Dietary Adherence

A QUESTIONNAIRE OF THE DIETARY ADHERENCE AMONG

TYPE 2 DIABETES PATIENTS

WITH NUTRITION INTERVENTION

By

Shannon B. Denney

A thesis
submitted to the Faculty of D'Youville College
Division of Academic Affairs
in partial fulfillment of the requirements
for the degree of

Master of Science

in

Dietetics

Buffalo, NY

April 8, 2009
 UMI Number: 1465914

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 Dietary Adherence

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Copyright © 2009 by Shannon B. Denney. All rights reserved. No part of

this thesis may be copied or reproduced in any form or by any means without
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 Dietary Adherence

in

THESIS APPROVAL

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on

April 8, 2009
 Dietary Adherence

iv

Abstract

The purpose of this study was to determine whether there was a significant

difference in dietary adherence of adult type 2 diabetic patients after receiving

two or more nutrition education sessions from a Registered Dietitian compared to

adult type 2 diabetic patients after receiving no education or a single nutrition

education session. The Pathophysiology and Care Management Algorithm of

Type 2 Diabetes Mellitus provided a conceptual framework and the dietary

adherence was obtained using an adapted version of The Summary of Diabetes

Self-Care Activities questionnaire. The results indicate a statistically significant

difference (p = 0.02) in dietary adherence between the two groups (n =33),

determined by a /-test comparing the mean number of responses on diet questions

for each group. This study and corresponding research indicate there is greater

dietary adherence with more nutrition intervention from a Registered Dietitian.

 Dietary Adherence

Table of Contents

List of Tables vii

List of Figures viii
List of Appendices ix

Chapter

I. INTRODUCTION 1

Statement of Purpose 3
Conceptual Framework 3
Significance and Justification 6
Assumptions 9
Research Questions 9
Definitions of Terms 10
Variables 12
Limitations 12
Summary ; 13

II. REVIEW OF THE LITERATURE 14

Introduction 14
Overview of Diabetes 14
Prevalence of Diabetes 16
Diabetes Nutrition Intervention
Treatment and Prevention of Diabetes
Overview 17
MNT Goals . 18
Carbohydrates 20
Tools for Glycemic Control 21
Sweeteners and Fiber 22
Protein 23
Fat 25
Energy Balance and obesity..... 26
Micronutrients 28
Complications 29
Prevention 33
Standards of Practice and Professional Performance 34
Introduction 34
 Dietary Adherence

vi

Nutrition Assessment 36
Nutrition Diagnosis 38
Nutrition Intervention 38
Nutrition Monitoring and Evaluation 40
Provision of Services 41
Application of Research 41
Communication and Application of Knowledge 42
Utilization and Management of Resources 43
Quality in Practice 43
Continued Competence and
Professional Accountability 44
Effectiveness of MNT 44
Outcomes for Adults with Type 2 Diabetes 44
Cost-effectiveness of MNT 52
Measurement Tool 54
Diabetes Self-Care Activities Questionnaire 54
Summary 60

III. PROCEDURES 62

Introduction 62
Setting 62
Population and Sample 62
Data Collection Methods 63
Human Rights Protection 65
Tools 66
Treatment of Data 67
Summary 69

References 71

IV. Article 81
References 108
Tables 113

Appendices 117
 Dietary Adherence

vii

List of Tables

Demographic Description of the Sample (N= 33) 113

Means and Standard Deviations for the Diet Score and Exercise
Score of each Group (7V=33) 114

Descriptive Statistics on Diabetes Self-Care Activities Advised to

Follow by the Patients' Health Care Professional (JV = 33) 115

Descriptive Statistics on the Barriers or Problems to Diet, Exercise,

and Blood Glucose Testing (N= 33) 116
 Dietary Adherence

viii

List of Figures

Figure

1. Pathophysiology and Care Management Algorithm: Type 2 Diabetes

Mellitus 4
 Dietary Adherence

ix

List of Appendices

Appendix

A Letter of Permission for Copy writed Conceptual Framework 117

B Questionnaire 119

C Letter of Approval from IRB 126

D Letter to Diabetes Outpatient Facility Requesting Permission 128

E Letter of Permission from Diabetes Outpatient Facility 131

F Cover Letter 133

 Dietary Adherence

CHAPTER I

INTRODUCTION

The prevalence of nutrition and lifestyle related diseases such as type 2

diabetes and obesity has dramatically increased and there is a major need for

reviewing current treatment strategies. Medical nutrition therapy is supported by

scientific evidence to manage diabetes and to reduce the complications of the

disease (Kulkarni et al., 2005). More than 18.5 million Americans have diabetes,

with 1.3 million new cases diagnosed annually (Kulkarni et al., 2005). Diabetes is

the sixth leading cause of death in the United States as stated by the American

Dietetic Association (Kulkarni et al, 2005). Many individuals are unaware they

have diabetes and many others living with diabetes have not received proper care

to manage their disease.

Nutrition education is a vital component of high-quality diabetes care.

One of the goals of Healthy People 2010 is to increase to 60% the proportion of

individuals with diabetes who receive formal diabetes education (Norris,

Engelgau, & Venkat Narayan, 2001). The American Dietetic Association and the

American Diabetes Association have developed standards of practice in diabetes

care, nutrition related recommendations, and principles for the treatment and the

prevention of diabetes and related complications (Bantle et al., 2008; Kulkarni et

 Dietary Adherence

al., 2005). Registered Dietitians have an important role of incorporating their

specialized knowledge and skills into quality nutrition education on diabetes and

to encourage proper self-management of their disease.

Health status can be examined to determine the effectiveness of nutrition

education. Studies have established that healthful diets and physical activity

improve glycemic control and insulin sensitivity in persons with type 2 diabetes

(Lemon et al., 2004). Examples of the health status outcome variables that can be

monitored are body weight, body mass index (BMI), blood glucose levels,

duration of high blood glucose levels, hemoglobin A1C, total cholesterol, and

triglycerides. These clinical outcomes have been shown to improve with diet and

exercise intervention.

In this study, the researcher attempted to determine the dietary adherence

among type 2 diabetic patients after two or more nutrition education sessions from

a Registered Dietitian compared to the dietary adherence of type 2 diabetic

patients after a single nutrition education session. The researcher expected to find

a significant difference in the dietary adherence of the adult type 2 diabetic

patients after two or more nutrition education sessions from a Registered Dietitian

compared to the adult type 2 diabetic patients with a single nutrition education

session from a Registered Dietitian. The significant difference would be in favor

of type 2 diabetic patients receiving two or more nutrition education sessions with

a Registered Dietitian.
 Dietary Adherence

Statement of Purpose

The purpose of this study was to determine whether there was a significant

difference in dietary adherence of adult type 2 diabetic patients after receiving

two or more nutrition education sessions from a Registered Dietitian compared to

adult type 2 diabetic patients after receiving a single nutrition education session.

This analysis was conducted via a questionnaire.

Conceptual Framework

The conceptual framework for this study was based on the

Pathophysiology and Care Management Algorithm of Type 2 Diabetes Mellitus,

developed by Anderson and Garner (2000) and presented in Krause 's Food and

Nutrition Therapy (p.770). The Pathophysiology and Care Management

Algorithm of Type 2 Diabetes Mellitus describes the process of etiology,

pathophysiology, and management of type 2 diabetes Mellitus (Figure 1).

Anderson and Garner used this algorithm to describe the causes of type 2

diabetes, symptoms commonly found in clinical practice, and the proper medical

and nutrition management.

The Pathophysiology and Care Management Algorithm of Type 2

Diabetes Mellitus has three stages in the process: etiology, pathophysiology, and

management. The etiology of type 2 diabetes includes genetic factors, risk factors,

environmental factors, and intake of excessive calories. The risk factors include
 Dietary Adherence

'••>."*{:

, Type 2 Diabetes Mellitus

. . • ' • •' ••• • ••••• i •' •••

• i. .,
1
• ' • • • • • - . • I . • , • : ; . : . . . . . . . . . . . . . i -. . "i> i - •
• • ' • . ' i . I;I . 1

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Algorithm content devetoped by John J B. Anderson, PhD, and Sanford C Garner, PhD, 2000. Updated by Marion J Franz, MS, RD,
LO CDE. 2006

Figure 1

Pathophysiology and Care Management Algorithm: Type 2 Diabetes Mellitus.

Note: used with permission (Appendix A).

 Dietary Adherence

physical activity, older age, and obesity. The pathophysiology involves clinical

findings and symptoms (variable). The clinical findings include abnormal pattern

of insulin secretion and action, decreased cellular uptake of glucose and

increased postprandial glucose, and increased release of glucose by liver

(gluconeogenesis) in early morning hours. The variable symptoms include

hyperglycemia, excessive thirst, frequent urination, polyphagia, and weight loss.

The medical management describes the diagnosis, monitoring, and

medication. The medical diagnosis includes fasting serum glucose greater than

126 mg/dl, nonfasting glucose greater than 200 mg/dl (with symptoms), and oral

glucose tolerance test greater than 200 mg/dl. Blood glucose and A1C testing are

monitored after diagnosis. The medications that can be taken for type 2 diabetics

include sulfonylureas, non-sulfonylurea secretagogues, biguanides, alpha-

glucosidase inhibitors, thiazolidinediones, and incretins.

Nutrition management includes lifestyle strategies, nutrition education,

energy restriction to promote 5%-10% weight loss, and blood glucose monitoring

to determine adjustments in food or medications. The lifestyle strategies can

include food/eating and physical activity. Nutrition education is based on

carbohydrate counting and fat modification. The Pathophysiology and Care

Management Algorithm of Type 2 Diabetes Mellitus describes the etiology,

pathophysiology, and management of type 2 diabetes.

 Dietary Adherence

This conceptual framework was appropriate for this study because it

provided a model to determine how diabetic patients are diagnosed and monitored

and the methods of nutrition management. This model shows nutrition education

as an intervention for treatment of type 2 diabetes. This study supported the use

nutrition education on helping manage diabetes by monitoring dietary adherence

to a consistent carbohydrate diet. This model illustrates that health can be

monitored through blood glucose and A1C testing. Body weight, BMI, duration of

high blood glucose, cholesterol, and triglycerides are also monitored in diabetes

patients to prevent further complications. The model explains how healthcare

professionals determine the etiology of the disease, diagnosis based on symptoms

and clinical findings, and how a Registered Dietitian can manage their disease

nutritionally.

Significance and Justification

Medical nutrition therapy is essential in the management and prevention of

further complications in diabetes. Medical nutrition therapy (MNT) has been

beneficial for persons with type 2 diabetes as evidenced by significant

improvements in medical and clinical outcomes. This included significant

improvements in glucose control (fasting blood glucose (FBG) and hemoglobin

A1C (HbAlC) levels), serum cholesterol level, and weight (Franz et al., 1995a).

The Diabetes Control and Complications Trial (DCCT) determined that intensive

therapy effectively delays the onset and slows the progression of diabetic
 Dietary Adherence

retinopathy, nephropathy, and neuropathy in patients with Type 1 Diabetes (The

Diabetes Control and Complications Trial Research Group, 1993). This influential

and comprehensive study showed that keeping blood glucose levels as close to

normal as possible slows the onset and progression of complications of diabetes.

This study has paved the way for research in treatment of diabetes. Evidenced-

based nutrition principles and recommendations for treatment and prevention of

diabetes and further complications have been established due to the DCCT trials.

Medical nutrition therapy has been shown to be cost effective. Each year

92 billion dollars are spent on health care for person with diabetes. Franz et al.

(1995b) found that "If net costs are considered (per-patient costs - cost savings

due to therapy changes), the cost-effective ratios become $5.32 for Basic Care and

$4.20 for Practice Guideline Care, assuming the medical changes in therapy was

maintained for 12 months" (p. 1018). In the Practice Guideline group, the

subjects yielded an average 12-month cost savings of $31.49 and $3.13 cost

savings in the Basic Care group (Franz et al,, 1995b). The DCCT trials indicated

that new strategies are needed to adapt methods of intensive treatment for use in

the general community at less cost and effort (The Diabetes Control and

Complications Trial Research Group, 1993). Franz et al. (1995a) reported that it

was not possible to determine what specific nutrition or exercise strategies

correlate most closely with improved glycemic control.

 Dietary Adherence

This study may help identify greater dietary adherence of patients with

type 2 diabetes with more nutrition intervention, two or more education sessions,

with a Registered Dietitian. This may support the effectiveness of nutrition

education by determining a significant difference in the dietary adherence in type

2 diabetic patients after two or more education sessions compared to a single

nutrition education session with a Registered Dietitian. The DCCT trials and the

American Dietetic Association have demonstrated the need for further research in

specific nutrition strategies for treatment and prevention of complications in type

2 diabetes. Diabetes Care has stated the need for research in the area of increasing

adherence and long-term success of intervention strategies for sustained lifestyle

change within their evidence-based nutrition principles and recommendations

(Franz et al., 2002). There also is a need for further research in clinical

intervention trials utilizing evidence-based guides to link nutrition intervention to

outcomes (Lemon et al, 2004).

Through a review of medical records, clinical outcomes were measured to

show an improvement in health in type 2 diabetes patients (Lemon et al, 2004).

Further research to identify the predictors and correlates of glycemic control

needs to be implemented because knowledge levels and self-monitoring blood

glucose levels do not correlate well with blood glucose (Norris et al., 2001). More

research of high methodological quality in diverse study populations and settings

and using generalizable interventions is needed to assess the effectiveness of self-

 Dietary Adherence

management interventions on sustained glycemic control, cardiovascular disease

risk factors, microvascular and cardiovascular disease and quality of life (Norris

et al., 2001). In the study by Franz et al. (1995a), it was not possible to determine

what specific nutrition or exercise strategies correlate most closely with improved

glycemic control. A further study associating variables with improved glucose

control needs to be undertaken (Franz et al., 1995a). This study can support the

effectiveness of nutrition education with a Registered Dietitian in type 2 diabetic

patients through dietary adherence after at least two education sessions compared

to type 2 diabetic patients with a single nutrition education session.

Assumptions

For the purpose of this study, the following assumptions hold:

1. The participants in the study accurately and honestly responded to the

questionnaire.

3. The questionnaire accurately reflected dietary intakes and lifestyle

patterns of the subjects.

Research Questions

The research questions answered in this study were:

1. Was there a significant difference between the dietary adherence of

adult patients with type 2 diabetes after two or more nutrition education sessions

with a Registered Dietitian compared to the dietary adherence of adult patients

 Dietary Adherence

10

with type 2 diabetes after a single nutrition education session with a Registered

Dietitian based on self-reported data in a questionnaire?

Definitions of Terms

The terms in the research questions were defined theoretically and

operationally.

Adult Patients

Theoretical definition: fully developed and mature. Operationally defined

as subjects aged at least 20 years old based on the age requirement in a study by

Lemon et al. (2004) monitoring outcomes after nutrition intervention in adults

with type 2 diabetes. This age group was used based on sufficient cognitive

awareness to participate.

Consistent Carbohydrate Diet

Theoretical definition: to have a steady amount of carbohydrates in the

diet. Operationally defined as a diet that provides a constant amount of

carbohydrates at each meal with the use of a variety of starches (Franz et al.,

2002). The constant amount of carbohydrates at meals for the subjects of this

study was measured by question 15 on the questionnaire (Appendix B).

Dietary Adherence

Theoretical definition: to hold or maintain a specific diet.

Operationally defined as the maintenance to a consistent carbohydrate diet used

by diabetic patients according to current standards of the American Dietetic

 Dietary Adherence

11

Association (Franz et al., 2002). Dietary adherence was measured by the

Summary of Diabetes Self-care Activities questionnaire (Toobert, Hampson, &

Glasgow, 2000). Dietary adherence was measured by the mean number of days

from the diet questions asking the frequency of the specific diet recommendations

followed for each subject group. The two groups were compared using an

independent sample Mest to determine whether there was a significant difference

in dietary adherence.

Nutrition Education

Theoretically and operationally defined as a formal process to instruct or

train a patient/client in a skill or to impart knowledge to help patients/clients

voluntarily manage or modify food choices and eating behavior to maintain or

improve health (American Dietetic Association, 2009).

Registered Dietitian

Theoretically and operationally defined as a professional trained in foods

and the management of diets (dietetics) who is credentialed by the Commission

on Dietetic Registration of the American Dietetic Association. Credentialing is

based on completion of a BS or MS degree from an ADA approved dietetic

program and passing a registration examination (Mosby, 2006).

Type 2 Diabetes

Theoretically and operationally defined as a form of diabetes mellitus that

develops especially in adults and most often in obese individuals and that is
 Dietary Adherence

12

characterized by hyperglycemia resulting from impaired insulin utilization

coupled with the body's inability to compensate with increased insulin production

(Merriam-Webster Dictionary, 2005).

Variables

The independent variable is nutrition education by a Registered Dietitian.

The dependent variable is dietary adherence.

Limitations

The following were some of the limitations associated with this study:

1. This study took place in only one geographical location: Buffalo, New

York.

2. The small sample size may have limited findings from being applicable

to all type 2 diabetic patients.

3. Findings from this study may not be applicable to all type 2 diabetic

patients because the sample is one of convenience.

4. This study utilizes self-reported data for dietary adherence subject to

human error of recalling information.

5. The Diabetes Self-Care Activities Questionnaire was adapted by

removing sections which do not pertain to this study and may affect the validity

and reliability found with the original questionnaire.

 Dietary Adherence

13

Summary

This chapter has discussed type 2 diabetes as an increasing nutrition-

related disease and that review of current treatment strategies is needed. This

study attempted to determine a significant difference in dietary adherence among

adults with type 2 diabetes after two or more nutrition education sessions with a

Registered Dietitian when compared to the adults with type 2 diabetes after a

single nutrition education session with a Registered Dietitian. The

Pathophysiology and Care Management Algorithm of Type 2 Diabetes Mellitus

was used as the conceptual framework. The framework stated the process of

etiology, pathophysiology and nutrition and medical management of type 2

diabetes mellitus. Medical nutrition therapy (MNT) has been proven to result in

significant improvements in medical and clinical outcomes and beneficial for

persons with type 2 diabetes and to be cost effective method of treatment. This

study made assumptions regarding honesty of subjects and the questionnaire

accurately reflected dietary intakes and lifestyle. Terms unfamiliar to the reader

were defined, theoretically and operationally. The independent variable included

nutrition education by a Registered Dietitian and the dependent variable was

dietary adherence. Limitations included the use of a single geographic area, small

sample size, convenient sample, and use of self-reported data. The following

chapter discusses the review of the literature.

 Dietary Adherence

14.

CHAPTER II

REVIEW OF THE LITERATURE

Introduction

Through an extensive review of the literature, the need for medical

nutrition therapy (MNT) to reduce the complications of diabetes and manage the

disease is strongly supported. MNT has been proven to result in significant

improvements in clinical outcomes and has also been proven to be beneficial for

persons with type 2 diabetes. This is the reason for the evolution of nutrition

therapy of type 2 diabetes. There is a need for research in the area of increasing

adherence and long-term success of intervention strategies for sustained lifestyle

change within evidence-based nutrition principles and recommendations. It was

evident from the literature that medical nutrition therapy is effective and cost-

effective.

Overview of Diabetes

Diabetes Mellitus is a group of diseases characterized by high blood

glucose concentrations resulting from defects in insulin secretion and/or insulin

action. Persons with diabetes have bodies that do not produce or respond to

insulin, a hormone produced by the beta cells of the pancreas that is necessary for

the use or storage of body fuels (Mahan & Escott-Stump, 2008). Hyperglycemia,
 Dietary Adherence

15

or elevated blood glucose, occurs with ineffective insulin production and it can

lead to serious complications and premature death.

