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Canadian Dietitians' Use and Perceptions Of Glycemic Index in Diabetes Management

Posted on: Sunday, 2 April 2006, 06:00 CDT

By Kalergis, Maria; Pytka, Evelyne; Yale, Jean-Franois; Mayo, Nancy; Strychar, Irene

Abstract

Purpose: Several health organizations, including the Canadian Diabetes Association, advocate use of the glycemic index (GI) in the nutritional management of diabetes. However, the clinical utility and applications of the GI remain controversial. Our goal was to determine, via a postal survey, whether dietitians were using the GI and barriers to its use if they were not.

Methods: This cross-sectional study was conducted in 2003. Members of Dietitians of Canada and the Ordre professionnel des dittistes du Qubec (n=6,060) were first contacted by mail to identify those working with individuals with diabetes. Among respondents (n=2,857), 1,805 worked with individuals with diabetes and were sent a questionnaire. Using Chi-square analyses, users and nonusers were compared for their professional characteristics, perceived benefits, barriers, general knowledge about the concept, and confidence in teaching the GI.

Results: Among questionnaire respondents (n=1,057), 39% (n=415) used the GI and 61% (n=642) did not. Overall, users were more likely to have a greater diabetes patient caseload, perceived greater benefits and had greater confidence in teaching the concept. Nonusers cited lack of teaching tools and lack of knowledge on how to teach the concept as major barriers.

Conclusions: Further research is required to identify the clinical reasoning that triggers dietitians to apply the concept in their practice.

(Can J Diet Prac Res 2006;67:21-27)

Rsum

Objectif. Plusieurs organisations lies la sant, notamment l'Association canadienne du diabte, prconisent l'usage de l'indice glycmique (IG) dans le traitement nutritionnel du diabte. Cependant, l'utilit et les applications cliniques de l'IG restent controverses. Notre objectif tait de dterminer, au moyen d'une enqute mene par la poste, si les dittistes utilisent l'IG et, si elles ne le font pas, les obstacles l'utilisation de ce concept.

Mthodes. Cette tude transversale a t mene en 2003. On a d'abord contact par la poste des membres des Dittistes du Canada et de l'Ordre professionnel des dittistes du Qubec (n=6060) afin de reprer les personnes qui travaillaient auprs des diabtiques. Parmi les rpondantes (n=2857), 1805 travaillaient auprs des diabtiques et on leur a envoy un questionnaire. l'aide d'analyses du chi carr, les utilisatrices et les non-utilisatrices ont t compares quant leurs caractristiques professionnelles, aux avantages et obstacles perus, aux connaissances gnrales sur le sujet et leur aisance enseigner l'IG.

Rsultats. Parmi les personnes ayant rpondu au questionnaire (n=1057), 39% (n=415) utilisaient l'IG et 61% (n=642) ne l'utilisaient pas. Dans l'ensemble, les utilisatrices taient plus susceptibles de desservir un plus grand nombre de patients diabtiques, de percevoir plus d'avantages et d'avoir plus d'aisance enseigner le concept Les non-utilisatrices ont mentionn, comme obstacles principaux, l'absence d'outils d'enseignement et le manque de connaissances sur la faon d'enseigner le concept.

Conclusions. Des recherches plus approfondies sont ncessaires pour dterminer les raisons cliniques qui incitent les dittistes appliquer le concept dans leur pratique.

(Rev can prat rech ditt 2006;67:21-27)

INTRODUCTION

Diabetes has been described as the "the perfect epidemic", afflicting an estimated 104 million people worldwide in the year 2000 (1). This figure is expected to double by 2010 (2). The goal of clinical management for all forms of diabetes is to control metabolic abnormalities in order to prevent acute (hyperglycemia and hypoglycemia) and long-term (retinopathy, nephropathy, neuropathy and cardiovascular disease) complications without negatively impacting on quality of life (3). Two landmark studies have confirmed that attainment of glycemic control as close as possible to normal is necessary to prevent long-term complications in both type 1 and 2 diabetes (4,5). This requires an intensive approach to management Nutrition is of utmost importance in intensive management (6) and has often been described as the cornerstone of diabetes care (3).

The principle goals in nutritional management of diabetes include optimizing glycemic, lipid, and weight control. An important component of improving glycemic control is to balance food intake with endogenous and/or exogenous insulin levels. Historically, there have been several attempts to control the glycemic response to food, particularly foods rich in carbohydrate (7). One way to classify the glycemic response of various carbohydrate foods is the glycemic index (GI). This term was first coined byjenkins to describe the extent that blood glucose rises after a 50-g carbohydrate portion of a test food in comparison to the same amount of carbohydrate from a standard or reference food, usually glucose or white bread (8,9).

