Practices and perceptions of registered dietitians regarding the use of carbohydrate counting and barriers associated with it in the dietary management of type 1 diabetes mellitus.

Abstract

Introduction: Diabetes mellitus (DM) is one of the most prevalent chronic diseases worldwide with an estimated 451 million people currently living with diabetes between the ages of 18-99 years. Approximately 87-91% of people with diabetes in high-income countries have type 2 diabetes mellitus (T2DM), while 7-12% have type 1 diabetes mellitus (T1DM). In South Africa, there are an estimated 2.3 million people living with diabetes and of those people, 5-15% have T1DM. The diabetic should receive individualised nutrition therapy, which includes promoting and supporting healthy eating by achieving and maintaining body weight and individual glycaemic goals. Carbohydrate counting is a meal planning method that alongside the adjustment of insulin assists in managing and maintaining blood glucose levels and is commonly used in the management of T1DM. With carbohydrate counting, the individual is taught to identify carbohydrates in foods (carbohydrate awareness) and determine the amount of carbohydrates that are consumed at one time. They are then taught to give the correct amount of insulin depending on the portion of carbohydrate eaten to prevent hyperglycaemia and hypoglycaemia, and maintain normal blood glucose levels. Carbohydrate counting has been shown to improve glycaemic control as well as quality of life, however, it must be taught by someone who has clinical expertise in the field, such as an experienced registered dietitian. Although international guidelines recommend that carbohydrate counting be offered to all newly diagnosed patients with T1DM, there are currently no recommendations specific to the South African population and little or no information regarding practices and perceptions of dietitians regarding carbohydrate counting. Aim: This study aimed to determine the practices and perceptions of registered dietitians regarding the use of carbohydrate counting and the barriers associated with it in the dietary management of T1DM. It also aimed to determine if there is a need for further training on carbohydrate counting amongst dietitians in KZN. Objectives: i) To determine which dietary management approach is most commonly used by dietitians in KZN when educating patients with T1DM. ii) To determine if dietitians in KZN use carbohydrate counting in the dietary management of patients with T1DM. iii) To determine the perceptions of dietitians in KZN towards the use of carbohydrate counting in the dietary management of T1DM. iv) To determine the barriers which prevent dietitians in KZN from using carbohydrate counting in the dietary management of T1DM. v) To determine if dietitians in KZN see a need for further education/training in the area of carbohydrate counting.

Method: A cross-sectional descriptive study was conducted via a link to a questionnaire on SurveyMonkey that was attached to an email. The link was distributed to the dietitians who were members of the Association of Dietetics in South Africa (ADSA) in KZN. The KZN Department of Health (DOH) uploaded the survey on their intranet website under the surveys section, where the DOH dietitians could access the survey. Data was analysed using the IBM Statistical Package for Social Sciences (SPSS) version 26.0. Results: Sixty-nine dietitians participated in the survey, 78% (n=54) of which qualified at the University of KwaZulu-Natal (UKZN). Although the majority (76.8%; n=53) of the dietitians indicated that they gave dietary management advice to patients with T1DM, a significant 85.5% (n=59) indicated that most of their patients presented with T2DM (p<0.05). The glycaemic index, portion control using the healthy eating plate, carbohydrate counting using nutritional labels, carbohydrate counting using household measures and carbohydrate awareness i.e. making patients aware of which foods contain carbohydrate, were all significant dietary management approaches used by dietitians (p<0.05). The majority of the dietitians (60.9%; n=42) indicated that they had not received additional training on diabetes management. Dietitians agreed that they required further training or education on the use of carbohydrate counting as a dietary management approach to manage patients with T1DM (p<0.05). Dietitians agreed that there were numerous barriers to their use of carbohydrate counting in the management of diabetes. These barriers included a lack of training, confidence and experience, patient illiteracy, lack of financial resources, time, blood glucose records and poor patient motivation. Dietitians agreed that carbohydrate counting was useful as a dietary management approach (p<0.05) and that it was an essential part of the dietary management of T1DM (p<0.05). Conclusion: Although dietitians in KZN stated that they used carbohydrate counting as a dietary management method, their practices varied. There was a willingness amongst dietitians working in both the private and public sectors to receive more training on carbohydrate counting and to apply it to patient care. Although dietitians agreed that carbohydrate counting was a useful and essential method in the dietary management of T1DM, a number of barriers prevented the use of this method. A lack of training, confidence and experience influenced whether or not dietitians taught their patients to carbohydrate count. There is a potential for carbohydrate counting to be used by the dietitians in KZN who participated in the study. However, further training and

resources are required. This study has highlighted a need for South African guidelines on the dietary management of T1DM, as there is currently none in place.