage; however, without continued support and guidance, regression to a previous behavior can occur. The patient needs to be reminded of his goals and to reflect on how the behavior change has had a positive impact in his life. Table 1 outlines the different stages of behavior change and appropriate suggestions for each stage.
A common challenge with diabetes self-management is adhering to the dietary guidelines. When the need for weight loss is added to the struggle, frustration is common. Diet education can be provided regardless of the patient’s stage of change. However, specific diet and weight loss techniques should not be implemented until the patient is ready to make a change. The patient should be reminded that even small changes in his diet will promote weight loss and help maintain normal blood sugar levels. Although various methods are available to create a diet for someone with diabetes, the Plate Method provides a visual guide that helps patients control portions sizes.4 No special tools or counting are required, and this method can be used anywhere, on any plate. First, an imaginary line is drawn down the middle of a (preferably 9-inch) dinner plate. One half of the plate is divided again into two sections. The patient is instructed to fill the large section (half the plate) with nonstarchy vegetables such as spinach, carrots, lettuce, mushrooms, peppers, or broccoli. Next, the patient selects starchy foods, such as whole grain bread, brown rice, wheat pasta, or corn for one of the small sections, and in the last small section, the patient will select a choice of lean protein the size of a deck of playing cards. Encourage lean protein such as chicken or turkey without the skin, tuna, salmon, or lean cuts of beef. In order to receive adequate carbohydrates, an 8-oz glass of skim or low-fat milk and a piece of fruit completes the meal. Table 2 lists the foods that are appropriate for each section. If it is too overwhelming for the patient to change portion sizes, the HCP can encourage a change in another area, such as cutting calories from beverages. Rather than drinking soda, juice, sweetened coffee, or milkshakes, which are full of empty calories and excess sugar, the HCP can suggest the patient drink water, unsweetened tea, artificially-sweetened drinks like Crystal Light, or seltzer water with lemon or lime juice. The patient should be encouraged to eat at regular times, everyday. Skipping meals does not facilitate weight loss and may cause fluctuations in blood sugar levels. Additionally, appropriate snacking throughout the day can be discussed with the patient. Snacking on the right foods can keep blood sugars stable and prevent overeating at the next meal. Snacking should be thought of as an opportunity to optimize nutritional intake and increase energy levels. The size of a snack depends on the patient’s caloric requirements and carbohydrate allowance. Generally, a snack with 15 g of carbohydrates is adequate.5 Table 3 lists several snack options. Portions sizes should be noted, because this is typically a stumbling block for people trying to lose weight. The patient needs to be reminded to eat slowly by chewing thoroughly and setting the utensil down in between bites. The HCP can suggest the patient have a motivational quote or mantra that will keep the patient on track. Often, food journals or meal tracking logs assist patients in being accountable for their daily intake and meal choices.
The Wound Connection
When compromised skin integrity is a concern for an overweight patient with diabetes, maintaining optimal glycemic control is imperative. Approximately 15% of patients with diabetes develop a foot ulcer and 84% of them will end up with lower leg amputations.6 Elevated blood glucose has been shown to hinder the normal wound healing process. An unhealed wound can not only lead to infections and amputations, but also to increased production of free radicals, which may lead to dementia and atherosclerosis.7 Meeting the nutrient requirements for healing and ensuring glycemic control through dietary intervention and weight loss is crucial for a patient with poor skin integrity. If the patient requires a more individualized plan, a registered dietitian (RD) can be consulted to provide a complete individualized nutrition assessment to meet the patient’s needs and facilitate healing.
To effectively convey the importance of appropriate diabetes management, including weight loss, HCPs must communicate in a manner that resonates with the patient. Providing information, guidance, and support relevant to the patient’s unique life situation is vital to improving quality of life. Developing appropriate and effective strategies that not only address the technical skills of diabetes management, but also focus on the individual’s level of motivation to engage in their care is crucial. Members of the healthcare team need to partner with the patient to implement appropriate behavior change strategies to improve disease management and quality of life. There are several different strategies for behavior change and weight loss; providing a personalized plan tailored to individual needs is best.
1. American Diabetes Association. Diabetes Statistic. Available at: www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed July 9, 2012. 2. McAndrew L, Napolitano N, Pogach L, et al. The impact of self-monitoring of blood glucose on a behavioral weight loss intervention for patients with type 2 diabetes. Diabetes Educator. 2012; doi:10.1177/0145721712449434. 3. Coleman M, Pasternak R. Effective strategies for behavior change. Primary Care Clin Office Pract. 2012;39:281–305. 4. American Diabetes Association. Create Your Plate. Available at: www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/. Accessed July 7, 2012. 5. American Diabetes Association. Snacking Smart with Diabetes. Available at: www.diabetes.org/food-and-fitness/food/planning-meals/snacks/?loc=askthe.... Accessed July 12, 2012. 6. Collins N, Toiba R. The importance of glycemic control in wound healing. Ostomy Wound Manage. 2010;56(9):18–24. 7. Collins N. Diabetes, nutrition, and wound healing. Adv Skin Wound Care. 2003;16(6):291–294. Nancy Collins, PhD, RD, LD/N, FAPWCA is a registered dietitian based in Las Vegas, NV, and founder and executive director of RD411.com. For the past 23 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Colleen Sloan, RD, LD/N is a clinical dietitian at JFK Medical Center in Atlantis, FL. In addition, she serves as a nutrition expert for community-based nutrition workshops and food demonstrations and is also a contributor and part of the management team for RD411.com. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.