Although the GI has made it easy to predict the glycemic response to predominantly carbohydrate-rich foods, the clinical utility of this concept has been seriously questioned, especially as it pertains to mixed meals (10,11). Furthermore, some educators believe that the GI is too complicated to teach and there has been concern that patients may misapply it (11,12). Partly for these reasons, and citing a lack of convincing scientific evidence (11), the American Diabetes Association does not currently endorse the GI for application in clinical practice (13,14). However, the GI is being advocated by most diabetes and health organizations worldwide, including the World Health Organization, the Diabetes Nutrition Study Group of the European Association for the Study of Diabetes and the Canadian Diabetes Association (15-18). The joint Food and Agriculture Organization (FAO) and World Health Organization (WHO) expert consultation report (15) suggests using the GI as a way to guide food choices and to develop lists of high, medium and low GI foods. The report also suggests how the GI can be applied to mixed meals or whole diets.

Furthermore, there is a growing body of scientific evidence, including data from epidemiological and clinical studies linking low GI diets with improved outcomes, including decreased risk of developing type 2 diabetes and improved metabolic control and quality of life in individuals with established diabetes (19-31). However, no study to date has evaluated health professionals' perceptions about the application of the GI concept in everyday practice.

The objectives of this study were to determine current practices and perceptions of dietitians in Canada in relation to the use of GI in the nutritional management of individuals with diabetes mellitus, and to identify barriers to implementation. We expected that dietitians who "use" the GI concept would be more likely to perceive greater benefits, fewer barriers and have greater confidence in teaching the concept and higher knowledge scores than would nonusers (32,33).

RESEARCH DESIGN AND METHODS

Participants and study design

To achieve our objectives, we performed a Canada-wide postal survey (34) of all dietitians who were active members of Dietitians of Canada (DC) and the Ordre professionnel des dittistes du Qubec (OPDQ) in 2002. DC and OPDQ granted permission for a one-time distribution of a selfadministered questionnaire. The exclusion criteria were: students, retired members, DC members living outside of Canada and DC members from Quebec who were also OPDQ members.

A two-pronged sampling strategy was employed. A total of 6,060 dietitians (DC=4,014 and OPDQ=2,046) were first contacted via a one- page, two-sided (bilingual) postcard containing two questions. The purpose of this postcard was to identify dietitians who counselled individuals with diabetes and if they taught the GI concept at the time of the survey in 2003. Dietitians who reported counselling individuals with diabetes and who were using the GI concept were considered "users". Dietitians who reported counselling individuals with diabetes but did not currently use the GI concept in their practice were considered "nonusers". The research team then sent all "users" and "nonusers" a fourpage questionnaire along with a consent form. The questionnaire took 10-15 minutes to complete; respondents were asked to return it in a supplied stamped, addressed envelope. Incentives included: 10 prizes of $50 for postcard respondents and one prize of $500 for questionnaire respondents. Winners were notified by mail. The study was approved by the ethics committees of McGill University and the Centre hospitalier de l'Universit de Montral.

Questionnaire

The 20-item questionnaire was developed by three dietitians of the research team, two practicing and one researcher, all having extensive experience in diabetes management The questionnaire was designed to determine dietitians' use of the GI concept, its perceived benefits, barriers to and confidence with applying it in practice, general knowledge about the GI, and professional characteristics. Clinical experience, the literature, the Health Belief Model and Social Cognitive Theory guided the research team in developing the questions. The questionnaire was pilot-tested and validated (face and content validity) with a sample of ten other practising hospital dietitians with diverse experience in diabetes (fi\ve francophone and five anglophone). These dietitians provided comments on the content and clarity of the questions and on suggestions for change; the questionnaire was subsequently revised. The final version was translated into French, and checked for accuracy by the French-speaking members of the research team.

Dietitians who identified themselves as using the GI concept (users) were asked to complete questions that elaborated on the type of clients with whom it was used (i.e., type 1, type 2, gestational diabetes) and how it was incorporated into teaching. Dietitians who did not use the GI concept (nonusers) were asked to indicate why they did not use it.

Both users and nonusers were asked questions about perceived benefits and barriers to teaching the GI concept. Perceived benefits in teaching the concept consisted of six items: How useful do you feel that the GI is:

1. as a general concept of fast and slow acting carbohydrates?

2. as part of daily meal planning?

3. for teaching of hypoglycemic treatment?

4. for problem-solving when blood sugar levels are erratic?

5. for weight control?

6. in improving a client's sense of empowerment?

Responses could range from 1 (not useful) to 4 (very useful).

Perceived barriers consisted of nine items: To what extent do you feel the following are barriers to teaching the GI to clients with diabetes?

1. Lack of awareness of the GI concept

2. Lack of knowledge of the GI concept

3. Lack of knowledge of how to teach the GI

4. Lack of teaching tools by which to teach the GI

5. Lack of time to teach the GI concept

6. Complexity of teaching the GI concept

7. Complexity for clients to understand

8. Complexity for clients to apply

9. Lack of convincing scientific evidence for using the GI.

Responses could range from 1 (not a barrier) to 4 (major barrier).