There are two types of Diabetes Mellitus: Type 1 and Type 2. Type 1

accounts for 5% to 10% of all diagnosed cases of diabetes (Centers for Disease

Control and Prevention (CDC), 2008; Mahan & Escott-Stump, 2008). Type 1

diabetes is insulin-dependent with the primary defect of pancreatic beta-cell

destruction (Mahan & Escott-Stump, 2008). The risk factors for type 1 diabetes

may be autoimmune, genetic, or environmental and there is no known prevention

(CDC, 2008). Type 2 diabetes is non-insulin dependent and it results from a

combination of insulin resistance and beta cell failure. Insulin resistance is

decreased tissue sensitivity or responsiveness to insulin. When the cells do not

utilize insulin properly, the blood glucose rises. The need for insulin to lower

blood glucose levels is greater and the pancreas gradually loses the ability to

produce it (CDC, 2008). Type 2 diabetes results from a combination of genetic

predisposition and risk factors such as behavioral and environmental.

Type 2 diabetes accounts for 90% to 95% of all diagnosed cases of

diabetes (CDC, 2008; Mahan & Escott-Stump, 2008). Type 2 diabetes is

associated with older age, obesity, family history of diabetes, history of

gestational diabetes, impaired glucose metabolism, physical inactivity, and

race/ethnicity. Gestational diabetes is a form of glucose intolerance diagnosed in

some women during pregnancy (CDC, 2008). The complications of diabetes

 Dietary Adherence

16

include macrovascular diseases, microvascular diseases, and neuropathy. Type 2

diabetes can be controlled by medical nutrition therapy (MNT).

Prevalence of Diabetes

Diabetes and its complications are a significant cause of morbidity and

mortality in the U.S. Diabetes is the seventh leading cause of death in the United

States, which is likely underreported (CDC, 2008). Only about 35 to 40 percent of

decedents with diabetes had it listed anywhere on the death certificate and only

about 10 to 15 percent had it listed as the underlying cause of death (CDC, 2008).

Approximately 90% of those diagnosed with diabetes in the United States have

type 2 diabetes. The prevalence of diagnosed diabetes for U.S. adults greater than

or equal to 20 years of age has increased to 23.5 million from 10.2 million people

(CDC, 2008; Harris et al., 1998). The prevalence of impaired fasting glucose

(100-125 mg/dL) was 57 million in 2007 compared to 29 million in 1998 (CDC,

2008; Harris et al., 1998). According to NHANES II and NHANES III,

prevalence of diabetes increased from 8.9% in the years 1976-1980 to 12.3% in

the years 1988-1994 who are 40-74 years of age (CDC, 2008; Harris et al, 1998).

There is more recent data for impaired fasting glucose but not for impaired

glucose tolerance (140-199 mg/dL). Diabetes now affects nearly 23.7 million

Americans and more than 5.7 million are undiagnosed (CDC, 2008).

Type 2 diabetes is associated with particular ethnicities and age. The

races/ethnicities that are at high risk for type 2 diabetes and its complications
 Dietary Adherence

17

include African Americans, Hispanic/Latino Americans, American Indians, Asian

Americans and Native Hawaiians or other Pacific Islanders (CDC, 2008)

"Clinically-based reports and regional studies suggest that Type 2 diabetes in

children and adolescents is being diagnosed more frequently, particularly in

American Indians, African Americans, and Hispanic/ Latino Americans" (CDC,

2008, p.l). There are 12.2 million people in the age group of 60 years or older

have diabetes. Men account for 12 million and women account for 11.5 million

people with diabetes in the age group of 20 years or older (CDC, 2008).

Diabetes Nutrition Intervention

Treatment and Prevention of Diabetes

Overview

The American Dietetic Association and the American Diabetes

Association both have published nutrition therapy recommendations but use

different processes for their development. The American Dietetic Association

evidence-based nutrition practice guidelines are developed based on a four-phase

systematic process for identifying, analyzing, and synthesizing scientific evidence

(Franz, Boucher, Green-Pastors, & Powers, 2008). The American Diabetes

Association uses an evidence-grading system different than American Dietetic

Association by assigned ratings of A, B, or C, depending on the quality of

evidence (Franz et al., 2008). The recommendations for the American Dietetic

Association first describe "what to do" and then state "why." The
 Dietary Adherence

18

recommendations are rated as Strong, Fair, Weak, Consensus, or Insufficient

evidence and as conditional or imperative statements.

MNT Goals

The American Diabetes Association nutrition principles and

recommendations attempted to define an ideal nutrition diet order that would

apply to people with diabetes. The goal of nutrition intervention is to assist and

facilitate individual lifestyle and behavior changes that will lead to improved

metabolic control (Franz et al., 2002). The goals of MNT in the 2008

recommendations are to decrease the risk of diabetes and cardiovascular disease

by promoting healthy food choices and physical activity leading to moderate

weight loss that is maintained (Bantle et al., 2008). It sets recommendations for

carbohydrates, protein, dietary fat, energy balance and obesity, micronutrients,

acute complications, and prevention.

The goals of MNT established by the American Diabetes Association

apply to all persons with diabetes. These goals should be established during

nutrition education sessions between the Registered Dietitian and the patient with

diabetes or at risk for diabetes. These goals are to attain and maintain optimal

metabolic outcomes, including blood glucose levels in the normal range or as

close to normal as is safely possible to prevent or reduce the risk for

complications of diabetes. It also includes a lipid and lipoprotein profile that

reduces the risk for macrovascular disease and blood pressure levels that reduce
 Dietary Adherence

19

the risk for vascular disease (Bantle et al., 2008; Franz et al., 2002). The second

goal for all persons with diabetes is to prevent, or at least slow, the rate of

development of chronic complications of diabetes by modifying nutrient intake

and lifestyle as appropriate for prevention and treatment of obesity, dyslipidemia,

cardiovascular disease, hypertension, and nephropathy. The third goal is to

address individual nutritional needs, taking into consideration personal and

cultural preferences and lifestyle while respecting the individual's wishes and

willingness to change (Bantle et al., 2008; Franz et al., 2002). The fourth goal is

to maintain the pleasure of eating by only limiting food choices when indicated by

scientific evidence (Bantle et al., 2008). These four goals pertain to all individuals

with diabetes.

The American Diabetes Association also developed goals of MNT that

apply to specific situations. These include youth with type 1 diabetes, youth with

type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to

meet the nutritional needs of these unique times in the life cycle (Bantle et al.,

2008). For youth with type 2 diabetes, the goal is to facilitate changes in eating

and physical activity habits that reduce insulin resistance and improve metabolic

status. For individuals being treated with insulin or insulin secretagogues, the goal

is to provide self-management education for treatment (and prevention) of

hypoglycemia, acute illnesses, and exercise-related blood glucose problems

(Bantle et al., 2008; Franz et al., 2002). Individuals who have pre-diabetes or
 Dietary Adherence

20

diabetes should receive individualized MNT; such therapy is best provided by a

registered dietitian familiar with the components of diabetes MNT (Bantle et al.,

2008). Nutrition education should be sensitive to the personal needs, willingness

to change, and ability to make changes of the individual with pre-diabetes or

diabetes (Bantle et al., 2008). The goals of MNT pertain to specific situations and

recommendations for effective MNT practices.

Carbohydrates

Carbohydrate recommendations were made for persons with type 2

diabetes. Carbohydrates should be referred to the preferred terms: sugars, starch

and fiber instead of the use of poorly defined terms such as simple sugars,

complex carbohydrates, and fast-acting carbohydrates. Carbohydrate and

monounsaturated fat should together provide 60-70% of energy intake.

Percentages of carbohydrate should be based on individual nutrition assessment.

An individual's metabolic profile and need for weight loss should be considered

when determining the monounsaturated fat content of the diet because increasing

fat intake may result in increased energy intake (Franz et al., 2002). Substituting

saturated fats in the diet with monounsaturated fats can improve insulin sensitivity

but has no effect on insulin secretion (Vessby et al., 2001). This study with 162

healthy subjects showed that the beneficial outcome of improved insulin

sensitivity was not seen in individuals with a high fat intake (Vessby et al., 2001).

Foods containing carbohydrate from whole grains, fruits, vegetables, and low-fat
 Dietary Adherence

21

milk should be included encouraged for good health (Bantle et al., 2008, Franz et

al., 2002). In individuals with type 2 diabetes, postprandial glucose levels and

insulin responses to a variety of starches and sucrose are similar if the amount of

carbohydrate is constant.

Tools for Glycemic Control

There are tools to achieve glycemic control such as carbohydrate counting,

carbohydrate exchanges, and the glycemic index. With regard to the glycemic

effect of carbohydrates, the total amount of carbohydrate in meals or snacks is

more important than the source or type (Sheard et al., 2004). The glycemic index

is a measure of the rate at which an ingested food causes the level of glucose in

the blood to rise (Merriam-Webster, 2005). The glycemic index of a food is the

increase above fasting in the blood glucose area over 2 hours after ingestion of a

constant amount of that food divided by the response to a reference food (Bantle

et al, 2008; Sheard et al, 2004). Monitoring carbohydrate, whether by

carbohydrate counting, exchanges, or experienced-based estimation, remain a key

strategy in achieving glycemic control. The use of glycemic index and load may

provide a modest additional benefit over that observed when total carbohydrate is

considered alone (Sheard et al., 2004). A Registered Dietitian can evaluate which

tool is best for their patient based on current research and efficiency of use by

their patient.
 Dietary Adherence

22

Sweeteners and Fiber

Sucrose and sucrose containing foods do not need to be restricted by

people with diabetes because they do not increase glycemia to a greater extent

than isocaloric amounts of starch (Bantle et al., 2008). Sucrose should be

substituted for other carbohydrate sources or covered with insulin or other

glucose-lowering medication (Bantle et al., 2008). Care should be taken to avoid

excess energy intake. As with the general population, consumption of fiber is to

be encouraged but there is no reason to recommend that people with diabetes

consume higher amounts of fiber than other Americans (Bantle et al., 2008; Franz

et al., 2002). Studies have suggested that high fiber diets can reduce postprandial

glycemia and have cholesterol-lowering effects. One study compared a diet

containing 24 grams of fiber per day to a diet containing 50 grams of fiber per day

found that the intake of food high in dietary fiber improved glycemic control,

reduced hyperinsulinemia, and decreased plasma lipids (Chandalia et al., 2000).

Potential barriers for high fiber intakes include palatability, limited food choices,

and gastrointestinal side effects (Bantle et al., 2008; Chandalia et al., 2000). It is

recommended that patients with diabetes be encouraged to achieve fiber intake

goals set for the general population of 14 grams per 1,000 kcal (Bantle et al.,

2008). There are specific carbohydrate recommendations for the secondary

prevention of controlling diabetes.

 Dietary Adherence

23

Protein

It is recommended that the usual intake of protein (15-20%) is the same

for all persons regardless of whether they have diabetes. The average energy

intake of 15-20% in the United States is fairly consistent from infants to the

elderly and appears to be similar in people with diabetes (Franz et ah, 2002).

Therefore, the usual protein intake does not need to be modified as long as renal

function is normal (Bantle et ah, 2008; Franz et ah, 2002). In individuals with

type 2 diabetes, ingested protein can increase insulin responses without increasing

plasma glucose concentrations. Therefore, protein should not be used to treat

acute or prevent nighttime hypoglycemia (Bantle et ah, 2008). Individuals with

controlled diabetes have no increase in blood glucose concentration when

ingesting protein. Protein is just as potent a stimulant of insulin secretion as

carbohydrate (Franz et ah, 2002; Gannon, Nuttal, Damberg, Gupta, & Nuttal,

2000). A study reported that during the 8 hour period after subjects with type 2

diabetes ingested 50 grams of protein in the form of very lean beef, about 20 to 23

grams of protein were deaminated, which would yield about 11 to 13 grams of

glucose according to biochemical pathways (Gannon et ah, 2000). The study

found only 2 grams of glucose were in circulation. This confirms that ingested

protein does not result in a significant increase in glucose concentration (Gannon

et ah, 2000). The protein requirement may be greater than the Recommended

Dietary Allowance (RDA) but not greater than usual intake for individuals with
 Dietary Adherence

24

diabetes and especially those that are not in optimal glucose control. The long-

term effects of diets high in protein and low in carbohydrate are unknown. A

small, short-term study in diabetes suggests that diets with protein content >20%

of total energy reduce glucose and insulin concentrations, reduce appetite and

increase satiety (Gannon & Nuttall, 2004). A high protein/ low carbohydrate diet

ingested for 5 weeks reduced the circulating glucose concentration in people with

untreated type 2 diabetes (Gannon & Nuttall, 2004). Serum insulin was decreased,

glucagon was increased, and serum cholesterol was unchanged. Another study

concluded diets that are high in carbohydrate and low to moderate in fat tend to be

lower in energy (Kennedy, Bowman, Spence, Freedman, & King, 2001). The

Continuing Survey of Food Intake by Individuals 1994-1996 was used to examine

popular diets. In a comparison of low-carbohydrate diets (<30% of energy from

carbohydrate [high protein diets] and high-carbohydrate diets (>55% of energy

from carbohydrate), diet quality was lower and total and saturated fat intake was

higher on the lower carbohydrate diet (Kennedy et al., 2001). The BMIs were

significantly lower for men and women on the high carbohydrate diet; the highest

BMIs were noted for those on a low carbohydrate diet (Kennedy et al., 2001).

High protein and low carbohydrate diets may produce short-term weight loss and

improved glycemia but it has not been established that weight loss is maintained

long-term, and the long-term effects on kidney function are unknown (Bantle et

al., 2008; Franz et al, 2002). The long-term effect of such diets on plasma LDL
 Dietary Adherence

25

cholesterol is also a concern. Protein intake for persons with diabetes should be

similar to the protein intake for all persons.

Fat

The primary goal for dietary fat intake in persons with diabetes is to limit

the intake of saturated fat and cholesterol. Saturated fat is the principal dietary

determinant of LDL cholesterol. Individuals with diabetes have an increased risk

of coronary heart disease with higher intakes of dietary cholesterol. Fish

consumption is associated with a reduced risk from all-cause, ischemic heart

disease and stroke mortality across 36 countries (Kris-Etherton, Harris, & Appel,

2002). Men who ate at least some fish weekly had a lower coronary heart disease

morality rate than that of men who ate none (Kris-Etherton et al., 2002). The

goals for patients with diabetes regarding fat intake is the same for individuals

with cardiovascular disease (Bantle et al., 2008). This limits the intakes of

saturated fat to <7% of total calories which is the same for individuals with high

LDL cholesterol (> 100 mg/dl) (Bantle et al., 2008). The recommendation for

dietary cholesterol is the same for individuals with high LDL cholesterol of < 200

mg/day. The intake of transunsaturated fatty acids should be minimized.

Decreasing saturated fatty acids and increasing monounsaturated fatty acids have

been found to improve insulin sensitivity (Vessby et al., 2000). A 10 week study

resulted in insulin sensitivity and plasma low density lipoprotein cholesterol

concentrations improved with the diet rich in polyunsaturated fatty acids

 Dietary Adherence

26

compared with the diet rich in saturated fatty acids (Summers et al., 2002). There

was a decrease in abdominal subcutaneous fat area (Summers et al., 2002). Two

or more servings of fish per week provide n-3 polyunsaturated fatty acids and are

recommended (Bantle et al., 2008; Kris-Etherton et al., 2002). In addition to

providing n-3 fatty acids, fish frequently displace high-saturated fat containing

foods form the diet (Kris-Etherton et al., 2002). The energy derived from

saturated fat can be reduced if weight loss is desirable or replaced with either

carbohydrate or monounsaturated fat if weight loss is not a goal. Fat intake should

be individualized and appropriate for ethnic and cultural backgrounds.

Energy Balance and Obesity

Many individuals with type 2 diabetes are overweight, with about 36%

having a BMI of greater than 30 kg/m , which would be considered obese. With

the effects of obesity on insulin resistance, weight loss is an important MNT goal

for obese individuals with type 2 diabetes. In insulin-resistant individuals, reduced

energy intake and modest weight loss improved insulin resistance and glycemia in

short-term (Franz et al, 2002). Weight loss is recommended for all such

individuals who have or are at risk for diabetes (Bantle et al., 2008). Dietitian-led

lifestyle case management resulted in greater weight loss, reduced waist

circumference, reduced HbAic level, less use of prescription mediations, and

improved health-related quality of life compared with usual care (Wolf et al.,

2004). For weight loss, either low-carbohydrate or low-fat calorie-restricted diets

 Dietary Adherence

27

may be effective in the short term (up to 1 year). For patients on low-carbohydrate

diets, monitor lipid profiles, renal function, and protein intake (in those with

nephropathy), and adjust hypoglycemic therapy as needed (Bantle et al., 2008).

Weight loss can improve blood glucose levels and reduce risk for further

complications in obese patients with type 2 diabetes.

Many interventions can help with weight loss such as lifestyle changes in

diet and exercise, medications and surgery. Structured programs that emphasize

lifestyle changes can produce long-term weight loss of 5-7% of starting weight

(The Diabetes Prevention Program Research Group, 1999). The lifestyle changes

include education, reduced fat (less than 30% of daily energy) and energy intake,

regular physical activity, and regular participant contact (The Diabetes Prevention

Program Research Group, 1999). The Diabetes Prevention Program (DPP)

participants received training in diet, exercise, and behavior modification from

case managers who met with them for at least 16 sessions in the first 24 weeks

and monthly thereafter (The Diabetes Prevention Program Research Group,

1999). Physical activity and behavior modification are important components of

weight loss programs and are most helpful in maintenance of weight loss (Bantle

et al., 2008). Reduction in the incidence of diabetes was directly associated with

changes in lifestyle (Tuomilehto et al., 2001). The cumulative incidence of

diabetes after four years was 11 percent in the intervention group and 23 percent

in the control group. The intervention group also lost more weight than the control
 Dietary Adherence

28

group (Tuomilehto et al., 2001). Weight loss medications may be considered in

the treatment of overweight and obese individuals with type 2 diabetes and can

help achieve a 5-10% weight loss when combined with lifestyle modification.

Bariatric surgery may be considered for some individuals with type 2 diabetes and

BMI > 35 and can result in marked improvements in glycemia (Bantle et al.,

2008). The long-term benefits and risk of bariatric surgery individuals with pre-

diabetes or diabetes continue to be studied.

Micronutrients

Micronutrients prevent deficiency diseases and are important in

maintaining the health of patients with diabetes when taken in the range of

Dietary Reference Intake (DRI). Individuals with diabetes should be educated

about the importance of acquiring daily vitamin and mineral requirements from

natural food sources, and about the potential toxicity of megadoses of vitamin and

mineral supplements. There is no clear evidence of benefit from vitamin or

mineral supplementation in people with diabetes who do not have underlying

deficiencies; exceptions are folate and calcium (Bantle et al., 2008; Franz et al.,

2002). The most frequent origin of deficiencies in micronutrients is an inadequate

diet and health care professionals should focus more on nutrition education rather

than micro nutrient supplementation to gain metabolic control of their patients

(Guerrero-Romero & Rodriguez-Moran, 2005). There has been an interest in

antioxidant therapy as a form of treatment because diabetes may be a state of

 Dietary Adherence

29

increased oxidative stress. Clinical trial data indicate the lack of benefit with

respect to glycemic control and progression of complications (Hasanain &

Mooradian, 2002). Clinical trial data also provide evidence of the potential harm

of vitamin E, carotene, and other antioxidant supplements and do not support the

use of antioxidant supplements for cardiovascular disease risk reduction

(Hasanain & Mooradian, 2002). Routine supplementation of the diet with

antioxidants, such as vitamins E and C and carotene, is not advised because of

uncertainties related to long-term efficacy and safety (Bantle et al., 2008; Franz et

al., 2002). Chromium, magnesium, and antioxidants are essential elements

involved in the action of insulin and energetic metabolism, and are without

serious adverse effects, but there is insufficient clinically based evidence for their

use in treatment in diabetes (Guerrero-Romero & Rodriguez-Moran, 2005). Long

term studies are still needed to evaluate the safety and beneficial role of these

supplements as complementary therapies in the management of type 2 diabetes

and therefore can not be recommended (Bantle et al., 2008; Guerrero-Romero &

Rodriguez-Moran, 2005). People with diabetes can receive adequate vitamins and

minerals from natural sources when eating an adequate diet.

