Effectiveness of a dietician-led intervention in reducing glycated haemoglobin among people with type 2 diabetes in Nepal: a single centre, open-label, randomised controlled trial

Background

Nutrition education and counselling are considered a cornerstone for the management of type 2 diabetes (T2D). However, there is limited research related to the management of T2D through dietary approach, particularly in low-income and middle-income countries (LMICs) like Nepal. This study assessed the effectiveness of a dietician-led dietary intervention in reducing glycated haemoglobin (HbA1c) levels among people with T2D.

Methods

An open-label, two-armed, hospital-based, randomised controlled trial was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Participants were randomly assigned to either dietician-led dietary intervention group (n = 78) or usual care control group (n = 78). People with type 2 diabetes with HbA1c >6.5% and aged 24-64 years were included in the study. The primary outcome was a change in HbA1c level over six months, and secondary outcomes included changes in biochemical and clinical parameters, Problem Areas in Diabetes (PAID) score, diabetic knowledge, dietary adherence, and macronutrient intake level. Data were analysed using an intention-to-treat approach. This trial is registered with ClinicalTrials.gov, NCT04267367.

Findings

Between August 15, 2021 and February 25, 2022, 156 people with type 2 diabetes were recruited for the study, of which 136 participants completed the trial. At six months of follow-up, compared to baseline values, the mean HbA1c (%) level decreased in the intervention group by 0.48 (95% CI: -0.80 to -0.16), while it increased in the control group by 0.22 (95% CI: -0.21 to 0.66). In an adjusted model, the reduction in HbA1c (%) levels for the intervention was 0.61 (95% CI: -1.04 to -0.17; p = 0.006). In addition, fasting blood glucose was decreased by 18.96 mg/dL (95% CI: -36.12 to -1.81; p = 0.031) after the intervention. The intervention resulted in the reduction of BMI, waist and hip circumference, PAID score, dietary adherence, and macronutrient intake in the intervention group compared to the control group.

Interpretation

The dietician-led intervention improved glycaemic control, improved macronutrient intake, and clinical outcomes among people with type 2 diabetes. The dietician-led intervention may be considered for diabetes management in LMICs.

Funding

The research was funded by the University Grants Commission (UGC), Nepal.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

The health effects of medical nutrition therapy by dietitians in patients with diabetes: A systematic review and meta-analysis: Nutrition therapy and diabetes

AIMS

Intensive lifestyle, dietary interventions and patient education have been recommended as key milestones in to facilitate the management of Diabetes and contain the growing incidence. We performed a systematic review and meta-analysis to assess the health benefits of medical nutrition therapy among patients with diabetes.

DESIGN

A systematic search was performed in MEDLINE/PubMed, SCOPUS, and Cochrane library from onset up to February 2019 to identify trials investigating the health effect of Medical nutrition (MNT) in patients with diabetes. Random-effects models were used to calculate the effect sizes as weighted mean difference (WMD) and 95% confidence intervals (CI).

RESULTS

Eleven studies containing 1227 participants were included in the meta-analysis. Pooled results showed a significant reduction in Fasting blood sugar (FBS) (WMD= -8.85mg/dl, 95% CI: -14.41, -3.28), HbA1c (WMD: -0.43%, 95% CI: -0.69, -0.17), weight (WMD: -1.54kg, 95% CI: -2.44, -0.64), Body mass index (BMI) (WMD: -0.34 Kg/m2, 95% CI: -0.52, -0.17), waist circumference (WMD: -2.16cm, 95% CI: -4.09, -0.23), cholesterol (WMD: -4.06mg/dl, 95% CI: -7.31, -0.81), Systolic blood pressure (SBP) (WMD: -7.90mmHg, 95% CI: -13.03, -2.77). Results of meta-regression analysis based on age of participants and duration of intervention were not significant.

CONCLUSIONS

Patients with diabetes who received medical nutrition therapy showed significant improvements in outcome measures of FBS, HbA1c, weight, BMI, waist circumference, cholesterol, and SBP.

Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association

Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.

Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control

OBJECTIVE

Assess effect of diabetes self-management education and support methods, providers, duration, and contact time on glycemic control in adults with type 2 diabetes.

