Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial

Diabetes medical nutrition therapy: practical tips to improve outcomes

PURPOSE

To describe the evolving and expanding role of nurse practitioners (NPs) in providing diabetes medical nutrition therapy (MNT) as the United States faces epidemics of diabetes and obesity.

DATA SOURCES

Scientific literature and reports from the public health, diabetes, and nutrition fields.

CONCLUSIONS

Although clinically effective for both prevention and treatment of diabetes, MNT is often underutilized. The majority of people with diabetes are cared for by primary care providers; the role of NPs as primary care providers is evolving and expanding. NPs are recognized as leaders who creatively adapt to the rapidly changing health care delivery system.

IMPLICATIONS FOR PRACTICE

NPs can serve as role models by presenting accurate, basic nutrition messages, referring patients to registered dietitians for MNT, reinforcing nutrition and the importance of lifestyle change as primary treatments for their disease, and following up on their patients' progress with nutrition interventions.

Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes

PURPOSE

This meta-analysis was conducted to assess the effect of educational and behavioral interventions on body weight and glycemic control in type 2 diabetes.

METHODS

Studies selected for analysis were published randomized controlled trials that evaluated educational and behavioral interventions (no drug interventions) in type 2 diabetes (sample size > or = 10). These criteria were applied to searches of electronic databases and relevant bibliographies. Data were independently abstracted by 2 reviewers and adjudicated by consensus.

RESULTS

Of the 63 articles that met the inclusion criteria, 18 provided enough information for pooled estimates of glycohemoglobin (total Ghb, HbA1, or HbA1C). These 18 studies yielded 2720 participants (sample sizes of 18 to 749). Interventions ranged from 1 to 19 months; follow-up ranged from 1 to 26 months. Glycohemoglobin was reduced by a mean of 0.43%. When results were stratified by quality score, glycohemoglobin was -0.50% and -0.38% for studies with high and low quality scores, respectively. When weighting studies by sample size, fasting blood glucose was reduced by 24 mg/dL and weight by 3 lbs.

CONCLUSIONS

Previous educational and behavioral interventions in type 2 diabetes have produced modest improvements in glycemic control. Future research should refine such interventions and improve methodology.

REAP and WAVE: new tools to rapidly assess/discuss nutrition with patients

Dietary changes can be helpful in preventing or treating a variety of prevalent health problems. Physicians can be helpful in helping patients make positive dietary changes, be physically active and lose weight, but, for a variety of reasons, many physicians do little nutrition counseling. There is a need for brief, user-friendly tools to enable physicians to rapidly and accurately assess patients' diets and exercise habits as well as provide information to aid the physician in delivering effective nutrition counseling. The purpose of this paper is to discuss two new tools, WAVE and REAP, that have been developed by the Nutrition Academic Award to help physicians and other health care providers conduct nutrition assessment and counseling with their patients in a practical and effective manner. The WAVE acronym and tool is designed to encourage provider/patient dialogue about the pros and cons of the patients' current status related to Weight, Activity, Variety and Excess. The Rapid Eating and Activity Assessment for Patients (REAP) is a brief validated questionnaire that is designed to aid providers in performing a brief assessment of diet and physical activity. An accompanying Physician Key aids the provider in discussing the patient's answers and counseling them appropriately. REAP and WAVE can be helpful tools to facilitate nutrition assessment and counseling in the provider office. Depending on patients' health priorities and how much time is available, these tools can be used in a variety of ways to discuss nutrition with patients during a clinical encounter in 1-9 min.

Evolution of diabetes medical nutrition therapy

Research supports the importance of medical nutrition therapy in achieving diabetes treatment goals. For persons requiring insulin therapy, the first priority is to integrate an insulin regimen into the patient's lifestyle. For type 2 diabetes, the priority is to focus on lifestyle strategies (that is, nutrition and exercise) that will improve metabolic outcomes at diagnosis and as the disease progresses. Patients with diabetes need nutrition recommendations that are supported by scientific evidence and that can be easily understood and translated into everyday life. To achieve positive outcomes, a coordinated team effort that provides continued education and support is essential.

The economics of screening and treatment in type 2 diabetes mellitus

A systematic review of the literature was conducted to identify articles on the economics of type 2 diabetes mellitus. Articles were classified into two main categories: cost/burden-of-illness studies of type 2 diabetes and economic evaluations of type 2 diabetes interventions. This systematic review was supplemented by an overview of the findings relating to economic evaluations of associated diabetic complications. A number of conclusions emerge from this review, the most important of which is that intensive treatment of patients with type 2 diabetes appears to be relatively cost effective compared with more conservative strategies. This finding reflects the cost offsets that arise from the range and degree of complications attributable to diabetes. Primary prevention of type 2 diabetes also appears to be cost effective, particularly in high-risk groups. The evidence on screening for type 2 diabetes is less conclusive and further economic analysis is required.

Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports

OBJECTIVE

To systematically evaluate the published evidence regarding the characteristics and effectiveness of disease management programmes.

DESIGN

Meta-analysis.

DATA SOURCES

Computerised databases for English language articles during 1987-2001.

STUDY SELECTION

102 articles evaluating 118 disease management programmes.

MAIN OUTCOME MEASURES

Pooled effect sizes calculated with a random effects model.

RESULTS

Patient education was the most commonly used intervention (92/118 programmes), followed by education of healthcare providers (47/118) and provider feedback (32/118). Most programmes (70/118) used more than one intervention. Provider education, feedback, and reminders were associated with significant improvements in provider adherence to guidelines (effect sizes (95% confidence intervals) 0.44 (0.19 to 0.68), 0.61 (0.28 to 0.93), and 0.52 (0.35 to 0.69) respectively) and with significant improvements in patient disease control (effect sizes 0.35 (0.19 to 0.51), 0.17 (0.10 to 0.25), and 0.22 (0.1 to 0.37) respectively). Patient education, reminders, and financial incentives were all associated with improvements in patient disease control (effect sizes 0.24 (0.07 to 0.40), 0.27 (0.17 to 0.36), and 0.40 (0.26 to 0.54) respectively).

CONCLUSIONS

All studied interventions were associated with improvements in provider adherence to practice guidelines and disease control. The type and number of interventions varied greatly, and future studies should directly compare different types of intervention to find the most effective.

Diet and exercise among adults with type 2 diabetes: findings from the third national health and nutrition examination survey (NHANES III)

OBJECTIVE

To describe diet and exercise practices from a nationally representative sample of U.S. adults with type 2 diabetes.

METHODS

We analyzed data from 1,480 adults older than 17 years with a self-reported diagnosis of type 2 diabetes in the Third National Health and Nutrition Examination Survey (NHANES III). Fruit and vegetable consumption was obtained from a food frequency questionnaire; the percentages of total calories from fat and saturated fat were obtained from a 24-h food recall. Physical activity was based on self report during the month before the survey.

RESULTS

Of individuals with type 2 diabetes, 31% reported no regular physical activity and another 38% reported less than recommended levels of physical activity. Sixty-two percent of respondents ate fewer than five servings of fruits and vegetables per day. Almost two thirds of the respondents consumed >30% of their daily calories from fat and >10% of total calories from saturated fat. Mexican Americans and individuals over the age of 65 years ate a higher number of fruits and vegetables and a lower percentage of total calories from fat. Lower income and increasing age were associated with physical inactivity. Thirty-six percent of the sample were overweight and another 46% were obese.

CONCLUSIONS

The majority of individuals with type 2 diabetes were overweight, did not engage in recommended levels of physical activity, and did not follow dietary guidelines for fat and fruit and vegetable consumption. Additional measures are needed to encourage regular physical activity and improve dietary habits in this population.

Quality of care in diabetes: understanding the guidelines

We are in the midst of a global pandemic of diabetes. Despite the increasing burden of the disease, measurements of quality repeatedly show poor adherence to or implementation of current guidelines for diabetes care. This article will provide a brief review of the most significant randomized controlled clinical trials relevant to the current guidelines and then discuss essential treatment goals and the evidence that supports them. Several practical clinical questions related to the implementation of modern diabetes guidelines will be raised and answered. Finally, reasons for the poor quality performance observed will be examined.

Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control

OBJECTIVE

To evaluate the efficacy of self-management education on GHb in adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We searched for English language trials in Medline (1980-1999), Cinahl (1982-1999), and the Educational Resources Information Center database (ERIC) (1980-1999), and we manually searched review articles, journals with highest topic relevance, and reference lists of included articles. Studies were included if they were randomized controlled trials that were published in the English language, tested the effect of self-management education on adults with type 2 diabetes, and reported extractable data on the effect of treatment on GHb. A total of 31 studies of 463 initially identified articles met selection criteria. We computed net change in GHb, stratified by follow-up interval, tested for trial heterogeneity, and calculated pooled effects sizes using random effects models. We examined the effect of baseline GHb, follow-up interval, and intervention characteristics on GHb.

RESULTS

On average, the intervention decreased GHb by 0.76% (95% CI 0.34-1.18) more than the control group at immediate follow-up; by 0.26% (0.21% increase - 0.73% decrease) at 1-3 months of follow-up; and by 0.26% (0.05-0.48) at > or = 4 months of follow-up. GHb decreased more with additional contact time between participant and educator; a decrease of 1% was noted for every additional 23.6 h (13.3-105.4) of contact.

CONCLUSIONS

Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect. The benefit declines 1-3 months after the intervention ceases, however, suggesting that learned behaviors change over time. Further research is needed to develop interventions effective in maintaining long-term glycemic control.

Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: results from a randomized controlled trial

BACKGROUND

Few diabetes education programs have been designed specifically for older adults. This study evaluated the impact of a nutrition intervention on the blood glucose and lipoprotein levels of adults > or =65 years of age without functional limitations but with type 2 diabetes for > or =1 year.

