Eating and pumping: evaluating the nutrition service of the insulin pump clinic at the Royal Melbourne Hospital. (Insight: Original Research).

Abstract

Objective: To determine the effectiveness of a nutrition information session in an insulin pump clinic in improving knowledge and food choices, and to assess patient satisfaction with the session.

Design: An eight-part self-administered questionnaire.

Subjects: Twenty-five patients who had attended insulin pump training from August 2000 to July 2001 were invited by mail to participate in the study.

Setting: Insulin pump 'stabilisation clinic' at The Royal Melbourne Hospital, Victoria.

Main outcome measures: Patient-rated usefulness of the written information, retention of nutrition messages, dietary changes made and best aspects of the program.

Results: Sixteen patients responded. Eleven had attended the nutrition session and of these ten received written information. Four patients reported carbohydrate counting and glycaemic index as the most useful information. Of the 11, eight demonstrated retention of messages consistent with nutrition information provided; five made dietary changes; six reported the best thing about the nutrition session was confirmation that their knowledge and food practice was in line with current recommendations; and four suggested a follow-up session and more time with the dietitian as improvements.

Conclusion: Patient-reported improvements in dietary practice and positive feedback about the nutrition sessions indicate the value of dietetic education in the insulin pump clinic. As the number of patients treated with insulin pumps increases in Australia, sharing of information and nutrition research is encouraged to develop best practice.

Key words: insulin pump, diabetes mellitus, dietary counselling, nutrition education

Introduction

The importance of nutrition intervention by a dietitian for diabetes management is well accepted (1,2) and leads to improved health outcomes (3,4). In particular, dietary advice on carbohydrate foods is an integral part of nutrition intervention because of the evidence that different carbohydrate foods affect blood glucose control (5).

Through the 1990s the findings of the Diabetes Control and Complications Trial (DCCT) (6) have led to more intensive insulin treatment, designed to normalise glycosylated haemoglobin ([HbA.sub.1C]). One approach used in the DCCT was treatment with insulin pumps, referred to as continuous subcutaneous insulin infusion. This is a relatively common form of treatment in the US but until recently, has been uncommon in Australia. However, the increased publicity regarding the positive outcomes with insulin pump therapy (7-9) has led many patients to seek this treatment in Australia. The insulin pump provides a continuous basal infusion of short acting insulin to reduce hepatic glucose production and normalise glucose in the fasting state thus mimicking the normal function of the pancreas. Before meals, the person infuses a predetermined bolus of insulin, the dose being based on the carbohydrate content of the food to be eaten and the blood glucose concentration. This treatment approach allows greater flexibility in lifestyle and food choices.

A clinic specifically designed to commence people on an insulin pump was established at the Royal Melbourne Hospital. To date, there have been no published reports of such clinics in Australia, and no reports on the role of the dietitian in these clinics. From the inception of the clinic at the hospital, a dietitian has worked closely with the diabetes educator and endocrinologist to provide education and advice aimed at promoting self-care and effective management of diabetes for people using an insulin pump.

Patients commencing with the pump at the hospital undergo one-and-a-half days of training with the diabetes educator to learn to operate the pump and to set the initial basal rates and pre-meal boluses. The nutrition session is held at the end of the second half-day and is normally 45 to 60 minutes' duration. Patients training in pairs attend the nutrition session together. For the insulin pump to be effective, patients must learn to match pre-meal insulin boluses with meals through carbohydrate counting (10,11). Being able to provide this information in a practical way is an important role for the dietitian in these clinics (12).

Written information available in the nutrition session includes information on carbohydrate exchanges and glycaemic index (GI), developed by the hospital's Nutrition Department, and the Sanitarium[R] booklets, 'Facts on fat' and 'Sugar update'. Most patients attending the clinic have had diabetes for many years and have had previous intervention from a dietitian, but informal feedback from patients indicated that the information formerly provided might not be meeting their needs. The objective of this study was to determine whether the nutrition information provided was useful and resulted in improved knowledge and food choices, as rated by the patients.