METHOD

We searched MEDLINE, CINAHL, EMBASE, ERIC, and PsycINFO to December 2013 for interventions which included elements to improve participants' knowledge, skills, and ability to perform self-management activities as well as informed decision-making around goal setting.

RESULTS

This review included 118 unique interventions, with 61.9% reporting significant changes in A1C. Overall mean reduction in A1C was 0.74 and 0.17 for intervention and control groups; an average absolute reduction in A1C of 0.57. A combination of group and individual engagement results in the largest decreases in A1C (0.88). Contact hours ≥10 were associated with a greater proportion of interventions with significant reduction in A1C (70.3%). In patients with persistently elevated glycemic values (A1C>9), a greater proportion of studies reported statistically significant reduction in A1C (83.9%).

CONCLUSIONS

This systematic review found robust data demonstrating that engagement in diabetes self-management education results in a statistically significant decrease in A1C levels.

PRACTICE IMPLICATIONS

The data suggest mode of delivery, hours of engagement, and baseline A1C can affect the likelihood of achieving statistically significant and clinically meaningful improvement in A1C.

Connected health: a review of the literature

The presence of social support, and more recently, connection, has been linked to multiple health benefits and longevity measures and the lack of connection is associated with premature morbidity and mortality. Connected health is a growing industry, and we were interested in determining whether or not scholars in the field have established the ways in which technology could facilitate or promote connection between patients and healthcare providers. This integrative literature review sought to collect and analyze research studies addressing social support or connection in a sample of patients with diabetes to evaluate the social support or connection metrics in use, the type of technology deployed by researchers to achieve connection, and to assess the state of the science in this area. We hypothesized that being connected to someone who cares is good for your health. We believe this holds true even when connection is accomplished with mobile technologies. Thirty five studies were included in this review, 21 utilized technology to enhance patient-provider connection. The articles included in this review were from a total of more than nine countries and took place in hospital, physician office, and community settings. They represented people from childhood through to old age. Technologies evaluated include: telephone interventions, email, text messaging, interactive voice response (IVR), video blogs, apps, websites, and social media. There were multiple operational definitions of social support and self-management used as variables within the studies. Findings from this review suggest that being connected does matter to patients with diabetes, and being connected to family matters the most, even though the associations are complex and not always predictable. Furthermore, patients with diabetes will utilize a variety of technologies to connect with healthcare providers, team members, and even other people with the same disease. The use of technology with diabetes patients positively impacts a variety of health outcomes, such as HbA1c, weight, physical activity, healthy eating, cholesterol and frequency of glycemic monitoring.

Lifestyle intervention: nutrition therapy and physical activity

Diabetes now affects more than 29 million Americans, and more than 9 million of these people do not know they have diabetes. In adults, type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes and is the focus of this article. Lifestyle intervention is part of the initial treatment as well as the ongoing management of type 2 diabetes. Lifestyle intervention encompasses a healthful eating plan, physical activity, and often medication to assist in achievement of glucose, lipid, and blood pressure goals. Patient education and self-care practices are also important aspects of disease management.

Bariatric endocrinology: principles of medical practice

Obesity, is a chronic, biological, preventable, and treatable disease. The accumulation of fat mass causes physical changes (adiposity), metabolic and hormonal changes due to adipose tissue dysfunction (adiposopathy), and psychological changes. Bariatric endocrinology was conceived from the need to address the neuro-endocrinological derangements that are associated with adiposopathy, and from the need to broaden the scope of the management of its complications. In addition to the well-established metabolic complications of overweight and obesity, adiposopathy leads to hyperinsulinemia, hyperleptinemia, hypoadiponectinemia, dysregulation of gut peptides including GLP-1 and ghrelin, the development of an inflammatory milieu, and the strong risk of vascular disease. Therapy for adiposopathy hinges on effectively lowering the ratio of orexigenic to anorexigenic signals reaching the the hypothalamus and other relevant brain regions, favoring a lower caloric intake. Adiposopathy, overweight and obesity should be treated indefinitely with the specific aims to reduce fat mass for the adiposity complications, and to normalize adipose tissue function for the adiposopathic complications. This paper defines the principles of medical practice in bariatric endocrinology-the treatment of overweight and obesity as means to treat adiposopathy and its accompanying metabolic and hormonal derangements.

