610

Dietitian-coached management in combination

with annual endocrinologist follow up improves
global metabolic and cardiovascular health in
diabetic participants after 24 months
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13

Marie-Claude Battista, Mélissa Labonté, Julie Ménard, Farrah Jean-Denis,

Ghislaine Houde, Jean-Luc Ardilouze, and Patrice Perron

Abstract: This 24 month study evaluated the effect of dietitian coaching combined with minimal endocrinologist follow up
on the glycemic control and cardiovascular risks of diabetic participants, compared with conventional endocrinologist follow
up. Participants with type 1 or type 2 diabetes were assigned to either the control group with conventional endocrinologist
follow up (C; n = 50) or the dietitian-coached group (DC; n = 51) with on-site diabetes self-management education every
3 months combined with annual endocrinologist followup. Over the 24 month intervention, weight (–0.7 vs. +2.1 kg; p =
0.04), BMI (+0.3 vs. +0.7 kg/m2; p = 0.009), and waist circumference (–1.3 vs. +2.4 cm; p = 0.01) significantly differed
between the DC and control groups. HbA1C dropped significantly in participants of the DC versus the control group (–0.6%
vs.–0.3%; p = 0.04). This was accompanied by improved overall energy intake (–548 vs. –74 kcal/day; p = 0.04). However,
no link associated glycemic control to nutrient intake or intensiveness of pharmacotherapy. Coaching by a dietitian improves
glycemic control and reduces certain cardiovascular risk factors in diabetic subjects, demonstrating that a joint dietitian–
endocrinologist model of care provides a convenient strategy for cardiovascular risk management in the diabetic population.
For personal use only.

Key words: dietitian, educator, diabetes, metabolic control, glycemic control, cardiovascular outcomes.
Résumé : Cette étude d’une durée de 24 mois évalue, comparativement au suivi traditionnel d’un endocrinologue, l’effet
de la supervision d’une diététiste combinée à un suivi minimal de l’endocrinologue sur le contrôle glycémique et les risques
cardiovasculaires chez des diabétiques. Les participants présentant un diabète de type 1 ou 2 sont assignés soit au groupe de
contrôle incluant le suivi traditionnel de l’endocrinologue (C; n = 50), soit au groupe expérimental incluant le suivi du dié-
tétiste (DC; n = 51) et comprenant sur place un enseignement de l’autocontrôle tous les trois mois combiné au suivi annuel
de la part de l’endocrinologue. Après 24 mois de suivi, la masse corporelle (–0,7 vs. +2,1 kg; p = 0,04), l’IMC (+0,3
vs. +0,7 kg/m2; p = 0,009) et le tour de taille (–1,3 vs. +2,4 cm; p = 0,01) diffèrent significativement entre les groupes DC
et C respectivement. La valeur de HbA1C a diminué significativement dansle groupe DC comparativement au groupe C :
(–0,6 % vs. –0,3 %; p = 0,04). Dans l’ensemble l’apport d’énergie est plus faible : (–548 kcal vs. –74 kcal/jour; p = 0,04).
Cependant, on n’observe aucune relation entre le contrôle de la glycémie et l’apport nutritionnel ou l’ampleur de la pharma-
cothérapie. La supervision par un diététiste améliore le contrôle de la glycémie et diminue le risque de troubles cardiovascu-
laires chez des diabétiques; le modèle combinant le suivi du diététiste et de l’endocrinologue constitue donc une stratégie
efficace pour la gestion des risques cardiovasculaires dans la population des diabètes.
Mots‐clés : diététiste, formateur, diabète, contrôle métabolique, contrôle glycémique, conséquences cardiovasculaires.
[Traduit par la Rédaction]

Introduction over 300 million individuals by 2025 (WHO 2001). In 2009,

The incidence of diabetes mellitus is increasing at an
alarming rate. According to the World Health Organization
(WHO), the number of individuals with type 2 diabetes
(T2D) will double over the next 25 years and will affect
the Canadian Diabetes Association (CDA) anticipated that
approximately 3 million Canadians will have developed dia-
betes in 2011 (CDA 2009). This growing epidemic threatens
to overwhelm healthcare services worldwide, especially given
its exacerbating effect on associated burdens, which include

Received 7 September 2011. Accepted 19 January 2012. Published at www.nrcresearchpress.com/apnm on 25 April 2012.
M.-C. Battista,* M. Labonté,* J. Ménard, F. Jean-Denis, G. Houde, J.-L. Ardilouze†, and P. Perron.† Division of Endocrinology,
Department of Medicine, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12th Ave North, Sherbrooke,
QC J1H 5N4, Canada.
Corresponding author: Patrice Perron (e-mail: Patrice.Perron@USherbrooke.ca).
*First authors.
†Senior authors.

