The Impact of RDNs on Non-Communicable Diseases: Proceedings from The State of Food and Nutrition Series Forum.

In the United States, nutrition-related morbidities are rising steadily at rates corresponding to increasing overweight and obesity in the population. Such morbidities take huge tolls on personal health and impose high costs on health care systems. In 2019, the Academy of Nutrition and Dietetics (Academy) and the Academy of Nutrition and Dietetics Foundation (Academy Foundation) embarked on a new project titled "The State of Food and Nutrition Series" to demonstrate the value of nutrition interventions led by registered dietitian nutritionists for individuals with the following 3 high-priority non-communicable diseases that affect many in the United States and globally: type 2 diabetes mellitus, chronic kidney disease, and hypertension. Poor nutritional status contributes to disease onset and progression in these non-communicable diseases, and appropriate medical nutrition therapy can prevent or delay worsening and ameliorate poor health outcomes. However, many people who have these conditions do not have access to an registered dietitian nutritionist, and consequently do not receive the nutrition care they need. On February 19-20, 2020 in Arlington, VA, as the first stage in The State of Food and Nutrition Series, the Academy and the Academy Foundation gathered health care policymakers, clinicians, and researchers from across the country for the State of Food and Nutrition Series Forum, where Academy leaders sought input to build a comprehensive research strategy that will quantify the impact of patient access to registered dietitian nutritionist-led nutrition interventions for type 2 diabetes mellitus, chronic kidney disease, and hypertension. This article summarizes the findings of that forum.

Current trends in epidemiology of cardiovascular disease and cardiovascular risk management in type 2 diabetes.

With the advances in diabetes care, the trend of incident cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM) has been decreasing over past decades. However, given that CVD is still a major cause of death in patients with diabetes and that the risk of CVD in patients with T2DM is more than twice that in those without DM, there are still considerable challenges to the prevention of CVD in diabetes. Accordingly, there have been several research efforts to decrease cardiovascular (CV) risk in T2DM. Large-scale genome-wide association studies (GWAS) and clinical cohort studies have investigated the effects of factors, such as genetic determinants, hypoglycaemia, and insulin resistance, on CVD and can account for the unexplained CV risk in T2DM. Lifestyle modification is a widely accepted cornerstone method to prevent CVD as the first-line strategy in T2DM. Recent reports from large CV outcome trials have proven the positive CV effects of sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in patients with high CVD risk. Overall, current practice guidelines for the management of CVD in T2DM are moving from a glucocentric strategy to a more individualised patient-centred approach. This review will discuss the current epidemiologic trends of CVD in T2DM and the risk factors linking T2DM to CVD, including genetic contribution, hypoglycaemia, and insulin resistance, and proper care strategies, including lifestyle and therapeutic approaches.

Cost effectiveness of dietitian-led nutrition therapy for people with type 2 diabetes mellitus: a scoping review.

BACKGROUND: The management of diabetes costs in excess of $1.3 trillion per annum worldwide. Diet is central to the management of type 2 diabetes. It is not known whether dietetic intervention is cost effective. This scoping review aimed to map the existing literature concerning the cost effectiveness of medical nutrition therapy provided by dietitians for people with type 2 diabetes. METHODS: Thirteen scientific databases, including MEDLINE, EMBASE and CINAHL, as well as multiple official websites, were searched to source peer-reviewed articles, reports, guidelines, dissertations and other grey literature published from 2008 to present. Eligible articles had to have assessed and reported the cost effectiveness of dietetic intervention for adults with type 2 diabetes in developed countries. Experimental, quasi-experimental, observational and qualitative studies were considered. RESULTS: Of 2387 abstracts assessed for eligibility, four studies combining 22 765 adults with type 2 diabetes were included. Dietetic intervention was shown to be cost-effective in terms of diabetes-related healthcare costs and hospital charges, at the same time as also reducing the risk of cumulative days at work lost to less than half and the risk of disability 'sick' days at work to less than one-seventh. CONCLUSIONS: The findings highlight the importance of advocacy for medical nutrition therapy for people with type 2 diabetes, with respect to alleviating the great global economic burden from this condition. Further studies are warranted to elucidate the factors that mediate and moderate cost effectiveness and to allow for the generalisation of the findings.