Relationship between adherence to diet, glycemic control and cardiovascular risk factors in patients with type 1 diabetes: a nationwide survey in Brazil

Background

To determine the relationship between adherence to the diet reported by patients with type 1 diabetes under routine clinical care in Brazil, and demographic, socioeconomic status, glycemic control and cardiovascular risk factors.

Methods

This was a cross-sectional, multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The data was obtained from 3,180 patients, aged 22 ± 11.8 years (56.3% females, 57.4% Caucasians and 43.6% non-Caucasians). The mean time since diabetes diagnosis was 11.7 ± 8.1 years.

Results

Overall, 1,722 (54.2%) of the patients reported to be adherent to the diet without difference in gender, duration of diabetes and socioeconomic status. Patients who reported adherence to the diet had lower BMI, HbA1c, triglycerides, LDL-cholesterol, non HDL-cholesterol and diastolic blood pressure and had more HbA1c at goal, performed more frequently self-monitoring of blood glucose (p < 0.001), and reported less difficulties to follow specific schedules of diet plans (p < 0.001). Less patients who reported to be adherent were obese or overweight (p = 0.005). The quantity of food and time schedule of the meals were the most frequent complaints. Logistic regression analysis showed that ethnicity, (Caucasians, (OR 1.26 [1.09-1.47]), number of medical clinical visits in the last year (OR 1.10 [1.06-1.15]), carbohydrate counting, (OR 2.22 [1.49-3.30]) and diets recommended by diabetes societies’, (OR 1.57 [1.02-2.41]) were related to greater patients’ adherence (p < 0.05) and age, [adolescents (OR 0.60 [0.50-0.72]), high BMI (OR 0.58 [0.94-0.98]) and smoking (OR 0.58 [0.41-0.84]) with poor patients’ adherence (p < 0.01).

Conclusions

Our results suggest that it is necessary to rethink medical nutrition therapy in order to help patients to overcome barriers that impair an optimized adherence to the diet.

Factors associated with consulting a dietitian for diabetes management: a cross-sectional study

BACKGROUND

Type 2 Diabetes (T2D) has reached epidemic levels in the Middle East region. Despite evidence that it improves health outcomes and saves health costs, dietary counseling for T2D remains grossly under-investigated in this region. The aim of this study was to assess the frequency and determinants of use of dietary counseling services by T2D patients in Lebanon and recommend corrective measures that may guide the planning, organization and delivery of care for chronic diseases in general and diabetes care in particular.

METHODS

A non-experimental cross-sectional design was utilized to survey outpatients with T2D in two major health centers in Lebanon. Patients diagnosed with T2D were invited to complete a questionnaire consisting of five sections: socio-demographic characteristics, disease attributes, patients' perceptions regarding T2D management, practice of lifestyle modifications, and referral by a physician to a dietitian. The outcome of interest was the use of dietary counseling services by T2D patients at least once since their diagnosis. Descriptive statistics and logistic regression analyses were used to evaluate the frequency and determinants of dietary counseling services utilization.

RESULTS

A total of 332 T2D patients completed the questionnaire (response rate 94.6%). Although 75% of study participants believed that dietitians can assist them in changing their dietary habits, only 38% had consulted with a dietitian. Among study participants, only 34% were referred to a dietitian by their physician. The main determinants of the use of dietary counseling services were referral by a physician (OR: 112.25; 95% CI = 42.74-294.84), the presence of outpatient social or private health insurance (OR: 5.86; 95% CI = 2.40-14.25) and the belief that a dietitian can assist in changing dietary habits (OR: 3.74; 95% CI = 1.33-10.54).

CONCLUSIONS

The findings of this study show suboptimal use of dietary counseling services by T2D patients in Lebanon. Key determinants were physicians' referral, financial support for outpatient care, and patients' belief in the usefulness of dietary counseling. Suggested interventions entail enhancing the planning and organization of care through inter-professional collaboration between physicians and dietitians; promoting public financing for high quality outpatient care that includes dietary counseling; and promoting the value of dietary counseling and improving the public image of dietitians.

Nutrition therapy recommendations for the management of adults with diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.