Perceived confidence consisted of one item: At present, how confident do you feel teaching the GI to clients? Responses could range from 1 (not confident) to 4 (very confident). Knowledge of the GI concept was assessed with five items. Respondents were asked to indicate true, false, or do not know to the following statements (correct answer provided in brackets) :

1. Foods witii identical grams of carbohydrate may have different effects on post-meal glycemia if types of carbohydrate are different (true).

2. Carbohydrate-containing foods can be classified according to their GI (true).

3. There are exchange lists for foods containing high, medium and low GI (true).

4. The GI is the rise in blood glucose that a food produces compared to a reference food (i.e., glucose or white bread) (true).

5. The Canadian Diabetes Association currently recommends use of the GI in diabetes management (true).

Professional characteristics included: number of individuals with diabetes counselled per week, membership in diabetes associations, certification in diabetes education, year of graduation as a dietitian and degrees obtained.

Statistical analyses

All data were analyzed using the SPSS program (35). Descriptive statistics were used to characterize response rates and professional characteristics of respondents. Cronbach coefficient alpha was calculated to determine internal consistency of the perceived benefits (0.81), perceived barriers (0.84) and knowledge (0.31) measures. Chi-square analysis was used to determine differences between users and nonusers of the GI concept. Before chi-square analysis, number of diabetic patients counselled per week was regrouped to five or fewer per week and more than five per week. Perceived usefulness scores were regrouped into two categories: not useful (scores of 1 and 2) and useful (scores of 3 and 4). Perceived barrier scores were regrouped into two categories: not a barrier (scores of 1 and 2) and a barrier (scores of 3 and 4). Perceived confidence scores were regrouped into two categories: not confident (scores of 1 and 2) and confident (scores of 3 and 4). Bonferonni adjustment was made for the 26 comparisons (0.0526=0.019: p<0.0019 to be significant).

Table 1

Postcard and questionnaire response

RESULTS

Postcard and questionnaire response rates

Of the 6,060 dietitians who were first contacted via the postcard, 2,857 (47%) responded. Among respondents, 1,805 dietitians (63%) counselled individuals with diabetes and were thus eligible to receive the four-page questionnaire. Of these, 724 (40%) were identified as wsmand 1,081 (60%) were identified as nonusers of the GI concept. Table 1 outlines the postcard response rate by province. The response rate range was 56-59% in six provinces and the territories, with lower rates in Ontario (51%), PEI (49%) and Quebec (31%).

Of the 1,805 dietitians who were sent the four-page questionnaire, 1,062 (59%) completed and returned it. Of these, five dietitians were excluded from the analysis because they did not meet the inclusion criteria of teaching diabetes and had incorrectly received a questionnaire.

Table 2

Characteristics of questionnaire respondents (n=1,057)

Respondents' characteristics

Characteristics of questionnaire respondents (n=1,057) are outlined in Table 2: 54% graduated before 1990, 11% had graduate education, 15% were Certified Diabetes Educators, and 40% counselled more than five individuals with diabetes per week. Forty-five percent worked in an outpatient hospital clinic and 36% identified themselves as being the sole dietitian in the department. For diabetic meal planning, 68% of respondents used Canada's Food Guide to Healthy Eating, 53% used the No Concentrated Sugars approach, 50% used the Good Health Eating Guide, 10% used the Quebec (ADQ) Exchange System, and 53% used carbohydrate counting. Of respondents who completed the questionnaire, 39% (n=415) used the GI concept and 61%(n=642) did not, which were similar proportions to those who responded to the postcard.

Use and nonuse of GI

Of the 415 dietitians who used the GI concept, 90% used it as a general concept of fast and slow acting carbohydrate and 56% used it for problem solving in patients with erratic blood sugar levels (Table 3). Ninety-four percent reported using it for clients with type 2 diabetes and 59% used it for clients with type 1 diabetes.

Of the 642 dietitians who did not use the GI, 57% felt that it was too complex for clients to understand, 46% indicated that there was a lack of educational resources for teaching the concept and 31% were uncertain how to use the concept (Table 3).

Table 3

Users' reported applications of the GI and nonusers' reasons for nonuse

Differences between users and nonusers

Table 4 outlines the differences between users and nonusers. Compared to nonusers, a larger proportion of users were more likely to have a higher caseload of patients with diabetes, to have graduated before 1990 and to be Certified Diabetes Educators. Users were also more likely to have greater confidence in teaching the GI concept and to perceive more benefits in using the concept The majority of users (67%) correctly identified that the CDA recommends use of the GI concept in the nutritional management of diabetes, in contrast to 26% of nonusers. Nonusers perceived more barriers to using the GI concept.