Complications

There are evidenced based MNT goals for treating and controlling

diabetes complications (tertiary prevention), which include hypoglycemia,

hypertension, dyslipidemia, nephropathy, catabolic illness. Hypoglycemia is

 Dietary Adherence

30

falling blood glucose levels and can slow the blood glucose metabolism in the

brain leading to devastating effects on the brain and to death (Cryer, Davis, &

Shamoon, 2003). Hypoglycemia is mostly an issue for type 1 diabetics but can

also be an issue for type 2 diabetics taking insulin secretagogues. Changes in food

intake, physical activity, and medications can contribute to hypoglycemia.

Hypoglycemia can be treated by a glucose tablet, about 15-20 grams, or

carbohydrate in the form of juice, a soft drink, milk, crackers or a meal (Cryer et

al., 2003). The blood glucose may be only temporarily corrected for with 15-20

grams of ingested glucose (Cryer et al., 2003). Plasma glucose should be tested

again in 50 minutes, as additional treatment may be necessary (Bantle et al.,

2008). Proper treatment for hypoglycemia prevents damaging effects on the brain

and death.

MNT for the management of hypertension focuses on weight reduction

and reducing sodium intake. The Joint National Committee 7 recommendations

are consistent with guidelines form the American Diabetes Association, which has

also recommended that blood pressure in diabetics be controlled to levels of

130/80 mm Hg or lower (Chobanin et al., 2003). The goals should be to reduce

sodium intake to 2400 mg per day for normotensive and hypertensive individuals

with a diet high in fruits, vegetables, and low-fat diary products lowers blood

pressure (Bantle et al., 2008). Diets such as the DASH (Dietary Approaches to

Stop Hypertension) diet can be followed to prevent and manage progression of

 Dietary Adherence

31

micro and macrovascular complications of diabetes. The DASH diet emphasizes

fruits, vegetables, and low-fat diary products; included whole grains, poultry, fish,

and nuts; and was reduced in fats, red meats, sweets, and sugar-containing

beverages (Chobanin et al., 2003). In most individuals, a modest amount of

weight loss beneficially affects blood pressure. Another guideline from the

American Diabetes Association recommends target A1C is as close to normal as

possible without significant hypoglycemia (Bantle et al., 2008). Reducing sodium

and fat intake and weight loss can lower hypertension in people with diabetes.

Dysplipidemia, or abnormal lipid levels, is found in type 1 or 2 diabetes

patients. For persons with elevated plasma LDL-cholesterol, saturated fatty acids

and transunsaturated fatty acids should be limited to less than 10% and perhaps to

less than 7% of energy (Franz et al., 2002; Lichtenstein et al., 2006). For persons

with elevated plasma triglycerides, reduced HDL cholesterol, and small dense

LDL cholesterol (the metabolic syndrome), improved glycemic control, modest

weight loss, restricted intake of saturated fats, increased physical activity, and

incorporation of monounsaturated fats may be beneficial (Franz et al., 2002;

Lichtenstein et al., 2006). Obese individuals manifest dyslipidemia that persist

despite improved glycemic control and this dyslipidemia is strongly associated

with increased amount of abdominal fat. Dietary fat restriction and weight loss

will lead to decreased plasma triglycerides and a modest lowering of LDL

cholesterol. Regular physical activity also reduces plasma triglycerides and

 Dietary Adherence

32

improves insulin sensitivity (Franz et al., 2002). DASH diets, replacing saturated

fats with monounsaturated fats or carbohydrates have been shown to lower

cholesterol levels. Weight loss and decreased fat intake will lower dyslipidemia,

but lipid lowering medications can be used if goals for serum lip levels are not

achieved by lifestyle improvements.

Microalbuminuria predicts the later development of nephropathy in

persons with diabetes. End stage renal disease is usually the consequence of

nephropathy, or macroalbuminuria. In patients with microalbuminuria, reduction

of protein to 0.8 to 1.0 g/kg/body weight per day in individuals with diabetes and

the earlier stages of Chronic Kidney Disease and to 0.8 g/kg/body weigh per day

in the later stages of Chronic Kidney Disease may improve measures of renal

function and is recommended (Bantle et al., 2008; Franz et al, 2002). A study

determined that 0.8 g/ kg body weight/ day was the optimal protein content in

type 2 diabetic patients with microalbuminuria and a protein restriction of less

than 0.8 g/ kg body weight/ day was not necessary for patients at this stage of

diabetic nephropathy (Narita et al., 2001). This study showed that this optimal

protein content has been associated with slowing the decline in renal function

(Narita et al., 2001). Dyslipidemia may increase albumin excretion and the rate of

progression of diabetic nephropathy (Bantle et al., 2008). With the proper protein

restriction, the progression of diabetic nephropathy can be declined.

 Dietary Adherence

33

Catabolic disease states result in a change in body compartments that may

be characterized by an increased extracellular fluid compartment and an

associated shrinkage of body fat and body cell mass. The catabolic state is

induced by injury, inflammation, or severe illness. During catabolic illness,

careful and continuous monitoring of nutritional and glycemic status is critical to

ensure that increased nutritional needs are being met and that hyperglycemia is

prevented (Schafer et al., 2004). The energy needs of most hospitalized patients

can be met by providing 25-35 kcal/kg body weight (Schafer et al, 2004). Care

must be taken not to overfeed patients, because it can lead to hyperglycemia. For

patients with normal hepatic and renal function, protein needs are between 1.0 to

1.5 g/kg body weight; the higher end of the range being for more stressed patients

(Schafer et al., 2004). There are specific recommendations for complications of

diabetes.

Prevention

MNT can play a role in the prevention of diabetes in high-risk individuals

(primary prevention). Clinical trial data from both the Finnish Diabetes

Prevention Study (Tuomilehto et al., 2001) and the Diabetes Prevention Program

(Knowler et al, 2002) in the U.S. supported the potential for moderate weight loss

to reduce the risk for type 2 diabetes. Among individuals at high risk for

developing type 2 diabetes, structured programs that emphasize lifestyle changes

that include moderate weight loss (7% body weight) and regular physical activity
 Dietary Adherence

34

(150 min/ week), with dietary strategies including reduced calories and reduced

intake of dietary fat, can reduce the risk for developing diabetes and therefore

recommended (Knowler et al, 2002; Tuomilehto et al., 2001). Individuals at high

risk for type 2 diabetes should be encouraged to achieve the USDA

recommendation for dietary fiber and foods containing whole grains (Bantle et al.,

2008). There is not sufficient, consistent information to conclude that low-

glycemic load diets reduce the risk for diabetes. Low-glycemic index foods that

are rich in fiber and other important nutrients are to be encouraged. Lifestyle

changes such as decreased energy intake and increased physical activity can

prevent diabetes.

Standards of Practice and Professional Performance

Introduction

The Diabetes Care and Education Dietetic Practice Group of the American

Dietetic Association developed new Standards of Practice and Standards for

Professional Performance for Registered Dietitians working with diabetes

patients. The Standards of Practice for the RD in diabetes care are Nutrition

Assessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition

Monitoring and Evaluation (Kulkarni et al., 2005). The Standards of Professional

Performance for RDs in diabetes care are Provision of Services, Application of

Research, Communication and Application of Knowledge, Utilization and

Management of Resources, Quality in Practice, and Continued Competence and

 Dietary Adherence

35

Professional Accountability. The Standards of Practice and Standards for

Professional Performance applies to all clinical nutrition patients although the

Diabetes Care and Education Dietetic Practice Group applied these standards

specifically for diabetes care.

The scope of practice describes the range of roles, functions,

responsibilities, and activities which dietetics practitioners are educated and

authorized to perform; individualized as determined by state practice acts and

facility policies and privileges. The Scope of Dietetics Practice Framework is a

tool with resources to assist in making decisions about appropriate levels of safe

and effective scope of practice for the dietetics professional (Franz et al., 2008).

Standards of Practice in Nutrition Care and Standards of Professional

Performance are four standards of practice in nutrition care and six standards of

professional performance describe a competent level of dietetics practice and

professional performance.

The Standards of Practice in Nutrition Care and Standards of Professional

Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in

diabetes care are standards that build on the core standards and serve as a guide

for the Registered Dietitian to evaluate and improve practice and demonstrate

competence in diabetes care. The standards are also reflective of the knowledge

and skills required for additional certifications (ex. Certified Diabetes Educator

(CDE) and Board-Certified-Advanced Diabetes Management (BC-ADM). A

 Dietary Adherence

36

generalist is an RD who is new to diabetes care and is learning the principles that

underpin practice. An RD who provided MNT for a number of medical conditions

and an RD recognizes that nutrition intervention is necessary (Franz et al., 2008;

Kulkarni et al., 2005). A specialist is an RD who has developed a deeper

understanding of diabetes care and has the ability to modify his or her diabetes

practice as needed depending on the situation. The specialist RD recommends the

intervention (solution) to the client and provider (Franz et al., 2008; Kulkarni et

al., 2005). An advanced is an RD who has developed a more intuitive

understanding of diabetes care and whose practice reflects a broad range of skills

and judgments acquired through a combination of experiences and education

(Franz et al, 2008; Kulkarni et al., 2005). The advanced RD makes changes in

various aspects of a person's diabetes care in collaboration with the client's

provider.

Nutrition Assessment

The first standard of practice for a Registered Dietitian in diabetes care is

nutrition assessment. Nutrition assessment is a systemic process of obtaining,

verifying, and interpreting data in order to make decisions about the cause of

nutrition-related problems (Lacey & Pritchett, 2003). It is initiated by a referral

and/or screening of individuals or groups for nutritional risk factors. Nutrition

Assessment also includes continual assessment and analysis of the client or

community's needs. The RD evaluates dietary intake for factors that affect health
 Dietary Adherence

37

conditions including nutrition risk. They determine nutritional adequacy, health

status, and functional and behavioral status (Lacey & Pritchett, 2003). The

nutritional adequacy is determined from a dietary history or detailed nutrient

intake of the patient. Health status is determined from anthropometric and

biochemical measurements, physical and clinical conditions, physiological and

disease status. They also evaluate medication management which involves

prescription, over-the counter, herbal medications, medication allergies, food and

drug interactions and adherence (Kulkarni et al., 2005). Other indicators for

nutrition assessment are evaluating complications and risks of diabetes.

Registered dietitians evaluate diagnostic tests, procedures, and evaluations such as

blood glucose levels. They also evaluate physical activity habits and restrictions.

Psychosocial, socioeconomic, functional and behavioral factors related to food

access, selection, preparation, and understanding of the health condition are

determined at a nutrition assessment (Lacey & Pritchett, 2003). The RD will also

evaluate client knowledge, readiness to learn, and potential for behavior changes.

This will include any history of previous nutrition care service medical nutrition

therapy. An RD identifies standards by which data will be compared, identifies

possible problem areas for making nutrition diagnoses, and documents and

communicates the nutrition assessment (Lacey & Pritchett, 2003). The nutrition

assessment provides the foundation for the nutrition diagnosis, which is the next

step in the Nutrition Care Process.

 Dietary Adherence

38

Nutrition Diagnosis

The nutrition diagnosis describes an actual occurrence, risk of, or potential

for developing a nutrition problem that dietetics professionals are responsible for

treating. The RD will derive the nutrition diagnosis from the assessment data.

They will identify and label the problem, determine etiology, and define

characteristics of the client's signs and symptoms. A nutrition diagnosis should

not be mistaken for a medical diagnosis which does not change as long as the

disease or condition exists. A nutrition diagnosis changes as the patient's response

changes (Lacey & Pritchett, 2003). They classify the nutrition diagnosis and

validate it with clients, family members or other health care professionals when

appropriate (Kulkarni et al., 2005). They document the nutrition diagnosis in a

written statement in a format referred to as a PES statement. The format is the

problem (P), etiology (E), and the signs and symptoms (S) (Lacey & Pritchett,

2003). Critical thinking skills are crucial in the diagnosis step to find patterns and

relationships among the data and possible causes, state the problem clearly,

suspend judgment, ruling out specific diagnoses, and prioritizing the importance

of problems for patient safety. The RD will re-evaluate and revise the nutrition

diagnoses if additional assessment information is known.

Nutrition Intervention

The next step in the Nutrition Care Process for diabetes is nutrition

intervention. This is where the RD will implement appropriate planned actions

 Dietary Adherence

39

designed with the intent of changing a nutrition-related behavior, risk factor,

environmental condition, or aspect of health status for an individual, target group,

or the community (Lacey and Pritchett, 2003). The Registered Dietitian prioritizes

the nutrition diagnoses based on severity of problem and the likelihood that a

nutrition intervention will impact the problem and the client's perception of

importance. Registered Dietitians consult the nationally developed evidence-

based practice guidelines for appropriate values for control or improvement of the

disease or conditions (Lacey & Pritchett, 2003). They determine client-focused

expected outcomes for each nutrition diagnosis that are in observable and

measurable terms. The RD confers with the client, caregivers, or other health

professionals, policies and program standards to make certain the interventions

are appropriate. The RD will write a nutrition prescription, develops an education

plan or community program, create policies that influence nutrition programs and

standards (Kulkarni et al., 2005). They ensure the intervention plan content is

based on best available evidence. They define the time and frequency of care

including intensity, duration, and follow-up. They also identify resources and/or

referrals needed. Registered Dietitians implement the nutrition intervention by

communicating the plan of nutrition and diabetes-related care and carries out the

plan (Lacey & Pritchett, 2003). They continue data collection and modify the plan

of care as needed. They individualize nutrition diabetes-related interventions to

the setting and the client. They collaborate with other health care professionals
 Dietary Adherence

40

and follow up and verify the implementation is occurring and the needs are being

met (Lacey & Pritchett, 2003). They revise strategies as changes in condition/

response occurs and they document the nutrition intervention.

Nutrition Monitoring and Evaluation

The last step in the Nutrition Care Process is nutrition monitoring and

evaluation. Registered Dietitians monitor progress by checking client

understanding and adherence with the plan and identifying positive and negative

outcomes. They measure outcomes by selecting standardized evidence-based

outcome indicators that are relevant to the client and directly related to the

nutrition diagnosis and the goals established in the intervention plan (Lacey &

Pritchett, 2003). They evaluate outcomes by using standardized indicators to

compare current finding with previous status, intervention goals and/or reference

standards. They document the progress, changes in behavior and outcomes, and

future plans for nutrition care (Lacey & Pritchett, 2003). Based on the findings,

the Registered Dietitian makes the decision to continue care of discharge the

patient from nutrition care when it is necessary and appropriate. If nutrition care is

continued the nutrition care process cycles back to the assessment, diagnosis and

intervention. If care does not continue, the patient may be monitored for change in

status and necessary nutrition care at another time.

 Dietary Adherence

41

Provision of Services

There are six standards for professional performance. The first standard is

provision of services. The dietetic professionals provide, facilitate, and promote

quality services based on client needs and expectations, current knowledge, and

professional experience (Kieselhorst, Skates, and Pritchett, 2005). This includes

the RD providing input into the development of appropriate screening parameters

to ensure that the screening process is effective (Kieselhorst et al., 2005; Kulkarni

et ah, 2005). They contribute to the development of a referral process to ensure

that the public has an identifiable method of being linked to dietetic professionals

who will ultimately provide services. They collaborate with the client to assess

needs, background, and resources to establish mutual goals. They also implement

quality practice by following an evidence-based approach, policies, procedures,

legislation, licensure, credentialing, competency, regulatory requirements, and

practice guidelines (Kieselhorst et al., 2005; Kulkarni et al., 2005). The dietetics

professional provides quality service based on client goals and needs.

Application of Research

The second standard is application of research. Effective application,

support, and generation of dietetics research in practice encourages continuous

quality improvement and provides documented support for the benefit of the

client (Kieselhorst et al., 2005). A Registered Dietitian locates and reviews the

best available research findings for their application to dietetics practice and bases
 Dietary Adherence

42

their practice on sound scientific research and theory. They integrate the best

available research, such as evidence-based practice guidelines, with

clinical/managerial expertise and client values (Kieselhorst et al., 2005; Kulkarni

et al, 2005). They promote research through alliances and collaboration with

dietetics and other professionals (Kulkarni et al., 2005). They also contribute to

the development of new knowledge and research in dietetics and share research

data through various media. A dietetics professional effectively applies,

participates in, or generates research to enhance the field.

Communication and Application of Knowledge

The third standard is communication and application of knowledge.

Dietitians work with and through others while using their unique knowledge of

food, human nutrition, and management, and their skills in providing services

(Kieselhorst et al., 2005). A Registered Dietitian has knowledge related to a

specific area of professional service and communicates and integrates this

knowledge to clients and students. They share knowledge and information with

clients and help students and clients apply this knowledge. They contribute to the

development of new knowledge and seek out information to provide effective

services (Kulkarni et al., 2005). Registered Dietitians communicate, manage

knowledge, and support-decision making using information technology. A dietetic

professional effectively applies knowledge and communicates with others.

 Dietary Adherence

43

Utilization and Management of Resources

The fourth standard for professional performance is utilization and

management of resources. Dietitians demonstrate appropriate use of time, money,

facilities, and human resources facilities delivery of quality services (Kieselhorst

et al., 2005). They use a systemic approach to maintain and manage professional

resources successfully. They also analyze safety, effectiveness, and cost in

planning and delivering services and products. They justify the use of resources

by documenting consistency with plan, continuous quality improvement, and

desired outcomes (Kulkarni et al, 2005). They also educate the help clients to

identify and secure available resources and services (Kieselhorst et al., 2005;

Kulkarni et al., 2005). Each dietetics professional uses resources effectively and

efficiently in practice.

Quality in Practice

The fifth standard is quality in practice. Quality practice requires regular

performance evaluation and continuous improvement of services (Kieselhorst et

al., 2005). This involves a Registered Dietitian to continually understand and

measure quality of food and nutrition and services in terms of structure, process,

and outcomes. They identify performance improvement criteria to monitor

effectiveness of services (Kulkarni et al., 2005). They identify errors and hazards

in food and nutrition care and services. They identify and compare expected

outcomes. They also implement an outcomes management system to evaluate the

 Dietary Adherence

44

effectiveness and efficiency of practice (Kieselhorst et al., 2005; Kulkarni et al.,

2005). The dietetics professional evaluates the quality and effectiveness of

practice and revises practice as needed.

Continued Competence and Professional Accountability

The last standard in professional performance is continued competence

and professional accountability. Professional practice requires continuous

acquisition of knowledge and skill development to maintain creditability

(Kieselhorst et al., 2005). Registered Dietitians conduct self-assessment at regular

intervals to identify professional strengths and weaknesses. They identify the

needs for professional development and mentor others. They also develop and

implement a plan for professional growth and documents professional

development activities (Kulkarni et al., 2005). A dietetic professional engages in

lifelong self-development to improve knowledge and enhance professional

competence.

Effectiveness of MNT

Outcomes for Adults with Type 2 Diabetes

Positive clinical outcomes in adults receiving nutrition intervention for

type 2 diabetes have been evidenced from the literature. Health, behavior, and

quality of life outcomes after nutrition intervention in adult, type 2 diabetes

patients have improved (Lemon et al., 2004). Medical nutrition therapy has been

proven to be cost-effective for people with type 2 diabetes (Franz et al., 1995b).
 Dietary Adherence

45

The research found MNT to be effective in improving outcomes and to be cost-

effective treatment.