METHODS

Ninety-eight people were randomized to the experimental or control group. A pretest-posttest control group design was used to evaluate the intervention. Ninety-two people (94%) completed the study. The 10-week intervention incorporated principles from information processing, learning theory, and Social Cognitive Theory to meet the needs of older adults. Analysis of covariance compared outcomes between groups. The paired t test compared results within groups.

RESULTS

Participants exceeded the guidelines for optimal glycemic control at pretest. The experimental group had greater improvements in fasting plasma glucose (P = 0.05) and glycated hemoglobin (P < 0.01) than the control group. Significantly more participants in the experimental group than control group met the treatment goals for total cholesterol at posttest (P < 0.05).

CONCLUSIONS

Older adults with diabetes need additional education to achieve metabolic control. Nutrition education can improve metabolic control among this cohort. Improved metabolic outcomes reduce the morbidity and mortality associated with diabetes.

Lack of multidisciplinary collaboration is a barrier to outcomes research

OBJECTIVES

To identify and describe methods of collaboration used by dietitians to conduct outcomes research and to identify perceived barriers to participation in outcomes research.

DESIGN

A questionnaire was mailed to dietitians to obtain descriptive information about outcomes research involvement. Details of collaborative research experiences were collected in follow-up telephone interviews.

SUBJECTS

Subjects were a regional sample of 300 dietitians from the Clinical Nutrition Managers practice group of The American Dietetic Association. One hundred fifty-three subjects (51%) responded to the questionnaire and 25 of 42 eligible respondents were interviewed.

ANALYSIS

Frequency counts on questionnaire and closed-ended interview data were analyzed. Chi2 tests were used to identify significant associations between participation in outcomes research and demographic variables. Content analysis of open-ended interview data was used to detect emergence of recurrent themes.

RESULTS

Forty-two (27%) respondents had conducted outcomes research. Although all respondents collaborated on at least 1 project, half collaborated only with other dietitians, and 27 of 42 (64%) did not report research findings outside their facility. Interview data suggest that collaboration, especially between disciplines, enhances the entire research process and generates benefits beyond the specific project. The most frequently cited barriers among respondents who had not conducted outcomes research (n=111) were lack of research skills (65%) and lack of time or staff (41%).

APPLICATIONS

These findings support the assertion that lack of multidisciplinary involvement is a barrier to generating evidence of nutrition therapy effectiveness. Educators, health care professionals, and dietitians must model and encourage multidisciplinary, collaborative outcomes research in diverse practice settings.

A taxonomy for diabetes educational interventions

Diabetes education is a cornerstone of diabetes self-care management. Despite terrific progress in refining educational interventions, the diabetes literature continues to contain substantial inconsistencies in reporting the elements of educational interventions. This unnecessary variation in the quality of reporting has led to difficulties in understanding the results of educational research in diabetes. We provide a taxonomy that should prove helpful, both in the conceptual design of diabetes educational interventions and in the reporting of those interventions. An application of this taxonomy to 30 diabetes educational randomized controlled trials is presented to highlight the extent of variation in diabetes educational interventions.

Factors affecting the use of dietetic services by patients with diabetes mellitus

AIMS

Dietary counselling is vital for patients with diabetes, yet many do not access professional advice. This study investigated the use of dietetic services by patients with diabetes within Sunderland Health District.

METHODS

Diabetic patients were identified from the laboratory module of the Hospital Information System (HIS). Eight thousand five hundred and ninety-seven patients were identified, and cross referenced to dietetic records, producing a comprehensive database for analysis.

RESULTS

Only 58.8% of the sample had dietetic records. Those with records were more likely to be: older (63.8 vs. 61.7 years, P < 0.01); male (52.6% vs. 46.8%, P < 0.05); accessing hospital diabetes services (P < 0.001); to have lipids and renal function checked (both P < 0.001); and to have poor blood glucose control (HbA(1c) > 7.5% to 58.7% vs. 29.9%, P < 0.001). Frequent attenders were most likely to be women, those with poor control, and those with shorter duration of diabetes (P < 0.001). In a logistic regression model, duration of diabetes, insulin treatment, obesity and hyperlipidaemia were the main determinants of increased use.

CONCLUSIONS

This study confirmed that many patients with diabetes do not make use of professional dietetic services, and has highlighted some of the routinely documented characteristics that are associated with use of dietetic services. There appears to be scope to improve uptake of dietetic services by patients with diabetes, and to investigate further individual factors that affect access and attendance.

Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials

OBJECTIVE

To systematically review the effectiveness of self-management training in type 2 diabetes.