Appl. Physiol. Nutr. Metab. 37: 610–620 (2012) doi:10.1139/H2012-025 Published by NRC Research Press
 Battista et al.
cardiovascular risk factors and diseases (Coutinho et al.
1999).
To curb this trend, intensive lifestyle interventions and pa-
tient education are fundamental and regarded as milestones in
disease management. It is recognized that effective patient
education impacts positively on care, self-management, and
adherence (Albano et al. 2008; Davies et al. 2008). Accord-
ingly, national recommendations suggest that the role of dia-
betes educators should be enhanced in cooperation with the
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13
treating physician to improve coordination of care and pro-
mote improvements in diabetes management (Blonde et al.
2006; CDA 2008). Currently, even though multidisciplinary
diabetes care team studies that include physicians, nurses,
pharmacists, and (or) dietitians, have demonstrated a range
of successful data regarding diabetes management; many
methodological concerns have been raised with respect to
small sample size, short intervention period, or study bias
(Haskell et al. 2006; Trento et al. 2008; Ma et al. 2009; Far-
saei et al. 2011).
Registered dietitians are highly skilled professionals, rec-
ognized as both quality care providers and educators for dia-
betic patients (Franz 2007). It follows that dietitians have an
important role to play within multidisciplinary diabetes care
teams. Accordingly, the Diabetes Prevention Program pro-
vided clear indications for an integral role of the dietitian
into lifestyle management to help patients change their eating
For personal use only.
and exercise behaviours and prevent diabetes complications
(Wylie-Rosett and Delahanty 2002).
Despite the variety of educational programs, including
multidisciplinary team coaching, which have been developed
for people with diabetes, few studies actually aimed to im-
prove the quality of such programs. One way to improve ex-
isting programs might be through a minimal multidisciplinary
team composed of a single highly skilled educator/coach act-
ing together with a physician. To our knowledge, the role of
dietitian–educators combined with endocrinologist follow up
of diabetes-related cardiovascular outcome has never been as-
sessed over long-term management and treatment of type 1
and type 2 diabetes in Canada. Here, we put forth a joint
model of care combining registered dietitian coaching with
annual endocrinologist follow up, to better monitor and pro-
mote global metabolic and cardiovascular health in diabetic
patients. This study compared conventional care provided by
endocrinologists alone over a 24 month period with the pro-
posed dietitian–endocrinologist joint model.
Research design and methods
Participants
Participants were recruited through the Diabetes Clinic at
the Centre Hospitalier Universitaire de Sherbrooke (CHUS)
Fleurimont and Hôtel-Dieu sites, located 8 km apart. For lo-
gistical reasons, participants were referred to the dietitian-
coached (DC) group when seen at the Hôtel-Dieu site or re-
ferred to the control group when seen at the Fleurimont site.
However, all patients were evaluated by the same group of
endocrinologists according to the same guidelines. The only
difference between the two hospital sites was that the dieti-
tian’s practice was based at the Hôtel-Dieu site. Participants
were recruited between April 2007 and April 2008, and
were aged between 33 and 78 years. The participants were
611
included in the study if they had a diagnosis of T2D and a
HbA1c ≥ 7.0% (CDA 2003) or a diagnosis of T1D and dis-
played at least one of the following cardiovascular risks:
LDL-C ≥ 2.0 mmol/L; blood pressure (≥130/80) or taking blood
pressure medication; triglycerides >1.5 mmol/L; HDL-C <
0.90 mmol/L; or a total cholesterol to HDL-C ratio >4.0.
Participants were excluded if they were pregnant, receiving
corticosteroids, or had been seen more than three times by
their endocrinologist for extra follow up care. Exclusion cri-
teria were minimal in order to assess real world day-to-day
clinical practice. The Research Ethics Institutional Review
Board of the Étienne–Le Bel Clinical Research Centre at
the CHUS approved the research protocol. Upon determin-
ing patient eligibility, the endocrinologist first provided an
explanation of the study and then referred the control group
to the research assistant and the DC group to the dietitian
for informed consent. Consent was provided in writing prior
to participation as required by all applicable laws and regu-
lations.
Intervention program
When assigned to the control group, participants received
conventional care and follow up; for example, they were
seen 1–3 times a year by an endocrinologist and also by a
general practitioner. During these visits, CDA recommenda-
tions regarding nutrition and physical activity were taught to
the patients (CDA 2003, 2008). When needed, medication
was adjusted to meet CDA recommended glucose, lipid, and
cardiovascular target values. In the DC group, in addition to
the annual follow-up visit with the endocrinologist, partici-
pants were seen every 3 months by the dietitian and also re-
ceived monthly phone calls between visits as a motivational,
educational, and therapy adjustment tool. Each 30 min visit
with the DC group participants consisted of (1) blood sam-
pling for biochemical tests; (2) anthropometric measure-
ments; (3) non-smoking reinforcement and support as
required; (4) review of self-monitoring glucose data — par-
ticipants were asked to monitor their blood glucose twice
daily with a glucometer; (5) advice on physical activity; (6)
counselling and education regarding nutrition and dietary
plans; (7) pharmacotherapy adjustment upon consultation
with the endocrinologist; (8) complication management; and
above all (9) motivational support.
Physical activity recommendations
Participants of the DC group were provided with pedome-
ters (Yamax, SW-200, Ill., USA) and asked to exercise
60 min per day at moderate intensity (CDA 2003, 2008).
Physical activity in both groups was also assessed using a
standardized questionnaire (Pereira et al. 1997). Daily energy
expenditure associated with reported activities was calculated
as metabolic equivalent task (MET) (Ménard et al. 2005).
Nutrition educational program
In the DC group, participants were supported in the devel-
opment and maintenance of healthy nutritional behaviours ac-
cording to the Canadian Nutrition Recommendations
published by the CDA (2003, 2008) and Eating Well with
Canada’s Food Guide (Health Canada 2007). The first goal
was to introduce the concept of appropriate portion size and
to emphasize the impact of carbohydrate count on glycemic
Published by NRC Research Press
 612
control. The second goal was to avoid excessive energy in-
take. A 3 day food record, including 2 weekdays and 1 week-
end day, was given at baseline and every 6 months as a
motivational tool to the DC group. This was reviewed by the
dietitian to evaluate dietary compliance and provide partici-
pants with adequate individualized diet plans. Food record
logbooks were also provided to control group participants
and returned to the research assistant but were not reviewed
at baseline or at yearly visits. However, records were ana-
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13
lyzed by the dietitian for all participants of both groups using
the NUTRIFIQ software for statistical analyses (version 2.5,
3rd revision, Québec, Canada, 2005).
Pharmacotherapy adjustments
Pharmacotherapy as introduced, increased, or adjusted by
the endocrinologist was reported to the DC group partici-
pants by the dietitian as required (at each 3 month visit) for
those who had not reached CDA treatment goals with life-
style interventions. For control group participants, pharmaco-
therapy was adjusted by an endocrinologist at routine visits
(1–3 times a year) and also by a general practionner.
Briefly, optimal dosage and number of medications were
intensified according to therapeutic goals, secondary effects,
and patient acceptance. Diabetes-treating agents used at a
maximal daily dosage were the following: sulfonylurea
20 mg, meglitinide 16 mg, biguanide 2550 mg, and thiazoli-
For personal use only.
dinedione (rosiglitazone) 8 mg. Upon failure of the above to
yield HbA1c ≤ 7%, bedtime intermediate-acting insulin was
added. Thereafter, insulin type, frequency of injections (1–4),
and dosages were adjusted as needed. Lipid-lowering agents
used at a maximal daily dosage consisted of the following:
statins 80 mg to lower LDL-C, fibrates (fenofibrate)
200 mg were prescribed for hypertriglyceridemia and low
HDL-C. To maintain blood pressure level <130/80 mm
Hg, any one of the following drugs was added and in-
creased as recommended (CDA 2003, 2008) as initial ther-
apy, in the following order: ACE inhibitor, long-acting
calcium channel antagonists, thiazide-like diuretic, cardiose-
lective beta blocker, angiotensin II receptor antagonists, and
alpha-blocker. Pharmacotherapy data for all participants was
computerized. Moreover, for facilitating comparisons and
given that several types of hypoglycemic, anti-hypertensive,
and lipid-lowering drugs could also be given to patients in
the control group, each oral drug dosage was calculated as
a percentage of the maximum recommended dosage.
Refill compliance rate was also monitored over the phone
with the participant’s pharmacist every 3 months. While there
is no such thing as a consensual standard of “good compli-
ance” since the level of compliance required to achieve de-
sired effects varies according to pharmacotherapy and within
participants, for the purposes of this study however, a cut-off
point of 80% was used to classify participants as compliant
(above 80%) or non-adherent (below 80%). Albeit arbitrary,
this cut-off point is commonly used in compliance studies
for fusing antihyperglycemic and antihypertensive drugs
(Lau and Nau 2004; Van Wijk et al. 2004).
Measurement of clinical and biochemical parameters
For DC participants, clinical and anthropometrical meas-
urements were recorded at each visit with the dietitian as op-
posed to only yearly for control group participants. BMI was
Appl. Physiol. Nutr. Metab. Vol. 37, 2012
calculated from body weight and height measurements. Waist
circumference was measured with a flexible tape midway be-
tween the last rib and the iliac crest, at the end of a normal
expiration. Systolic (SBP) and diastolic blood pressure (DBP)
were assessed using an electronic sphygmomanometer (VSM
MedTech Devices Inc., Coquitlam, BC.). Blood samples
were taken following a 12 h overnight fast. Plasma glucose
levels were measured using the glucose oxidase method. Se-
rum was used to measure glycated hemoglobin (HbA1C) by
high-performance liquid chromatography (Bio-Rad VAR-
IANT, Hercules, Calif.). Total cholesterol, HDL-C and trigly-
ceride concentrations were measured by a colorimetric
method (Johnson & Johnson Clinical Diagnostics, Rochester,
NY). LDL-C was calculated using the Friedewald formula.
Creatinine and microalbuminuria were, respectively, meas-
ured by colorimetric (CREAplus, Cobas) and immunoturbidi-
metric (ALBT2, Cobas) assays.
Statistical analysis
Statistical analyses were carried out according to the inten-
tion-to-treat principle. Distribution of continuous variables
was assessed for normality and residual distribution was veri-
fied prior to performance of repeated-measures analysis of
covariance (ANCOVA). If not normally distributed, nonpara-
metrical analyses were performed and expressed as median
(25e – 75e percentiles). Otherwise, parametrical analysis were
conducted and expressed as mean ± SD or mean ± SEM.
Baseline characteristics and outcome variables at 24 months
and baseline (d) were compared using independent student t
test, Mann–Whitney, or c2 tests. Intra-group analyses were
performed using the Wilcoxon test. Changes in proportion in
the same group were assessed with the McNemar test. Where
applicable, Pearson or Spearman correlations were performed
between the most significant parameters as a d of 24 months
to baseline, for each group. Parameters that were analyzed
longitudinally were tested with repeated measures ANCOVA
with baseline values as covariates where appropriate. Where
applicable, linear regression analyses were conducted to cor-
rect for baseline differences. All p values were computed for
a two-tailed test set for an a level of 0.05. The analyses were
performed using the SPSS software version 15.0 (Chicago,
Ill., USA).
Results
According to our inclusion criteria, 101 patients were re-
cruited at baseline; 51 were included in the DC group and
50 in the control group. During the 24 month follow up,
four patients were excluded and three dropped out of the DC
group. In the control group, two participants dropped out,
three died — two from cancer complications and one from a
ruptured aneurysm — and one suffered from a stroke. Ac-
cordingly, 44 patients completed the study in each group.
The majority of participants were T2D non-smoking women.
At baseline, no significant group differences relative to age,
sex, smoking status, diabetes type, diabetes duration, or num-
ber of participants on insulinotherapy were observed (Ta-
ble 1). However, at baseline, micro- and macrovascular
complications were significantly more frequent in the DC
group than in the control group. Accordingly, statistically dif-
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 Battista et al.
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Table 1. Baseline characteristics and changes of clinical parameters in diabetic patients after receiving either a dietitian-coached (DC) intervention or conventional care.