Energy Expenditure in Free-Living Japanese People with Obesity and Type 2 Diabetes, Measured Using the Doubly-Labeled Water Method.

We determined the total energy expenditure (TEE) of healthy overweight or obese people, and those with impaired glucose tolerance and/or impaired fasting glycemia (IGT/IFG), or type 2 diabetes (T2DM) using the doubly-labeled water method. As a second purpose, we compared the measured TEE with the target energy intake recommended in the treatment guidelines for diabetes. The participants were normal glucose tolerance (NGT), and IGT/IFG (n=11) and T2DM (n=9) patients, who were 50-59 y and had a body mass index >25 kg/m2. The median TEE/body mass (BM) values were 32.6, 33.3, and 34.4 kcal/kg BM and the TEE/target BM values (target BM: BM at a BMI of 22 kg/m2) were 43.7, 50.2, and 46.5 kcal/kg target BM for each group, respectively, and did not differ significantly among them. Obese Japanese participants with T2DM in this study had lower TEE/BM than previously studied in non-obese participants with T2DM. In IGT/IFG or T2DM patients, if 30 kcal/kg target BM was used as the energy coefficient, on the basis of the treatment guidelines, the difference between TEE and the target energy intake would be -1,174±552 kcal (-38±11%). When 35 kcal/kg target BM was used as the energy coefficient, the difference between TEE and the target energy intake would be -877±542 kcal (-27±13%). Thus, the energy coefficients used to estimate target energy intake during lifestyle modification in obese/overweight patients with T2DM are considered to be quite low during the first step of diet therapy.

Economic benefit of dietetic-nutritional treatment in the multidisciplinary primary care team.

INTRODUCTION: Chronic diseases and aging are placing an ever increasing burden on healthcare services worldwide. Nutritional counselling is a priority for primary care because it has shown substantial cost savings. This review aims to evaluate the evidence of the cost-effectiveness of nutritional care in primary care provided by health professionals. A literature search was conducted using PubMed/MEDLINE between January 2000 and February 2019. The review included thirty-six randomized controlled trials (RCTs) and systematic reviews conducted in healthy people and people with obesity, type-2 diabetes mellitus, cardiovascular risk or malnutrition. All the RCTs and reviews showed that nutritional intervention led by dietitians-nutritionists in people with obesity or cardiovascular risk factors was cost-effective. Dietary interventions led by nurses were cost-effective in people who needed to lose weight but not in people at high cardiovascular risk. Some dietary changes led by a primary care team in people with diabetes were cost-effective. Incorporating dietitians-nutritionists into primary care settings, or increasing their presence, would give people access to the healthcare professionals who are best qualified to carry out nutritional treatment, and may be the most cost-effective intervention in terms of health expenditure. Notwithstanding the limitations described, this review suggests that incorporating dietitians-nutritionists into primary health care as part of the multidisciplinary team could be regarded as an investment in health. Even so, more research is required to confirm the conclusions.

INTRODUCCIÓN: Las enfermedades crónicas y el envejecimiento suponen una carga cada vez mayor para los servicios de salud en todo el mundo. El asesoramiento nutricional es una prioridad para la atención primaria porque ha demostrado ahorros sustanciales de costes. Esta revisión tiene como objetivo evaluar la evidencia de la relación coste-efectividad de la atención nutricional en la atención primaria proporcionada por profesionales de la salud. se realizó una búsqueda bibliográfica utilizando PubMed/MEDLINE entre enero de 2000 y febrero de 2019. La revisión incluyó 36 ensayos controlados aleatorios (ECA) y revisiones sistemáticas realizadas en personas sanas y personas con obesidad, diabetes mellitus de tipo 2, riesgo cardiovascular o desnutrición. Todos los ECA y las revisiones mostraron que la intervención nutricional dirigida por dietistas-nutricionistas en personas con obesidad o factores de riesgo cardiovascular fue coste-efectiva. Las intervenciones dietéticas dirigidas por enfermeras fueron coste-efectivas en personas que necesitaban perder peso pero no en personas con alto riesgo cardiovascular. Algunos de los cambios en la dieta dirigidos por un equipo de atención primaria en personas con diabetes también fueron coste-efectivos. La incorporación de dietistas-nutricionistas en entornos de atención primaria, o aumentar su presencia, daría a las personas acceso a los profesionales de la salud mejor calificados para llevar a cabo el tratamiento nutricional, y resultaría más rentable en términos de gasto en salud. A pesar de las limitaciones descritas, esta revisión sugiere que incorporar dietistas-nutricionistas en atención primaria como parte del equipo multidisciplinario podría considerarse una inversión en salud. Aun así, se requiere más investigación para confirmar las conclusiones.

