Our role statement was developed by members of the Diabetes Interest Group. It lists the skills and knowledge of an Accredited Practising Dietitian (APD) working in the area of diabetes.

Knowledge

• Pathophysiology of all types of diabetes including: risk factors, diagnostic criteria, usual presentation, acute emergencies, co-morbidities, complications, optimal/suboptimal blood glucose profiles, and the differences in nutritional approaches for type 1 as compared with type 2, gestational and other forms of diabetes mellitus.
• Standard diabetes management goals and strategies for different populations, while understanding the need for individualisation including: targets for glycaemia (for example, HbA1c, fasting and post-prandial blood glucose, and continuous glucose monitoring metrics such as ‘time-in-range’), lipids, blood pressure; complications screening and advice regarding foot care; exercise; home blood glucose monitoring; insulin delivery; and which health professionals are best placed to address each area.
• Nutrition implications of oral and injectable diabetes medications and their delivery, including their profile of action (peak, duration) in relation to food and risk of hypoglycaemia.
• Nutrition implications of evolving diabetes technologies including: insulin dosing apps and glucose meters; continuous and flash glucose monitoring systems; hybrid-closed loop insulin delivery systems; and associated terminology (for example, ‘flexible dosing’, ‘carbohydrate ratio’, ‘sensitivity factor’, ‘insulin on board’).
• Current, evidence-based medical nutrition therapies for diabetes and related complications/co-morbidities such as obesity, cardiovascular diseases, kidney disease, coeliac disease, gastroparesis and disordered eating.
• Available diabetes services and schemes, and client access/eligibility including: local diabetes centres and hospital services; private diabetes related clinicians; National Diabetes Services Scheme and Medicare initiatives.

Skills

• Assessment of an individual, including detailed nutrition and carbohydrate assessment (amounts, type, timing) in relation to their diabetes management plan/targets, medications or insulin, blood glucose patterns, and other factors affecting glycaemia (for example, physical activity).
• Provide individualised medical nutrition therapy, including recommendations for modification of current intake, appropriate to age, type of diabetes, comorbidities/health concerns, risk of hypoglycaemia and management targets; integrating lipid, blood pressure, glycaemic and weight management goals with physical activity and healthy eating strategies.
• Provide nutrition education to people with diabetes both individually and within a group setting, using a variety of tools such as: food/blood glucose records, carbohydrate counting, glycaemic index, portion modelling, meal planning, label reading, cooking/recipe adjustments and behaviour modification.
• Behaviour change, self-management and client centred counselling skills to facilitate long-term and/or community-based management.

Activities entry level APDs would conduct

• Provide individualised medical nutrition therapy for low complexity cases within skill and experience level. For example, diet- and tablet-treated pre-diabetes, type 2 diabetes and gestational diabetes.
• Consult with a diabetes-experienced APD for complex individual cases until further upskilling has been undertaken.; For example, type 1 diabetes, type 2 or gestational diabetes on insulin, complex obesity, multiple co-morbidities, pregnancy in pre-existing diabetes and paediatric cases, depending on prior experience.
• Deliver nutrition group education for pre-diabetes, type 2 diabetes and gestational diabetes including optimal meal patterns, carbohydrate amounts and types, and nutrition strategies to address comorbidities.

Activities APDs working at a higher level would conduct

• Provide individualised medical nutrition therapy for complex diabetes cases (for example, highly unstable blood glucose, insulin pump therapy, morbid obesity, gastroparesis).
• Provide advanced carbohydrate counting education (individual and/or group) and assessment of suitability/readiness for flexible insulin therapy and/or insulin pump therapy, based on carbohydrate counting knowledge and skills.
• Conduct analysis of the impact of carbohydrate and other macronutrients, physical activity, alcohol, disordered eating and diabetes medications/insulin on glycaemia. This includes interpretation of graphs, summaries and food records available from diabetes technologies, such as insulin pumps, continuous/flash glucose monitoring systems and apps.
• Provide input into diabetes team treatment decisions, where these relate to the individual’s diet (for example, carbohydrate ratios, insulin pump bolus types, safety and efficacy of low carbohydrate diets) and complex care co-ordination.

Activities dietitians working in this area of practice do not usually undertake

• Endorse intensive diet restrictions and ‘sugar free’ diets for frail and aged people with diabetes, where malnutrition can be a greater risk than mild hyperglycaemia. Refer to the NDSS diabetes management in aged care handbook for more information.
• Manage individuals without the involvement of other members of a diabetes multidisciplinary team, such as general practitioner, endocrinologist, diabetes educator, exercise physiologist, podiatrist etc.
• Provide education, counselling or interventions beyond dietetic scope of practice, such as in-depth diabetes self-management education, psychological counselling, foot assessments, insulin adjustments and activities involving skin penetration (including insertion of insulin pump or continuous/flash glucose monitor), without undertaking appropriate steps to extend scope of practice (for example, post-graduat training to become a Credentialled Diabetes Educator, or local health network approval process for extended scope of practice).
• Many APDs undertake additional training to become Credentialled Diabetes Educators (CDEs). Refer to the joint publication by Australian Diabetes Educators Association and Dietitians Australia for more information.

For more, download the full role statement.