Effectiveness of diabetes MNT interventions has been shown by

significant clinical outcomes in studies. Randomized controlled trials and

observational studies of MNT have documented decreases in HBAlc o f - 1 % to

2%, depending on the type and duration of diabetes (Franz et al, 2008). A 6

month randomized controlled trial had 648 subjects with type 2 diabetes at the

Grady Health System Diabetes Clinic, which is primarily urban and African

American (Ziemer et al., 2003). The subjects were 90% African American, 65%

women, and 78% were obese based on the criteria of greater than 120% ideal

weight. The subjects were randomized to receive instruction by a Registered

Dietitian in either a healthy food choices meal plan or an exchange-based meal

plan to compare the impact on glycemic control, weight loss, serum lipids, and

blood pressure at 6 months of follow-up (Ziemer et al., 2003). In the healthy food

choices meal plan, the HbAlc decreased from 9.7 to 7.8%; and in the exchange-

based meal plan, the HbAlc decreased from 9.6 to 7.7%. Significant

improvements in glycemic control over 6 months were seen by both groups but

the exchange-based meal plan group had a 1.9% decrease in HbAlc (Franz et al.,

2008; Ziemer et al., 2003). A 3 month observational study analyzed 500 medical

charts from a physician to obtain 175 subjects with type 2 diabetes or

cardiovascular disease (Gaetke, Stuart, & Truszczyska, 2006). The records were
 Dietary Adherence

46

categorized into two groups based on whether the patient had attended or not

attended a single nutrition education session from the same dietitian (Gaetke et

al, 2006). There were significant improvements in mean fasting blood glucose,

mean hemoglobin A1C, mean total cholesterol level, mean triglyceride level,

mean ratio of total cholesterol to HDL level, and BMI and weight decreased from

baseline to 3 months in the group attending a single nutrition education session

(Gaetke et al., 2006). The participants of this study had a 2.6% decrease in HbAlc

(Franz et al., 2008; Gaetke et al., 2006). Diabetes MNT has the greatest impact at

initial diagnosis, and it continues to be effective at any time during the disease

process. Outcomes resulting from nutrition interventions are generally known in 6

weeks to 3 months and evaluation should be done at these times (Franz et al.,

2008). At 3 months, if no clinical improvement has been seen in glycemic control,

the RD needs to recommend a change in medications. Research shows that many

types of nutrition interventions are effective and there are multiple encounters to

provide education initially and on a continued basis.

Health, behavior, and quality of life have been shown to improve with

nutrition intervention. An observational study had 244 physician referred subjects

from 31 sites with type 2 diabetes (Lemon et al., 2004). In this 6 month study,

subjects received nutrition education from a RD and health and lifestyle indicators

were measured at baseline, 3 months and 6 months. Weight, body mass index, and

glycosylated hemoglobin value improved significantly between 3 months and 6

 Dietary Adherence

47

months (Lemon et al., 2004). The subjects had a 1.7% decrease in HgAlc (Franz

et al., 2008; Lemon et al., 2004). This study showed adult type 2 diabetes

patients' improvement in weight and glycemic control, coronary heart disease

risk, and self-management behaviors between baseline and 3 months and also

baseline and 6 months after education with a Registered Dietitian (Lemon et al.,

2004). In the same study, mean diet/lifestyle and exercise responses improved as

well as blood glucose self-monitoring frequency and results. A quality of life

assessment showed that self-perception of health status improved over the course

of the study (Lemon et al., 2004). Also, overall medication use and

antihypertensive medication use declined between baseline and 3 months and then

to 6 months. A 12 month randomized controlled trial consisted of 147 health plan

members with type 2 diabetes and obesity (Wolf et al, 2004). The participants

were randomized to lifestyle case management or usual care. An RD case

manager met with participants individually six times throughout the year for 4

hours each time. Participants attended six 1-hour small group session and brief

monthly phone contacts provided support (Wolf et al., 2004). The other randomly

assigned usual care group received educational material and could join other

weight management or diabetes care program. Patients in the lifestyle case

management group resulted in greater weight loss (3 kg) and reduced waist

circumference (4.2 cm) compared to the usual care group (Wolf et al., 2004). The

case management group had reduced hemogloblin A1C levels (p = 0.02) with the
 Dietary Adherence

48

greatest difference at 4 months of-0.59% (Wolf et al., 2004). The case

management group had less use of prescription medications by 0.8 fewer

medications per day than participants treated with usual care. Improved health-

related quality of life (p < 0.05) with intervention from a Registered Dietitian case

manager compared to usual care in seven of nine quality of life domains (Wolf et

al, 2004). Improvements in clinical outcomes are evident of effectiveness of

nutrition intervention.

A review of research articles on the effectiveness on self-management

training in type 2 diabetes supported positive effects on the patients. Norris and

colleagues reviewed 72 studies to review the effectiveness of self-management

training. The positive effects were self-management training on knowledge,

frequency, and accuracy of self-monitoring of blood glucose, self-reported dietary

habits, and glycemic control (Norris et al, 2001). Most studies measuring changes

in diabetes knowledge demonstrated improvement with education, including those

with follow-up of 6-12 months after the last intervention contact. One study

involving a 12 month follow-up had 87 subjects with significantly increased

knowledge in the intervention group (p < 0.001) (Norris et al, 2001). The

intervention group consisted of five group sessions over six months, focusing on

weight loss and the control group treatment consisted of individual education on

weight loss by a dietitian with 3 or more visits in 12 months. Positive dietary

changes included improvements in dietary carbohydrate or fat intake, a decrease

 Dietary Adherence

49

in consumption of lower glycemic-index foods (Norris et al., 2001). A few studies

demonstrated improvement in dietary changes corresponded to improvements in

weight and glycemic control (Norris et al., 2001). One such study had 148

subjects with a follow-up after six months after receiving individual counseling

by a dietitian, with three home visits. The intervention group received advice to

decrease fat to <30% total calories while the control group received advice to

decrease carbohydrates to <40% total calorie intake (Norris et al, 2001). The

intervention group had decreased fat and cholesterol intake, increased

carbohydrate intake with a between group difference ofp < 0.001 (Norris et al.,

2001). There was a study that noted increase in quality of life at 18 months for an

intervention subgroup that received intensive education on both diet and physical

activity (Norris et al., 2001). There was 76 subjects with the first intervention

group had a diet focus, the second intervention group had a physical activity

focus, the third intervention group had a diet and physical activity focus, and the

control study had only didactic teaching. There was decreased HbAlc in the

intervention groups versus the control at 18 months (difference 1.8%, p < 0.05)

and decreased blood glucose in the intervention groups versus the control at six

months (p < 0.037) (Norris et al., 2001). Evidence supports the effectiveness of

self-management training in type 2 diabetes.

Another study evaluated the effectiveness of MNT administered according

to practice guidelines nutrition care (PGC) compared to basic nutrition care (BC)
 Dietary Adherence

50

(Franz et al, 1995a). There were 85 participants randomly assigned to the BC

group and 94 participants to the PGC group, totaling 179 newly diagnosed type 2

diabetic patients in the study. The PGC group consisted of an initial session with

a dietitian of approximately 1 hour and two follow up sessions of approximately

30 to 45 minutes. The BC group consisted of only one visit of approximately 1

hour with a dietitian. At 6 months, PGC resulted in significant improvements in

blood glucose control as indicated by fasting plasma blood glucose (9.1 mmol/L)

and hemoglobin A1C levels (7.4%) (Franz et al., 1995a). The BC resulted in

significant improvements in hemoglobin A1C levels (9.2 mmol/L) at 6 months

(Franz et al., 1995a). The PGC group had a mean fasting blood glucose level at 6

months that was 10.5% lower than the level at entry, and the BC group had a

5.3% lower value (Franz et al., 1995a). The PGC subjects had significant

improvements in cholesterol values (5.4 mmol/L) at 6 months. From entry to 6

months, both groups had significant weight loss with the PGC group decreased

from 93.8 ± 19.9 kg to 92.3+19.8 kg and the BC group decreased 93.7±22.2 kg to

92.0+21.2 kg (Franz et al., 1995a). Persons with diabetes longer than 6 months

tended to do better with PGC than with BC. MNT provided by dietitians resulted

in significant improvements in medical and clinical outcomes in both

experimental groups and is beneficial to persons with type 2 diabetes (Franz et al.,

1995a). MNT is proven to be an effective treatment for type 2 diabetes patients.

 Dietary Adherence

51

The Diabetes Control and Complications Trial was the pivotal study in

diabetes treatment research. The research group had 1,441 type 1 diabetes patients

with no retinopathy or mild retinopathy (DCCT research group, 1993). They

were randomly assigned to the intensive therapy that either administered an

external insulin pump or by three or more daily insulin injections. The other group

had conventional therapy with one or two daily insulin injections. The patients

were followed for a mean of 6.5 years. A statistically significant difference in the

average glycosylated hemoglobin value was maintained after base line between

the intensive-therapy and conventional therapy groups (DCCT research group,

1993). The mean value for all glucose profiles in the intensive therapy group was

155+30 mg per deciliter, as compared with 231+ 55mg per deciliter in the

conventional therapy group (DCCT research group, 1993). Within the secondary

intervention cohort, the patients of the intensive therapy group had a higher

cumulative incidence of sustained progression of retinopathy by three steps or

more during the first year than did those in the conventional therapy group.

Intensive therapy reduced the average risk of such progression by 54% (95%

confidence interval, 39 to 66%) during the entire study period (DCCT research

group, 1993). A consistent reduction in the risk of retinopathy with intensive

therapy was evident in all subgroups in both the primary prevention and the

secondary intervention cohorts (DCCT research group, 1993). Intensive therapy

reduced the mean adjusted risk of microalbuminuria by 34% in the primary

 Dietary Adherence

52

prevention cohort and by 43% in the secondary intervention cohort (DCCT

research group, 1993). Intensive therapy reduced the appearance of clinical

neuropathy at 5 years by 69% in patients in the primary prevention cohort who

did not have neuropathy at baseline and by 57% in the secondary intervention

cohort (DCCT research group, 1993). The results determined intensive therapy

effectively delays the onset and slows the progression of diabetic retinopathy,

nephropathy, and neuropathy in patients with type 1 diabetes.

Cost-effectiveness ofMNT

MNT is cost-effective for persons with type 2 diabetes. Diabetes

prevention is more cost-effective than diabetes treatment found in a review of four

published studies of intensive glycemic management for type 2 diabetes mellitus

(Urbanski, Wolf, & Herman, 2008). There are a limited number of controlled

trials that include full cost analyzes of diabetes education. Research published to

date indicates diabetes education is likely cost-effective, particularly when

provided to those patients with the poorest glycemic control (Urbanski et al.,

2008).The cost-effectiveness of the PGC group compared with the BC group was

calculated using per-patient costs and glycemic outcomes for the 6 months of the

study (Franz et al., 1995b). Cost-effectiveness ratios are expressed as cost per unit

of improvement in glycemic control. The net cost-effectiveness ratios were also

calculated to explore the effect of cost savings associated with therapy changes on

cost-effectiveness determinations. The patients in the PGC group experienced a

 Dietary Adherence

53

mean 1.1 +J2.8 mmol/L decrease in fasting plasma glucose level 6 months after

entry to the study, for a total per-patient cost of $112 (Franz et al., 1995b).

Patients in the BC group experienced a mean 0.4 + 2.7 mmol/L decrease, for a

total per-patient cost of $42 (Franz et al., 1995b). If net costs are considered, the

cost-effectiveness ratios become $5.32 for BC and $4.20 for PGC, assuming the

medical changes in therapy were maintained for 12 months. Based on the

examination of the cost of providing nutrition care to diabetes patients and the

diabetes cost of illness, it has been concluded that the beneficial medical

outcomes from MNT make it well worth the relatively small monetary investment

(Franz et al., 1995b). Wolf and colleagues completed a 1-year randomized

controlled trial comparing usual medical care to usual care plus lifestyle case

management provided by a Registered Dietitian (Urbanski et al., 2008; Wolf et

al., 2004). People who received lifestyle case management had substantially

greater weight loss, reduced hemoglobin A1C, and decreased prescription

medication use, compared to usual medical care (Urbanski et al, 2008; Wolf et

al., 2004). Wolf and colleagues evaluated the same 147 health plan members with

obesity and type 2 diabetes to determine the program and health care costs of a

lifestyle intervention (Wolf et al., 2007; Wolf et al, 2004). The net cost of the

intervention was $328 per person per year. Case management participants had

fewer inpatient admissions of 2.8% compared to 22.5% in usual care participants,

which substantially lowered medical costs (Urbanski et al, 2008; Wolf et al.,
 Dietary Adherence

54

2007). The mean net total costs were $3,586 per person per year less among case

management compared with usual care (Wolf et al., 2007). Implications for the

RD are that MNT among a high-risk population with type 2 diabetes and obesity

is cost-saving by decreasing health plan costs by 34% (Urbanski et al., 2008).

MNT has been concluded to be effective in improving clinical outcomes and cost-

effective for the patient.

Measurement Tool

Diabetes Self-Care Activities Questionnaire

The Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) is

a brief self-report questionnaire of diabetes self-management. It involves general

diet, specific diet, exercise, blood-glucose testing, foot care, and smoking

(Toobert et al., 2000). For the purposes of this study, blood-glucose testing, foot

care and smoking questions were excluded. The questionnaire has been proven to

be reliable and valid self-report measure of diabetes self-management that is

useful both for research and practice (Toobert et al., 2000). The seven studies

reviewed by Toobert et al. demonstrated that the SDSCA is a multidimensional

measure of diabetes self-management with adequate internal and test-retest

reliability, evidence of validity and sensitivity to change (Fiel et al., 2000;

Glasgow et al., 1992; Glasgow et al., 1998; Glasgow and Toobert, 2000; Glasgow

et al., 2000; & Wagner et al., 2001) This study reported on the use of the SDSCA
 Dietary Adherence

55

in 7 studies in which SDSCA data have not been previously reported, involving a

subject pool of about 2,000 people with diabetes (Toobert et al., 2000.)

The mean ages of the participants of the 7 samples ranged from 45 to 67

years of age and average diabetes duration ranged from 6.3 to 13 years (Toobert

et al., 2000). The means and standard deviations (SD) for each subscale for each

study provided information for comparative purposes, which mean higher

percentages indicate better self-care on all scales. The mean levels computed

across all 7 studies for each scale were as follows: general diet: mean = 58.6, SD

= 28.7, n = 1,409; specific diet: mean = 67.5, SD = 16.9, n = 973; and exercise:

mean = 34.3, SD = 31.9, n= 883 (Toobert et al., 2000). The other subscales of

blood glucose testing, medication taking, and foot care were excluded from this

study. The internal consistency of the scales, assessed by average inter-item

correlations, was acceptable (mean = 0.47) except for specific diet, which was

consistently unreliable (r = 0.07-0.23) (Toobert et al, 2000). The various

components of a healthy diet are not highly correlated and it is necessary to

measure these components separately to obtain an accurate assessment of eating

patterns. Test-retest correlations over 3-4 months were examined for the

observational studies and for control groups in the intervention studies. All the

studies were significant except for 3, with the general diet ranging from r = 0.55-

0.67; specific diet ranging from r = 0.42-0.61; and exercise ranging from r = 0.42-

0.55 (Toobert et al., 2000). Test-retest reliability was moderate across these
 Dietary Adherence

56

studies and may be an underestimate. The intervention studies analyzed have

control groups have a modest self-monitoring intervention. The participants who

volunteered for a randomized control trial demonstrate a commitment to making

behavioral changes. Both of these factors could have produced some behavioral

changes over the test-retest interval in these patients, resulting in lowered

stability.

The validity estimates for diet and exercise were based on multiple

methods of self-report. For dietary comparisons, these included 3 or 4 day foods

records, food-frequency questionnaires, Food Habits Questionnaires, and the

Block Fat Screener (Fiel et al., 2000; Glasgow et al., 1992; Glasgow et al., 1998;

Glasgow & Toobert, 2000; & Glasgow et al., 2000). For exercise comparisons,

these included the Stanford 7 day recall, the Physical Activity Scale for the

Elderly, exercise self-monitoring data, or attendance at an exercise class. The

correlations between the dietary and exercise subscales and criterion variables

were all significant with a range of r = -0.54 to -0.01 (Toobert et al., 2000). Some

of the dietary correlations were as high as those reported between much longer

measures. Previous studies have reported significant correlations of the original

SDSCA subscales with other criterion measures (Toobert & Glasgow, 1994). For

the diet amount subscale, there were statistically significant correlations for

average self-monitored calories in two of the three studies (Study 1: r = -0.29, p <

0.01; and Study 3: r = -0.21, p < 0.01); and for average percent of calories from
 Dietary Adherence

57

fat in all three studies (Study 1: r = -0.21, p < 0.05; Study 2: r = -0.35, p < 0.01;

and Study 3: r = -0.35, p < 0.01) (Toobert & Glasgow, 1994). The sensitivity to

change of the SDSCA was assessed using the responsiveness index. The

responsiveness to change resulted in a wide range of-0.05 to 0.43. Student's t

tests evaluating pre to post change among intervention conditions revealed

significant improvement on SDSCA scales in 6 of the 9 comparisons with a range

of 0.000 to 0.032 (Toobert et al., 2000). Both of the correlations of the original

and revised SDSCA are evidence for the validity of this self-report scale.

The SDSCA is probably the most widely used self-report instrument for

measuring diabetes self-management in adults given earlier studies (Toobert et al.,

2000.) The revised SDSCA by Toobert et al. included the following changes: does

not include questions on medication taking because of strong ceiling effects and a

lack of variability among respondents contributing to lowered test-retest

reliability for these times, dropping of the specific diet scale because it lacks

internal consistency, and one of the specific diet questions on meals with "sweets"

was modified because it no longer reflects current standards of MNT (Toobert et

al., 2000).

The Summary of Diabetes Self-Care Activities Questionnaire (SDSCA)

has been widely used in earlier studies and the revised SDSCA has been recently

used in studies analyzing adherence. The researchers of the original SDSCA

found multiple measures having different scales to assess adherence to each

 Dietary Adherence

58

regimen component. Scoring the original SDSCA questionnaire involved using

raw scores from each measure, which were then converted to standard scores

having a mean of zero and a standard deviation of one (Toobert & Glasgow,

1994). The standardized scores were then averaged to form a composite score for

each regimen behavior. The purpose of this procedure was to give items with

differing scales equal weighing (Toobert & Glasgow, 1994). The original version

of the SDSCA used either the number of days per week or percent of time as the

response options (Toobert & Glasgow, 1994). The revised SDSCA simplified

scoring and interpretation by using the metric "days per week" instead of

percentages. Comparisons of data based on the new questionnaire with previous

research would need to be converted to percentages (Toobert et al., 2000).

