Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian health service.
ABSTRACT We used the Indian Health Service (IHS) Diabetes Care and Outcomes Audit to assess the effectiveness of clinical nutrition education in reducing HbA(1c) levels and to test the relative effectiveness of clinical nutrition education when it was delivered by a registered dietitian (RD) compared with an educator from another discipline (non-RD).
We examined clinical care data collected by the IHS Diabetes Care and Outcomes Audit of 7490 medical records during 2001. Glycemic control was assessed by using the difference between the two most recent HbA(1c) levels during 2001. Age, BMI, duration of diabetes, type of treatment, proteinuria, and facility were included as covariates. Clinical nutrition education was defined as documentation in the record of any diet instruction and educator discipline classified as RD or non-RD. ANCOVA methods were used to assess the effects of diet education and educator discipline on differences between the two HbA(1c) measurements and to adjust for differences in the distribution of covariates among the education groups.
After adjustment for age, sex, type of treatment, duration of diabetes, BMI, initial HbA(1c) level, and clinical facility, clinical nutrition education and educator discipline were each associated with changes in HbA(1c) levels (P < 0.001). Those receiving clinical nutrition education from an RD or from an RD as well as a non-RD had the largest improvements in HbA(1c) levels (-0.26 and -0.32, respectively) compared with those receiving either only non-RD or no clinical nutrition education (-0.19 and -0.10, respectively).
Clinical nutrition education in the IHS is associated with favorable trends in glycemic control. To be effective, clinical nutrition education should be delivered by an RD or a team that includes an RD.
Dataset: Clinical Practice Guidelines Nutrition Therapy Canadian Diabetes Association Clinical Practice Guidelines Expert Committee[show abstract] [hide abstract]
ABSTRACT: KEY MESSAGES People with diabetes should receive nutrition counselling by a registered dietitian. Nutrition therapy can reduce glycated hemoglobin (A1C) by 1.0% to 2.0% and, when used with other components of diabetes care, can further improve clinical and metabolic outcomes. Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes who are overweight or obese. The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences. Replacing high glycemic index carbohydrates with low glycemic index carbohydrates in mixed meals has a clinically significant benefit for gly-cemic control in people with type 1 and type 2 diabetes. Intensive lifestyle interventions in people with type 2 diabetes can produce improvements in weight management, fitness, glycemic control and cardiovascular risk factors. A variety of dietary patterns and specific foods have been shown to be of benefit in people with type 2 diabetes. Consistency in carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight. Introduction Nutrition therapy and counselling are an integral part of the treatment and self-management of diabetes. The goals of nutrition therapy are to maintain or improve quality of life and nutritional and physiological health; and to prevent and treat acute and long-term complications of diabetes, associated comorbid conditions and concomitant disorders. It is well documented that nutrition therapy can improve gly-cemic control (1) by reducing glycated hemoglobin (A1C) by 1.0% to 2.0% (2e5) and, when used with other components of diabetes care, can further improve clinical and metabolic outcomes (3,4,6,7), resulting in reduced hospitalization rates (8). Furthermore, frequent follow-up (i.e. every 3 months) with a registered dietitian (RD) has been associated with better dietary adherence in type 2 diabetes (7). Nutrition therapy provided by an RD with expertise in diabetes management (9,10), delivered in either a small group and/or an individual setting (11e13), has demonstrated benefits for those with, or at risk for, diabetes. Individual counselling may be preferable for people of lower socioeconomic status (8), while group education has been shown to be more effective than individual counselling when it incorporates principles of adult education, including hands-on activities, problem solving, role playing and group discussions (14). Additionally, in people with type 2 diabetes, culturally sensitive peer education has been shown to improve A1C, nutrition knowledge and diabetes self-management (15), and web-based care management has been shown to improve glycemic control (16). Diabetes education programs serving vulnerable pop-ulations should evaluate the presence of barriers to healthy eating (e.g. cost of healthy food, stress-related overeating) (17) and work toward solutions to facilitate behaviour change. In general, people with diabetes should follow the healthy diet recommended for the general population in Eating