A very interesting paper was published on 7th November 2016 called “Dietitians’ practice in giving carbohydrate advice in the management of type 2 diabetes: a mixed methods study”. The abstract can be seen here. I’ve reviewed the full article for this post.
The article caught my attention as I spotted the lead author, dietitian Paul McArdle, (@PMcArdleRD) on twitter report the paper as follows:
48% of #dietitians advise #type2 #diabetes patients to restrict carbohydrate: http://onlinelibrary.wiley.com/doi/10.1111/jhn.12436/abstract … @DMEG_BDA @BrDieteticAssoc
If 48% of dietitians are advising type 2 diabetes patients to restrict carbohydrate, what are the other 52% doing? And what is a dietitian’s idea of restricting carbohydrate? Let’s take a look…
The study & participants
The study was simple in concept: UK Registered Dietitians, who consult with type 2 diabetes patients 1-1, were contacted through various methods (including social media), and asked to take part in a survey. 377 survey responses were received, of which 320 were complete and able to be used in the analysis for this article.
The survey asked questions in three main areas: 1) the type of carbohydrate advice given; 2) the level of carbohydrate restriction supported/advised; and 3) the confidence felt by diabetes specialist dietitians (DSDs) and non-diabetes-specialist dietitians (non-DSDs) in giving carbohydrate advice.
The profile of the dietitians surveyed was as follows (Table 1):
– Gender: 96% of the 320 dietitians who completed the survey were female.
– Age: the largest age group was the 25-34 age group with 34% of respondents. Fewer than 5% of the dietitians surveyed were under 24 years of age and approximately 10% were aged 55 or over. By far the majority were aged 25-54.
– Experience: 56% of respondents had been qualified as a registered dietitian for 10 years or more.
– Employment: Only 6.6% of respondents were non-NHS. 93.4% were NHS employees. The majority (81%) were in NHS pay bands 6 and 7, which means they earn between £26,302 and £41,373.
1) The type of carbohydrate advice given
Table 2 in the paper detailed the responses to five questions about carbohydrate advice:
Q1) What advice do you usually give regarding GI (Glycaemic Index)?
Q2) What advice do you usually give regarding GL (Glycaemic Load)?
Q3) How often do you advise or support patients to implement a carbohydrate restriction?
Q4) For you, what would represent a realistic carbohydrate restriction in type 2 diabetes? (ZH – that’s an interesting way of phrasing it – what do you think is realistic, not what do you think is healthy, or better still, optimal).
Q5) What does the term carbohydrate awareness mean to you?
Questions 1, 2 and 5 allowed multiple responses, so percentages weren’t given, but they can still be calculated and are still informative. For example, the single biggest response to question 1 was “I cover GI as a general concept only” – to which 63% (200/320) of dieticians responded positively. In addition to this, 30 respondents (9.4%) reported “I don’t usually cover GI.” These statements should be mutually exclusive, so 72% of dietitians surveyed ignore or gloss over GI.
Ditto for Q2 on Glycaemic Load “I cover GL as a general concept only” was the answer receiving the biggest response with 164/320 dieticians reporting this – more than half of respondents. 119 replied “I don’t usually cover GL”, meaning that 88% of dietitians surveyed ignore or gloss over GL.
I don’t value GI or GL personally (far too variable and inconsistent), but they are ‘allowed’ by the National Institute for Care and Health Excellence (NICE) guidelines – many thanks to Dr Unwin for spotting this.
The two most interesting questions need to be reported in full:
Q3) How often do you advise or support patients to implement a carbohydrate restriction?
|Rarely (5% of the time)|
|Sometimes (10% of the time)|
|Occasionally (25% of the time)|
|Frequently (50% of the time)|
The number used by the lead author, Paul McArdle in his tweet “48% of #dietitians advise #type2#diabetes patients to restrict carbohydrate” came from adding together the percentage responses for “occasionally” and “frequently” in the table above = 48.2%. However, dietitians can be in the highest (“frequently”) category while not advising carbohydrate restriction 50% of the time and dietitians can be in the second highest (“occasionally”) category while not advising carbohydrate restriction 75% of the time.