An earlier study using the original SDSCA mailed the questionnaire with a

sample of 2,056 individuals with diabetes (Ruggiero et al., 1997). The researchers

of this study scored the SDSCA questionnaire by using a composite score to

assess the level of self-management. A composite score was used for the

following items: number of the last 7 days individuals performed the behavior of

interest, number of recommended behaviors performed in the last 7 days (five-

point Likert scale: none to all), and frequency of performing each recommended

behavior in the last month (five point Likert scale: never to always) (Ruggiero et

al., 1997). Each item was standardized using T-scores (50 + 10, mean + SD);

then, all of the items were available for each behavior were averaged to calculate
 Dietary Adherence

59

the composite score for that behavior (Ruggiero et al., 1997). There were three

groups of subjects: participants with type 1 diabetes, type 2 diabetes using insulin,

and type 2 diabetes not using insulin. The majority of all groups reportedly

received some recommendation for diet, those with type 2 using insulin were

most likely to report having been given diet recommendations (87 vs. <80% for

other groups). The participants with type 2 diabetes (>75%) were given more

exercise recommendations than those with type 1 diabetes (<60%) (Ruggiero et

al., 1997). X2 comparisons indicated significant differences across diabetes type

for each behavior. X2 analyses indicated significant differences between the two

groups on the exercise regimens they were given (X2^) = 28.8, p < 0.00001)

(Ruggiero et al., 1997). X2 analyses indicated significant differences between

participants with type 2 diabetes using insulin and the other groups on the diet

recommendations they were given (X (2) =29.3, p <0.00001) (Ruggiero et al.,

1997). Earlier studies of the SDSCA used percentages for comparisons.

More recent studies have used the revised SDSCA (Toobert et al., 2000).

There were 53 participants with type 2 diabetes who responded to mailed surveys

from a diabetes clinic in the South East of England (Asimakopoulou & Hampson,

2005). The study analyzed biases in self-reports of self-care behaviors in type 2

diabetes patients. The researchers of this study used percent of time as their

response option for the SDSCA questionnaire. For the analysis, items were

combined to form subscales "General Diet", "Specific Diet", "Medication taking"

 Dietary Adherence

60

and "Blood Glucose testing", in line with Toobert et al.'s (2000)

recommendations. Descriptive statistics for these subscales were used and a

higher percent indicates a higher behavior frequency. Relatively high percentages

were reported for following a healthy diet in the General diet subscale (daily

77.11%; weekly 72.97%; monthly 71.71%) (Asimakopoulou & Hampson, 2005).

Relatively low percentages were reported for unhealthy eating, the specific diet

subscale (daily 16.61%; weekly 19.90%; monthly 19.17%) (Asimakopoulou &

Hampson, 2005). Participants reported less successful dietary control than the

daily records suggested, in both weekly (16.56,;? < 001) and monthly (18.78,p

<001) estimates (Asimakopoulou & Hampson, 2005). This study found

participants overestimated the frequency with which they had eaten unhealthy and

had failed to limit their caloric intake. This study used percentages and descriptive

statistics to score the revised SDSCA. The adapted SDSCA questionnaire was

used to scale the dietary adherences of the subjects.

Summary

Through an extensive review of the literature, the need for medical

nutrition therapy to reduce the reduce complications of diabetes and manage the

disease is strongly supported. Diabetes Mellitus is a group of diseases

characterized by high blood glucose concentrations resulting from defects in

insulin secretion and/or insulin action. Diabetes and its complications are a

significant cause of morbidity and mortality in the U.S. Diabetes is the seventh
 Dietary Adherence

61

leading cause of death in the United States (CDC, 2008). The American Diabetes

Association nutrition principles and recommendations attempted to define an

ideal nutrition diet order that would apply to people with diabetes. The Diabetes

Care and Education Dietetic Practice Group of the American Dietetic Association

developed new Standards of Practice and Standards for Registered Dietitians

working with diabetes patients. Positive clinical outcomes in adults receiving

nutrition intervention for type 2 diabetes have been evidenced from the literature.

The Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) is a brief

self-report questionnaire of diabetes self-management.

 Dietary Adherence

62

CHAPTER III

PROCEDURES

Introduction

The purpose of this research study was to determine whether there was a

significant difference in the dietary adherence of adult type 2 diabetic patients

after two or more nutrition education sessions from a Registered Dietitian when

compared to the dietary adherence of adult type 2 diabetic patients after a single

nutrition education session with a Registered Dietitian. The information was

obtained using an adapted version of The Summary of Diabetes Self-Care

Activities questionnaire (Toobert et al., 2000).

Setting

Questionnaires were mailed out to patients with type 2 diabetes in western

New York. Names were obtained from a patient list of a local Registered Dietitian

of an outpatient facility for diabetes patients.

Population and Sample

The sample for the current research study was a sample of convenience.

Subjects were obtained from a patient list from a local Registered Dietitian of an

outpatient facility for diabetes patients and were mailed a questionnaire. The

patient list was coded by numbers to protect the researcher from knowing the
 Dietary Adherence

63

names of the subjects. The master name-numbers list remained with the

Registered Dietitian of the outpatient facility without the researcher having

knowledge of subjects' names throughout the course of the study. The subjects

that were willing to participate in this study were patients that returned the

questionnaire. The subjects of the study were told the researcher was analyzing

how nutrition can help manage diabetes. If they were willing to participate in the

study, they read the cover letter (Appendix F) and returned the questionnaire

within one month. They were mailed reminder postcards after two weeks to send

in the questionnaire if they were willing to participate in the study. The first

questions of the questionnaire asked if they were 20 years of age or older and if

they have type 1 or type 2 diabetes. The subjects were asked when they were

diagnosed with diabetes. Those that answered they were 20 years of age and older

with type 2 diabetes were used in the study based on an age requirement in a

study by Lemon et al. 2004. A sample of 30 individuals (minimum) was

considered sufficient. Sampling occurred over one month.

Data Collection Methods

Before the study was conducted, approval was obtained from the

Institutional Review Board (IRB) at D'Youville College (Appendix C). The

outpatient facility participating in the study received a letter requesting permission

to use their patient list to mail questionnaires (Appendix D). Permission to collect

data on patients from the facility was also granted (Appendix E).
 Dietary Adherence

64

After obtaining approval from the facility, data were collected by mailing

questionnaires to individuals from the patient list of the outpatient facility. The

subjects were recruited by convenience sampling using a cover letter (Appendix

F), questionnaire, and postage paid return envelope, which were sent to each

participant. The RD at the outpatient facility mailed out the questionnaire with the

cover letter to the patients on the master patient list. The participants mailed the

questionnaire to the researcher using the mailing code located on the top corner of

their questionnaire. The mailing code assures that the researcher does not have

knowledge of the participants' names and addresses. The cover letter informed the

subjects that their participation was voluntary and the return of the questionnaire

(Appendix B) would be considered their implied consent to participate in the

study. The cover letter informed the subjects that there were no right or wrong

answers. The subjects were told it was an anonymous questionnaire and to answer

the questions at the best of their abilities. They would be mailed a reminder

postcard after two weeks to send in the questionnaire if they were willing to

participant in the study. The first questions of the questionnaire asked if the

subjects were 20 years of age or older and if the subjects have type 1 or 2

diabetes. The subject was also asked when they have been diagnosed with

diabetes. If the participants were 20 years of age or older with type 2 diabetes,

they were used in the study. The cover letter gave the researcher's address and
 Dietary Adherence

65

telephone number as well as the thesis director's address and telephone number to

answer any questions the subjects had on completing the questionnaire.

The questionnaire used in the research was adapted from Toobert,

Hampson, & Glasgow (2000) for this study. The tool has been tested and found to

have validity, internal and test-retest reliability, and sensitivity to change (Toobert

et al., 2000).

Human Rights Protection

Before the study was conducted, permission was granted from the

Institutional Review Board (IRB) of D'Youville College (Appendix C). Also,

permission was granted from the outpatient facility where the patient list was

generated (Appendix E). The cover letter informed subjects that their participation

was voluntary and anonymous. No human rights were violated in this research.

The patients were mailed a cover letter and questionnaire from the RD of

the outpatient facility to assure that the researcher had no knowledge of subjects'

names or addresses. The participants received a cover letter explaining the

purpose of the study, directions to the questionnaire, and completing the survey

implied their consent to be participants in the study. The participants were assured

their information was anonymous and the purpose of the mail coding number that

was written on the questionnaire. They were asked not to put their name on the

questionnaire and mail back to the researcher's address with the provided return
 Dietary Adherence

66

paid postage envelope. The cover letter informed the participants they could

request for the results of the study.

Tools

The researcher in this study adapted the Diabetes Self-Care Activities

Questionnaire from the Toobert et al. (2000) study. This questionnaire was

adapted by removing questions on blood glucose testing, medications, foot care,

and smoking. It was adapted by using questions pertaining to diet and exercise

after receiving nutrition education from a Registered Dietitian. A 24 hour recall

was suggested by Toobert et al., 2000 to analyze specific diet because the

subscale in the SDSCA was consistently unreliable. This study did not use a 24

hour recall due to infeasibility of the following information: height, weight, and

specific diet prescription for each participant of the study.

The five page questionnaire was in three sections. The first section asked

demographic information such as the participants' age, the type of diabetes they

have, when they were diagnosed with diabetes, and how many nutrition education

sessions they attended (Appendix B). The second section asked questions on diet,

exercise, and self-care recommendations and scored by the mean number of days.

The second section asked specific questions were asked on their diet over the last

seven days and the last month. The questionnaire asked if they followed a

healthful eating plan in the last seven days and over the past month how many

days a week they followed their diet. The questionnaire asked how many days a
 Dietary Adherence

67

week they ate fruits and vegetables, consistent carbohydrates, fiber and whole

grains, high fat foods after receiving nutrition education. It also asked how many

days a week they exercised for 30 minutes after receiving nutrition education. The

self-care recommendations of the second section asked questions on what their

health care provider advised the patient to do regarding their diet, exercise, and

testing their blood glucose. The third section asked for the participates' comments

on any problems they had with following a consistent carbohydrate diet, exercise,

and testing their blood glucose levels. At the end of the third section, there was a

page for any additional comments at the end of the questionnaire for participants

to write anything they felt important.

The questionnaire used in this study was adapted by the researcher from

an existing tool, The Diabetes Self-Care Activities Questionnaire (Toobert et al,

2000). The questionnaire has been demonstrated to be a multidimensional

measure of diabetes self-care management with adequate internal and test-retest

reliability, evidence of validity and sensitivity to change (Toobert et al., 2000).

The questionnaire was of use to public domain as stated by the authors.

Treatment of Data

This questionnaire was designed to determine whether there was a

significant difference between the dietary adherence of adult patients with type 2

diabetes after two or more nutrition education sessions from a Registered

Dietitian when compared to the dietary adherence of adult patients with type 2
 Dietary Adherence

68

diabetes after a single nutrition education session from a Registered Dietitian. The

data analysis methodology used in this study was similar to the studies reviewed

by the researcher (Lemon et al, 2004; Toobert et al., 2000). No scoring was

necessary for Section 1 of the questionnaire because it was demographic data. The

data was used for identifying whether the subject met the criteria for the study.

Descriptive statistics were used to provide a description of the sample obtained.

Type 1 diabetes patients were excluded and persons less than 20 years of age were

also excluded from the study. Section 2 of the questionnaire pertains to questions

about diabetes self-care activities during the past 7 days. The score of Section 2

was determined by calculating the mean of the responses (number of days) for the

general diet questions 5 and 6. The mean of the responses (number of days) was

calculated for the specific diet questions 7, 8, 9 reversing question 8 (0=7, 1=6,

2=5, 3=4, 4=3, 5=2, 6=1, 7=0). The score for general diet and the score for

specific diet were summed and this total diet score compared the dietary

adherence between the two groups via an independent sample /-test using

Microsoft excel software. The score for the exercise questions 10 and 11 was the

mean of the number of days selected for each question. No scoring was necessary

for the self-care recommendations. Descriptive statistics were used to determine

which self-care recommendations were given to the participant. The scores for

each subscale (general diet, specific diet, and exercise) were used to compare the

two groups of participants. The score for each subscale of this study were
 Dietary Adherence

69

compared to previous studies' scores for the same subscale. Section 3 of the

questionnaire addressed the participants' problems with following a consistent

carbohydrate diet, exercise, and testing their blood glucose levels. The

participants could add additional comments they felt important. No scoring of

Section 3 was necessary but barriers to diet, exercise, and testing blood glucose

were noted for each group and reported descriptively. Descriptive statistics and an

independent sample /-test were used to determine the difference between the

dietary adherence of participants with 2 or more nutrition education sessions

compared to the participants with a single nutrition education session using

Microsoft excel software. The "days per week" scale was converted to

percentages to compare to results of previous studies that utilitized The Diabetes

Self-Care Activities Questionnaire. The responses for 0 days were converted to

0%, 1 to 2 days were converted to 25%, 3 to 4 days were converted to 50%, 5 to 6

days were converted to 75%, and 7 days were converted to 100%. The score for

each of the subscales of general diet, specific diet and exercise in this study were

compared to previous studies' scores for the same subscale.

Summary

The purpose of this research study was to determine whether that was a

significant difference in dietary adherence of adult type 2 diabetic patients after

two or more nutrition education sessions from a Registered Dietitian when

compared to the dietary adherence of adult type 2 diabetic patients after a single
 Dietary Adherence

70

nutrition education session with a Registered Dietitian. The sample for the current

research study was a sample of convenience by using participants that returned

the mailed questionnaire. The subjects were obtained through a patient list from a

Registered Dietitian of an outpatient facility for diabetes patients in western New

York. Before the study was conducted, approval was obtained from the

Institutional Review Board (IRB) at D'Youville College and the outpatient

facility participating in the study received a letter requesting permission to obtain

the patient list from the Registered Dietitian. The researcher in this study adapted

the Diabetes Self-Care Activities Questionnaire from Toobert (2000) to address

the dietary adherence after a single nutrition education session versus two or more

nutrition education sessions. The scores from the questionnaire after receiving a

single nutrition education session compared to two or more nutrition education

sessions were analyzed through a independent sample Mest. The questionnaire

has been studied and found to be valid and reliable measure of diabetes self-care

activities.
 Dietary Adherence

71

References '

American Dietetic Association. (2009). International dietetics and nutrition

terminology (IDNT) reference manual. Chicago, IL: American Dietetic

Association.

Anderson, J., & Garner, S. (2000). Pathophysiology and care management

algorithm: Type 2 diabetes mellitus. In L.K. Mahan & S. Escott-Stump,

Krause's food and nutrition therapy, 12th Edition (p. 770). St. Louis,

MO: Saunders, Elsevier, Inc.

Asimakopoulou, K., & Hampson, S. (2005). Biases in self-reports of self-care

behaviours in type 2 diabetes. Psychology, Health, & Medicine, 10(3),

305-314.

Bantle, J., Wylie-Rosett, J., Albright, A., Apovian, C , Clark, N., Franz, M., et al.

(2008). Nutrition recommendations and interventions for diabetes: a

position statement of the American Diabetes Association. Diabetes Care,

57(1) S61-78.

Centers for Disease Control and Prevention. (2008). National

Diabetes Fact Sheet: General Information and National Estimates on

Diabetes in the United States, 2007. Retrieved October 1, 2008, from

www.cdc.gov/diabetes
 Dietary Adherence

72

Chandalia, M., Garg, A., Luthohann, D., von Bergmann, K., Grundy, S., &

Brinkley, L. (2000). Beneficial effects of a high dietary fiber intake in

patients with type 2 diabetes. New England Journal of Medicine, 342(19),

1392-1398.

Chobanin, A., Bakris, G., Black, H., Cushman, W., Green, L., Izzo, J., Jones, D.,

Materson, B., Oparil, S., Wright, J., Roccella, E., & the National high

blood pressure education program coordinating committee. (2003).

Hypertension, 42, 1206-1252.

Cryer, P., Davis, S., & Shamoon, H. (2003). Hypoglycemia in diabetes. Diabetes

care, 26(6), 1902-1912.

The Diabetes Control and Complications Trial Research Group. (1993). The

diabetes control and complications trial: Implications for policy and

practice. New England Journal of Medicine, 329(14), 1035-1036.

The Diabetes Prevention Program Research Group. (1999). The diabetes

prevention program: design and methods for a clinical trial in the

prevention of type 2 diabetes. Diabetes Care, 22(A), 623-634.

Fiel, E., Glasgow, R., Boles, S., & McKay, H. (2000). Who participates in

internet-based self-management programs? A study among novice

computer users in a primary care setting. The Diabetes Educator, 26(5),

806-811.
 Dietary Adherence

73

Franz, M , Boucher, J., Green-Pastors, J., & Powers, M. (2008). Evidence-based

nutrition practice guidelines for diabetes and scope and standards of

practice. Journal of the American Dietetic Association, 108(4), S52-58.

Franz, M., Bantle, J., Beebe, C, Brunzell, J., Chaisson, J., Garg, A., Holzmeister,

L., Hoogwerf, B., Mayer-Davis, E., Mooradian, A., Purnell., J., &

Wheeler, M. (2002). Evidence-based nutrition principles and

recommendations for the treatment and prevention of diabetes and related

complications. Diabetes Care, 25(1), 148-198.

Franz, M., Monk, A., Barry, B., McClain, K., Weaver, T., Cooper, N., Upham, P.,

Bergenstal, R., & Mazze, R. (1995a). Effectiveness of medical nutrition

therapy provided by dietitians in the management of non-insulin-

dependent diabetes mellitus: A randomized, controlled clinical trial.

Journal of the American Dietetic Association, 66(9), 1009-1017.

Franz, M., Splett, P., Monk, A., Barry, B., McClain, K., Weaver, T., Upham, P.,

Bergenstal, R., & Mazze, R. (1995b). Cost-effectiveness of medical

nutrition therapy provided by dietitians for persons with non-insulin-

dependent diabetes mellitus. Journal of the American Dietetic Association,

95(9), 1018-1024.
 Dietary Adherence

74

Gaetke, L., Stuart, M , & Truszcynska, H. (2006). A single nutrition counseling

session with a Registered Dietitian improves short-term clinical outcomes

For rural Kentucky patients with chronic diseases. Journal of the

American Dietetic Association 106(1), 109-112.

Gannon, M., & Nuttall, J. (2004). Effect of a high-protein, low-carbohydrate diet

on blood glucose control in people with type 2 diabetes. Diabetes, 53,

2375-2382.

Gannon, M., Nuttall, J., Damberg, G., Gupta, V., & Nuttal, F. (2000). Effect of

protein ingestion on the glucose appearance rate in people with type 2

diabetes. Journal of Clinical Endocrinology and Metabolism, 86(3),

1040-1047.

Glasgow, R., La Chance, P., Toobert, D., Brown, J., Hampson, S., & Riddle, M.

(1998). Long term effects and costs of brief behavioural dietary

invention for patients with diabetes delivered from the medical office.

Patient Education and Counseling, 32, 175-184.

Glasgow, R., Strycker, L., Toobert, D., & Eakin, E. (2000). A social-ecologic

approach to assessing support for disease self-management: the chronic

illness resources survey. Journal of Behavioral Medicine, 23(6), 559-583.

Glasgow, R., & Toobert, D. (2000). Brief, computer-assisted diabetes dietary self-

management counseling: effects on behavior, physiologic outcomes, and

quality of life. Medical Care, 38(11), 1062-1073.

 Dietary Adherence

75

Glasgow, R., Toobert, D., Hampson, S., Brown, J., Lewinsohn, P., & Donnelly, J.

(1992). Improving self-care among older patients with type 2 diabetes: the

"sixty something..." study. Patient Education and Counseling, 19, 61-74.

Guerrero-Romero, F., & Rodriguez-Moran, M. (2005). Complementary therapies

for diabetes: the case for chromium, magnesium, and antioxidants.

Archives for Medical Research, 36, 250-257.

Harris, M., Flegal, K., Cowie, C, Eberhardt, M., Goldstein, D., &

Little, R. (1998). Prevalence of Diabetes, impaired fasting glucose,

and impaired glucose tolerance in U.S. adults: The Third National Health

and nutrition examination survey, 1988-1994. Diabetes Care, 27(4),

518-524.

Hasanain, B., & Mooradian, A. (2002). Antioxidant vitamins and their influence

in diabetes mellitus. Current Diabetes Reports, 2, 448-456.