Baseline Changes from baseline to 24 months

Dietitian-coached (DC) Control (C) group; (n Dietitian-coached Adjusted p
group(n = 44) = 44) p value (DC) group Control (C) group p value value
Baseline caracteristics
Age (yrs) 60±11 59±11 0.67 — — —
Sex M/F, n (%) 10 (23) / 33(77) 15 (34) / 30 (66) 0.35 — — —
Smokers, n (%) 7 (16) 7 (16) 0.77 — — —
Type 1/2 diabetes, n (%) 7 (16) / 37 (84) 8 (18) / 36 (82) 0.77 — — —
Diabetes duration (yrs) 15±8 16±10 0.66 — — —
Insulin therapy, n (%) 32 (73) 37 (84) 0.20 — — —
Microvascular complications, 36 (82) 27 (63) 0.04
For personal use only.

n (%)
Macrovascular complica- 18 (41) 9 (21) 0.04
tions, n (%)
Clinical measurements
Weight (kg) 92±19 89±16 0.41 –0.7±4.2 2.1±4.4 0.004 0.003
BMI (kg/m2) 32±6 31±5 0.29 –0.3±1.5 0.7±1.8 0.009 0.001
WC (cm) 110±16 106±13 0.22 –1.3±1.4 2.4±7.3 0.009 0.01
Sbp (mm Hg) 130±15 133±17 0.40 –8.6±14.5 –3.0±15.9 0.94
Dbp (mm Hg) 74±9 77±11 0.12 –5.3±7.8 –1.3±10.3 0.049 0.07
FG (mM) 8.6±3.0 8.5±3.2 0.93 –0.7±3.8 –1.0±4.4 0.66
HbA1c (%) 7.9 (7.3–8.4) 7.7 (7.3–8.4) 0.87 –0.6 (–1.2–0.0) –0.3 (–0.7–0.2) 0.04 0.009
TC (mM) 3.81±0.77 4.07±0.79 0.16 –0.3±0.6 –0.3±0.71 0.93
LDL-C (mM) 1.88±0.67 2.04±0.68 0.30 –0.2±0.6 –0.2±0.6 0.76
HDL-C (mM) 1.19 ± 0.35 1.27±0.36 0.30 0.0±0.2 –0.1±0.2 0.22
TG (mM) 1.47 (1.06 – 2.13) 1.37 (0.83–2.27) 0.37 –0.1 (–0.4–0.2) 0.1 (–0.4–0.3) 0.13
TC/HDL-C 3.24 ± 1.02 3.44±1.31 0.43 0.1±0.7 0.0±0.8 0.70
A/C (mg/L) 1.4 (0.6 – 7.9) 1.2 (0.5–4.7) 0.20 –0.6 (–3.4 – –0.1) –0.2 (–0.9–0.7) 0.08
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Note: Results are expressed as mean ± SD, n (%) or median (1st–3rd interquartile ranges). A t test, c2 or Mann–Whitney test was used to test group difference at baseline. Depending on data
distribution, student t test or Mann–Whitney test was used to determine clinical parameters modification between both groups after the 24 months intervention. p <0.05 was considered signifi-
cantly different. Last p value column refers to linear regression analysis adjusting for micro- and macrovascular differences observed at baseline between groups. The number of observations
varies between 37 and 44. A, albumin; A/C, urinary albumine/creatinine (microalbuminuria); BMI, body mass index; C, control; DC, dietitian-coached; Dbp, diastolic blood pressure; F, female;
FG, fasting glucose; HbA1c, glycated hemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; M, male; N/A, not applicable; TG, triglycerides;
Sbp, systolic blood pressure; TC, total cholesterol; WC, waist circumference.