Will the plant-based movement redefine physicians' understanding of chronic disease?

The world is experiencing a cataclysmically increasing burden from chronic illnesses. Chronic diseases are on the advance worldwide and treatment strategies to counter this development are dominated by symptom control and polypharmacy. Thus, chronic conditions are often considered irreversible, implying a slow progression of disease that can only be hampered but not stopped. The current plant-based movement is attempting to alter this way of thinking. Applying a nutrition-first approach, the ultimate goal is either disease remission or reversal. Hereby, ethical questions arise as to whether physicians' current understanding of chronic illness is outdated and morally reprehensible. In this case, physicians may need to recommend plant-based diets to every patient suffering from chronic conditions, while determining what other socioecological factors and environmental aspects play a role in the chronic disease process. This article provides insights to aspects of diet and chronic illness and discusses how the plant-based movement could redefine current understanding of chronic disease. The ethical justifications for recommending of a plant-based diet are analyzed. The article concludes that not advocating for plant-based nutrition is unethical and harms the planet and patients alike.

Farming for Life: Pilot assessment of the impact of medical prescriptions for vegetables on health and food security among Latino adults with type 2 diabetes.

BACKGROUND: In the United States, Latino families have a disproportionate burden of diabetes and associated complications. AIM: This pilot study assessed the feasibility of using medical prescriptions of organic vegetables to improve health outcomes among Latinos with type 2 diabetes (T2D). METHODS: Latino participants (n = 21, 91% female, age 56 ± 11.1 years) with T2D received 12 weeks of medically prescribed organic vegetables. Weight, waist circumference, blood pressure, and HbA1c were measured pre and post-intervention. Food security was also assessed. RESULTS: Over 12 weeks, there was a significant fall in systolic (p = 0.03) and diastolic (p = 0.01) blood pressure. A total of 14 participants lost weight (median weight loss among responders was 1.9 pounds), and waist circumference decreased in 9 of 19 responders by a median of 1.5 inches. HbA1c was unchanged (6.7 ± 1.1% at baseline versus 7.0 ± 1.1% post-intervention). CONCLUSIONS: Medical prescriptions of organic vegetables may have measurable health benefits for adult Latinos with T2D.

The dietetic workforce distribution geographic atlas provides insight into the inequitable access for dietetic services for people with type 2 diabetes in Australia.

AIM: Dietetic intervention delivered by Accredited Practising Dietitians is demonstrated to improve clinical outcomes of type 2 diabetes. The aim of the present study was to assess the accessibility to dietetic intervention for people with type 2 diabetes in Australia. METHODS: Prevalence data and dietitian workforce distribution data were sourced from Diabetes Australia and Dietitians Association of Australia, respectively. Geographical information system mapping and statistical analysis were used to compare the ratios of dietitians to people with type 2 diabetes across the states of Australia and by index of socio-economic advantage and disadvantage in each state. RESULTS: An inequitable distribution of the dietetic workforce and that of the people with type 2 diabetes across Australia was demonstrated. An uneven distribution of the workforce is evidenced across states when compared to the distribution of type 2 diabetes prevalence; with New South Wales having a better ratio than Victoria and South Australia. Maps and prevalence data revealed the dietetic workforce was mostly concentrated in affluent urban centres whereas the type 2 diabetes prevalence rates were higher in rural and remote areas and in areas of lower socio-economic status. CONCLUSIONS: This research highlights the need to address the limited access to dietetic intervention for those in rural, remote and disadvantaged areas which also have the greatest need. The financial burden of treating diabetic complications on the national health budget necessitates government initiatives. These should include better use of telehealth dietetic consultations and incentives for dietitians to work in rural, remote and disadvantaged areas.

Standard medical nutrition therapy of 25 kcal/kg ideal bodyweight/day often does not reach even resting energy expenditure for patients with type 2 diabetes.