Kennedy, E., Bowman, S., Spence, J., Freedman, M., & King, J. (2001). Popular

diets: correlation to health, nutrition, and obesity. Journal of the American

Dietetic Association, 101(4), 411-420.

Kieselhorst, K., Skates, J., & Pritchett, E. (2005). American Dietetic Association:

Standards of practice in nutrition care and updated standards of

professional performance. American Dietetic Association, 105(5), 641-

645 e. 10.
 Dietary Adherence

76

Knowler, W., Barrett-Connor, E., Fowler, S., Hamman, R., Lachin, J., Walker,

E., & Nathan, D. (2002). Reduction in the incidence of type 2 diabetes

with lifestyle intervention or metformin. The New England Journal of

Medicine, 346(6), 393-403.

Kris-Etherton, P., Harris, W., & Appel, L. (2002). Fish consumption, fish oil,

omega-3 fatty acids, and cardiovascular disease. Circulation, 106, 2747-

2757.

Kulkarni, K., Boucher, J., Daly, A., Shwide-Slavin, C , Silvers, B.,

O'Sullivan Malliet, J., & Pritchett, E. (2005). American Dietetic

Association: Standards of practice and standards of professional

performance for Registered Dietetians (generalist, specialty, and

advanced) in diabetes care. Journal of the American Dietetic Assocation,

105(5), 819-824.e22.

Lacey, K., & Pritchett, E. (2003). Nutrition care process and model: ADA adopts

road map to quality care and outcomes management. Journal of the

American Dietetic Association, 103(%), 1061-1072.

Lemon, C , Lacey, K., Lohse, B., Olson Hubacher, D., Klawitter, B., & Palta, M.

(2004). Outcomes monitoring of health, behavior, and quality of life after

nutrition intervention in adults with type 2 diabetes. Journal of the

American Dietetic Association, 104(12), 1805-1815.

 Dietary Adherence

77

Lichtenstein, A., Appel, L., Brands, M , Carnethon, M., Daniels, S., Franch, H.,

Franklin, B., Kris-Etherton, P., Harris, W., Howard, B., Karanja, N.,

Lefevre, M., Rudel, L., Sacks, F., Van Horn, L., Winston, M., & Wylie-

Rosett, J. (2006). Diet and lifestyle recommendations revision 2006.

Circulation, 114, 82-96.

Mahan, L., & Escott-Stump, S. (2008). Krause's Food and Nutrition Therapy

(12th ed.). St. Louis, MA: Saunders Elsevier, Inc.

Merriam-Webster, Incorporated. (2005). Merriam-Webster online dictionary.

Springfield, MA: Merriam-Webster Inc. Retrieved February 24, 2008,

From http://www.merriam-webster.com/

Mosby, Inc. (2006). Mosby 's Pocket Dictionary of Medicine, Nursing and Health

Professions (5th ed.). St. Louis, MA: Mosby, Inc.

Narita, T., Koshimura, J., Meguro, H., Kitazato, H., Fujita, H., & Ito, S. (2001).

Determination of optimal protein contents for a protein restriction diet in

type 2 diabetic patients with microalbuminuria. Tohoku Journal of

Experimental Medicine 193, 45-55.

Norris, S., Engelgau, M., & Venkat Narayan, K. (2001). Effectiveness of

self-management training in type 2 diabetes: A systemic review of

randomized controlled trials. Diabetes Care, 24(3), 561-587.

 Dietary Adherence

78

Ruggiero, L., Glasgow, R., Dryfoos, J., Rossi, J., Prochaska, J., Orleans, C,

Prokhorov, A., Rossi, S., Greene, G., Reed, G., Kelly, K., Chobanian, L.,

& Johnson, S. (1997). Diabetes self-management: self-reported

recommendations and patterns in a large population. Diabetes Care, 20(4),

568-576.

Schafer, R., Bohannon, B., Franz, M., Freeman, J., Holmes., A., McLaughlin, S.,

Haas, L., Kruger, D., Lorenz, R., & McMahon, M. (2004). Diabetes

nutrition recommendations for health care institutions. Diabetes Care,

27, s55-s57.

Sheard, N., Clark, N., Brand-Miller, J., Franz, M., Pi-Sunyer, F., Mayer-Davis, E.,

Kulkarni, K., & Geil, P. (2004). Dietary carbohydrate (amount and type)

in the prevention and management of diabetes: a statement of the

American Diabetes Association. Diabetes Care, 27(9), 2266-2271.

Summers, L., Fielding, B., Bradshaw, H., Ilic, V., Beysen, C , Clark, M., Moore,

N., & Frayn, K. (2002). Substituting dietary saturated fat with

polyunsaturated fat changes abdominal fat distribution and improves

insulin sensitivity. Diabetologia, 45, 369-377.

Toobert, D., Hampson, S., & Glasgow, R. (2000). The Summary of

Diabetes Self-Care Activities Measure. Diabetes Care, 23(7), 943-950.

 Dietary Adherence

79

Toobert, D., & Glasgow, R. (1994). Assessing diabetes self-management: the

summary diabetes self-care activities questionnaire. In C. Bradley,

Handbook of Psychology and Diabetes (p. 351-375). Chur, Switzerland:

Harwood Academic.

Tuomilehto, J., Lindstrom, J., Eriksson, J., Valle, T., Hamalainen, H.,

Ilane-Parikka, P., Keinanen-Kiukaanniemi, S., Laakso, M , Louheranta,

A., Rastas, M., Salminen, V., Uusitupa, M , Aunola, S., Cepaitits, Z.,

Moltchanov, V., Hakumaki, M., Mannelin, M., Martikkala, V., &

Sundvall, J. (2001). Prevention of type 2 diabetes mellitus by changes in

lifestyle among subjects with impaired glucose intolerance. New England

Journal of Medicine, 34(\8), 1343-1350.

Urbanski, P., Wolf, M , & Herman, W. (2008). Cost-Effectiveness of diabetes

education. Journal of the American Dietetic Association, 108(4), S6-11.

Vessby, B., Unsitupa, M., Hermansen, K., Riccardi, G., Rivellese, A., Tapsell, L.,

Nalsen, C, Berglund, L., Louheranta, A., Rasmussen, B., Calvert, G.,

Maffetone, A., Pedersen, E., Gustafsson, I., & Storlien, L. (2001).

Substituting dietary saturated for monounsaturated fat impairs insulin

sensitivity in health men and women: the KANWU study. Diabetologia

44, 312-319.
 Dietary Adherence

80

Wagner, E., Grothaus, L., Sandhu, N., Galvin, M., McGregor, M., Artz, K., &

Coleman, E. (2001). Chronic care clinic for diabetes in primary care:

a system-wide randomized trial. Diabetes Care, 25(4), 695-700.

Wolf, A., Siadaty, M., Yaeger, B., Conaway, M , Crowther, J., Nadler, J., &

Bovbjerg, V. (2007). Effects of lifestyle intervention on health care costs:

improving control with activity and nutrition (ICAN). Journal of the

American Dietetic Association 707(8), 1365-1373.

Wolf, A., Conaway, M., Crowther, J., Hazen, K., Nadler, J., Oneida, B., &

Bovbjerg, V. (2004). Translating lifestyle intervention to practice in obese

patients with type 2 diabetes. Diabetes Care 27, 1570-1576.

Ziemer, D., Berkowitz, K., Panayioto, R., El-Kebbi, I., Musey, V., Anderson, L.,

Wanko, N., Fowke, M., Brazier, C, Dunbar, V., Slocum, W., Bacha, G.,

Gallina, D., Cook, C , & Phillips, L. (2003). A simple meal plan

emphasizing healthy food choices is as effective as an exchange-based

meal plan for urban African Americans with type 2 diabetes. Diabetes

Care 26, 1719-1724.

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A Questionnaire of the Dietary Adherence Among Type 2 Diabetes Patients

with Nutrition Intervention

Authors: Shannon Denney BS/MS Dietetic Student; Charlotte Baumgart PhD,

RD; Edward Weiss PhD, RD; Walter Iwanenko PhD.

ABSTRACT

Objective. To determine the dietary adherence among type 2 diabetic patients

after two or more nutrition education sessions from a Registered Dietitian

compared to the dietary adherence of type 2 diabetic patients after a single

nutrition education session.

Design. Mailed questionnaires with 17 diabetes self-care questions, 33 people

with type 2 diabetes returned the questionnaires. Participants from a Registered

Dietitian's patient list from a local outpatient diabetes facility in western New

York. The questionnaire used in this study was adapted by the researcher from an

existing tool by Toobert et al., The Diabetes Self-Care Activities Questionnaire to

measure the dietary adherence and self-care activities of the participants (1).

Subjects/setting. Patients with type 2 diabetes (20 years and older) who have

received nutrition education from a Registered Dietitian (RD). Thirty three

participants returned the questionnaire including 16 patients with type 2 diabetes

who received 2 or more nutrition education sessions with an RD and 17 patients

with type 2 diabetes who received no nutrition education or a single nutrition

 Dietary Adherence

82

education session with an RD. An RD employed at a local outpatient facility for

diabetes in western New York mailed out questionnaires to their patients.

Main Outcome Measures. Dietary adherence and diabetes self-care activities of

type 2 diabetic patients who received no nutrition education or a single nutrition

education session with an RD compared to type 2 diabetic patients who received 2

or more nutrition education sessions with an RD were measured.

Statistical Analyses. The Diabetes Self-Care Activities Questionnaire has been

demonstrated to be a multidimensional measure of diabetes self-care management

with adequate internal and test-retest reliability, evidence of validity and

sensitivity to change (1). Dietary adherence was measured by the mean number of

days from the diet questions asking the frequency of the specific diet

recommendations followed for each subject group. The dietary adherence of the

participants were compared using an independent sample Mest to compare the

mean of the responses for the diet questions for each group (0-1 nutrition

education session vs. 2 or more nutrition education sessions). The responses to the

other sections of the questionnaire were reported using descriptive statistics to

describe exercise and self-care activities advised by their health care professional.

Results. The results indicated a statistically significant difference (p = 0.02) in

dietary adherence among the type 2 diabetic patients with 2 or more nutrition

education sessions with an RD compared to the type 2 diabetic patients with none

or a single nutrition education session. This was determined by an independent

 Dietary Adherence

83

sample /-test which compared the mean number of responses (mean number of

days following the diet) on diet questions for each group of type 2 diabetic

patients. The group who received 2 or more nutrition education sessions had a

mean of 5.02 days (75%) compared to the group with none or a single nutrition

education session which had a mean of 3.9 days (50%). The group with 2 or more

nutrition education sessions had a mean of 3.9 days of exercise (50%) compared

to the group with none or a single nutrition education session which had a mean

of 2.5 days of exercise (25%).

Conclusions. Patients with type 2 diabetes who received more nutrition

intervention (2 or more nutrition education sessions from an RD) have greater

dietary adherence compared to less intervention (0-1 nutrition education sessions

with an RD). Dietary adherence measured by the adapted Diabetes Self-Care

Activities Questionnaire included following a healthful eating plan such as a

consistent carbohydrate diet, eating more fruits and vegetables, and eating less

high-fat foods. Patients with type 2 diabetes would benefit from more nutrition

intervention with emphasis on a consistent carbohydrate diet, exercise and

checking blood glucose. This study concluded that with more intervention from a

Registered Dietitian, the patient followed their diet plan and had a statistically

significant difference in dietary adherence than the group with less intervention

from an RD. As evident by this study and related research, patients with type 2

diabetes would benefit on an emphasis of consistent carbohydrates, low fat, high

 Dietary Adherence

84

fiber and incorporating more fruits and vegetables. This study and related research

indicates the effectiveness of more nutrition intervention for dietary adherence in

type 2 diabetic patients.

 Dietary Adherence

85

INTRODUCTION

Prevalence. Diabetes and its complications are a significant cause of morbidity

and mortality in the U.S. The Centers of Disease Control and Prevention (CDC)

estimated that diabetes is the seventh leading cause of death in the United States,

which is likely underreported (2). Approximately 90% of those diagnosed with

diabetes in the United States have type 2 diabetes. The prevalence of diagnosed

diabetes for U.S. adults greater than or equal to 20 years of age has increased to

23.5 million from 10.2 million people (2-3). According to NHANES II and

NHANES III, prevalence of diabetes increased from 8.9% in the years 1976-1980

to 12.3% in the years 1988-1994 who are 40-74 years of age (2-3). The CDC

estimated that diabetes now affects nearly 23.7 million Americans and more than

5.7 million are undiagnosed (2).

Treatment and Prevention. The American Diabetes Association nutrition

principles and recommendations attempted to define an ideal nutrition diet order

that would apply to people with diabetes. The goal of nutrition intervention is to

assist and facilitate individual lifestyle and behavior changes that will lead to

improved metabolic control (4). The goals of Medical Nutrition Therapy (MNT)

in the 2008 recommendations are to decrease the risk of diabetes and

cardiovascular disease by promoting healthy food choices and physical activity

leading to moderate weight loss that is maintained (5). It sets recommendations

for carbohydrates, protein, dietary fat, energy balance and obesity, micronutrients,
 Dietary Adherence

86

acute complications, and prevention. The Diabetes Care and Education Dietetic

Practice Group of the American Dietetic Association developed new Standards of

Practice and Standards for Professional Performance for Registered Dietitians

working with diabetes patients. The Standards of Practice for the RD in diabetes

care are Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and

Nutrition Monitoring and Evaluation (6). The Standards of Professional

Performance for RDs in diabetes care are Provision of Services, Application of

Research, Communication and Application of Knowledge, Utilization and

Management of Resources, Quality in Practice, and Continued Competence and

Professional Accountability. The Standards of Practice and Standards for

Professional Performance applies to all clinical nutrition patients although the

Diabetes Care and Education Dietetic Practice Group applied these standards

specifically for diabetes care.

Effectiveness of MNT. Positive clinical outcomes in adults receiving nutrition

intervention for type 2 diabetes have been evidenced from the literature. Health,

behavior, and quality of life outcomes after nutrition intervention in adult, type 2

diabetes patients have improved (7). Randomized controlled trials and

observational studies of MNT have documented decreases in HBAlc o f - 1 % to

2%, depending on the type and duration of diabetes (8). A 3 month observational

study by Gaetke, Stuart, & Truszczyska analyzed 500 medical charts from a

physician to obtain 175 subjects with type 2 diabetes or cardiovascular disease

 Dietary Adherence

87

(9). The records were categorized into two groups based on whether the patient

had attended or not attended a single nutrition education session from the same

dietitian (9). There were significant improvements in mean fasting blood glucose,

mean hemoglobin A1C, mean total cholesterol level, mean triglyceride level,

mean ratio of total cholesterol to HDL level, and BMI and weight decreased from

baseline to 3 months in the group attending a single nutrition education session

(9). The participants of this study had a 2.6% decrease in HbAlc (8-9). An

observational study had 244 physician referred subjects from 31 sites with type 2

diabetes (Lemon et al., 2004). In this 6 month study, subjects received nutrition

education from a RD and health and lifestyle indicators were measured at

baseline, 3 months and 6 months. Weight, body mass index, and glycosylated

hemoglobin value improved significantly between 3 months and 6 months (7).

The subjects had a 1.7% decrease in HgAlc (7-8). This study showed adult type 2

diabetes patients' improvement in weight and glycemic control, coronary heart

disease risk, and self-management behaviors between baseline and 3 months and

also baseline and 6 months after education with a Registered Dietitian (7). In the

same study, mean diet/lifestyle and exercise responses improved as well as blood

glucose self-monitoring frequency and results. A quality of life assessment

showed that self-perception of health status improved over the course of the study

(7). Also, overall medication use and antihypertensive medication use declined

between baseline and 3 months and then to 6 months.

 Dietary Adherence

88

Another study conducted by Franz et al. evaluated the effectiveness of

MNT administered according to practice guidelines nutrition care (PGC)

compared to basic nutrition care (BC) (10). There were 85 participants randomly

assigned to the BC group and 94 participants to the PGC group, totaling 179

newly diagnosed type 2 diabetic patients in the study. The PGC group consisted

of an initial session with a dietitian of approximately 1 hour and two follow up

sessions of approximately 30 to 45 minutes. The BC group consisted of only one

visit of approximately 1 hour with a dietitian. At 6 months, PGC resulted in

significant improvements in blood glucose control as indicated by fasting plasma

blood glucose (9.1 mmol/L) and hemoglobin A1C levels (7.4%) (10). The BC

resulted in significant improvements in hemoglobin A1C levels (9.2 mmol/L) at 6

months (10). The PGC group had a mean fasting blood glucose level at 6 months

that was 10.5% lower than the level at entry, and the BC group had a 5.3% lower

value (10). The PGC subjects had significant improvements in cholesterol values

(5.4 mmol/L) at 6 months. From entry to 6 months, both groups had significant

weight loss with the PGC group decreased from 93.8 + 19.9 kg to 92.3+19.8 kg

and the BC group decreased 93.7+22.2 kg to 92.0+21.2 kg (10). Persons with

diabetes longer than 6 months tended to do better with PGC than with BC. MNT

provided by dietitians resulted in significant improvements in medical and clinical

outcomes in both experimental groups and is beneficial to persons with type 2

 Dietary Adherence

89

diabetes (10). MNT is proven to be an effective treatment for type 2 diabetes

patients.

The Diabetes Control and Complications Trial was the pivotal study in

diabetes treatment research. The research group had 1,441 type 1 diabetes patients

with no retinopathy or mild retinopathy (11). They were randomly assigned to the

intensive therapy that either administered an external insulin pump or by three or

more daily insulin injections. The other group had conventional therapy with one

or two daily insulin injections. The patients were followed for a mean of 6.5

years. A statistically significant difference in the average glycosylated

hemoglobin value was maintained after base line between the intensive-therapy

and conventional therapy groups (11). The mean value for all glucose profiles in

the intensive therapy group was 155+ 30 mg per deciliter, as compared with 231+

55mg per deciliter in the conventional therapy group (11). Within the secondary

intervention cohort, the patients of the intensive therapy group had a higher

cumulative incidence of sustained progression of retinopathy by three steps or

more during the first year than did those in the conventional therapy group.

Intensive therapy reduced the average risk of such progression by 54% (95%

confidence interval, 39 to 66%) during the entire study period (11). A consistent

reduction in the risk of retinopathy with intensive therapy was evident in all

subgroups in both the primary prevention and the secondary intervention cohorts

(11). Intensive therapy reduced the mean adjusted risk of microalbuminuria by

 Dietary Adherence

90

34% in the primary prevention cohort and by 43% in the secondary intervention

cohort (11). Intensive therapy reduced the appearance of clinical neuropathy at 5

years by 69% in patients in the primary prevention cohort who did not have

neuropathy at baseline and by 57%) in the secondary intervention cohort (11). The

results determined intensive therapy effectively delays the onset and slows the

progression of diabetic retinopathy, nephropathy, and neuropathy in patients with

type 1 diabetes.

Cost-effectiveness of MNT. Medical Nutrition Therapy is cost-effective for

persons with type 2 diabetes. Diabetes prevention is more cost-effective than

diabetes treatment found in a review of four published studies of intensive

glycemic management for type 2 diabetes mellitus (12). There are a limited

number of controlled trials that include full cost analyzes of diabetes education.