613
 614
ferent biochemical parameters were corrected for these base-
line differences.
Effects of dietitian intervention on clinical parameters
Table 1 presents clinical and biochemical results as base-
line values and their variation at the final 24 month follow
up. In comparison with control group participants who
gained weight, participants of the DC group lost weight
(+2.1 vs. –0.7 kg, p = 0.004) and shortened their waist cir-
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cumference (+2.4 vs. –1.3 cm, p = 0.009) over time. Accord-
ingly, change in BMI was significantly different between
groups: +0.7 in control vs. +0.3 in DC group, p = 0.009.
These parameters remained significantly different between
groups, even after correction for micro- and macrovascular
complications (weight p = 0.003, waist circumference p =
0.01, BMI p = 0.001). At 24 months, no significant improve-
ment in fasting plasma glucose between the DC and control
participants regardless of baseline glucose was observed.
However, we found a significant improvement in HbA1c re-
gardless of baseline differences in participants of the DC
group as compared to control subjects (–0.6% vs. –0.3%,
p = 0.04; adjusted p for micro- and macrovascular compli-
cations, p = 0.009). While diastolic blood pressure (DBP)
seemed to drop differently between control group and DC
group participants over time (–1.3 vs. –5.3 mm Hg, p =
0.049), this difference was abolished after adjustment for
For personal use only.
micro- and macrovascular complications (p = 0.07).
To confirm data presented in Table 1 that depicts steady-
state clinical data between groups at baseline and 24 months,
avoid time-fluctuation bias, and better assess the evolution of
our intervention, parameters that were statistically different
between 24 months and baseline were linearly analyzed. Re-
sults obtained from this longitudinal analysis showed that
weight (Fig. 1A), BMI (Fig. 1B), waist circumference
(Fig. 1C), diastolic blood pressure (Fig. 1D), and HbA1c
(Fig. 1E) were significantly different between groups over
the study course. After correction for complications, all pa-
rameters remained significant, and only a tendency toward
group difference was observable in the case of DBP
(Fig. 1D).
Effects of dietitian intervention on lifestyle behaviors
Table 2 shows the analyses of the 3 day food records. At
baseline, participants of the DC group were consuming 34%
more kcal per day (p = 0.005) than participants in the control
group. In terms of energy intake, the intervention resulted in
a net reduction of energy (–548 vs. –74 kcal/day; p = 0.001
vs. p = 0.179), and saturated fat (–3% vs. –1%; p = 0.005 vs.
p = 0.179) intake over the 24 month period in the DC versus
the control group. Monounsaturated fat intake was similarly
and significantly decreased in both groups over time. Since
participants of the DC group ingested fewer kcal per day
than the participants of the control group, the 24 month inter-
vention resulted in significantly lower absolute values (g/day)
of protein (–14 vs. +1 g/day; p = 0.012 vs. p = 0.234), car-
bohydrates (–25 vs. +4 g/day; p = 0.019 vs. 0.196), and total
lipid intake (–30 vs. –5 g/day; p = 0.002 vs. 0.679). Over the
course of the study period, a significant difference between
groups was observed in terms of energy (kcal/day) (p =
0.045) although a similar tendency was observed for carbo-
hydrates (p = 0.059).
Appl. Physiol. Nutr. Metab. Vol. 37, 2012
In the DC group, the intervention failed to result in any
improvement in the number of steps as measured by pedom-
eter per day (p = 0.737). Accordingly, no difference in daily
expenditure in leisure activities either within or between
groups was observed.
Effects of dietitian intervention on pharmacotherapy
adjustments
Participant compliance with anti-hypertensive, anti-diabetes,
or cholesterol lowering agents was excellent and ranged be-
tween 96% and 100% for each group over the entire study
period (data not shown). Table 3 shows the percentage of
the maximum daily dosage for each drug used. At
24 months, participants of the DC group received 50%
more angiotensin-converting enzyme inhibitor compared to
baseline (p = 0.04). In the control group, at 24 months,
participants were taking an additional 49% (p = 0.04) and
30% (p = 0.02) of their initial dosages of calcium-channel
antagonist and diuretic drugs, respectively. Table 4 shows
that the number of participants on pharmacotherapy did not
differ between groups and during the intervention. However,
the number of anti-hypertensive drugs was increased in the
DC group (p = 0.04) at 24 months in comparison to base-
line. At 24 months, insulin doses rose significantly by 18%
in the DC group as compared to only 7% in the control
group (Table 3), although the number itself of participants
taking insulin did not significantly increase (Table 4).
Correlations
In the DC group, improvement in HbA1c was positively as-
sociated with fasting glucose (r = 0.52; p = 0.001). With re-
spect to cardiovascular improvement, although no association
between reduction in DBP and increased number of anti-
hypertensive agents was observed, there was a positive cor-
relation between delta 24 months to baseline DBP and
waist circumference in the DC group (r = 0.362; p =
0.02). Moreover, in the DC group, no correlation was ob-
served between changes in HbA1c and weight (r = 0.053;
p = 0.747) or waist circumference (r = 0.165; p = 0.310).
Discussion
We compared a joint model of diabetes care management
combining a motivational intervention program given by a
registered dietitian and a minimal yearly endocrinologist fol-
low up to regular endocrinologist follow up, over a 24 month
period, with HbA1c and cardiovascular risk factors as primary
results. We showed that the joint dietitian-coached model of
intervention was successful as HbA1c, weight, BMI, waist cir-
cumference, and dietary intakes were significantly modified
between groups over the 24 month period. However, we were
unable to directly associate these improvements to any spe-
cific intervention given by the dietitian, suggesting an overall
benefit of the program. Moreover, this is the first study, to our
knowledge, to be conducted by a team composed only of a di-
etitian and an endocrinologist over a 24 month period in Can-
ada. Previously, a Taiwanese study evaluated the impact of
dietitian management, in a primary-care setting, on glycemic
control over a 12 month period (Huang et al. 2010).
Surprisingly, we observed that participants of the DC
group presented twice as many micro- and (or) macrovascular
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 Battista et al. 615

Fig. 1. Evolution of cardiovascular risk factors and glycemic control parameters in the two study groups over the entire course of intervention.
(A) Weight (kg); (B) Body Mass Index (BMI; kg/m2); (C) Waist circumference (cm); (D) Diastolic blood pressure (mm Hg); (E) Hemoglobin
A1c concentrations (%). Dietitian-coached (DC) results are shown using the black dots and full line while control (C) results are represented
by open dots and dotted lines. Results are expressed as mean (dots) ± SEM (bars). Boxes, p: are representative of intergroup interaction as
determined by repeated measures ANCOVA using a linear model. Adjusted p: analyses are adjusted for micro- and macrovascular differences
observed between groups at baseline. Residues distribution was verified and normally distributed for each parameter. The number of observa-
tions varies between 38 and 44.
100 A 34 B 112 C
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Waist circumference (cm)

110
33
95

BMI (kg/m2)
Weight (kg)

108
32
106
90
31
104
p=0.002 p=0.009 p=0.009
adjusted p=0.001 adjusted p=0.001 adjusted p=0.01
85 30 102
0 12 24 0 12 24 0 12 24
Time (months) Time (months) Time (months)

85 D 8.5 E
Diastolic blood pressure
For personal use only.

80
8.0
HbA1c (%)
(mmHg)

75 p=0.049 p=0.03 DC group

adjusted p=0.07 adjusted p=0.01 Control group
7.5
70

65 7.0
0 12 24 0 12 24
Time (months) Time (months)