RESEARCH DESIGN AND METHODS

MEDLINE, Educational Resources Information Center (ERIC), and Nursing and Allied Health databases were searched for English-language articles published between 1980 and 1999. Studies were original articles reporting the results of randomized controlled trials of the effectiveness of self-management training in people with type 2 diabetes. Relevant data on study design, population demographics, interventions, outcomes, methodological quality, and external validity were tabulated. Interventions were categorized based on educational focus (information, lifestyle behaviors, mechanical skills, and coping skills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle behaviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease risk factors; and economic measures and health service utilization.

RESULTS

A total of 72 studies described in 84 articles were identified for this review. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in studies with short follow-up (<6 months). Effects of interventions on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration may be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. No studies demonstrated the effectiveness of self-management training on cardiovascular disease-related events or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studies reviewed, and external generalizability was often limited.

CONCLUSIONS

Evidence supports the effectiveness of self-management training in type 2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness of self-management interventions on sustained glycemic control, cardiovascular disease risk factors, and ultimately, microvascular and cardiovascular disease and quality of life.

Dietary advice given by a dietitian versus other health professional or self-help resources to reduce blood cholesterol

BACKGROUND

The average level of blood cholesterol is an important determinant of the risk of coronary heart disease. Blood cholesterol can be reduced by dietary means. Although dietitians are trained to provide dietary advice, for practical reasons it is also given by other health professionals and occasionally through the use of self-help resources.

OBJECTIVES

To assess the effects of dietary advice given by a dietitian compared with another health professional, or the use of self-help resources, in reducing blood cholesterol in adults.

SEARCH STRATEGY

We searched The Cochrane Library (to Issue 2 1999), MEDLINE (1966 to January 1999), EMBASE (1980 to December 1998), Cinahl (1982 to December 1998), Human Nutrition (1991 to 1998), Science Citation Index, Social Sciences Citation Index, hand searched conference proceedings on nutrition and heart disease, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials of dietary advice given by a dietitian compared with another health professional or self-help resources. The main outcome was difference in blood cholesterol between dietitian groups compared with other intervention groups.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eleven studies with 12 comparisons were included, involving 704 people receiving advice from dietitians, 486 from other health professionals and 551 people using self-help leaflets. Four studies compared dietitian with doctor, seven with self-help resources, and one compared dietitian with nurse. Participants receiving advice from dietitians experienced a greater reduction in blood cholesterol than those receiving advice only from doctors (-0.25 mmol/L (95% CI -0.37, -0.12 mmol/L)). There was no statistically significant difference in change in blood cholesterol between dietitians and self-help resources (-0.10 mmol/L (95% CI -0.22, 0.03 mmol/L)). No statistically significant differences were detected for secondary outcome measures between any of the comparisons with the exception of dietitian versus nurse for HDLc, where the dietitian groups showed a greater reduction (-0.06 mmol/L (95% CI -0.11, -0.01)). No significant heterogeneity between the studies was detected.

REVIEWER'S CONCLUSIONS

Dietitians were better than doctors at lowering blood cholesterol in the short to medium term, but there was no evidence that they were better than self-help resources. The results should be interpreted with caution as the studies were not of good quality and the analysis was based on a limited number of trials. More evidence is required to assess whether change can be maintained in the longer term. There was no evidence that dietitians provided better outcomes than nurses.

An integrative literature review of cardiac risk factor management in diabetes education interventions

PURPOSE

The purposes of this paper are to (1) review the literature on educational interventions for adults with type 2 diabetes; (2) determine what kinds of interventions have been studied; (3) identify which interventions have included cardiac risk factor management; (4) determine how effective these interventions have been on metabolic control, diabetes-related outcomes, and cardiovascular-related outcomes; and (5) make recommendations for further research on combined interventions designed to promote optimal diabetes and cardiac risk factor management in adults with type 2 diabetes.

METHODS

Using an integrative literature review approach, 64 studies on diabetes education interventions for adults with diabetes published between 1987 and 1998 were reviewed; 44 met these criteria.

RESULTS

Few studies included cardiac risk factor management, which should be an integral part of diabetes management. Most studies demonstrated a beneficial effect of education on the management of type 2 diabetes but not cardiovascular risk.

CONCLUSIONS

Identifying strategies that promote effective disease management for improved diabetes control and reduction of cardiac events in adults with diabetes is essential. Further intervention studies focusing on the combined management of diabetes and cardiac risk factors are warranted.

Diabetes training for dietitians: needs assessment, program description, and effects on knowledge and problem solving

Recent changes in management and medical nutrition therapy for diabetes mellitus have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitian's New Role in Diabetes Management is a 2 1/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (+/- standard deviation) scores on pre- and postests of knowledge and problem solving were 69 +/- 13% and 86 +/- 9%, respectively (P < 0.01). The SNAP program needs assessment, training methods, and knowledge problem-solving test are relevant to all types of education programs in clinical dietetics.

Guidelines in professions allied to medicine

BACKGROUND

Clinical practice guidelines aim to reduce inappropriate variations in practice and to promote the delivery of evidence-based health care.