Well with Canada's Food Guide (18). This involves consuming a variety of foods from the 4 food groups (vegetables and fruits; grain products; milk and alternatives; meat and alternatives), with an emphasis on foods that are low in energy density and high in volume to optimize satiety and discourage overconsumption. This diet may help a person attain and maintain a healthy body weight while ensuring an adequate intake of carbohydrate (CHO), fibre, fat and essential fatty acids, protein, vitamins and minerals. Overall, nutrition counselling should be individualized, regu-larly evaluated and reinforced in an intensive manner (19-21), and incorporate self-management education (22). As evidence is limited for the rigid adherence to any single dietary prescription (23,24), nutrition therapy and meal planning should be individu-alized to accommodate the individual's age, type and duration of diabetes, concurrent medical therapies, treatment goals, values, preferences, needs, culture, lifestyle, economic status (25), activity level, readiness to change and abilities. Applying the evidence from the sections that follow, Figure 1 and Table 1 present an algorithm which allows for this level of individualization of therapy in an evidence-based framework. Energy As an estimated 80% to 90% of people with type 2 diabetes are overweight or obese, strategies that include energy restriction to achieve weight loss are a primary consideration (26). A modest weight loss of 5% to 10% of initial body weight can substantially improve insulin sensitivity, glycemic control, hypertension and
Article: Small Rice Bowl-Based Meal Plan versus Food Exchange-Based Meal Plan for Weight, Glucose and Lipid Control in Obese Type 2 Diabetic Patients.[show abstract] [hide abstract]
ABSTRACT: The Korean National Health and Nutrition Examination Surveys reported 65% of daily energy intake (EI) as carbohydrate (CHO) in the Korean population and main source of CHO was cooked rice. We used a standardized-small sized rice bowl for diet education and investigated its effectiveness on body weight, glucose and lipid, compared to the conventional food exchange system in type 2 diabetes obese women. Type 2 diabetic women with body mass index >/= 23 kg/m(2) were randomly assigned to small rice bowl-based meal plan (BM) and food exchange-based meal plan (ExM) group. Both groups were asked to reduce their EI by 500 kcal/day for 12 weeks. The macronutrient composition was instructed: 55 to 60% of EI as CHO, 15 to 20% as protein, and 20 to 25% as fat. BM group received only a simple instruction for application of the rice bowl. Nutrient intake was estimated with the 3-day dietary records. Finally, 44 subjects finished the study. The percent reduction of body weight was significant both BM group (-5.1 +/- 2.6%) and ExM group (-4.8 +/- 2.8%) after 12 weeks (P < 0.001) but there was no difference between the groups. There was no difference in the proportional change of CHO, protein and fat in EI between the groups. Additionally, the change of HbA1c and low density lipoprotein-cholesterol were not significantly different between the two groups. The BM group was as effective as ExM for body weight and glucose control in type 2 diabetes obese women.Korean Diabetes Journal 04/2010; 34(2):86-94.
Article: The Small Rice Bowl-Based Meal Plan was Effective at Reducing Dietary Energy Intake, Body Weight, and Blood Glucose Levels in Korean Women with Type 2 Diabetes Mellitus.[show abstract] [hide abstract]
ABSTRACT: The typical Korean diet includes rice, which is usually served in a rice bowl. We investigated the effects of a meal plan using rice bowls of varying sizes on dietary energy intake (EI), body weight (BW), and blood glucose levels. Forty-two obese women with type 2 diabetes mellitus were randomly assigned to use either a 200 mL small rice bowl (SB), a 380 mL regular rice bowl (RB), or to a control group (C). Both intervention groups were asked to reduce their EI by 500 kcal/day for 12 weeks and simple instructions for using the assigned bowl were provided. Dietary EI and proportion of macronutrients (PMN) were estimated from 3-day dietary records. Reduction of EI was more prominent in the SB group compared to the RB and C group, although EI decreased significantly from baseline in all groups. Carbohydrate and fat intakes of the SB group were decreased greater than those of the RB and C group. However, changes in PMN were not significant across the 3 groups. Reduction of BW and HbA1c levels in the SB group was more prominent compared to the C group. Although, BW and HbA1c were decreased significantly from baseline in both bowl groups. There was no statistical difference between the two groups. The small rice bowl-based meal plan was effective at reducing EI, BW, and blood glucose levels, and the observed reductions in EI, carbohydrate, and fat intake were greater than those of the regular rice bowl-based meal plan.Korean Diabetes Journal 12/2010; 34(6):340-9.