complications at baseline than did control group partici-
pants. Data were corrected for this confounding factor, and
showed significant improvement in glycemic control for DC
group participants, with levels similar to recently observed
in a joint pharmacist–physician and dietitian–nurse follow-
up study (Haskell et al. 2006; Ma et al. 2009; Hammad et
al. 2011).
With regard to glycemic control, the drop in HbA1c (0.6%)
was similar to that reported in recent randomized controlled
trials. Using dietitian-coached diabetes management together
with GP care, Huang and colleagues showed a 0.7% drop in
HbA1c over a 12 month period in poorly controlled diabetic
participants (n = 75) compared to only 0.2% in control sub-
jects (n = 79) (Huang et al. 2010). The LOADD study, per-
formed in participants who were hyperglycemic despite
optimized drug treatment, showed that individualized and in-
tensive nutritional intervention resulted in a 0.4% HbA1c dif-
ference between intervention (n = 45) and control (n = 48)
groups, over a 6 month period, without significant changes
in plasma glucose levels (Coppell et al. 2010), as also ob-
served in this study. Although the drop in HbA1c may seem
modest (0.6%), the relationship between HbA1c and diabetes-
associated complications is linear, suggesting that any reduc-
tion in HbA1c profoundly impacts complications and associ-
ated outcomes. Indeed, the UKPDS reported that for every
1% drop in HbA1c, microvascular complications fall by
30%–35% in obese T2D patients (UK Prospective Diabetes
Study Group 1998).
In line with our aim to reduce cardiovascular risk factors
in our participants, we observed that our intervention posi-
tively impacted on adiposity in the DC group versus the con-
trol group, as measured over the course of the intervention by
weight (–0.7 vs. +2.1 kg), BMI (+0.3 vs. +0.7 kg/m2) and
waist circumference (–1.3 vs. +2.4 cm). Similar results were
reported for the LOADD study (Coppell et al. 2010). This ef-
fect on adiposity is an improvement over our previous study,
as although our intensive 18 month multidisciplinary inter-
vention did cut HbA1c in poorly controlled diabetic patients,
it did not curb weight gain (Ménard et al. 2005). Thus, the
weight loss (–0.7 kg) demonstrated in diabetic patients of
the DC group is of clinical importance. This result sharply
contrasts with results from the use of anti-diabetic drugs and
insulin for which weight gain is, in fact, a common side ef-
fect (Leslie et al. 2007; Holman et al. 2009). The fact that

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 616 Appl. Physiol. Nutr. Metab. Vol. 37, 2012

Table 2. Changes in nutrient intake and physical activity at baseline and 24 months after receiving either a dietitian-coached (DC) interven-
tion or conventional care.

Dietitian-coached group (n = 30) Control group (n = 16) p value d

between
Nutrient intake Baseline 24 months Baseline 24 months groups
Energy (kcal/day) 2362 (1812–2664)†† 1814 (1548–2300) 1768 (1568–2109) 1694 (1499–1962) 0.045
***
Protein
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13

Energy (%) 17 (15–19) 18 (16–20) 16 (14–19) 18 (16–21) 0.368

g/day 95 (83–108) †† 81 (68–100) ** 76 (65–82) 77 (69–89) 0.014
Carbohydrates
Energy (%) 43 (38–48) 47 (41–53)* 46 (42–53) 47 (43–50) 0.059
g/day 238 (193–300) 213 (170–260) * 203 (169–273) 207 (176–230) 0.393
Fat
Energy (%) 40 (34–43) 36 (29–40) 37 (33–41) 36 (33–39) 0.189
g/day 94 (72–128) † 64 (55–104) ** 73 (67–88) 68 (60–84) 0.028
Saturated fat (%) 13 (11–15) 10 (9–13)** 13 (10–16) 12 (10–13) 0.580
Monounsaturated fat (%) 16 (13–17) 14 (11–15)* 17 (13–20) 13 (12–15)* 0.433
Polyunsaturated fat (%) 7 (6–9) 7 (5–8) 8 (6–9) 7 (5–9) 0.612
Fibers (g/day) 18 (14–24) 20 (16–24) 17 (15–23) 17 (13–21) 0.240
Physical activities
Steps/daya 4411 (2686–8711) 5155 (2380–7344) — — N/A
Daily expenditure in lei- 0.55 (0.04–1.59) 0.83 (0.01–2.49) 0.94 (0.00–1.67) 0.25 (0.00–1.41) 0.064
sure activitiesb (kcal/kg/
day)
Note: Results are expressed as median (1st–3rd interquartile ranges). The Mann–Whitney test was used for inter-group data analysis at baseline and at
For personal use only.

24 months; †p ≤ 0.05, ††p ≤ 0.01. The Wilcoxon’s signed-rank test was used for intra-group data analysis; *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001. The p value
in the last column refers to the delta difference (24 months – baseline) between groups using the Mann–Whitney test. MED (IQR) = median interquartile
range.
a
n = 20 in the DC group.
b
n = 42 and 44 in the DC and control group, respectively.

the majority (77%) of DC participants were on insulinoher-
apy at 24 months — and that insulin doses at 24 months
were 18% above those at baseline — would seem to suggest
that the joint dietitian-coached intervention actually overcame
the obesogenic effects of medication. In line with this, is the
observation that intensification of anti-diabetic drug therapy
in the control group participants resulted in added adiposity
(weight: +2.1 kg; BMI: +0.7 kg/m2; waist circumfer-
ence: +2.4 cm over the 24 month intervention period). While
added adiposity was observed in the absence of increased
caloric intake, it is important to stress that nutritional data
were self-reported by participants. In fact, control group par-
ticipants followed Canadian energy recommendations (i.e.,
2150 kcal/day for men and 1750 kcal/day for women). Obe-
sity, and particularly abdominal adiposity, is a recognized and
independent cause of cardiometabolic risk (Gastaldelli and
Basta 2010). Importantly, the Quebec Health Survey (Poirier
et al. 2005), which studied more than 1800 men and women,
concluded that obesity, fasting insulin, insulin sensitivity, and
blood pressure were largely explained by variations in waist
circumference, one of the main parameters modified in our
study. Our joint dietitian-coached care management model
thus offers an interesting and innovative alternative strategy
to reduce diabetes-associated complications and cardiovascu-
lar diseases.
With respect to blood pressure and lipid control, our study
intervention failed to provide any clear benefit over regular
care. Even though DBP seemed to improved in DC partici-
pants compared to controls, only a tendency was observable
after correction for baseline differences. Data from the litera-
ture seem conflicting as to the effectiveness of intervention
on blood pressure and lipid control (Haskell et al. 2006;
Huang et al. 2010; Coppell et al. 2010). Results suggest that
our joint dietitian-coached intervention is no better than other
interventions using combined and diverse medical specialists.
One possible explanation for the intervention’s failure to im-
prove DBP or lipids may simply be due to the fact that base-
line values were already close to target levels and that
antihypertensive and lipid medications are effective.
As our intervention was dietitian-based, we also questioned
the benefit of promoting better lifestyle habits on cardiovas-
cular and metabolic improvement. It is well known that, in
the diabetic population, recommended dietary and physical
activity guidelines are seldom followed (Nelson et al. 2002).
Our current joint dietitian-coached intervention resulted in
greater reductions in energy intake — a 23% drop in energy
intake was observed in the DC group at 24 months — than
were our previous study using a multitherapy program (11%
over 12 months — Ménard et al. 2005) and the dietitian-
coached Taiwanese study (12% at 12 months — Huang et al.
2010). Compared to Huang et al. (2010) our current nutri-
tional intervention also resulted in a greater drop in monoun-
saturated (+12.5% in our study vs. +6.0%), saturated
(–23.1% vs. –11.3%), and absolute total fat (–31.9% vs.
–11.9%) intake, although carbohydrate and protein intakes
were similar in both studies. It was previously shown,
inT2D patients, that a reduction in saturated fat intake was
associated with improved glycemic control (Nelson et al.

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 Battista et al.
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Table 3. Dosage of oral medications as a percentage of the maximum daily dosage at baseline and 24 months after receiving either a dietitian-coached (DC) intervention or
conventional care.

Dietitian-coached group Control group

Drugs n Baseline 24 months n Baseline 24 months
Glucose-lowering agents
Sulfonylurea 8 75 (31–100) 50 (31–50) 6 50 (23–81) 44 (31–63)
Meglitinide N/A N/A N/A 2 69 (47–56) 44 (9–56)
For personal use only.