OBJECTIVES

To identify and assess the effects of studies of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (1975 to 1996), EMBASE, Cinahl and Sigle to 1996, the NHS Economic Evaluations Database (1994 to 1996), DHSS-Data (1983 to 1996), the Database of Abstracts of Reviews of Effectiveness (1994 to 1996) and reference lists of articles. We also hand searched the journal Quality in Health Care, made personal contact with content experts and contacted libraries identified by an expert panel.

SELECTION CRITERIA

Randomised trials, controlled before-and-after studies and interrupted time series analyses of the introduction of interventions comparing 1. Clinical guidelines plus dissemination and/or implementation strategies versus no guidelines; 2. Guidelines plus dissemination and/or implementation strategies versus guidelines plus alternative dissemination and/or implementation strategies; and 3. (post hoc) Guidelines used by professions allied to medicine versus standard physician care. The participants were nurses, midwives and other professions allied to medicine.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eighteen studies were included involving more than 467 health care professionals. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. The various behaviours targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies were identified for comparison 1. Three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies were identified for comparison 2 but it was difficult to draw firm conclusions because of poor methods. Six studies were identified for comparison 3 (post hoc). These studies generally supported the hypothesis that there was no difference between care given by nurses using clinical guidelines and standard physician care.

REVIEWER'S CONCLUSIONS

There is some evidence that guideline-driven care is effective in changing the process and outcome of care provided by professions allied to medicine. However, caution is needed in generalising findings to other professions and settings.

Nutrition management and physical activity as treatments for diabetes

Diabetes is essentially a self-management disease in which patients must learn to integrate blood glucose monitoring with nutrition management and physical activity and, if needed, oral agents or insulin. This almost always requires behavior change. The American Diabetes Association diet is no longer a meaningful prescription, because recommendations are now based on individualized nutrition assessment and treatment goals. Physical activity recommendations, as an adjunct to nutrition management, should also be individualized. Using a team approach, focusing on individualization of nutrition management and physical activity, applying behavior change concepts, and providing frequent follow-up can improve self-management and result in improved metabolic control. Primary care practitioners are in a unique position to oversee this process.

Diabetes patient education research: an integrative literature review

PURPOSE

The purpose of this study is to summarize the accumulated state of knowledge in the area of diabetes patient education research and highlight important issues that research has left unanswered.

METHODS

An integrative literature review was conducted on the topic of diabetes patient education between the years 1985 and 1998. Keywords used in the computerized search were diabetes mellitus, patient education, health education, research, and behavior change. The databases searched were MEDLINE, CINAHL, HealthSTAR, EMBASE, and CHID-HE. A total of 78 papers were reviewed.

RESULTS

Most studies lacked a theoretical framework and the majority of studies were conducted in an outpatient setting. HbA1c was the most frequently employed outcome measure, with little, if any, description of the interventions.

CONCLUSIONS

Much has been learned in terms of the effectiveness of diabetes education on improving knowledge. However, other topic areas and outcomes need further exploration.

Interventions to promote diabetes self-management: state of the science

PURPOSE

The purpose of this paper is to review the diabetes education literature that has emerged over the past 20 years to determine what we currently know about diabetes self-management interventions and their effectiveness in producing improved health outcomes.

METHODS

Findings of studies that were reported prior to 1990 were compared with findings of studies that have been conducted since 1990 to determine what recent changes and patterns in diabetes self-management education have occurred. Future directions in diabetes self-management research and practice were projected from these findings.

RESULTS

Most studies lacked adequate descriptions of the interventions tested, which precludes replication or application of the most effective strategies to clinical practice. Trends in interventions have evolved from education only to education plus behavioral models, with more attention given to interventions specifically for minority populations. The interventions that have been designed and tested seem to be longer, with more emphasis on simple, practical approaches to diabetes self-management.

CONCLUSIONS

The literature supports the effectiveness of diabetes education and behavioral interventions in improving psychosocial and health outcomes. The question of how to best achieve these improved outcomes continues to need further exploration.

If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness

It is increasingly acknowledged that diabetes and other chronic illnesses are major public health problems. Medicare and many managed health care organizations have recognized the enormous personal and societal costs of uncontrolled diabetes in terms of complications, patient quality of life, and health care system resources. However, the current system of reactive acute-episode focused disease care practiced in many settings does not adequately address this public health problem. An alternative proactive, population-based approach to chronic illnesses such as diabetes is proposed and illustrated. This multilevel systems approach addresses supportive and inhibitory social-environmental factors at multiple levels (personal, family, health care team, work, neighborhood, community). Key disciplines contributing to a population-based approach to diabetes include epidemiology, behavioral science, health care services, public health, health economics, and quality of life professions. Current and potential contributions of each of these disciplines are illustrated and an integrative, population-based systems approach to diabetes management and prevention of complications is proposed. This approach is also seen as applicable to other chronic illnesses.

Economic implications of an early postoperative enteral feeding protocol

OBJECTIVE

To study the cost-effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections.