Research published to date indicates diabetes education is likely cost-effective,

particularly when provided to those patients with the poorest glycemic control

(12).Franz et al. compared the cost-effectiveness of the PGC group with the BC

group, which was calculated using per-patient costs and glycemic outcomes for

the 6 months of the study (13). Cost-effectiveness ratios are expressed as cost per

unit of improvement in glycemic control. The net cost-effectiveness ratios were

also calculated to explore the effect of cost savings associated with therapy

changes on cost-effectiveness determinations. The patients in the PGC group

experienced a mean 1.1 ^2.8 mmol/L decrease in fasting plasma glucose level 6
 Dietary Adherence

91

months after entry to the study, for a total per-patient cost of $112 (13). Patients

in the BC group experienced a mean 0.4 + 2.7 mmol/L decrease, for a total per-

patient cost of $42 (13). If net costs are considered, the cost-effectiveness ratios

become $5.32 for BC and $4.20 for PGC, assuming the medical changes in

therapy were maintained for 12 months. Based on the examination of the cost of

providing nutrition care to diabetes patients and the diabetes cost of illness, it has

been concluded that the beneficial medical outcomes from MNT make it well

worth the relatively small monetary investment (13). Wolf and colleagues

completed a 1 -year randomized controlled trial comparing usual medical care to

usual care plus lifestyle case management provided by a Registered Dietitian (12,

14). People who received lifestyle case management had substantially greater

weight loss, reduced hemoglobin A1C, and decreased prescription medication

use, compared to usual medical care (12, 14). Wolf and colleagues evaluated the

same 147 health plan members with obesity and type 2 diabetes to determine the

program and health care costs of a lifestyle intervention (14-15). The net cost of

the intervention was $328 per person per year. Case management participants had

fewer inpatient admissions of 2.8% compared to 22.5% in usual care participants,

which substantially lowered medical costs (12, 15). The mean net total costs were

$3,586 per person per year less among case management compared with usual

care (15). Implications for the RD are that MNT among a high-risk population

with type 2 diabetes and obesity is cost-saving by decreasing health plan costs by
 Dietary Adherence

92

34% (12). MNT has been concluded to be effective in improving clinical

outcomes and cost-effective for the patient.

Purpose. The purpose of this study was to determine whether there was a

significant difference in dietary adherence of adult type 2 diabetic patients after

receiving two or more nutrition education sessions from a Registered Dietitian

compared to adult type 2 diabetic patients after receiving a single nutrition

education session. This analysis was conducted via a questionnaire.

MEASUREMENT TOOL

The Diabetes Self-Care Activities Questionnaire has been proven to be reliable

and valid self-report measure of diabetes self-management that is useful both for

research and practice (1). The seven studies reviewed by Toobert et al.

demonstrated that the SDSCA is a multidimensional measure of diabetes self-

management with adequate internal and test-retest reliability, evidence of validity

and sensitivity to change (16-21)

The mean ages of the participants of the 7 samples ranged from 45 to 67

years of age, average diabetes duration ranged from 6.3 to 13 years with a total

subject pool of 2,000 people (1). The means and standard deviations (SD) for

each subscale for each study provided information for comparative purposes,

which mean higher percentages indicate better self-care on all scales. The mean

levels computed across all 7 studies for each scale were as follows: general diet:

mean - 58.6, SD = 28.7, n = 1,409; specific diet: mean = 67.5, SD = 16.9, n =

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973; and exercise: mean = 34.3, SD = 31.9, n= 883 (1). The other subscales of

blood glucose testing, medication taking, and foot care were excluded from this

study. The internal consistency of the scales, assessed by average inter-item

correlations, was acceptable (mean = 0.47) except for specific diet, which was

consistently unreliable (r = 0.07-0.23) (1). Test-retest correlations over 3-4

months were examined for the observational studies and for control groups in the

intervention studies. Test-retest reliability was moderate across these studies and

may be an underestimate (general diet ranging from r = 0.55-0.67; specific diet

ranging from r = 0.42-0.61; and exercise ranging from r = 0.42-0.55) (1). The

intervention studies analyzed have control groups have a modest self-monitoring

intervention.

The validity estimates for diet and exercise were based on multiple

methods of self-report. For dietary comparisons, these included 3 or 4 day foods

records, food-frequency questionnaires, Food Habits Questionnaires, and the

Block Fat Screener (16-20). For exercise comparisons, these included the

Stanford 7 day recall, the Physical Activity Scale for the Elderly, exercise self-

monitoring data, or attendance at an exercise class. The correlations between the

dietary and exercise subscales and criterion variables were all significant with a

range of r = -0.54 to -0.01 (1). For the diet amount subscale, there were

statistically significant correlations for average self-monitored calories in two of

the three studies (Study 1: r = -0.29,p < 0.01; and Study 3: r = -0.21,p < 0.01);
 Dietary Adherence

94

and for average percent of calories from fat in all three studies (Study 1: r = -0.21,

p < 0.05; Study 2: r = -0.35, p < 0.01; and Study 3: r = -035,p < 0.01) (22). The

sensitivity to change of the SDSCA was assessed using the responsiveness index,

resulted in a wide range of-0.05 to 0.43. Student's t tests evaluating pre to post

change among intervention conditions revealed significant improvement on

SDSCA scales in 6 of the 9 comparisons with a range of 0.000 to 0.032 (1). Both

of the correlations of the original and revised SDSCA are evidence for the validity

of this self-report scale.

The Summary of Diabetes Self-Care Activities Questionnaire (SDSCA)

has been widely used in earlier studies and the revised SDSCA has been recently

used in studies analyzing adherence. The researchers of the original SDSCA

found multiple measures having different scales to assess adherence to each

regimen component. The original version of the SDSCA used either the number

of days per week or percent of time as the response options (22). The revised

SDSCA simplified scoring and interpretation by using the metric "days per week"

instead of percentages. Comparisons of data based on the new questionnaire with

previous research would need to be converted to percentages (1).

More recent studies have used the revised SDSCA (1). There were 53

participants with type 2 diabetes who responded to mailed surveys from a diabetes

clinic in the South East of England (23). The study analyzed biases in self-reports

of self-care behaviors in type 2 diabetes patients. The researchers of this study

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95

used percent of time as their response option for the SDSCA questionnaire. For

the analysis, items were combined to form subscales "General Diet", "Specific

Diet", "Medication taking" and "Blood Glucose testing", in line with Toobert et

al.'s (2000) recommendations. Descriptive statistics for these subscales were used

and a higher percent indicates a higher behavior frequency. Relatively high

percentages were reported for following a healthy diet in the General diet subscale

(daily 77.11%; weekly 72.97%; monthly 71.71%) (23). Relatively low

percentages were reported for unhealthy eating, the specific diet subscale (daily

16.61%; weekly 19.90%; monthly 19.17%) (23). Participants reported less

successful dietary control than the daily records suggested, in both weekly (16.56,

p< 001) and monthly (18.78,/? <001) estimates (23). This study used percentages

and descriptive statistics to score the revised SDSCA.

The researcher in this study adapted the Diabetes Self-Care Activities

Questionnaire from the Toobert et al. (2000) study. This questionnaire was

adapted by removing questions on blood glucose testing, medications, foot care,

and smoking. It was adapted by using questions pertaining to diet and exercise

after receiving nutrition education from a Registered Dietitian. A 24 hour recall

was suggested by Toobert et al., 2000 to analyze specific diet because the

subscale in the SDSCA was consistently unreliable. This study did not use a 24

hour recall due to infeasibility of the following information: height, weight, and

specific diet prescription for each participant of the study.

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The five page questionnaire was in three sections. The first section asked

demographic information such as the participants' age, the type of diabetes they

have, when they were diagnosed with diabetes, and how many nutrition education

sessions they attended (Appendix B). The second section asked questions on diet,

exercise, and self-care recommendations and scored by the mean number of days.

The second section asked specific questions were asked on their diet over the last

seven days and the last month. The questionnaire asked if they followed a

healthful eating plan in the last seven days and over the past month how many

days a week they followed their diet. The questionnaire asked how many days a

week they ate fruits and vegetables, consistent carbohydrates, fiber and whole

grains, high fat foods after receiving nutrition education. It also asked how many

days a week they exercised for 30 minutes after receiving nutrition education. The

self-care recommendations of the second section asked questions on what their

health care provider advised the patient to do regarding their diet? exercise, and

testing their blood glucose. The third section asked for the participates' comments

on any problems they had with following a consistent carbohydrate diet, exercise,

and testing their blood glucose levels. At the end of the third section, there was a

page for any additional comments at the end of the questionnaire for participants

to write anything they felt important.

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97

METHODS

Study Design and Sample. Subjects were 20 years or older with type 2 diabetes

who returned the mailed questionnaire. The subjects were patients of a Registered

Dietitian from a local outpatient facility for diabetes in western New York.

Following approval from the IRB at D'Youville College and permission from the

Registered Dietitian from the diabetes outpatient facility to conduct the study with

their patients, the researcher provided the RD with 200 questionnaires and a cover

letter to be mailed by the RD to their patients from the master patient/number list.

The response rate was 33% which included 33 patients returned the

questionnaires to the researcher (Appendix B). The RD mailed out 100 of the

questionnaires to the patients on the master list. A mailing code was placed on the

top corner of the questionnaires and used as the return address on the provided

postage paid envelope to assure the researcher does not have knowledge of the

participants' names and addresses. The cover letter explained the purpose of the

study, directions to the questionnaire, and completing the survey implied their

consent to be participants in the study. The participants were assured their

information was anonymous and the purpose of the mail coding number that was

written on the questionnaire. The questionnaires were to be returned one month

from the postage date the patient received the questionnaire.

Data Analysis. Dietary adherence was assessed through the use of a questionnaire

developed by Toobert et. Al. (2000) and adapted by the researcher for the
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98

purposes of this study. The Summary of Diabetes Self-Care Activities

Questionnaire (SDSCA) is a brief self-report questionnaire of diabetes self-

management which involves general diet, specific diet, exercise, blood-glucose

testing, foot care, and smoking (1). For the purposes of this study, blood-glucose

testing, foot care and smoking questions were excluded.

The data analysis methodology used in this study was similar to the

studies reviewed by the researcher (7, 1). No scoring was necessary for Section 1

of the questionnaire because it was demographic data. The data was used for

identifying whether the subject met the criteria for the study. Descriptive statistics

were used to provide a description of the sample obtained. Type 1 diabetes

patients were excluded and persons less than 20 years of age were also excluded

from the study. Section 2 of the questionnaire pertains to questions about diabetes

self-care activities during the past 7 days. The score of Section 2 was determined

by calculating the mean of the responses (number of days) for the general diet

questions 5 and 6. The mean of the responses (number of days) was calculated for

the specific diet questions 7, 8, 9 reversing question 8 (0=7, 1=6, 2=5, 3=4, 4=3,

5=2, 6=1, 7=0). The score for general diet and the score for specific diet were

summed and this total diet score compared the dietary adherence between the two

groups via an independent sample /-test. The score for the exercise questions 10

and 11 was the mean of the number of days selected for each question. No scoring

was necessary for the self-care recommendations. Descriptive statistics were used
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to determine which self-care recommendations were given to the participant. The

scores for each subscale (general diet, specific diet, and exercise) were used to

compare the two groups of participants. The score for each subscale of this study

were compared to previous studies' scores for the same subscale. Section 3 of the

questionnaire addressed the participants' problems with following a consistent

carbohydrate diet, exercise, and testing their blood glucose levels. The

participants could add additional comments they felt important. No scoring of

Section 3 was necessary but barriers to diet, exercise, and testing blood glucose

were noted for each group and reported descriptively. Descriptive statistics and an

independent sample /-test were used to determine the difference between the

dietary adherence of participants with 2 or more nutrition education sessions

compared to the participants with a single nutrition education session. The "days

per week" scale was converted to percentages to compare to results of previous

studies that utilitized The Diabetes Self-Care Activities Questionnaire. The

responses for 0 days were converted to 0%, 1 to 2 days were converted to 25%, 3

to 4 days were converted to 50%, 5 to 6 days were converted to 75%, and 7 days

were converted to 100%. The score for each of the subscales of general diet,

specific diet and exercise in this study were compared to previous studies' scores

for the same subscale.

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RESULTS

Total Sample. Of the 200 mailed questionnaires, 33 patients with type 2 diabetes

returned the questionnaire. They were all 20 years of age and older and

participants of the study. There were 16 participants of the group with 2 or more

nutrition education sessions from a Registered Dietitian. There were 17

participants of the group with no nutritional intervention or had a single nutrition

education session with an RD. The group with 2 or more nutrition intervention

had 7 out of 16 patients diagnosed with type 2 diabetes within the last year and

the other group with less intervention had 12 out of 17 patients diagnosed with

type 2 diabetes within the last year.

Dietary and Exercise Adherence. An independent sample /-test was used to

compare the dietary adherence of the two groups using the means from the diet

questions using Microsoft excel software. There was a statistically significant

difference (p = 0.02) in dietary adherence among the type 2 diabetic patients with

2 or more nutrition education sessions with an RD compared to the type 2 diabetic

patients with none or a single nutrition education session. This was determined by

an independent sample /-test which compared the mean number of responses

(mean number of days) on diet questions for each group of type 2 diabetic

patients. The group who received 2 or more nutrition education sessions had a

mean of 5.02 days (75%) compared to the group with none or a single nutrition

education session which had a mean of 3.9 days (50%) (Table 2). The group with
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2 or more nutrition education sessions had a mean of 3.9 days of exercise (50%)

compared to the group with none or a single nutrition education session which

had a mean of 2.5 days of exercise (25%).

Diabetes Self-care Activities. The group with more nutritional intervention was

all advised to follow a consistent carbohydrate diet and most patients were told to

follow a low-fat eating pattern (94%) by their health care professional (Table 3).

The group with less nutritional intervention had 59% of patients told to eat a

consistent carbohydrate diet and 65% were told to eat a low-fat eating pattern.

Most patients of the group with 2 or more nutrition education sessions (94%)

were advised by their health care professional to eat more fiber, eat more fruits

and vegetables, and eat few sweets while the other group with less nutrition

educations sessions only had 53% of patients advised to follow these

recommendations. Most patients of the group with more nutrition intervention

were advised to exercise on a daily basis (88%) compared to the group with less

nutrition intervention with 35% of patients advised to exercise daily. There was

one patient in the group with no nutrition education or a single nutrition education

session that reported they were not advised to follow a specific diet or to exercise.

Barriers. The group with more nutrition education sessions reported fewer

problems with following their diet (25%) compared to the group with less

nutrition education sessions (59%) (Table 4). The problems described by the

group with less nutrition intervention (0-1 nutrition education session with an RD)
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were planning meals, overwhelmed with diabetes, difficult and time consuming to

count carbohydrates, etc. The group with more nutrition education sessions

reported less problems with following an exercise routine (31%) compared to the

group with less nutrition education sessions (47%). The problems reported by the

group with less nutrition intervention were tired from diabetes and medications,

rehabilitation from knee replacement, planning to establish an exercise routine,

etc. The group with 2 or more nutrition education sessions included patients with

no problems checking their blood glucose and the group with no nutrition

education or a single nutrition education session had 7 patients with no problems

and 10 questionnaires with no response to the question.

These results suggest that patients with type 2 diabetes that have received

2 or more nutrition education sessions with a Registered Dietitian have greater

dietary adherence compared to patients with no nutrition education or a single

nutrition education session. The patients with 2 or more nutrition education

sessions were more likely to follow a diet plan and exercise routine.

DISCUSSION

The results of this study indicate dietary adherence of patients with type 2

diabetes is greater with more nutrition intervention. The results also indicate type

2 diabetic patients with 2 or more nutrition education sessions follow a consistent

carbohydrate diet, follow an exercise routine, and know how to check their blood
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103

glucose levels. This study and corresponding research indicate the effectiveness

of Medical Nutrition Therapy (7, 10).

This study demonstrated that the more nutrition education sessions with a

Registered Dietitian the patient had, the greater the adherence was to the diet and

an exercise routine. In the corresponding research, a study conducted by Norris et

al. involving a 12 month follow-up had 87 subjects with significantly increased

knowledge in the intervention group (p < 0.001) (24). The intervention group

consisted of five group sessions over six months, focusing on weight loss and the

control group treatment consisted of individual education on weight loss by a

dietitian with 3 or more visits in 12 months. Positive dietary changes included

improvements in dietary carbohydrate or fat intake, a decrease in consumption of

lower glycemic-index foods (24). The intervention group received advice to

decrease fat to <30% total calories while the control group received advice to

decrease carbohydrates to <40% total calorie intake (24). The intervention group

had decreased fat and cholesterol intake, increased carbohydrate intake with a

between group difference ofp < 0.001 (24). This study had ap value of 0.02,

which indicates a statistically significant difference of adherence to diet with the

group with 2 or more nutrition education sessions with a Registered Dietitian.

The Summary of Diabetes Self-Care Activities Questionnaire (SDSCA)

has been used in previous studies comparing type 1 and type 2 diabetic patients

and used multiple measures having different scales to assess adherence. Scoring
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104

the original SDSCA questionnaire involved using raw scores from each measure,

which were then converted to standard scores having a mean of zero and a

standard deviation of one (22). The standardized scores were then averaged to

form a composite score for each regimen behavior. The purpose of this procedure

was to give items with differing scales equal weighing (22). Relatively high

percentages were reported for following a healthy diet in the General diet subscale

(daily 77.11%; weekly 72.97%; monthly 71.71%) (23). The diet and exercise

subscales of this study were compared to previous studies reported percentages.

This study found that the group with 2 or more nutrition education sessions had a

diet score of 75%, similar to Asimakopoulou & Hampson's findings. The group

with no nutrition education or a single nutrition education session had a diet score

of 50%, which is lower than the 71-77% reported in the Asimakopoulou &

Hampson's study.

Similar to previous studies that used the scale of the higher the percentage

the higher the frequency of the diabetes self-care activity (1). The group with 2 or

more nutrition education sessions had a higher percentage of establishing an

exercise routine (50%) compared to the group with none or a single nutrition

education session which had a lower percentage (25%). In previous studies, there

was a 24.7 + 27.9 average value for exercise conducted by Glasgow et al. (2000),

39.1 + 33.0 average value for exercise conducted by Glasgow et al. (1998), and

39.4 + 32.9 average value for exercise conducted by Feil et al. (2000) (16, 18-19).
 Dietary Adherence

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Both groups in this study had greater percentages than previous studies with the

greater percentages in the group with the most nutrition education.

Previous studies reported the frequency of the blood glucose testing and

medication taking while this study used descriptive statistics for each group of the

recommendations advised by the patient's health care professional. The group

with 2 or more nutrition education sessions had 100% of the patients advised to

check their blood glucose with a meter and with no problems checking their blood

glucose. The group with no nutrition education or a single nutrition education

session had 7 patients with no problems and 10 questionnaires with no response to

the question. Overall, the group with 2 or more nutrition education sessions had

less problems or barriers to their diet (25%), exercise routine (31%) and blood

glucose testing (0%) than the group with less nutrition education sessions (59%,

47%, respectively.

Study Limitations. The limitations of this study were it was conducted in only

one geographical location, western New York. The findings of this study may not

be applicable to all type 2 diabetic patients because the sample is one of

convenience from returned mailed questionnaires. This study also utilizes self-

reported data for dietary adherence subject to human error of recalling

information and misinterpreting the question. The SDSCA questionnaire was

adapted by removing sections which do not pertain to this study and may affect

the validity and reliability found with the original questionnaire. A sample size of
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106

30 participants was considered sufficient based on previous research studies (7),

which this study had 33 subjects. A larger sample size of 100 subjects would

result in findings to the questionnaire that would be applicable to all type 2

diabetic patients. There were 33 subjects that returned their questionnaire from the

100 questionnaires mailed by the RD. There was a 33% response rate of the

questionnaires. A post-hoc power analysis determined this study had a power of

27% using Power Analysis software. A sample size of 128 participants including

64 subjects in each group would increase the power of the study to 80% to show

more significance in results.

Further Research. Results of this study are important because they support

current research and indicate the effectiveness of medical nutrition therapy with

more intervention from a Registered Dietitian (7, 10). The data demonstrate there

is a greater adherence to diet and exercise routine and less barriers or problems

with their diet and exercise routine. Future research can identify the specific

barriers to diet and exercise among patients with multiple nutrition education

sessions compared to patients lacking any nutrition education.