Biguanide 28 78 (78–100) 78 (61–78) 24 88 (67–100) 78 (67–100)

Thiazolidinedione 9 100 (50–100) 50 (50–100) 12 100 (54–100) 100 (100–100)
Insulin dose (U/kg/day) 31 0.73 (0.49–1.13) 0.86 ** (0.50–1.40) 32 0.60 (0.34–0.95) 0.64 * (0.44–1.11)
Lipid-lowering agents
Statin 35 25 (25–50) 50 (25–50) 35 50 (25–50) 50 (25–50)
Fibrate N/A N/A N/A 3 80 (80–100) 80 (80–100)
Antihypertensive agents
Angiotensin-converting enzyme 18 50 (46–100) 75 (50–100)* 21 50 (38–94) 50 (50–100)
inhibitor
Calcium-channel antagonist 9 100 (58–100) 100 (58–100) 11 67 (50–100) 100 (83–100)*
Diuretic 19 10 (6–13) 13 (8–13) 23 10 (6–13) 13 (6–15)*
b-Blocker 13 50 (25–50) 25 (25–50) 9 25 (25–50) 38 (25–50)
Angiotensin-ІІ receptor antagonist 20 100 (50–100) 100 (50–100) 15 100 (100–100) 100 (50–100)
Alpha-1 blocker 3 20 (5–25) 20 (10–30) N/A N/A N/A
Note: Maximum daily dosages were chosen according to the 2007 and 2008 Compendium of Pharmaceuticals and Specialities. Results are expressed as median (1st–3rd interquartile ranges). The
Mann–Whitney test was used for inter-group data analysis. No differences were observed between groups at baseline. The Wilcoxon’s signed-rank test was used for intra-group data analysis; *p < 0.05.
N/A, not enough valid cases to proceed with analysis. For the same reason, no mention is made regarding beta-2 adrenergic agonist and incretin drugs.
Published by NRC Research Press

617
 618 Appl. Physiol. Nutr. Metab. Vol. 37, 2012

Table 4. Outcome of pharmacological therapies in participants at baseline and 24 months after receiving either a dietitian-coached (DC)
intervention or conventional care.

Dietitian-coached group (DC) Control group

Drugs Baseline 24 months p value Baseline 24 months p value
Glucose-lowering agents
0 OHA 13 (30) 16 (36) 0.416 15 (34) 16 (36) 0.293
1 OHA 13 (30) 14 (31) 9 (20) 13 (30)
2 OHA 10 (23) 7 (16) 11 (25) 9 (20)
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13

3 OHA 8 (18) 7 (16) 9 (20) 6 (14)

OHA alone 12 (27) 10 (23) 0.072 15 (34) 11 (25) 0.082
Insulin and OHA 13 (30) 15 (34) 10 (23) 11 (25)
Insulin alone 19 (43) 19 (43) 19 (43) 22 (43)
Lipid-lowering agents
0 agent 7 (16) 7 (16) 1.000 6 (14) 3 (7) 0.180
1 agent 33 (75) 33 (75) 30 (68) 33 (75)
2 agents 4 (9) 4 (9) 8 (18) 8 (18)
Antihypertensive agents
0 agent 6 (14) 5 (11) 0.040 3 (7) 4 (9) 0.502
1 agent 7 (16) 7 (16) 15 (34) 12 (27)
2 agents 17 (39) 12 (27) 7 (16) 9 (20)
3 agents 5 (11) 13 (30) 13 (30) 12 (27)
≥4 agents 9 (20) 7 (17) 6 (14) 7 (17)
Note: Results are expressed as the number and percentage of patients taking each category of medication. Insulin doses are expressed as median (1st–3rd
interquartile ranges). The Mann–Whitney test was used for inter-group insulin dose analysis at baseline. No differences were observed between groups at
baseline. The Wilcoxon’s signed-rank test was used to detect intra-group difference for insulin dose. p value column expresses McNemar test values for intra-
For personal use only.

group data analysis. OHA, oral hypoglycemic agents.

2002). In our current study, improvement in nutritional hab-
its in the DC group did not correlate with the improvement
of any clinical parameters. It is therefore unlikely that cardi-
ovascular risk factors and glycemic improvements seen in
DC participants are directly attributable to better dietary
habits. Nutritional data were self-reported by participants
and while food records are an important tool, they confer
inherent limitations to our study design and analysis. Impor-
tantly, the control group's food logbooks were simply
handed over by the participants to the research assistant
and were not reviewed with the participant. However, in
the DC group, food logbooks were immediately handed
over to the dietitian and carefully reviewed with partici-
pants. Thus, the dietitian immediately and actively started
promoting lower energy intake among DC participants by
closely investigating and assessing their daily intakes and
asking additional questions. This may explain, at least in
part, the difference in energy intake between groups at
baseline. Because of this bias and the fact that many partic-
ipants did not completed their logbooks, we chose not to
correct for biochemical data obtained with a greater number
of participants, with this nutritional variable.
Physical activity is another important aspect to consider in
any lifestyle management intervention. Because the current
study used only questionnaires and pedometers as motiva-
tional tools, it did not result in any significant improvement
in physical activity. This contrasts with our previously pub-
lished multidisciplinary approach in which a supervised exer-
cise program, given to diabetic patients, resulted in improved
physical activity in the intervention group compared to the
conventional care group (Ménard et al. 2005). One limitation
of our current study is related to providing participants with
only a pedometer for a relative long period, 24 months, as
motivation toward physical activity. Interestingly, a quantita-
tive bias was reported toward pedometers as obese partici-
pants were less compliant than the non-obese (Renault et al.
2010) and that long-term individual motivation was a major
issue associated with poor physical activity in this population
(Harvey et al. 2009). A recent report demonstrated that it was
easier for T2D patients to manage diet recommendations than
to exercise (Oftedal et al. 2011). Taken together, these results
suggest that diabetic patients need to be actively supervised
and motivated, on a frequent basis, rather than provided with
passive tools when expected to improve their physical activ-
ity habits.
It was previously thought that the successful intervention
in improving glycemic control was based on rapid and sus-
tained pharmacotherapy changes in diabetic patients (Mehuys
et al. 2010). In our current study, pharmacotherapy adjust-
ment was part of overall management in both groups. Results
show that the number of prescribed glucose-lowering agents
and their dosages was no different between groups. Insulin
doses however were increased at 24 months compared to
baseline, in both groups. In secondary analyses, we showed
that administration of anti-diabetic drugs did not correlate
with observed anthropometric or HbA1c measurements in the
DC group participants. Moreover, we showed that the drop in
HbA1c was not correlated with the rise in insulin in the DC
participants. Furthermore, HbA1c was improved independ-
ently of insulin therapy (data not shown). Thus, our results
suggest that the improvement on HbA1c in the DC partici-
pants was not exclusively attributable to medication adjust-
ment. Our results, however, apparently contradict those
reported by Wolf et al. (2004) showing that improved HbA1c
was accompanied by a reduction in the number of diabetic
medications and insulin use after 12 months of a registered