2) The level of carbohydrate restriction
Bearing in mind that we have just established that carbohydrate restriction is not commonly advised, the next and even more interesting question was:
Q4) For you, what would represent a realistic carbohydrate restriction in type 2 diabetes?
|Roughly 50% of total energy from carbohydrate|
|40-49.9% of total energy from carbohydrate|
|30-39.9% of total energy from carbohydrate|
|Less than 30% of total energy from carbohydrate|
|Ketogenic amounts of 20g of carbohydrate per day or less|
|Other/free text responses|
Only 1 dietitian in 320 would advise what should be the first line of defence in the treatment of type 2 diabetes: a very low carbohydrate diet (20-50 grams of carbohydrate daily would be more accurate than 20g, but the use of the word “ketogenic” explains the principle) (Ref 1). 92% of dietitians, who gave a quantitative response to this question, would advise type 2 diabetic patients to consume more than 30% of their total energy in the form of carbohydrate. For a typical female, consuming 2,000 calories a day, this would represent 150 grams of carbohydrate daily. I don’t have type 2 diabetes; I’ve got a BMI of 20 and it would be rare for me to consume 150 grams of carbohydrate in any one day (simply because if you eat real food and choose that real food for the nutrients it provides, you end up eating a lower carbohydrate higher fat diet). Yet the vast majority of dieticians consider 30% of energy from carbohydrate to be the bottom limit for people with a chronic inability to metabolise carbohydrate.
3) Confidence levels of dietitians surveyed
176 of the 320 dietitians surveyed were diabetes specialist dietitians (DSDs); 144 were non- diabetes specialist dietitians (non-DSDs). The survey reported that there were differences between the confidence levels of DSDs vs. non-DSDs in giving carbohydrate advice to type 2 diabetics (Table 3 of the paper).
All dietitians surveyed were asked to rate the statement: “I feel confident in teaching patients with type 2 diabetes about the quantity of carbohydrate in food” from strongly disagree; disagree; neutral; agree; to strongly agree. 92% of DSDs dietitians agreed or strongly agreed with this statement, compared to 60.4% of non-DSDs (17.4% of non-specialists were neutral, 17.4% disagreed and 4.9% strongly disagreed). It is troubling in itself that all 320 dieticians are seeing type 2 diabetes patients, but almost a quarter can’t agree with a statement that they feel confident teaching their patients about carbohydrate.
It was further found that diabetes specialist dietitians (DSDs) were more likely to advise/support patients in carb restriction and they were more likely to be at the lower end of carb restriction. However, this still showed that fewer than 10% of DSDs would advise less than 30% of total energy from carbohydrate.
As well as what is called “quantitative” data (numbers), “qualitative” data (descriptive) were available in this article. Three dietitians were prepared to be interviewed. Direct quotations were printed in the article from these three interviews. The article concluded that the qualitative interviews highlighted conflicting priorities with three sub-themes: the difference between empowerment and advice; how treatment decisions are made; and contradictory advice.
From the quotations that were shared in the article, I came to different conclusions:
1) The level of waffle was high.
Assuming that the best quotations were included in the article, here’s the first one used: “‘I think the basic skill is basically carbohydrate awareness. Which means basically education on what exactly carbohydrate foods are. Identify what are carbohydrate foods.”
The article sadly costs $38 – it would be worth a few bucks just to read the comments. It is clear that dietitians have no strategy for dealing with the serious condition that is type 2 diabetes and no consistency in advice. The sub-theme referred to as “empowerment and advice” is a euphemism for not giving direction: “it depends on the individual”; “it depends on what they want from the consultation”; “this person doesn’t like multiple injections, then maybe we will go with the twice a day insulin.”