AIMS/INTRODUCTION: In Japan, an ideal bodyweight (IBW) calculated by 22 × height (m)2 has commonly been used in the planning of medical nutrition therapy (MNT). However, there have been concerns regarding calorie deficits in fulfilling resting energy expenditure (REE) for patients with type 2 diabetes undergoing MNT as defined by 25 kcal/kg IBW/day. The objective of the present study was to measure REE in patients with type 2 diabetes and verify the validity of MNT with 25 kcal/kg IBW/day. MATERIALS AND METHODS: A retrospective cross-sectional study was carried out in 52 patients with type 2 diabetes (mean age was 65.9 ± 7.3 years, bodyweight 65.0 ± 11.3 kg, body mass index 24.9 ± 3.8 kg/m2 ). REE was measured by indirect calorimetry. RESULTS: The mean REE was 1,601.0 ± 253.1 kcal/day. Assuming that all patients strictly observed daily energy intake as 25 kcal/kg IBW/day, 41 of 52 patients (78.9%) did not reach their REE. The greater the bodyweight, the greater the difference between assumed energy intake as 25 kcal/kg IBW and REE. CONCLUSIONS: We call attention to the potential risk of total dietary energy intake set to 25 kcal/kg IBW/day. Clinicians should carefully plan MNT to not fall below a patient's REE to prevent sarcopenia and ensure MNT continuity.

Impact of interventions to reduce overnutrition on healthcare costs related to obesity and type 2 diabetes: a systematic review.

CONTEXT: In recent decades, obesity and type 2 diabetes mellitus (T2DM) have both become global epidemics associated with substantial healthcare needs and costs. OBJECTIVE: The aim of this review was to critically assess nutritional interventions for their impact on healthcare costs to community-dwelling individuals regarding T2DM or obesity or both, specifically using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) criteria to assess the economic components of the evidence. DATA SOURCES: Searches were executed in Embase, EconLit, AgEcon, PubMed, and Web of Science databases. STUDY SELECTION: Studies were included if they had a nutritional perspective, reported an economic evaluation that included healthcare costs, and focused on obesity or T2DM or both. Studies were excluded if they examined clinical nutritional preparations, dietary supplements, industrially modified dietary components, micronutrient deficiencies, or undernutrition; if they did not report the isolated impact of nutrition in complex or lifestyle interventions; or if they were conducted in animals or attempted to transfer findings from animals to humans. DATA EXTRACTION: A systematic review was performed according to PRISMA guidelines. Using predefined search terms, 21 studies evaluating food habit interventions or taxation of unhealthy foods and beverages were extracted and evaluated using CHEERS criteria. RESULTS: Overall, these studies showed that nutrition interventions and taxation approaches could lead to cost savings and improved health outcomes when compared with current practice. All of the included studies used external sources and economic modeling or risk estimations with population-attributable risks to calculate economic outcomes. CONCLUSIONS: Most evidence supported taxation approaches. The effect of nutritional interventions has not been adequately assessed. Controlled studies to directly measure economic impacts are warranted.

Influences of added sugar consumption in adults with type 2 diabetes risk: A principle-based concept analysis.

AIM: The aim of this study is to describe the concept added sugar in the context of type 2 diabetes (T2D) risk in adults. BACKGROUND: Dietary added sugars are associated with a greater risk for T2D; however, it is unclear if added sugars influence T2D risk directly or if their effects are mediated by excess caloric intake and weight gain. DESIGN: A principle-based concept analysis following the PRISMA guidelines was conducted to clarify the concept of added sugar. A systematic search was conducted using PubMed and Embase. Multidisciplinary, empirical evidence was appraised using four guiding principles outlined by the principle-based concept analysis method. RESULTS: Thirty-five publications were included in this concept analysis. The concept, added sugar in the context of T2D risk, was found to be epistemologically immature and lacked conceptual clarity. CONCLUSIONS: Added sugar is an immature concept warranting further refinement for conceptual advancement. To enhance conceptual clarity, the term "added sugar" should be used consistently in the scientific literature when discussing foods or beverages containing added sugars or caloric sweeteners. A clearer delineation of added sugar and its association with T2D risk in adults is critical to advance this concept within the scientific literature.