Method

Of the 27 patients who attended the insulin pump clinic from August 2000 to July 2001, 25 were invited by mail to participate in the study. This included those who did not attend a nutrition session. Two patients were less than 18 years old and therefore were not eligible to participate. Patients received a package that included a letter of invitation, an eight-part self-administered questionnaire (copies available from author) and a stamped self-addressed envelope. A reminder letter was sent one week after the due date to encourage participation.

The questionnaire was not previously piloted and included questions about age, occupation, height, weight, and the month of attendance at the clinic. Patients were also asked to indicate the written information they received, if they read it, whether it was useful to them, and to recall one of the messages from the nutrition session. Patients were asked to state whether they had altered their diet, reasons they had not done so, or if they had, what changes they made. The questionnaire used open-ended questions about the most and least useful aspects of the nutrition session and a question about how the nutrition service could be improved. The latter question had prompts such as need for follow-up, relevance, further learning requirements and presence of others in the session. As the number of subjects is small, statistical analyses are inappropriate and the results presented are a descriptive summary.

This project was approved by The Royal Melbourne Hospital Clinical Research and Ethics Committee as part of routine patient care.

Results

Of the 25 people invited to participate, 16 responded. Of these 16, 11 had attended both the pump training and the nutrition information session. Four were unable to attend the nutrition session due to other commitments and/or the dietitian being unavailable, and the remaining patient reported he did not require further nutrition education. Table 1 summarises the demographics of the 16 patients.

Of the 11 who attended the pump training and nutrition session, ten received written information. All ten reported reading through the information. Four found the information on carbohydrate counting and GI useful, two reported the sugar update useful, and one found information on fats useful (see Table 2). Five patients reported making dietary changes. These included using margarine instead of butter, using lower GI cereal, including lower GI snacks, changing type of rice eaten, counting carbohydrate more carefully and observing the effects of different carbohydrate types on blood glucose concentration more carefully. Those who did attend but did not make a dietary change reported that this was because they were already following an eating plan that was consistent with recommended guidelines. In contrast, the five patients who had not attended the nutrition session reported no dietary changes had been made since attending the clinic.

The 11 patients who attended the nutrition information session were asked to recall one message from the session. Eight messages recalled were consistent with information provided in the nutrition session, two were not, and one did not respond. Ten respondents provided feedback on 'the best thing about the nutrition session'. Six of the ten reported confirmation that they were doing the right things and two reported the session to be a good update. One patient responded that their blood glucose concentration had improved as a result of increased motivation and implementation of improved food choices after attending the nutrition session. In response to 'the worst thing about the nutrition session', there were four responses. Two were about having to make changes to their dietary practice, one reported the information was too broad and the other patient attending dominated the session, and the remaining patient reported that there was no information on the effect of protein on blood sugar concentrations.

On 'improving the nutrition service', four patients recommended a follow-up session, three suggested more time with the dietitian, and one recommended individual sessions. Other recommendations included e-mail access to the dietitian, provision of a list of relevant web sites, a newsletter, eating a meal out with the dietitian to practice carbohydrate counting in a restaurant, and recipes.

Discussion

In this study we assessed improvements in dietary knowledge and food choices, and patient satisfaction with a nutrition information session for patients commencing on an insulin pump.

The Humber of participants in this study is small, but this form of insulin treatment is new and few centres have more than one or two patients using a pump. Therefore, the results presented in this paper are a summary and have been qualitatively evaluated. A limitation of this study is that those who were invited to participate, but did not respond, may have different views from those who participated. Despite this, we believe the information provided by patients was informative and provides a starting point to guide provision of nutrition information to patients commencing on an insulin pump.

Patients who attended the clinic were generally well educated and within a healthy weight range. Few patients found the written information on fat and sugar useful. This is expected as information on fat and sugar is of a more general nature, than GI and carbohydrate counting which are comparatively more complex. The dietitian determined the level of patient's knowledge during the consultation and on the basis of this patients were given appropriate written information. Therefore, not all patients received all available written information.