Published by NRC Research Press

 Battista et al.
dietitian intervention in the case management group (Wolf et
al. 2004). Our results, even after a 24 month intervention,
were also contrary to the reported speculation by Wolf et al.
(2004) that, after the 12 month intervention, a drop in HbA1c
may precede the reduction in pharmacotherapy use (Wolf et
al. 2004). Nonetheless, our data do support the conclusion
that motivational care and management provided by a dieti-
tian is successful in improving metabolic and cardiovascular
risk factors independently of adjustments in medications. Ac-
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13
cordingly, the Diabetes Prevention Program study, performed
in glucose intolerant patients, which showed that lifestyle in-
tervention is more effective than medication in the prevention
of T2D (Wylie-Rosett and Delahanty 2002) had also evi-
denced that dietitians have a key role to play in lifestyle inter-
ventions.
Conclusion
We previously showed that a 12 month intensive multither-
apy given to poorly controlled T2D participants resulted in
the attainment of most of the CDA-recommended goals with
respect to glycemic control and cardiovascular outcomes
(Ménard et al. 2005). However, the benefits of this previous
intervention vanished as early as 6 months after cessation of
the program. One possible explanation for these results is that
even though multitherapy has proven to be very efficient dur-
For personal use only.
ing intervention, it may also often be challenging and diffi-
cult for patients to maintain. It is common knowledge that
most medical specialists are heavily burdened professionally.
The intervention required may seem, to some, painstakingly
time-consuming as opposed to other relatively more “aggres-
sive” interventions. We show that after a 24 month interven-
tion of dietitian coaching, in combination only with yearly
endocrinologist follow up, successfully improves glycemic
control and reduces cardiovascular risk factors in a high-risk
diabetic population. We also show that these benefits are not
directly associated with either greater intensive pharmacother-
apy or lifestyle management taken separately, but rather with
the intervention as a whole and mostly by motivation and hu-
man contact provided by the dietitian. Indeed, self-monitoring
of blood glucose, telephone counselling, and motivational
interviews have all proven their beneficial impact on dia-
betic and cardiovascular outcomes (Goode et al. 2011; Po-
lonsky et al. 2011; Welch et al. 2011). Our initial intention
was not to evaluate the contribution of each component of
the intensive management taken separately. We targeted life-
style intervention through education and registered dietitian-
based follow up over conventional care provided by the
endocrinologist alone, as is recommended in national asso-
ciation guidelines (Blonde et al. 2006; CDA 2008). Our
joint dietitian-coached model of care thus provides a highly
convenient strategy for cardiovascular risk management in
the diabetic population. However, randomized controlled tri-
als need to be conducted over several years of intervention
and include parallel assessment studies of care providers
and cost effectiveness.
Acknowledgements/disclosure
This is an investigator-initiated study supported by Pfizer.
No other external funding was received for this research.
M.-C.B. contributed to supervision, data interpretation and
619
wrote the manuscript. M.L. contributed to data acquisition,
data interpretation and analysis. J.M. was involved in study
design. F.J.-D. contributed to data acquisition. G.H. contrib-
uted to study design and data acquisition. J.-L.A. and P.P.
both participated in the study concept and design. P.P. also
participated in supervision, data acquisition, analyses, and
data interpretation. All of the authors critically revised the
manuscript for important intellectual content and gave final
approval for the article to be published.
References
Albano, M.G., Crozet, C., and d'Ivernois, J.F. 2008. Analysis of the
2004–2007 literature on therapeutic patient education in diabetes:
results and trends. Acta Diabetol. 45(4): 211–219. doi:10.1007/
s00592-008-0044-9. PMID:18633570.
Blonde, L., Dempster, J., Gallivan, J.M., and Warren-Boulton, E.
2006. Reducing cardiovascular disease risk in patients with
diabetes: a message from the National Diabetes Education
Program. J. Am. Acad. Nurse Pract. 18(11): 524–533. doi:10.
1111/j.1745-7599.2006.00171.x. PMID:17064330.
CDA. 2009. Clinical Practice Guidelines for the Prevention and
Management of Diabetes in Canada. Available from http://www.
diabetes.ca/files/cpg2008/cpg-2008.pdf.
CDAClinical Practice Guidelines Expert Committee. 2003. Clinical
practice guidelines for the prevention and management of diabetes
in Canada. Can. J. Diabetes, 27(Suppl 2): S1–S140.
CDAClinical Practice Guidelines Expert Committee. 2008. Clinical
practice guidelines for the prevention and management of diabetes
in Canada. Can. J. Diabetes, 32(Suppl. 1): S1–S225.
Coppell, K.J., Kataoka, M., Williams, S.M., Chisholm, A.W.,
Vorgers, S.M., and Mann, J.I. 2010. Nutritional intervention in
patients with type 2 diabetes who are hyperglycaemic despite
optimised drug treatment–Lifestyle Over and Above Drugs in
Diabetes (LOADD) study: randomised controlled trial. BMJ,
341(jul20 2):1–7. c3337. doi:10.1136/bmj.c3337. PMID:20647285.
Coutinho, M., Gerstein, H.C., Wang, Y., and Yusuf, S. 1999. The
relationship between glucose and incident cardiovascular events. A
metaregression analysis of published data from 20 studies of
95,783 individuals followed for 12.4 years. Diabetes Care, 22(2):
233–240. doi:10.2337/diacare.22.2.233. PMID:10333939.
Davies, M.J., Heller, S., Skinner, T.C., Campbell, M.J., Carey, M.E.,
Cradock, S., et al.Diabetes Education and Self Management for
Ongoing and Newly Diagnosed Collaborative. 2008. Effectiveness
of the diabetes education and self management for ongoing and
newly diagnosed (DESMOND) program for people with newly
diagnosed type 2 diabetes: cluster randomised controlled trial.
BMJ, 336(7642): 491–495. doi:10.1136/bmj.39474.922025.BE.
PMID:18276664.
Farsaei, S., Sabzghabaee, A.M., Zargarzadeh, A.H., and Amini, M.
2011. Effect of pharmacist-led patient education on glycemic
control of type 2 diabetics: a randomized controlled trial. J. Res.
Med. Sci. 16(1): 43–49. PMID:21448382.
Franz, M.J. 2007. The role of nutrition therapy and dietitians in the
management of the metabolic syndrome. Curr. Diab. Rep. 7(1):
60–65. doi:10.1007/s11892-007-0011-9. PMID:17254519.
Gastaldelli, A., and Basta, G. 2010. Ectopic fat and cardiovascular
disease: what is the link? Nutr. Metab. Cardiovasc. Dis. 20(7):
481–490. doi:10.1016/j.numecd.2010.05.005. PMID:20659791.