DESIGN

A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset.

SUBJECTS/SETTING

Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18-month period.

INTERVENTION

Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care.

OUTCOMES

A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups.

STATISTICAL ANALYSIS

Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent-samples t tests. Nonparametric Mann-Whitney rank sum tests were used to determine the cost significance of a nosocomial infection.

RESULTS

The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group.

CONCLUSION

An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost-effective.

The estimated costs and savings of medical nutrition therapy: the Medicare population

OBJECTIVES

To measure the potential savings from medical nutrition therapy (MNT) and to estimate the net cost to Medicare of covering these services for Medicare enrollees. This includes developing an estimate of the cost of providing medical nutrition services to the Medicare population and estimating the savings in hospital and other spending resulting from the use of these services.

DESIGN

Analysis of longitudinal data from the Group Health Cooperative of Puget Sound (Seattle, Wash) for persons aged 55 years and older who have coverage for MNT services.

SUBJECTS/SETTING

Persons aged 55 years and older who had diabetes (n = 12,308), cardiovascular disease (n = 10,895), or renal disease (n = 3,328) and who were covered under the Group Health Cooperative of Puget Sound, including Medicare beneficiaries enrolled in the plan's Medicare risk contract program. Extrapolation to the US Medicare population is based on data for persons served by the Group Health Cooperative of Puget Sound.

INTERVENTION

The use of MNT.

MAIN OUTCOMES MEASURE

Differences in health care utilization levels of persons with diabetes, cardiovascular disease, and renal disease who do and do not receive MNT. Differences in utilization were estimated for hospital discharges per calendar quarter, physician visits per quarter, and other outpatient visits per quarter.

STATISTICAL ANALYSES PERFORMED

Multivariate regression models of changes in utilization for persons after they receive MNT services.

RESULTS

Our analysis showed that MNT was associated with a reduction in utilization of hospital services of 9.5% for patients with diabetes and 8.6% for patients with cardiovascular disease. Also, utilization of physician services declined by 23.5% for MNT users with diabetes and 16.9% for MNT users with cardiovascular disease. The net cost of covering MNT under Medicare is estimated to be $369.7 million over the 1998 through 2004 period. The total cost of benefits is estimated to be $2.7 billion over this period. This would be partially offset by estimated savings of $2.3 billion resulting in net costs of $369.7 million. The program would actually yield net savings after the third year of the program, which would continue through 2004 and beyond.

CONCLUSION

After an initial period of implementation, coverage for MNT can result in a net reduction in health services utilization and costs for at least some populations. In the case of persons aged 55 years and older, the savings in utilization of hospital and other services will actually exceed the cost of providing the MNT benefit. These results suggest that Medicare coverage of MNT has the potential to pay for itself with savings in utilization for other services.

Evaluation of a food label nutrition intervention for women with type 2 diabetes mellitus

OBJECTIVE

To evaluate an educational intervention about the food label designed specifically for women with type 2 diabetes mellitus.

DESIGN

A pretest-posttest control group design. Participants received random group assignment.

SUBJECTS/SETTING

Forty-three women aged 40 to 60 years with type 2 diabetes living in a rural community in Pennsylvania participated. Forty participants (93%) completed the program.

INTERVENTION

Nine weekly group sessions were developed on the basis of findings from previous research among this sample. Principles from Ausubel's learning theory were also incorporated into program design and evaluation.

MAIN OUTCOME MEASURES

The effectiveness of the food label education program on participants' knowledge was determined using a multiple-choice test designed to measure declarative and procedural knowledge. A skills inventory assessed participants' perceived confidence in using the food label. The validity and reliability of the instruments had been established previously.

STATISTICAL ANALYSES

Analysis of variance was performed to compare groups. Paired t tests compared pretest and posttest results.

RESULTS

The experimental group showed a greater gain than the control group in total knowledge (P < .001), declarative knowledge (P < .001), and procedural knowledge (P < .01) at posttest. Posttest data showed a significant increase (P < .01) in experimental participants' perceived confidence in using the food label.

CONCLUSIONS

Women with diabetes need more education about the food label. This intervention is an effective outpatient education program. Participant knowledge and perceived confidence in using the food label improved significantly as a result of the intervention. Future research should assess retention of knowledge gained and the impact of the intervention on metabolic measures of diabetes management and control.

Effect of clinical guidelines in nursing, midwifery, and the therapies: a systematic review of evaluations

BACKGROUND

Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness, 18 evaluations of guidelines were identified that meet Cochrane criteria for scientific rigor.

METHODS

Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series design were identified through a combination of database and hand searching.

RESULTS

18 studies met the inclusion criteria. Three studies evaluated guideline dissemination or implementation strategies, nine compared use of a guideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared with standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring process and in which guidelines were expected to have a positive impact on performance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings.

CONCLUSIONS

Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care. However, many studies fell short of the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC) for methodological quality.