As determined by post-hoc power analysis, this study can be replicated with a

large sample size of at least 128 participants to have a power of 80% and more

significant results. Further research can identify the clinical outcomes by

measuring weight change in waist circumference, BMI, blood glucose levels, and
 Dietary Adherence

107

hemoglobin A1C to indicate further the effectiveness of Medical Nutrition

Therapy.

CONCLUSION

Patients with type 2 diabetes benefit from nutrition education with a

Registered Dietitian and MNT has shown in current research to be effective in

clinical outcome data. This study found a statistically significant difference in the

dietary adherence of the type 2 diabetic patients with 2 or more nutrition

education sessions from a Registered Dietitian compared to type 2 diabetic

patients with none or a single nutrition education session with a Registered

Dietitian. Greater dietary adherence can improve blood glucose levels and prevent

further diabetes complications when blood glucose levels are within an acceptable

range. Patients who have attended multiple sessions with an RD have a greater

understanding of diabetes and the recommendations necessary to improve the

progression of the disease. Further research is needed in the barriers to dietary

adherence and nutrition education strategies to various population and ethnic

groups to increase the effectiveness of MNT. This study had a small sample size

of 33 participants, which was sufficient for the study. Further analysis of this

study with a large sample size of at least 128 subjects would increase the power of

the study and the significance of the results.

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108

References

1. Toobert, D., Hampson, S., & Glasgow, R. (2000). The Summary of

Diabetes Self-Care Activities Measure. Diabetes Care, 23(1), 943-950.

2. Centers for Disease Control and Prevention. (2008). National Diabetes

Fact Sheet: General Information and National Estimates on

Diabetes in the United States, 2007. Retrieved October 1, 2008, from

www.cdc. gov/diabetes

3. Harris, M., Flegal, K., Cowie, C , Eberhardt, M., Goldstein, D., &

Little, R. (1998). Prevalence of Diabetes, impaired fasting glucose,

and impaired glucose tolerance in U.S. adults: The Third National Health

and nutrition examination survey, 1988-1994. Diabetes Care, 21(A), 518-

524.

4. Franz, M , Bantle, J., Beebe, C, Brunzell, J., Chaisson, J., Garg, A.,

Holzmeister, L., Hoogwerf, B., Mayer-Davis, E., Mooradian, A., Purnell.,

J., & Wheeler, M. (2002). Evidence-based nutrition principles and

recommendations for the treatment and prevention of diabetes and related

complications. Diabetes Care, 25(1), 148-198.

5. Bantle, J., Wylie-Rosett, J., Albright, A., Apovian, C, Clark, N., Franz,

M., et al. (2008). Nutrition recommendations and interventions for

diabetes: a position statement of the American Diabetes Association.

Diabetes Care, 31(1) S61-78.

 Dietary Adherence

109

6. Kulkarni, K., Boucher, J., Daly, A., Shwide-Slavin, C , Silvers, B.,

O'Sullivan Malliet, J., & Pritchett, E. (2005). American Dietetic

Association: Standards of practice and standards of professional

performance for Registered Dietetians (generalist, specialty, and

advanced) in diabetes care. Journal of the American Dietetic Assocation,

105(5), 819-824.e22.

7. Lemon, C , Lacey, K., Lohse, B., Olson Hubacher, D., Klawitter, B., &

Palta, M. (2004). Outcomes monitoring of health, behavior, and quality of

life after nutrition intervention in adults with type 2 diabetes. Journal of

the American Dietetic Association, 104(12), 1805-1815.

8. Franz, M , Boucher, J., Green-Pastors, J., & Powers, M. (2008). Evidence-

based nutrition practice guidelines for diabetes and scope and standards of

practice. Journal of the American Dietetic Association, 108(4), S52-58.

9. Gaetke, L., Stuart, M., & Truszcynska, H. (2006). A single nutrition

counseling session with a Registered Dietitian improves short-term

clinical outcomes for rural Kentucky patients with chronic diseases.

Journal of the American Dietetic Association 106(1), 109-112.

10. Franz, M., Monk, A., Barry, B., McClain, K., Weaver, T., Cooper, N.,

Upham, P., Bergenstal, R., & Mazze, R. (1995a). Effectiveness of medical

nutrition therapy provided by dietitians in the management of non-insulin-

 Dietary Adherence

110

dependent diabetes mellitus: A randomized, controlled clinical trial.

Journal of the American Dietetic Association, 66(9), 1009-1017.

11. The Diabetes Control and Complications Trial Research Group. (1993).

The diabetes control and complications trial: Implications for policy and

practice. New England Journal of Medicine, 329(14), 1035-1036.

12. Urbanski, P., Wolf, M., & Herman, W. (2008). Cost-Effectiveness of

diabetes education. Journal of the American Diejetic Association, 108(4),

S6-11.

13. Franz, M., Splett, P., Monk, A., Barry, B., McClain, K., Weaver, T.,

Upham, P., Bergenstal, R., & Mazze, R. (1995b). Cost-effectiveness of

medical nutrition therapy provided by dietitians for persons with non-

insulin-dependent diabetes mellitus. Journal of the American Dietetic

Association, 95(9), 1018-1024.

14. Wolf, A., Conaway, M , Crowther, J., Hazen, K., Nadler, J., Oneida, B., &

Bovbjerg, V. (2004). Translating lifestyle intervention to practice in obese

patients with type 2 diabetes. Diabetes Care 27, 1570-1576.

15. Wolf, A., Siadaty, M., Yaeger, B., Conaway, M , Crowther, J., Nadler, J.,

& Bovbjerg, V. (2007). Effects of lifestyle intervention on health care

costs: improving control with activity and nutrition (ICAN). Journal of the

American Dietetic Association 107(8), 1365-1373.

 Dietary Adherence

111

16. Fiel, E., Glasgow, R., Boles, S, & McKay, H. (2000). Who participates in

internet-based self-management programs? A study among novice

computer users in a primary care setting. The Diabetes Educator, 26(5),

806-811.

17. Glasgow, R., Toobert, D., Hampson, S., Brown, J., Lewinsohn, P., &

Donnelly, J. (1992). Improving self-care among older patients with type 2

diabetes: the "sixty something..." study. Patient Education and

Counseling, 19, 61-74.

18. Glasgow, R., La Chance, P., Toobert, D., Brown, J., Hampson, S., &

Riddle, M. (1998). Long term effects and costs of brief behavioural dietary

intervention for patients with diabetes delivered from the medical office.

Patient Education and Counseling, 32, 175-184.

19. Glasgow, R., & Toobert, D. (2000). Brief, computer-assisted diabetes

dietary self-management counseling: effects on behavior, physiologic

outcomes, and quality of life. Medical Care, 35(11), 1062-1073.

20. Glasgow, R., Strycker, L., Toobert, D., & Eakin, E. (2000). A social-

ecologic approach to assessing support for disease self-management: the

chronic illness resources survey. Journal of Behavioral Medicine, 23(6),

559-583.
 Dietary Adherence

112

21. Wagner, E., Grothaus, L., Sandhu, N., Galvin, M., McGregor, M., Artz,

K., & Coleman, E. (2001). Chronic care clinic for diabetes in primary

care: a system-wide randomized trial. Diabetes Care, 25(4), 695-700.

22. Toobert, D., & Glasgow, R. (1994). Assessing diabetes self-management:

the summary diabetes self-care activities questionnaire. In C. Bradley,

Handbook of Psychology and Diabetes (p. 351-375). Chur, Switzerland:

Harwood Academic.

23. Asimakopoulou, K., & Hampson, S. (2005). Biases in self-reports of self-

care behaviours in type 2 diabetes. Psychology, Health, & Medicine,

10(3), 305-314.

24. Norris, S., Engelgau, M., & Venkat Narayan, K. (2001). Effectiveness of

self-management training in type 2 diabetes: A systemic review of

randomized controlled trials. Diabetes Care, 24(3), 561-587.

 Dietary Adherence

113

Table 1. Demographic Description of the Sample (N = 33)

Group with 2 or more nutrition education sessions with an.RD(» == 16)

Diagnosis within last year mean #ofRD appointments

43.8 % 3.5

Group with no nutrition education or a single nutrition education session with an

RD(w=17)

Diagnosis within the last year mean # of RD appointments

70.6% 0.4
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Table 2. Means and Standard Deviations for the Diet Score and Exercise Score of

each Group (N = 33)

Group with 2 or more nutrition education sessions with an RD (n = 16)

# of responses M SD

Diet Score 80 5.02 2.25

Exercise Score 32 3.9 2.3

Group with no nutrition education or a single nutrition education session with an

RD (n = 17)

# ofresponses M SD

Diet Score 85 3.9 1.9

Exercise Score 34 2.5 1.9

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Table 3. Descriptive Statistics on Diabetes Self-Care Activities Advised to Follow

by the Patients' Health Care Professional (N = 33)

n=\6 n=\l

Self-Care Activity % of patients

Consistent Carbohydrate diet 100 59

Low-fat diet 94 65

Eat more fiber 94 53

Eat more fruits and vegetables 94 53

Eat less sweets 94 53

Exercise 88 35
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Table 4. Descriptive Statistics on the Barriers or Problems to Diet, Exercise, and

Blood Glucose Testing (N = 33)

n=\6 n=\7

Self-Care Activity % of patients

Diet 25 59

Exercise 31 47

Blood Glucose Testing 0 10

(no responses)
 Dietary Adherence

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Appendix A

Letter of Permission to use Copy writed

Conceptual Framework
 Dietary Adherence

118

From: John Anderson randers88@email.unc.edul

To: Penney,Shannon

Cc: Subject: Re: Request to use Type 2 DM algorithm for thesis

Shannon Denney,

You are welcome to use this algorithm (type 2 diabetes) in your thesis
at D'Youville College. Good luck.

John J. B. Anderson
Professor Emeritus
UNC-Chapel Hill, NC

Denney,Shannon wrote:

I am a graduate dietetics student at D'Youville College in New York State, and I

am conducting a study that examines the dietary adherence of type 2 diabetes
patients after receiving nutrition education from a Registered Dietitian.

I am requesting permission to use the Pathophysiology and Care Management

Algorithm of Type 2 Diabetes Mellitus in my thesis. It would be useful as the
conceptual framework to my study.

If you have any questions regarding my study, feel free to contact me at (585)
506-6249. You may also contact my thesis director, Charlotte Baumgart, at (716)
829-7752.

If you agree to grant me permission to use the algorithm, please respond by email
stating your approval. I thank you for your consideration and for your time.

Sincerely,

Shannon Denney
 Dietary Adherence

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Appendix B

Questionnaire
 Dietary Adherence

120

Diabetes Self-Care Questionnaire

Section 1

Please circle the appropriate answer on the right hand side:

1. Are you of at least 20 years of age or older? Yes No

2. What type of diabetes do you have? Type 1 Type 2

3. When were you diagnosed with diabetes?

Please write the approximate month and year

on the line provided.

4. How many times have you attended an appointment with a Registered

Dietitian? Please write the amount on the line provided.

Section 2

The questions below ask you about your diabetes self-care

activities during the past 7 days. Please circle the number of days

as accurately as you can remember:

Diet

5. How many of the last SEVEN DAYS have you followed a healthful eating

plan?

0 1 2 3 4 5 6 7
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121

6. On average, over the past month, how many DAYS PER WEEK have you

followed your eating plan?

0 1 2 3 4 5 6 7

7. On how many of the last SEVEN DAYS did you eat five or more servings of

fruits and vegetables?

0 1 2 3 4 5 6 7

8. On how many of the last SEVEN DAYS did you eat high fat foods such as red

meat or full-fat dairy products (ex. Cheese, ice cream, whole milk)?

0 1 2 3 4 5 6 7

9. On how many days of the last SEVEN DAYS did you space carbohydrates

evenly throughout the day?

0 1 2 3 4 5 6 7

Exercise

10. On how many of the last SEVEN DAYS did you participate in at least 30

minutes of physical activity? (Total minutes of continuous activity, including

walking).

0 1 2 3 4 5 6 7
 Dietary Adherence

122

11. On how many of the last SEVEN DAYS did you participate in a specific

exercise session (such as swimming, walking, biking) other than what you do

around the house or as part of your work?

0 1 2 3 4 5 6 7

Self-care Recommendations

12. What of the following has your health care team (doctor, nurse, dietitian, or

diabetes educator) advised you to do?

Please check all that apply:

• A. Follow a low-fat eating plan

• B. Follow a consistent carbohydrate diet

• C. Reduce the number of calories you eat to lose weight

• D. Eat lots of food high in dietary fiber

• E. Eat lots (at least 5 servings per day) of fruits arid vegetables

• F. Eat very few sweets (for example: desserts, non-diet sodas, candy bars)

• G. Other (specify):

• H. I have not been given any advice about my diet by my health care team.

13. Which of the following has your health care team (doctor, nurse, dietitian, or

diabetes educator) advised you to do?

Please check all that apply:

• A. Get low level exercise (such as walking) on a daily basis.

 Dietary Adherence

123

• B. Exercise continuously for at least 20 minutes at least 3 times a week.

• C. Fit exercise into your daily routine (for example, take stairs instead of

elevators, park a block away and walk, etc.)

• D. Engage in specific amount, type, duration and level of exercise.

• E. Other (specify):

• F.I have not been given advice about exercise by my health care team.

14. Which of the following has your health care team (doctor, nurse, dietitian, or

diabetes educator) advised you to do?

• A. Test your blood sugar using a drop of blood from your finger and a

color chart.

• B. Test your blood sugar using a machine to read the results.

D C. Test your urine for sugar.

• D. Other (specify):

• E. I have not been given any advice either about testing my blood or urine

sugar level by my health care team.

Section 3:

Comments

15. Were there any problems you had with following a consistent carbohydrate

diet?
 Dietary Adherence

124

16. Were there any problems you had following your exercise schedule?

17. Were there any problems you had when testing your blood glucose?

Additional comments:
 Dietary Adherence

125

Scoring Instructions for the Diabetes Self-Care questionnaire

Section 1:

No scoring necessary. Type 1 diabetes patients excluded and persons under 20

years of ago also excluded from the study.

Section 2:

General diet: mean number of days for question 5 and 6

Specific diet: mean number of days for questions 7, 8, 9 reversing question 6.

(0=7, 1=6, 2=5, 3=4, 4=3, 5=2, 6=1, 7=0)

Exercise: mean number of days for questions 10 and 11

Self-care recommendations: no scoring necessary

Section 3:

No scoring necessary. Barriers to diet, exercise, and testing blood glucose noted

for each group (2 or more nutrition education sessions vs. a single nutrition

education session).
 Dietary Adherence

126

Appendix C

Letter of Approval from IRB

 Dietary Adherence

127

D'Youville
C O L L E G E

(716)829-8000
FAX: (716) 829-7790

TO: Shannon Denney v

FROM: Dr. Catherine Lalonde c « ]\V
Institutional Review Board
DATE: • March 5, 2009
SUBJECT: IRB FULL APPROVAL
Thank you for submitting the materials requested by the
D'Youville College Institutional Review Board in regard to
your IRB application that was previously granted Approval
with Conditions.
I am pleased to inf orm,...ypw;: that: you;: Have^ met the conditions
specified and your application' toxthe: :D:V;¥puville College
Institutional Review.;>B'q^r.d";entit^ Of The
Dietary Adherence Among i:Type{ Z'\ pi:abe£es% Patients With
Nutrition Intervention "::has now: been; 'granitedrFULL APPROVAL
with respect to the|;pxotection/;of ^.human : subjects . This means
that you may now beginftypuf;:research'::unless*;ypu must first
apply: to the IRB afcjthej:^insti£utibn; ;W.here'^ou*'plan to conduct
the research. i'i?&:>-.t:-:::fe;.;' ^:C-::!'''M-is:'v'•!
Please note that you'^axe^requlred; tt) ;,xeport'back to this IRB
for further review of :>ybur:: ffrsearch^should: any of the
following occur: '":"f:':r':J\h/'".ii^'i'M..^H\;3:'':*"'"''
1. a major change in'th.fr method of data collection
2. unanticipated adverse effects on the human subjects
3. unanticipated difficulties in obtaining informed
consent or maintaining confidentiality
4. the research has not been completed one year from
the date of this letter
Congratulations and good luck on your research!

jg •
cc: Director of Graduate Studies
Dr. Charlotte Baumgart
.... File."
 Dietary Adherence

128

Appendix D

Letter to Diabetes Outpatient Facility Requesting Permission

 Dietary Adherence

129

Date
Contact Person
Address

Dear Contact Person

I am a graduate dietetics student at D'Youville College, and I am conducting a

study that examines dietary adherence of type 2 diabetes patients after nutrition
education from a Registered Dietitian. I need a minimum of 30 participants to
complete a 17 question questionnaire.

I am requesting permission to use your patient list to mail questionnaires to obtain

30 subjects for my study. Each questionnaire will be kept anonymous in that the
subjects will not be known to the researcher and master patient and number list
will be destroyed by the Registered Dietitian after the completion of the study.

If you have any questions regarding my study, feel free to contact me at (585)
506-6249. You may also contact my thesis director, Charlotte Baumgart, at (716)
829-7752.

If you agree to grant me permission to use your patient list, please send me a letter
of permission in the self-addressed stamped envelope provided for your
convenience. I would also ask that you please sign the attached sheet and send
that along with your letter. Please indicate in your letter the dates and times that
would be most convenient for you. Upon receipt of your approval, I will be
contacting you to schedule times to obtain your patient list. Thank you for your
consideration and for your time.

Sincerely,

Shannon Denney
 Dietary Adherence

130

I grant Shannon Denney permission to use the patient list for the study entitled

Dietary Adherence of Patients with Type 2 Diabetes at Propel Health. I

understand that the subjects' participation will be fully voluntary. All the

information obtained in the study will be kept at the strictest confidence. I

understand that the location of the study will be withheld when the data are

reported.

Name, Title
 Dietary Adherence

131

Appendix E

Letter of Permission from Diabetes Outpatient Facility

 Dietary Adherence

132

I grant Shannon Denney permission to use the patient list for the study entitled

Dietary Adherence of Patients with Type 2 Diabetes at Propel Health. I

understand that the subjects' participation will be fully voluntary. All the

information obtained in the study will be kept at the strictest confidence. I

understand that the location ofthe^study will be withheld when the data are

reported. <f

Name, Title
 Dietary Adherence

133

Appendix F

Cover Letter
 Dietary Adherence

134

Date
Contact Person
Address

Dear Contact Person

My name is Shannon Denney. I am a graduate student at D'Youville

College, and I am working on my Master's thesis. I am conducting a study that
analyzes how nutrition education from a Registered Dietitian can help manage
diabetes.

I am asking participants to fill out a 17 question questionnaire. It will take

approximately 20 minutes to complete. Your participation is completely voluntary
and your identity will be kept anonymous. This means that your name will not be
associated with your information, no one will be able to identify you, and
information about the study will be reported in group form only. Please do not
put your name on the questionnaire. A mailing code is placed on the top of the
questionnaire to prevent my knowledge of your name and address. By not
knowing your name, I will not be able to withdraw your data if you choose later
not to participate in this study. I will have no way to know which data are yours.
Consent to use your responses is implied with the return of your completed
questionnaire.

If you would like to participate in this study, please fill out a questionnaire
and return in one month. If you have questions about the research study, you may
contact me at (585) 506-6249 or you may contact my thesis director, Charlotte
Baumgart at (716) 829-7752 and your questions will be answered. If you would
like to be mailed a summary of the results of this study, please note at the bottom
of your questionnaire after Section 3. Your participation would be greatly
appreciated.

Sincerely,

Shannon Denney