Running head: IMPROVING GLYCEMIC CONTROL 1

Improving Glycemic Control for Adults with Type II

Diabetes Using Medical Nutrition Therapy
Ann Bordwine, Kaitlyn Butland, Darby Fleming, Jonathan McMullan, Julie
Musser, Carol Strock

James Madison University

School of Nursing
IMPROVING GLYCEMIC CONTROL USING MEDICAL NUTRITION THERAPY 2

INTRODUCTION

Type II diabetes is a prevalent issue that has been on the rise in the United
States, increasing from 5% in 1994 to 10% in 2014 (CDC). The countrys culture
consists of some unhealthy habits related to high-fat diets and sedentary
lifestyles, which increase the likelihood of developing type II diabetes. As future
nurses, we decided to explore what interventions we can implement in our
nursing practice to help patients better manage their diabetes. In order for
patients to live a life of vitality and not purely based sustenance, more
individualized, patient centered, complementary holistic therapies must be
explored. Education on nutrition is a vital part of the management process for
people with type II diabetes. Our research focused on the effects of Medical
Nutrition Therapy and whether there is a benefit of receiving Medical Nutrition
Therapy compared to basic nutrition guidance. Medical Nutrition Therapy
represents a promising complementary therapy to an exercise and medication
regimen. It is defined as individualised nutrition recommendations, preferably
by a dietitian while taking into account personal, cultural, and lifestyle
preference to achieve the target treatment goals (Nisak, 2013). Evidence
showed that Medical Nutrition Therapy was in fact more beneficial than the
basic nutrition guidance. Several studies analyzed the benefits of Medical
Nutrition Therapy and explained how it led to more benefits for the patients.

STUDY COMMONALITIES

All of these research studies implemented the Medical Nutrition Therapy

intervention using a specific population of adults with type II diabetes. These
studies all had a similar purpose to evaluate the outcome of carrying out this
type of therapy. They were completed over a short time with the longest studies
conducted over only six months, so short-term effects of the use of Medical
Nutrition Therapy were ultimately what were being assessed. Registered
dietitians were used to lead and carry out Medical Nutrition Therapy sessions,
IMPROVING GLYCEMIC CONTROL USING MEDICAL NUTRITION THERAPY 3

although the therapy itself involved a multidisciplinary approach. The results all
supported the use of Medical Nutrition Therapy. Research shows that there is a
significant benefit from using Medical Nutrition Therapy in patients with type II
diabetes. Medical Nutrition Therapy has shown to improve glycemic control in
patients with type II diabetes.

STUDY DIFFERENCES

The studies used for our research all had similar outcomes, but certain aspects of
the study samples, instruments, and interventions were different. The
participants from each study met specific age criteria. However, they varied
when it came to race and gender. One study in particular only focused on African
American women as their chosen sample. This was different from other studies
that were not race specific. In addition, one study chose to look at people who
were newly diagnosed with type II diabetes opposed to people who have had it
for a longer period of time. This could affect outcomes since these patients are
less familiar with the control of their illness. A difference that is seen regarding
interventions was whether the participants received individual or group therapy.
Also, the exact amount of Medical Nutrition Therapy session varied slightly from
study to study. Each study used questionnaires, assessment scores, and
indicated diabetes lab values as instruments. The instruments varied when it
came to the exact type of questionnaire, but all instruments produced the same
results.

GAPS IN LITERATURE AND LIMITATIONS

There were, unfortunately, several inconsistencies of note between the articles

reviewed. The style in which the Medical Nutrition Therapy was provided varied;
from one-on-one telephone interviews to group care settings, individual in-
person interviews, and the addition of vegetable planting/sowing lessons along
with Medical Nutrition Therapy in the Muchiri (2014) article. Demographics were
 IMPROVING GLYCEMIC CONTROL USING MEDICAL NUTRITION THERAPY 4

also quite varied between articles, though it did not appear to result in any
overall negative outcome in the commonality of the results. The Parker (2014)
article focused on pre-diabetic, obese and overweight participants rather than
those already diagnosed with type II diabetes, while the rest of the literature
required participants that were already diagnosed with type II diabetes.
However, even those articles varied in time of which diagnosis had occurred,
from recently diagnoses cases of type II diabetes to having been diagnosed for a
year or more.

RESULTS

PICO: For adults with type II diabetes, is there a benefit of receiving Medical Nutrition
Therapy compared to basic nutrition guidance?