Patients report positive nutrition counseling outcomes

OBJECTIVE

Assess outcomes of patient nutrition counseling.

DESIGN

A descriptive study based on the results of a telephone interview performed 2 to 8 weeks after counseling.

SUBJECTS/SETTING

Subjects were 400 adult patients referred for nutrition counseling at 2 academic health centers. Of these, 274 patients received nutrition counseling during hospitalization and 126 as outpatients.

STATISTICAL ANALYSIS

Descriptive statistics were used to summarize data and the Mann-Whitney U statistic and logistic regressions were used to test significant differences (P < .05) between inpatient and outpatient counseling outcomes.

RESULTS

Most patients (83%) gave a partial or full description of their diet modifications and 79% had a moderate or good understanding of their diet. Most patients reported that the dietitian's advice was suited to their special needs (88%) and that they knew what to eat (83%). A majority (62%) had made dietary changes, but 17% said they had had trouble changing their diets as suggested. After talking with a dietitian, 57% felt better emotionally, 37% felt better physically, 64% felt in control of their condition, and 43% noticed improved health indicators. Initial analysis indicated that outpatients reported better outcomes than inpatients; further analysis showed that these differences could be attributed to younger ages among the outpatient sample.

APPLICATIONS/CONCLUSIONS

Patient nutrition counseling has positive outcomes. Therefore, key counseling points should be introduced or reinforced in inpatient settings, in conjunction with multiple-session protocols during the pre- and/or posthospitalization continuum of care. Dietitians, managers, administrators, and credentialing agencies should work together to secure and promote the necessary physical, personnel, and financial resources to make this happen.

Nutrition Practice Guidelines for Type 1 Diabetes Mellitus positively affect dietitian practices and patient outcomes. The Diabetes Care and Education Dietetic Practice Group

OBJECTIVES

Assess the acceptance and ease of use of Nutrition Practice Guidelines for Type 1 Diabetes Mellitus by dietitians in a variety of settings; determine if nutrition care activities of dietitians change when practice guidelines are available; measure changes in patient control of blood glucose level, measured as glycated hemoglobin (HbA1c); compare patient satisfaction with care and perceptions about quality of life.

DESIGN

Using the approach of outcomes research, volunteer dietitians were recruited and assigned randomly to a usual care group or a practice guidelines group. Patients with type 1 diabetes were enrolled by dietitians and followed up for a 3-month period. Outcome measures included dietitian care activities, changes in patient HbA1c levels, and patient satisfaction and perceptions about quality of life.

SUBJECTS/SETTINGS

Dietitians from across the United States who responded to a recruitment notice participated. Their work settings included diabetes referral centers, endocrinology clinics, primary care and community health clinics, hospitals, and a worksite clinic. They recruited patients from their setting for the study. Outcome data were available from dietitians providing care to 24 patients using the new practice guidelines and dietitians providing care to 30 patients using more traditional methods.

STATISTICAL ANALYSIS

chi 2 Test, t test, and analysis of covariance.

RESULTS

Dietitians in the practice guidelines group spent 63% more time with patients and were more likely to do an assessment and discuss results with patients than dietitians in the usual care group. Practice guidelines dietitians paid greater attention to glycemic control goals. Levels of HbA1c improved at 3 months in 21 (88%) of practice guidelines patients compared with 16 (53%) of usual care patients. Practice guidelines patients achieved greater reductions in HbA1c level than usual care patients (-1.00 vs -0.33). This difference was statistically significant and clinically meaningful.

CONCLUSIONS/APPLICATIONS

Dietitians responded positively to practice guidelines for type 1 diabetes. Use of guidelines resulted in changes in dietitian practices and produced greater improvements in patient blood glucose outcomes at 3 months compared with usual care. Practice guidelines did not significantly influence patient satisfaction with care of perceived quality of life.

Lifestyle modifications for diabetes management

Nutrition therapy and physical activity can assist persons with diabetes to achieve metabolic goals. Several lifestyle strategies can be used. Monitoring metabolic parameters, including blood glucose, glycated hemoglobin, lipids, blood pressure, and body weight, as well as assessing for quality of life are essential to determine whether treatment goals are being achieved by lifestyle changes. If not, adjustments in the overall management plan need to be made.

Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus. Putting evidence into practice

PURPOSE

To summarise current knowledge of interventions that should improve the care of patients with type II diabetes mellitus. Interventions lie within the realms of preventions, screening, and treatment, all of which are focused on office practice.

METHODS

Review of the literature by a multidisciplinary team involved in the care of patients with diabetes, followed by synthesis of the literature into a clinical care guideline. Literature was identified through consultation with experts and a focused MEDLINE search.

MAIN RESULTS

An algorithm-based guideline for screening and treatment of the complications of diabetes was developed. The emphasis is on prevention of atherosclerotic disease, and prevention, screening, and early treatment of microvascular disease. Implementation of these practices has the potential to significantly improve quality of life and increase life expectancy in patients with type II diabetes mellitus.