Effects of a Personalized VLCKD on Body Composition and Resting Energy Expenditure in the Reversal of Diabetes to Prevent Complications.

The reversion of diabetes and the treatment of long-term obesity are difficult challenges. The failure mechanisms of rapid weight loss are mainly related to the wasting of lean mass. This single-arm study aims to evaluate the effects of a very low-calorie ketogenic diet (VLCKD) on body composition and resting energy expenditure in the short term reversal of diabetes mellitus Type 2. For eight weeks, subjects were administered a personalized VLCKD with protein intake based on lean mass and synthetic amino acidic protein supplementation. Each subject was assessed by anthropometry, Dual-energy X-ray Absorptiometry(DXA), bioimpedentiometric analysis (BIA), indirect calorimetry, and biochemical analysis. The main findings were the saving of lean mass, the reduction of abdominal fat mass, restored metabolic flexibility, the maintenance of resting energy expenditure, and the reversion of diabetes. These results highlight how the application of preventive, predictive, personalized, and participative medicine to nutrition may be promising for the prevention of diabetes and enhancement of obesity treatment.

An Examination of Medically Necessary Diets within the Framework of the Thrifty Food Plan.

The Thrifty Food Plan (TFP) determines the maximum allotment of nutrition assistance for over forty million Americans participating in the Supplemental Nutrition Assistance Program (SNAP). This research recalculates the official TFP allocations using a more straightforward model that minimizes cost subject to nutrient constraints to establish a baseline for adult females and males. We then examine three additional diet plans to evaluate their feasibility under the current SNAP benefit allotment: a diet for lactose intolerance, for persons with type 2 diabetes, and a diet for pregnant women. The first model calculates a diet plan that contains no fluid milk, taking into account that 1 in 4 Americans is lactose intolerant. The second model calculates a diet plan that is lower in carbohydrates (grains and fruits comprise less than 45% of calories), reflecting a recommended diet for a person with type 2 diabetes, approximately 10% of the U.S. population. The third model includes the Institute of Medicine's recommended diet for pregnancy. In each case, total daily cost per individual and allocation across food groups were compared. Our Lactose Intolerance, Type 2 Diabetes, and Pregnancy model for 20-50 year old females all return minimum food costs above the TFP budget allocation. This research demonstrates how the TFP provides an unrealistic assessment of need among 20-50 year old females with relatively common dietary needs. Results indicate that equalizing the TFP budget allocations between men and women would better accommodate the heterogeneous needs of America's poorest individuals.

Food consumption and glycemic testing of adults and elderly diabetic patients from Public Health: A systematic review of assessment methods.

AIMS: To map and discuss the different methods used to assess food consumption and glycemic testing of adults and elderly diabetic patients from Public Health. MATERIALS AND METHODS: A total of 710 records were identified by searching databases integrated by the Virtual Health Library website, between September and October 2017. The Newcastle Ottawa scale was used for study quality assessment. A total of 8 studies met inclusion criteria for analysis. Study characteristics were extracted and synthesized to generate comparisons. RESULTS: Food consumption was evaluated by Food Frequency Questionnaire, 24-hour Dietary Recall, Eating Attitudes Test (EAT-26), Questionnaire On Eating and Weight Patterns (QEWP-R), and questioning the salt intake. Glucose testing methods included Postprandial Glucose, Glycated Hemoglobin (HbA1C), fasting glucose, and self-reported diabetes. CONCLUSIONS: Most methods that access food consumption use single questionnaires, which are easy to administer and yield easily interpreted results. For glycemic testing, the majority used are conventional methods.

Educational intervention to improve the competence of Mexican physicians to provide nutritional management for diabetes mellitus type 2 / Intervención educativa para mejorar la competencia de médicos mexicanos para manejar nutricionalmente diabetes mellitus Tipo 2