Author, Study Sample Intervention Instruments Results/ Summary/

Yr. Purpose Description with Validity Statistical Conclusion
LOE and Size and Reliability Evidence
Al-Shookri, To evaluate N=200 subjects Usual nutritional Anthropometric There was a Medical nutrition
A., et. al. the between the care or practice measurements, significant therapy provided
(2012). effectiveness ages of 30-70 guidelines (height, weight, decrease in waist by a dietician
of MNT years with a nutritional care BMI, waist circumference provided for
LOE 2 delivered by diagnosis of received by a circumference) measurements improved outcomes
a dietician diabetes type II dietician in 2-3 glucose levels, and in fasting in both
compared to and no other separate and lipid profile. plasma glucose anthropometric and
usual chronic sessions. and HbA1C levels biochemical
nutrition complications. of those receiving factors. This type of
guidance practice therapy is more
given before guidelines beneficial for type II
discharge by nutritional care diabetic patients in
looking at compared to the improvement of
physical and usual nutrition long term metabolic
biochemical care groups with control.
changes in 57% reaching
patients over their target goal
a 6 month by the end of the
period. 6 month period.
Anna R. To N=76 obese or Medical Nutrition Primary outcome The MNT group MNT may play a
Parker, et. investigate overweight Therapy or usual measure: fasting showed role in improving
al., (2014). MNT vs. adult men and care groups. plasma glucose. significantly lower metabolic control
usual women Secondary HbA1c levels and as early as
LOE 2 nutrition care outcome decreased prediabetic stages,
effects in measure: HbA1c, Diabetes Risk therefore, reducing
prediabetic serum lipid levels, Scores compared the risk for
overweight and Diabetes Risk to the usual care developing
or obese Score. group. Both diabetes.
adults, from groups showed
baseline reduced
measuremen cholesterol levels.
ts to the end
of a 12-week
intervention.
 IMPROVING GLYCEMIC CONTROL USING MEDICAL NUTRITION THERAPY 5

Ball, L., et. This study N= 10 The participants A two-step data Participants show Many participants
al. (2015). looks at individuals underwent three analysis was a wide range in in the study felt
individuals recently one-on-one performed. methods of diet confused by all the
LOE 6 with type two diagnosed with semi-structured Including improvement. Not information being
diabetes type two telephone analyzing of the all participants provided and found
recently diabetes. interviews. The interview made changes to the information to
diagnosed first interview transcripts and a their dietary be conflicting.
experiencing occurred at the meta-synthesis behavior due to Participants felt
diet change beginning of the approach looked feeling they were not being
and long- study then at 3 at data across the overwhelmed. heard by
term and 6 months. three time points. healthcare
maintenance professionals and
of dietary rushed through
change. their appointments.
Health care
professional need
to improve their
dietary support for
patients newly
diagnosed with
type two diabetes.
Miller, S.T., To assess N=24 African Medical Questions from Behaviors Group MNT/MI
et. al. the efficacy American nutritional the expanded significantly intervention may
(2014) and women therapy using Summary of improved post- improve glycemic
acceptability Motivational Diabetes Self- intervention. control among AA
LOE 3 of a group Interviewing. Care behaviors women with type 2
medical with a reliability diabetes who are at
nutritional ranging from 0.56 high risk of the
therapy to 0.75. development or
(MNT) progression of
intervention, diabetes-related
using complications.
Motivational
Interviewing.
Muchiri, J., To evaluate N=40 men and Nutrition The primary Hemoglobin A1C This particular
et. al., the effect of women, aged Education outcome was the levels showed a study showed a
(2016). a participant- 40-70 with DM2 program that change in HbA1c gradual decline decline in the
customized that attended consisted of at 6 months. The over the 12 month hemoglobin A1C in
LOE 2 nutrition community three secondary period in the the group that was
education health clinics. components: (i) outcomes were intervention group provided with a
program on the curriculum changes in other as opposed to the nutrition education
glycated Hb (eight weekly clinical outcomes control group. program but not
(HbA1c), sessions, 2 to (BMI, blood necessarily enough
blood lipids, 25h each; (ii) pressure and to prove a distinct
blood follow-up blood lipids), correlation with the
pressure, sessions (four HbA1c and education.
BMI and monthly dietary behaviors Variables such as
dietary meetings and at 12 months. adherence to the
behaviors in two bi-monthly program may have
patients with meetings each played a part.
type 2 lasting 15h);
diabetes and (iii)
mellitus. vegetable
gardening
(demonstration
of
sowing/transplan
tation of
vegetables.
MY To evaluate N=100 men or Individualized HbA1C levels and Subjects achieved This study provides
Barakatun the effect of non-pregnant Medical knowledge significant additional evidence
Nisak, et. individualize women with nutritional assessment reduction in to support the
al., (2013). d Medical poorly therapy scores to assess glycemic control positive impact of
Nutrition controlled type administered by the effectiveness (measured by individualized MNT
LOE 3 Therapy 2 diabetes. a dietician and of the Nutritional fructosamine at intervention
intervention Clinical Practice therapy provided week 4 and administered by a
administered guidelines. by the dietician. HbA1c level at dietitian in
by a dietitian week 12) and improving diabetes
in individuals improvement in outcomes among
with type 2 waist subjects with type 2
IMPROVING GLYCEMIC CONTROL USING MEDICAL NUTRITION THERAPY 6

