Diabetes Forecast

Who Needs a Dietitian? You Do

How a nutrition expert can jump-start your plan for healthy eating

By Tracey Neithercott , , , ,
Who Needs a Dietitian?

Here’s the thing about nutrition across the nation: Most Americans know they should be eating healthfully—but really don’t know what that means. Or how to accomplish it. Add diabetes to the mix and that brings even more challenges. Managing blood glucose levels requires an understanding of how to balance food, exercise, and medication. This includes how these items affect the body immediately. In the long term, unhealthy eating patterns contribute to the risk of complications such as cardiovascular disease and high blood pressure. Talking to a registered dietitian will help you use what you eat and drink as a tool for blood glucose control now and your best health later.

Nutrition Education for All

Who needs a dietitian? Everyone who has diabetes should be working with a dietitian. That includes, of course, the newly diagnosed, who generally need a crash course in eating for diabetes management. But people who have had diabetes for years also benefit from some one-on-one time with a registered dietitian. “There’s so much information,” says Shelley Wishnick, RD, CDN, CDE, a registered dietitian at the Friedman Diabetes Institute at Beth Israel Medical Center. “There’s always something new to learn.” Sure, working with a dietitian will help you stay up-to-date on the latest nutrition information, but you’ll also learn about your diabetes as it changes over time.

Repeated visits. You’re unlikely to make strides if your visit is a one-time deal. “Making lifestyle changes is very difficult,” says Heather Gibbs, PhD, RD, a registered dietitian and clinical assistant professor at the University of Kansas Medical Center. “Even though a person can be brought up to speed about what they need to know in terms of diabetes and nutrition, there is so much to learn. You need repeated visits.”

Insurance benefits. Under the Affordable Care Act, nutrition counseling is considered a free preventive service for adults at high risk for chronic illness and is part of the essential health benefits covered by new plans. For seniors, Medicare covers three hours of doctor-prescribed medical nutrition therapy the first year a person is diagnosed with diabetes and then two hours per year after that. This service is separate from, and in addition to, diabetes self-management education. Many other insurance plans allow for the same, though your plan may cover more or less. The Academy of Nutrition and Dietetics recommends people with diabetes set three to four 45- to 95-minute appointments within the first three to six months of their diagnosis and, after that, have at least one appointment each year.

Working With an RD

Trained nutrition professionals. Many medical practices have a registered dietitian on staff. The RD and RDN (registered dietitian nutritionist) credentials signify the same level of accreditation. Many registered dietitians are also certified diabetes educators (CDEs), so your doctor’s office may have one person to fill both roles. It’s always a good idea to find a dietitian familiar with diabetes, and the CDE credential is an indication that your provider has extra training in diabetes management. Diabetes educators excel at explaining the intricacies of blood glucose management and the art of balancing meds, food, and exercise.

Seeking referrals. If your doctor’s office has no dietitian on staff, ask your health care provider for a referral. Your insurer may also have a list of dietitians it works with, or you could search for a registered dietitian in your area on the Academy of Nutrition and Dietetics’ website, www.eatright.org.

Be cautious, though. Not all nutrition professionals are alike. Registered dietitians have gone through extensive training and accreditation to get that RD or RDN after their names. Others, such as nutritionists, don’t always have the same level of training.

Partners in Meal Planning

Working together. Resist the urge to cast dietitians as villains threatening your food freedom. Yes, they’d prefer everyone eat plenty of fruits and veggies rather than binge on chicken wings and cheese fries, but they’re not the scary dictators many people envision. “[People have] heard the horror stories, and they think the dietitian is going to take everything from them,” says Constance Brown-Riggs, RD, CDE, MSEd, CDN, a registered dietitian in Long Island, N.Y., spokesperson for the Academy of Nutrition and Dietetics, and author of The African American Guide to Living Well With Diabetes. But, she says, those fears are unfounded.

Getting to know you. Instead of issuing orders, your dietitian will probably start the first appointment by asking you to fill out a form that will help him or her assess your current health and nutrition status. The dietitian may weigh you, calculate your body mass index (a ratio of weight to height that will help the dietitian determine your individual calorie needs), and possibly measure your waist and hips or analyze your body composition.

Your dietitian will most likely spend time getting to know you by asking about your physical activity patterns and medical history, and reviewing any blood work or other tests your doctor ordered (such as for blood pressure and cholesterol), your current eating patterns, and information about your diabetes control, such as your most recent A1C. He or she will also find out just how much you know about diabetes. For people with a new diabetes diagnosis, that may not be much. In that case, the dietitian may use the first appointment to go over information for your immediate needs, such as what foods contain carbohydrate and thus have the most effect on your blood glucose, how to treat hypoglycemia if you’re using insulin or sulfonylurea medications, and, if necessary, weight-control basics.

Setting goals. Regardless of how long you’ve had diabetes and how familiar you are with the disease, goal setting will be a large part of your visits. Your dietitian will help you work out objectives that are right for your individual needs and health care concerns. (For instance, someone with heart disease might aim to ditch fast food entirely to reduce excess calories and saturated fat while someone else’s target may be to eat fast food only on weekends as part of a gradual reduction.) “I don’t expect 10 changes at once,” says Wishnick. “It’s a transition process.” Once the person with diabetes meets one goal, it’s time to move on to the next goal together.