ABSTRACT Objective To evaluate the effect of a participative educational intervention on the clinical competence of Mexican family physicians regarding the nutritional management of patients with diabetes mellitus Type 2. Materials and Methods Quasi-experimental study with a before-and-after control group. Convenience sample included 60 family physicians distributed in two social security primary health care units, randomly selected: 30 in the "A" unit and 30 in the "B" unit. Unit "A" was assigned randomly as control group, and "B" unit as intervention group. The intervention consisted of a theoretical-practical course-workshop that lasted six months where real cases were discussed and solved. Clinical competence was evaluated by means of an instrument designed ex professo, with a maximum theoretical value of 100 and 94% reliability according to the Kuder-Richardson test. Medians of clinical competence were compared among groups, before and after intervention, using the Mann-Whitney U test, while frequencies distribution of clinical competence level were analyzed with the Kolmogorov-Smirnov test (p≤0.05). Results Overall medians and intervals for unit "A" were 28 (9-45) pre-intervention and 34 (11-51) pos-intervention, with before-after difference p>0.05; for unit "B", values were 32 (12-50) pre-intervention, 61 (36-82) pos-intervention, and before-after difference p≤0.05. No significant differences were found among groups pre-intervention (p>0.05), although they were observed pos-intervention (p≤0.05). Conclusions The educational intervention evaluated proved to improve, in a statistically significant way, the overall and by dimensions clinical competence level of Mexican family physicians for nutritional management of patients with diabetes mellitus type 2.(AU)

RESUMEN Objetivo Evaluar el efecto de una intervención educativa participativa sobre la competencia clínica de médicos familiares mexicanos para el manejo nutricio de pacientes con diabetes mellitus Tipo 2. Método Estudio cuasiexperimental con grupo control antes-después. Se estudió una muestra por conveniencia de 60 médicos familiares distribuidos en dos unidades médicas de atención primaria de seguridad social elegidas al azar, 30 en la "A" y 30 en la "B". La unidad "A" fue designada grupo control, y la "B" de intervención. La intervención consistió en un curso-taller teórico-práctico que duró seis meses, donde se discutieron y resolvieron casos reales. La competencia clínica se evaluó mediante un instrumento diseñado ex professo, con un valor teórico máximo de 100, y una fiabilidad de 94% según prueba de Kuder-Richardson. Se compararon las medianas de competencia clínica entre grupos antes y después mediante la prueba U de Mann-Whitney, y cinco las distribuciones de frecuencias de los niveles de competencia clínica mediante la prueba de Kolmogórov-Smirnov (p≤0,05). Resultados Medianas e intervalos de la calificación global: unidad "A" 28 (9-45) pre-intervención, 34 (11-51) pos-intervención, diferencia antes-después p≤0,05; unidad "B" 32 (12-50) pre-intervención, 61 (36-82) pos-intervención, diferencia antes-después p≤0,05. No se encontró diferencia significativa entre los grupos pre-intervención (p>0,05), y si pos-intervención (p≤0,05). Conclusiones La intervención educativa evaluada demostró mejorar, de forma estadísticamente significativa, el nivel de competencia clínica global y por dimensión, de médicos familiares mexicanos para el manejo nutricio de pacientes con diabetes mellitus tipo 2.(AU)

Temporal changes in diet quality and the associated economic burden in Canada.

A high-quality diet is associated with a reduced of risk of chronic disease and all-cause mortality. In this study, we assessed changes in diet quality and the associated economic burden in the Canadian population between 2004 and 2015. We used a prevalence-based cost-of-illness approach. We first calculated the diet quality using the Healthy Eating Index-Canada-2010 (HEI-C-2010) and 24-hour recall data from the Canadian Community Health Surveys (CCHS) on nutrition (CCHS 2004 cycle 2.2 and the CCHS-NU 2015). We then retrieved relative risks of HEI-2010 quintiles for chronic diseases from meta-analyses. Based on the proportions of the population following diets of varying qualities and these relative risks, we computed the population-attributable fractions and attributable costs (direct health care and indirect costs) by survey year (2004 and 2015) as well as by age and sex group. Costs were estimated in 2017 Canadian dollars for comparison purposes. We observed that on average the diet quality of Canadians improved between 2004 and 2015: the proportion of the Canadian population that did not eat a diet of high quality decreased from 83% to 76%. This improvement in diet quality translated in a decrease in economic burden of $133 million, down from $13.21 billion in 2004 to $13.08 billion in 2015. The economic burden decreased by $219 million among males but increased by $86 million among females. It also decreased among people under the age of 65 years ($333 million) but increased among those over 65 years ($ 200 million). Our findings suggest that, despite some temporal improvements, the diet of the majority of Canadians is of poor quality resulting in a high attributable economic burden. Policy and decision makers are encouraged to expand nutrition programs and policies and to specifically target the elderly in order to prevent chronic diseases and reduce health care costs.