diabetes circumference diabetes, with the

mellitus on and HDL- impact being most
glycaemic cholesterol after apparent for
control, the 12-week subjects with very
metabolic intervention. high HbA1c levels
parameters at the start of the
and dietary study.
intake.

LINKING EVIDENCE TO PRACTICE

Nursing Implications:
Referral of pre-diabetic patients or newly diagnosed diabetics to a Registered
Dietitian for individualized therapy
Educate patients and caregivers on the benefits of physical activity in
combination with diet changes to maintain metabolic control
Encourage patients to keep track of their own BMI, waist circumference, and
glucose monitoring
Identify ways to reduce risk factors for developing Type 2 Diabetes

CONCLUSION

With type II diabetes on the rise, more individualized, patient centered,

complementary holistic therapies must be explored. Research shows that there
is a significant benefit from using Medical Nutrition Therapy in patients with type
II diabetes, specifically improving glycemic control. Medical Nutrition Therapy
provides patients with a holistic treatment of care, preparing them to live the
best life possible and begin to fight type II diabetes. Four of the six studies used
individualized interviewing with a dietitian and the other two studies used group
interviewing with a dietitian to deliver Medical Nutrition Therapy. Given the
different methods of administering Medical Nutrition Therapy, more research is
needed to determine which method is of optimal benefit to patients with type II
diabetes. However, Medical Nutrition Therapy has presented promising results in
diagnostic levels and maintaining and improving quality of life in patients with
type II diabetes.
IMPROVING GLYCEMIC CONTROL USING MEDICAL NUTRITION THERAPY 7

REFERENCES

Al-Shookri, A., Khor, G. L., Chan, Y. M., Loke, S. C., & Al-Maskari, M. (2012). Effectiveness
of medical nutrition treatment delivered by dietitians on glycaemic outcomes
and lipid profiles of Arab, Omani patients with Type 2 diabetes. Diabetic
Medicine, 29(2), 236-244. doi:10.1111/j.1464-5491.2011.03405.x

Ball, L., Davmor, R., Leveritt, M., Desbrow, B., Ehrlich, C., & Chaboyer, W. (2016).
Understanding the nutrition care needs of patients newly diagnosed with type 2
diabetes: a need for open communication and patient-focussed consultations.
Australian Journal Of Primary Health, 22(5), 416-422. doi:10.1071/PY15063

Parker, A. R., Byham-Gray, L., Denmark, R., & Winkle, P. J. (2014). The Effect of Medical
Nutrition Therapy by a Registered Dietitian Nutritionist in Patients with
Prediabetes Participating in a Randomized Controlled Clinical Research Trial.
Journal Of The Academy Of Nutrition & Dietetics, 114(11), 1739-1748.
doi:10.1016/j.jand.2014.07.020

Miller, S. T., Oates, V. J., Brooks, M. A., Shintani, A., Gebretsadik, T., & Jenkins, D. M.
(2014). Preliminary Efficacy of Group Medical Nutrition Therapy and
Motivational Interviewing among Obese African American Women with Type 2
Diabetes: A Pilot Study. Journal Of Obesity, 1-7. doi:2014/345941

Muchiri, J. W., Gericke, G. J., & Rheeder, P. (2014). Effect of a nutrition education
programme on clinical status and dietary behaviours of adults with type 2
diabetes in a resource limited setting in South Africa: a randomised controlled
trial. Public Health Nutrition, 142-155. doi:
10.1017/S1368980015000956

Nisak, M. Y., Ruzita, A. T., Noimah, A. K., & Azmi, K. N. (February 2013). Medical nutrition
therapy administered by a dietitian yields favourable diabetes outcomes in
individual with type 2 diabetes mellitus. The Medical Journal of Malasia,
68(1):18-23.