I don’t know if dietitians think they’re being nice not saying it how it is, or if they think that this isn’t their job, but the message needs to be: “You have a very serious condition. Your life, limbs and eyes now depend on you taking as little carbohydrate and medication as possible from this point on. I’m now going to educate you about the carbohydrate content of food. Listen like your life depends on it, because it does.”
2) The level of ignorance was high.
One comment was possibly the dullest I have seen: “So, people who are wanting to control their weight they know that it’s the carbs that they need to inject for so, for example, if they want to have any carbs at lunch time, because sometimes you know, people, patients, have said to me that the insulin puts weight on and we keep saying that well actually insulin is non calories, its (sic) what you’re eating that would put the weight on…”
Insulin has no calories and so it has no impact on weight. Riiiight!
Another quotation was “I wouldn’t always promote, you know, don’t have a carb free day because we know carbs provide you with energy.” Yes but carbs are not essential nutrients i.e. they do not need to be consumed. The body will happily use fat for energy – dietary fat or body fat – and the outcome of the latter is weight loss, which could be extremely helpful for a diabetic.
3) Fat will be responsible for confusion.
Let’s assume that dietitians know that there are only three macronutrients (fat, protein and carbohydrate). Let’s assume that they also know that protein tends to stay fairly constant at around 15-20% of dietary intake (even better if we could assume that they know protein also has an impact on insulin and therefore needs to be moderated for diabetics). Let’s assume that they are aware that carbohydrates are bad news for blood glucose levels and therefore diabetics. They must then realise that carbohydrates need to be restricted. They should then realise that 30% of one’s intake in the form of carbohydrate is way too high. But this would mean that fat would need to make up the difference, at 50% of the diet or more, and this would cause a coronary in most dietitians. This is the limiting belief, for which there is no evidence, which needs to be overcome before dietitians can be a help, rather than a hindrance, in diabetes care. (Calories are clearly another limiting belief, but that’s for another day!)
Let us accept the numbers in the introduction to the article: “Diabetes affects over 3 million people in the UK and 415 million worldwide, most of whom are diagnosed with type 2 diabetes… Treating diabetes and its complications costs the National Health Service (NHS) approximately £10 billion ($14 billion) per year, accounting for approximately 10% of the budget.” We can thus agree on the scale of the problem.
We can also agree, as the opening line of the abstract states, “Carbohydrate is accepted as the principal nutrient affecting blood glucose in diabetes.”
This article shows that dietitians generally are confident in their advice – diabetes specialists especially so. Yet, fewer than one third (29.4%) of dietitians would recommend carbohydrate restriction even 50% of the time. More, (32.2%), would never, or hardly ever, recommend carb restriction. In the uncommon circumstances when carb restriction is supported, 92% of dietitians would advise type 2 diabetic patients to consume more than 30% of their total energy in the form of carbohydrate. Only 1 in 320 would advise the therapeutic level of carbohydrate for the treatment of type 2 diabetes.
The real cost to the NHS of 319 of these dietitians, therefore, is not the approximately £11 million annual salary bill (and pensions on top). It’s the lost opportunity in transforming the lives and health of the approximately 300,000 patients they likely reach annually between them and the impact that this could make on the avoidable £10 billion per annum that the NHS is currently wasting through employee ignorance.
The blame must lie primarily at the door of public health advisors – Public Health England and NICE – but dietitians must take responsibility for the advice that they give. If they think that the advice they’re giving is right, they are part of the problem. If they think that the advice they’re giving is wrong but continue to give it, they are part of the problem. The tragedy is that dietitians and those who teach dietetics are not joining together, as a force to be reckoned with, to demand change to save their patients. In my experience, too many of them spend their time trolling those calling for change rather than realising that they could be the change that is needed.
Ref 1: Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ, Westman EC, et al. Dietary Carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base. Nutrition (Burbank, Los Angeles County, Calif). 2014.