During your next visits, your dietitian may cover other aspects of nutrition aside from carbohydrate counting, blood glucose management, and weight control. He or she can help you create an eating plan that will address things such as special diets (for celiac disease, lactose intolerance, gastroparesis, or kidney disease, for example) and pregnancy. Dietitians can also address concerns such as portion control, reading nutrition labels, menu planning, eating out, and the glycemic index. Many will even take your recipes for your favorite foods and alter them to fit your dietary needs. Receiving information that fits your personal needs is what makes working with a dietitian so valuable.

A plan that works for you. “As opposed to telling that individual ‘No,’ we work with them to fit that food into their meal plan. It’s not a dictatorship,” says Brown-Riggs. So when one of her patients said she couldn’t follow a diet that banned chicken wings, Brown-Riggs explained how to include them in her healthier meal plan. Maybe her client could eat chicken wings only once a week or so. Maybe she could reduce the number of wings she ate per sitting. Or maybe she could learn a recipe for baked wings with half the fat of the fried version. As long as you’re open and honest, as this woman was, your dietitian will work with you to ensure your eating plan is tasty and satisfying.

Finding solutions. Because navigating diabetes care is never smooth sailing in a society with so many unhealthy food options, troubleshooting is a major part of working with a registered dietitian. He or she can help you determine whether something you’re eating is causing an after-breakfast blood glucose high, puzzle out how to eat for both diabetes and kidney disease, explain how to determine the carb count of foods without nutrition labels, and a host of other issues you’re not thinking of right now but will during the course of your life with diabetes.

An Active Role

You lead the team. As skilled as registered dietitians are, they can’t work magic. That means you’ll have to do your share of the work. “The patient is the most important person on the health care team,” Gibbs says. “They’re the ones who have to go home and live with it.” That means it’s your responsibility to log your blood glucose level and bring a record of your numbers to your appointment. Many people use paper logbooks, programs that download data from a blood glucose meter, or smartphone apps. It doesn’t matter which method you prefer as long as you arrive at your dietitian’s office armed with data. Without a record of your blood glucose levels, the dietitian can’t determine whether your meal plan is helping or hindering your diabetes care.

Keeping a record. It’s also helpful to keep a food journal, at least when you first start seeing a dietitian. But Gibbs warns against prettying up your diet for your dietitian. “There’s a tendency for people when they’re keeping their meal records to alter their food because they want to appear to do well,” she says. “I’d advise people to be honest. The dietitian is there to help you.”

And keep in mind: A dietitian won’t pass judgment on your nutritional sins. “No one’s going to yell at you,” says Wishnick. “No one’s perfect. There’s not a perfect way to eat.” The more open and accurate you are, the better you’ll be able to set and then meet realistic health goals.

Seeing patterns. Armed with your glucose, food, and physical activity log, your dietitian can perform the most important task: helping you understand how your eating patterns affect your blood glucose. By comparing data from your blood glucose log with a food journal, you can see how certain meals cause the blood glucose to rise or drastically spike. “It’s good for [you] to see how a meal affects [your] blood sugar,” Wishnick says. “Now you know, when I eat quinoa and chicken and vegetables, this is how my blood sugar acts.”

Asking and answering. It’s also up to you to make sure all of your questions are answered. Unclear about something your dietitian said? Not sure how to go about achieving the goal you set? Have other nutrition questions? Ask. Appointments with your dietitian will last much longer than the average visit to your physician—for reasons including the fact that dietitians generally go into more detail on health topics than doctors and allot more time for explaining basics of diabetes and nutrition management. That means you’ll have a greater opportunity to pose questions and make sure you understand the dietitian’s answers. It may help to arrive at the appointment with a list of questions. “I would be delighted for people to bring in questions they already have,” says Gibbs. “To me, that shows a commitment to learning information.”

A Parting of Ways

Finding the best fit. Just as you won’t mesh with every doctor you meet, you may not click with the first dietitian you visit. If that happens, it’s OK to part ways and find a new one. If a dietitian doesn’t listen to you or consider your opinions and fears, he or she may not be a good match for you. A good dietitian will act as a partner in meal planning, not a judge.

“The relationship and the rapport is an important aspect of being able to make changes,” Gibbs says. “I wouldn’t want a negative experience with one person to prevent them from finding another to work with.” Instead, use the experience to learn what you like and dislike in a registered dietitian.

5 Tips for Food Journaling

  1. Don’t rely on memory. Write down your snacks and meals as you eat them. We’re especially forgetful when it comes to the little nibbles here and there.
  2. Include it all. Yes, even that single piece of chocolate you ate while chatting with a coworker.
  3. Be specific. Estimate serving size to the best of your ability. That is, “six crackers” versus “a few crackers.”
  4. Record your numbers. Write down your premeal blood glucose, your estimate of how many grams of carbohydrate you ate and drank, and the number of calories in your meal or snack (if you’re trying to lose or maintain weight). To really see how food affects blood glucose, use your meter again two hours after your first bite of food.
  5. Note emotions. Get the most from your food journal by listing how you feel—sad, angry, bored, and so on—along with what you ate. It can help you spot and curb emotional eating.


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