Goode, A.D., Winkler, E.A., Lawler, S.P., Reeves, M.M., Owen, N.,
and Eakin, E.G. 2011. A telephone-delivered physical activity and
dietary intervention for type 2 diabetes and hypertension: does
intervention dose influence outcomes? Am. J. Health Promot. 25(4):
257–263. doi:10.4278/ajhp.090223-QUAN-75. PMID:21361811.
Published by NRC Research Press
 620
Hammad, E.A., Yasein, N., Tahaineh, L., and Albsoul-Younes, A.M.
2011. A randomized controlled trial to assess pharmacist-
physician collaborative practice in the management of metabolic
syndrome in a university medical clinic in jordan. J. Manag. Care
Pharm. 17(4): 295–303. PMID:21534640.
Harvey, J.T., Eime, R.M., and Payne, W.R. 2009. Effectiveness of the
2006 Commonwealth Games 10,000 Steps Walking Challenge.
Med. Sci. Sports Exerc. 41(8): 1673–1680. PMID:19568191.
Haskell, W.L., Berra, K., Arias, E., Christopherson, D., Clark, A.,
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by George Mason University on 05/02/13
George, J., et al. 2006. Multifactor cardiovascular disease risk
reduction in medically underserved, high-risk patients. Am. J.
Cardiol. 98(11): 1472–1479. doi:10.1016/j.amjcard.2006.06.049.
PMID:17126653.
Health Canada. 2007. Eating Well with Canada’s Food Guide.
Ottawa, ON: Health Products and Food Branch, Office of
Nutrition and Promotion. H39–166/1990E.
Holman, R.R., Farmer, A.J., Davies, M.J., Levy, J.C., Darbyshire, J.L.,
Keenan, J.F., and Paul, S.K.4-T Study Group. 2009. Three-year
efficacy of complex insulin regimens in type 2 diabetes. N.
Engl. J. Med. 361(18): 1736–1747. doi:10.1056/
NEJMoa0905479. PMID:19850703.
Huang, M.C., Hsu, C.C., Wang, H.S., and Shin, S.J. 2010.
Prospective randomized controlled trial to evaluate effectiveness
of registered dietitian-led diabetes management on glycemic and
diet control in a primary care setting in Taiwan. Diabetes Care, 33(2):
233–239. doi:10.2337/dc09-1092. PMID:19910499.
Lau, D.T., and Nau, D.P. 2004. Oral antihyperglycemic medication
For personal use only.
nonadherence and subsequent hospitalization among individuals
with type 2 diabetes. Diabetes Care, 27(9): 2149–2153. doi:10.
2337/diacare.27.9.2149. PMID:15333476.
Leslie, W.S., Hankey, C.R., and Lean, M.E. 2007. Weight gain as an
adverse effect of some commonly prescribed drugs: a systematic
review. QJM, 100(7): 395–404. doi:10.1093/qjmed/hcm044.
PMID:17566010.
Ma, J., Berra, K., Haskell, W.L., Klieman, L., Hyde, S., Smith, M.W.,
et al. 2009. Case management to reduce risk of cardiovascular
disease in a county health care system. Arch. Intern. Med. 169(21):
1988–1995. doi:10.1001/archinternmed.2009.381. PMID:
19933961.
Mehuys, E., Van Bortel, L., De Bolle, L., Van Tongelen, I.,
Annemans, L., Remon, J.P., and Giri, M. 2010. Effectiveness of
a community pharmacist intervention in diabetes care: a
randomized controlled trial. J. Clin. Pharm. Ther. 36(5): 602–
613. doi:10.1111/j.1365-2710.2010.01218.x. PMID:21143256.
Ménard, J., Payette, H., Baillargeon, J.P., Maheux, P., Lepage, S.,
Tessier, D., and Ardilouze, J.L. 2005. Efficacy of intensive
multitherapy for patients with type 2 diabetes mellitus: a
randomized controlled trial. CMAJ, 173(12): 1457–1466. doi:10.
1503/cmaj.050054. PMID:16293781.
Nelson, K.M., Reiber, G., and Boyko, E.J.NHANES III. 2002. Diet
and exercise among adults with type 2 diabetes: findings from the
third national health and nutrition examination survey (NHANES
III). Diabetes Care, 25(10): 1722–1728. doi:10.2337/diacare.25.
10.1722. PMID:12351468.
Oftedal, B., Bru, E., and Karlsen, B. 2011. Motivation for diet and
Appl. Physiol. Nutr. Metab. Vol. 37, 2012
exercise management among adults with type 2 diabetes. Scand. J.
Caring Sci. 25(4): 735–744. doi:10.1111/j.1471-6712.2011.00884.
x. PMID:21443543.
Pereira, M.A., FitzerGerald, S.J., Gregg, E.W., Joswiak, M.L., Ryan,
W.J., Suminski, R.R., et al. 1997. A collection of Physical Activity
Questionnaires for health-related research. Med. Sci. Sports Exerc.
29(6 Suppl.): S1–S205. PMID:9243481.
Poirier, P., Lemieux, I., Mauriege, P., Dewailly, E., Blanchet, C.,
Bergeron, J., and Després, J.P. 2005. Impact of waist circumfer-
ence on the relationship between blood pressure and insulin: the
Quebec Health Survey. Hypertension, 45(3): 363–367. doi:10.
1161/01.HYP.0000155463.90018.dc. PMID:15668356.
Polonsky, W.H., Fisher, L., Schikman, C.H., Hinnen, D.A., Parkin, C.G.,
Jelsovsky, Z., et al. 2011. A structured self-monitoring of blood
glucose approach in type 2 diabetes encourages more frequent,
intensive, and effective physician interventions: results from the
STeP study. Diabetes Technol. Ther. 13(8): 797–802. doi:10.
1089/dia.2011.0073. PMID:21568751.
Renault, K., Nørgaard, K., Secher, N.J., and Nilas, L. 2010. Physical
activity during pregnancy in obese and normal-weight women as
assessed by pedometer. Acta Obstet. Gynecol. Scand. 89(7): 956–
961. doi:10.3109/00016341003792459. PMID:20583938.
Trento, M., Basile, M., Borgo, E., Grassi, G., Scuntero, P., Trinetta,
A., et al. 2008. A randomised controlled clinical trial of nurse-,
dietitian- and pedagogist-led group care for the management of
type 2 diabetes. J. Endocrinol. Invest. 31(11): 1038–1042. PMID:
19169063.
UK Prospective Diabetes Study Group. 1998. Effect of intensive
blood-glucose control with metformin on complications in over-
weight patients with type 2 diabetes (UKPDS 34). Lancet, 352(9131):
854–865. doi:10.1016/S0140-6736(98)07037-8. PMID:9742977.
Van Wijk, B.L., Klungel, O.H., Heerdink, E.R., and de Boer, A.
2004. The association between compliance with antihypertensive
drugs and modification of antihypertensive drug regimen. J.
Hypertens. 22(9): 1831–1837. doi:10.1097/00004872-200409000-
00029. PMID:15311113.
Welch, G., Zagarins, S.E., Feinberg, R.G., and Garb, J.L. 2011.
Motivational interviewing delivered by diabetes educators: does it
improve blood glucose control among poorly controlled type 2
diabetes patients? Diabetes Res. Clin. Pract. 91(1): 54–60. doi:10.
1016/j.diabres.2010.09.036. PMID:21074887.
Wolf, A.M., Conaway, M.R., Crowther, J.Q., Hazen, K.Y., Nadler,
J.L., Oneida, B., and Bovbjerg, V.E.Improving Control with
Activity and Nutrition (ICAN) Study. 2004. Translating lifestyle
intervention to practice in obese patients with type 2 diabetes:
Improving Control with Activity and Nutrition (ICAN) study.
Diabetes Care, 27(7): 1570–1576. doi:10.2337/diacare.27.7.
1570. PMID:15220230.
WHO. 2001. Global burden of disease for the year 2001 by World
Bank region, for use in disease control priorities in developing
countries. 2nd ed. World Health Organization (WHO).
Wylie-Rosett, J., and Delahanty, L. 2002. An integral role of the
dietitian: implications of the Diabetes Prevention Program. J. Am.
Diet. Assoc. 102(8): 1065–1068. PMID:12171450.
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