Randomised-controlled trial of a web-based dietary intervention for patients with type 2 diabetes: changes in health cognitions and glycemic control.

BACKGROUND: Increasing prevalence and disease burden has led to an increasing demand of programs and studies focused on dietary and lifestyle habits, and chronic diseases such as type 2 diabetes mellitus (T2DM). We evaluated the effects of a 6-month web-based dietary intervention on Dietary Knowledge, Attitude and Behaviour (DKAB), Dietary Stages of Change (DSOC), fasting blood glucose (FBG) and glycosylated haemoglobin (HbA1c) in patients with uncontrolled HbA1c (> 7.0%) in a randomised-controlled trial (myDIDeA) in Malaysia. METHODS: The e-intervention group (n = 62) received a 6-month web-delivered intensive dietary intervention while the control group (n = 66) continued with their standard hospital care. Outcomes (DKAB and DSOC scores, FBG and HbA1c) were compared at baseline, post-intervention and follow-up. RESULTS: While both study groups showed improvement in total DKAB score, the margin of improvement in mean DKAB score in e-intervention group was larger than the control group at post-intervention (11.1 ± 0.9 vs. 6.5 ± 9.4,p < 0.001) and follow-up (19.8 ± 1.1 vs. 7.6 ± 0.7,p < 0.001), as compared to the baseline. Although there was no significant difference between intervention and control arms with respect to DSOC score and glycaemic control, the e-intervention group showed improved DSOC score (199.7 ± 18.2 vs193.3 ± 14.6,p = 0.046), FBG (7.9 ± 2.5 mmol/L vs. 8.9 ± 3.9 mmol/L,p = 0.015) and HbA1c (8.5 ± 1.8% vs. 9.1 ± 2.0%,p = 0.004) at follow-up compared to the baseline, whereas such improvement was not seen in the control group. CONCLUSIONS: Most important impact of myDIDeA was on the overall DKAB score. This study is one of the first to demonstrate that an e-intervention can be a feasible method for implementing chronic disease management in developing countries. Concerns such as self-monitoring, length of intervention, intense and individualized intervention, adoption of other domains of Transtheoretical Model and health components, and barriers to change have to be taken into consideration in the development of future intervention programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246687 .

Outcomes and Economic Benefits of Penn State Extension's Dining With Diabetes Program.

INTRODUCTION: Many diabetes education programs address the problem of diabetes, but little attention is given to the economic impact of such programs. Our objective was to assess the effectiveness of a community-based education program in improving diabetes-related lifestyle behaviors and biomarkers and ascertain the economic benefits of the program for adults aged 18 years or older with type 2 diabetes, prediabetes, or no diagnosis of diabetes in Pennsylvania. METHODS: From October 2012 through June 2015, Pennsylvania State University Extension's Dining with Diabetes program collected data on 2,738 adults with type 2 diabetes or prediabetes and adult family members without diabetes. The program consisted of 4 weekly 2-hour classes and a follow-up class conducted 3 months after the fourth 2-hour class. In the initial class and the follow-up class, participants completed a lifestyle questionnaire and their hemoglobin A1c and blood pressure were measured. Economic benefit was calculated as the medical expenditure cost savings resulting from program participation. RESULTS: At 3-month follow-up, a significant number of participants had improved their lifestyle behaviors (diet and physical activity), had reductions in hemoglobin A1c and blood pressure, and improved their diabetes status. The Dining with Diabetes program had a 5-year benefit-cost ratio of 2.49 to 3.35. CONCLUSION: Participants who completed the Dining with Diabetes program had significant improvements in diabetes-related biomarkers and lifestyle behaviors. If the Dining with Diabetes program were extended to half of the 1.3 million people living with diabetes in Pennsylvania and if they had similar improvements, the 1-year benefit to the state would be approximately $195 million, assuming a conservative 15% decrease in direct medical costs.

Eating with others and meal location are differentially associated with nutrient intake by sex: The Diabetes Study of Northern California (DISTANCE).

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating - frequencies of eating meals with others, meals prepared at home, and meals outside the home - are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men's versus women's propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) - albeit not significant - were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.