Overall, patients who attended the nutrition session responded positively to nutrition education, reporting that even if a specific dietary change had not been made, it improved their confidence with food choices. In contrast, those that had not attended the nutrition session did not report any dietary change. Although numbers are small, this provides evidence that attendance at the nutrition session should be encouraged and become part of standard practice.

It has been suggested that for people with an insulin pump, there can be an overemphasis on carbohydrate counting that can result in reduced carbohydrate intake and an increase in fat intake (11). This was not assessed in this study, but as carbohydrate counting is a key component of nutrition education, it is suggested that a diet history pre- and post-nutrition intervention be used to monitor such dietary change. Body weight, fat intake, haemaglobin [A.sub.1c] and serum lipids should also be included as routine measures in the clinic. Such measures would provide objective evidence when researching the role of medical nutrition therapy in insulin pump treatment. There is currently no such research reported in the literature.

Practice guidelines for medical nutrition therapy by dietitians for the management of non-insulin-dependent diabetes are available (13) and report that patients are more likely to be successful in improving diabetes management with ongoing nutrition therapy rather than a single nutrition session (12,13). In this study, two people recalled nutrition messages that were not consistent with information provided during the session. A follow-up session would be of benefit to ensure correct information is retained. Four patients stated that a follow-up session would have been useful. Follow-up sessions are currently being investigated at the hospital's clinic with the model expected to be referral to a dietitian in community or private practice when the patient leaves the hospital clinic and returns to his or her own endocrinologist.

In conclusion, following attendance at the nutrition information session, improvements in behaviour and food choices were reported, and patients gave positive feedback about their nutrition session. Insulin pump clinics also provide an avenue for research in medical nutrition therapy. A collegial approach to patient care with sharing of information, research and expertise is encouraged as the number of patients using pump therapy increases.

Table 1

Demographic information on the 16 patients responding to the mailed
questionnaire

Characteristic

Age (years)         31 to 50 (range)
Education           9 with tertiary qualifications
Weight (kg)         69 [+ or -] (mean [+ or -] SD)
BMI (kg/[m.sup.2])  25 [+ or -] (mean [+ or -] SD)

Table 2

Number of patients who received written information and patient- rated
usefulness of it. The figures are the number of patients responding in
the affirmative. Eleven patients attended the nutrition session

                Carbohydrate  Glycaemic  Facts on  Sugar
                counting      index      fat       update

Information         7             7          7       5
received
Information is      4             4          1       2
useful

References

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(3.) Franz MJ, Monk A, Barry B, MeClain K, Weaver T, Cooper N, ci al. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. J Am Diet Assoc 1995;95:l009-17.

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(9.) Boland E, Grey M, Gesterle A, Fredrickson L, Tamborlane WV. Continuous subcutaneous insulin infusion: a new way to lower risk of severe hypoglycaemia, improve metabolic control, and enhance coping in adolescents with Type 1 diabetes. Diabetes Care 1999;22:1779-84.

(10.) Savinetti-Rose B, Bolmer L. Understanding continuous subcutaneous insulin infusion therapy. Am J Nurs 1997;97(3):42-8.

(11.) Waldron S, Hannas R, Palmvig B. How do we educate young people to balance carbohydrate intake with adjustments of insulin? Horm Res 2002;57:62S-5S.

(12.) Rizor HM, Richards S. All our patients need to know about intensified diabetes management they learned in fourth grade. Diabetes Education 2000;26:392-4.

(13.) Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ. Practice guidelines for medical nutrition therapy by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc 1995;95:999-1006.

Nutrition Department, The Alfred

M. Voevodin, BSc(Hons), MNutrDiet, Dietitian

Burnet Clinical Research Unit

C. Steele, RN, RM, GradDipHealth Counselling, CertDiabEd, Diabetes Nurse Educator 

Department of Diabetes and Endocrinology, The Royal Melbourne Hospital

P.G. Colman, MBBS, FRACP, MD, Director

Nutrition Department, The western Hospital, Melbourne

K. Pierce, BSc, GradDipDiet, GradDipBusAdmin, Allied Health Manager

Correspondence: M. Voevodin, Nutrition Department, The Alfred, Commercial Road, Melbourne, Victoria 3004. Email: [e-mail]