DISCUSSION

In this Canada-wide survey, approximately 40% of responding dietitians, who were actively involved in diabetes management, reported using the GI concept in clinical practice. The majority of dietitians do not follow the Canadian Diabetes Association recommendations to apply the GI concept in diabetes management (16). The dietitians' use of the GI concept is more in line with the American Diabetes Association recommendation that does not advocate its routine clinical use (13-14). Only 26% of nonusers were aware of the Canadian Diabetes Association's recommendations, in contrast to 67% of users. Whether dietitians would be more likely to use the concept if they were aware that it was recommended by CDA is unknown. However, more nonusers (51%) than users (23%) felt that there was a lack of convincing scientific evidence to use the GI concept. Furthermore, over 75% of nonusers felt that the concept was difficult for clients to understand and apply. On the other hand, users of the GI concept were more likely to have a higher caseload of patients with diabetes. Therefore, clinical practice may be an important reason driving the application of the GI concept.

Table 4

Differences between users and nonusers of the GI concept

Our findings outline, for the first time, perceptions of the GI concept and barriers to its implementation. Barriers more frequently cited by nonusers compared to users of the GI concept included lack of teaching tools, complexity of the concept for clients to understand and lack of knowledge of how to teach the GI concept to clients. Since this study was undertaken, the Canadian Diabetes Association has developed a two-page teaching tool now available on its website (36). It briefly explains the GI concept and how it can be used by dietitians to help clients with diabetes make appropriate selections amongst foods rich in carbohydrate (36). Since die application of the concept in diabetes teaching can take different forms, a manual for dietitians that provides detailed suggestions on how to use the concept may be of interest

Almost all dietitians who reported using the GI did so by using it as a general concept of fast and slow acting carbohydrates, similar to the idea presented in the CDA teaching tool. Over 55% used it to resolve problems of erratic blood sugar levels and approximately half (49%) used it as part of teaching the daily meal plan.

It has been recommended that the starchy food group be the main focus in teaching the GI concept, as this food group contains the majority of high GI foods (37). The tool from die Canadian Diabetes Association can be useful in diis respect, since it includes a list of high, medium and low GI choices from the grain products or starchy food group. The concept may also be inte\grated into teaching the meal plan to the client (38-40). Clients could be taught to select at least one low GI choice per meal or to base at least two meals daily on low GI foods (37). Individuals who are taught the concept have found it simple and easy to use (37-39) and are reported not to misapply the concept (40). If used with a food choice system approach, clients can be taught to choose low GI foods from within the same food group. The GI concept can supplement existing nutritional strategies in the management of diabetes.

Nonusers also perceived themselves as being less confident than users in teaching the GI concept. This may be due to the greater number of perceived barriers and the fewer number of perceived benefits among nonusers.

The limitation of this study was the low response rate to die postcard from selected provinces. However, by using a two-pronged sampling strategy, we were able to achieve a response rate of 59% to the questionnaire. Further research is needed on frequency of use, the characteristics of patients taught the concept and the circumstances and clinical reasoning that trigger dietitians to apply die concept.

RELEVANCE TO PRACTICE

Recommended by the Canadian Diabetes Association, die GI is an emerging concept with important implications for improving glycemic control in individuals with diabetes. In order for practising dietitians to become more aware of the concept, it can be given special attention in continuing education programs and undergraduate training activities. A dietitian's GI teaching manual on how to apply the concept may also be useful. Workshops, including case studies, on how to apply the concept would provide dietitians with practical information so that they can tailor their teaching to the needs of their clients.

Acknowledgements

This study was made possible by a grant from the Canadian Foundation for Dietetic Research. We would like to thank the following individuals for their invaluable assistance: Bonnee Belfer, MSc, PDt; Alain Ishac, MSc, PDt; Lindsay McKinnon, BSc; and Joanne Auclair, Secretary of the Service of Endocrinology at the CHUM.

The GI is advocated by most diabetes organizations worldwide.

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MARIA KALERGIS, PhD, RD, CDE, McGill Nutrition and Food Science Centre, McGill University Health Centre, Montreal, QC; EVELYNE PYTKA, PDt, CDE, Endocrinology and Metabolism, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC; JEAN- FRANOIS YALE, MD, McGill Nutrition and Food Science Centre, McGill University Health Centre, Montreal, QC; NANCY MAYO, PhD, Department of Epidemiology and Biostatistics, McGill University Health Centre, Montreal, QC; IRENE STRYCHAR, EdD, RD, Notre-Dame Hospital of the Centre hospitalier de l'Universit de Montral and Department of Nutrition, Universit de Montral, Montreal, QC

Copyright Dietitians of Canada Spring 2006

Source: Canadian Journal of Dietetic Practice and Research

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