Prevalence of undiagnosed non-insulin-dependent diabetes mellitus and impaired glucose tolerance in a cohort of older persons with hypertension

OBJECTIVE

To determine the prevalence of undiagnosed non-insulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in a cohort of older persons with hypertension. To examine the usefulness of screening for NIDDM in this study population.

DESIGN

Cross-sectional study.

SETTING

University of Tennessee, Memphis and the General Clinical Research Center (GCRC).

PATIENTS

Ninety-five participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study.

MEASUREMENTS

A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels was performed before the beginning of the TONE intervention.

RESULTS

In this cohort, 43 participants (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had IGT, and 11 (11.6%) had undiagnosed NIDDM. The positive predictive value for NIDDM of a fasting glucose > or = 115 mg/dL in our participants was 57%. Hyperinsulinemia occurred in only one participant, a subject in the IGT group.

CONCLUSIONS

Our data demonstrate that undiagnosed NIDDM is common in our cohort of older persons who are being treated for essential hypertension and that impaired glucose tolerance may be more common than in the general population of the same age. Further, our data show that the vast majority of this older, obese, hypertensive cohort did not have fasting hyperinsulinemia. We also infer that a fasting glucose alone has a low positive predictive value for screening of NIDDM in our older cohort. As the prevalence of NIDDM and impaired glucose tolerance in older hypertensive patients in the general population is unknown, we believe that further investigation is needed to characterize the relationship of hypertension, glycemic status, and hyperinsulinemia in the general population.

Diabetes guidelines, outcomes, and cost-effectiveness study: a protocol, prototype, and paradigm

It is a milestone for our profession to have practice guidelines tested in a clinical trial that also provides cost-effectiveness data. Dietetics practitioners now have a model for studies examining MNT in other disorders and diseases. We also have an array of questions that can be asked in future studies. The challenges include examining the long-term management of diseases using MNT; determining changes in quality-of-life issues; and segmenting subjects according to variables likely to affect outcomes, such as duration of the disease. As a result of this and other studies related to diabetes (both completed and in progress), millions of people with NIDDM will be guided to achieve the best glycemic control possible within the framework of their lifestyles. The results of the DCCT may have implications for persons with NIDDM (18), as well as for dietitians (8). The UK Prospective Diabetes Study results should be released in the near future (19), and the VA Cooperative Study on Glycemic Control and Complications in Type II Diabetes (20) is examining intensive therapy for this population. Each of these studies emphasizes a treatment approach that places management of the disease in the hands of the client. This approach clearly is a paradigm shift: no longer are we talking about "diabetic diets." But then, maybe we just need to read a little history. In 1906, Hutchison (21) wrote," ... there is no such thing as 'a diabetic diet.'" And think about the information (or lack thereof) available to him.

Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus

OBJECTIVE

To conduct a cost analysis and cost-effectiveness study based on a randomized clinical trial of basic nutrition care (BC) and practice guidelines nutrition care (PGC) provided by dietitians in outpatient clinics.

DESIGN

Subjects with non-insulin-dependent diabetes mellitus (NIDDM) from three states (Minnesota, Florida, Colorado) were randomly assigned to a group receiving BC or a group receiving PGC for a 6-month clinical trial. Along with data about medical and clinical outcomes, data about cost resources were collected. The cost-effectiveness of PGC compared with BC was calculated using per-patient costs and glycemic outcomes for the 6 months of the study. A net cost-effectiveness ratio comparing BC and PGC, including the cost savings resulting from changes in medical therapy, was also calculated.

SUBJECTS

The study reports on a sample of 179 subjects with NIDDM between the ages of 38 and 76 years who completed the clinical trial.

RESULTS

Patients in the PGC group experienced a mean 1.1 +/- 2.8 mmol/L decrease in fasting plasma glucose level 6 months after entry to the study, for a total per-patient cost of $112. PGC costs included one glycated hemoglobin assay used by the dietitian to evaluate nutrition outcomes. Patients in the BC group experienced a mean 0.4 +/- 2.7 mmol/L decrease, for a total per-patient cost of $42. In the PGC group, 17 persons had changes in therapy, which yielded an average 12-month cost savings prorated for all patients of $31.49. In contrast, in the BC group, 9 persons had changes in therapy, for an average 12-month prorated cost savings of $3.13. Each unit of change in fasting plasma glucose level from entry to the 6-month follow-up can be achieved with an investment of $5.75 by implementing BC or of $5.84 by implementing PGC. If net costs are considered (per-patient costs--cost savings due to therapy changes), the cost-effectiveness ratios become $5.32 for BC and $4.20 for PGC, assuming the medical changes in therapy were maintained for 12 months.

APPLICATIONS

These findings suggest that individualized nutrition interventions can be delivered by experienced dietitians with a reasonable investment of resources. Cost-effectiveness is enhanced when dietitians are engaged in active decision making about intervention alternatives based on the patient's needs.