Publication: THE EFFICACY OF STRUCTURED LIFESTYLE INTERVENTION BASED ON TRANSCULTURAL DIABETES NUTRITION ALGORITHM WITH MOTIVATIONAL INTERVIEWING IN OVERWEIGHT AND OBESE TYPE 2 DIABETES MELLITUS PATIENTS
Date
2017
Journal Title
Journal ISSN
Volume Title
Publisher
International Medical University
Abstract
Background: The Transcultural Diabetes Nutrition Algorithm (tDNA) was
developed and validated by an international task force of independent diabetes and
nutrition experts (Mechanick et al., 2012). The algorithm was culturally customised
by local experts in Malaysia to suit our local populations (Zanariah et al., 2013).
The tDNA aims at guiding primary care providers to recommend a healthy lifestyle
intervention in a primary care setting based on initial risk evaluation. The tDNA
recommends medical nutrition therapy (MNT), consisting of natural foods, a
diabetes-specific formula, and increased physical activity, according to the
algorithm based on initial body weight, glycated haemoglobin (HbA1c), exercise
capacity and cardiovascular risk factors. Additionally, motivational interviewing
counselling (MI) was included to facilitate positive behaviour changes in most
lifestyle weight loss interventions. This study investigated the effectiveness of
structured lifestyle intervention based on tDNA care with MI counselling compared
to conventional counselling (CC) in overweight/obese T2DM patients in an
outpatient clinical setting.
Methodology: Two hundred and thirty overweight/obese T2DM patients, with
HbA1c >7% and not treated with insulin, were randomised into tDNA care (n=115)
and usual care (UC) (n=115). Patients in the tDNA group followed MNT consisting
of a structured low calorie meal plan using natural foods, incorporation of diabetesii
specific formulas as meal replacements, and exercise prescription of 150 min/week.
Patients in the tDNA group also received either MI counselling (tDNA-MI) (n=58)
or conventional counselling (tDNA-CC) (n=57). The UC group received standard
dietary and exercise advice using conventional counselling. The main outcomes of
the study were changes in weight and HbA1c. This study was carried for duration of
12 months.
Results: At 6 months, body weight decreased significantly more in the tDNA-MI
group (-6.9 ± 1.3 kg, p<0.001) than the tDNA-CC group (-5.3 ± 1.2 kg, p<0.001)
and UC group (-0.8 ± 0.5 kg, p=1.000). Similarly, HbA1c decreased significantly
more in tDNA-MI group (-1.1 ± 0.1%, p<0.001) than the tDNA-CC group (-0.5 ±
0.1%, p=0.001) and UC group (-0.2 ± 0.1%, p=0.260). Fasting plasma glucose
decreased significantly in tDNA-MI group but remained unchanged in tDNA-CC
and UC groups (tDNA-MI: -1.1 ± 0.3 mmol/L, p=0.011 vs. tDNA-CC: -0.6 ± 0.3
mmol/L, p=0.951 vs. UC: 0.1 ± 0.3 mmol/L, p=1.000). Similarly, waist
circumference decreased in the tDNA-MI group but remained unchanged in tDNACC
and UC groups (tDNA-MI: -4.0 ± 1.1 cm, p=0.002 vs. tDNA-CC: -2.7 ± 1.0
cm, p=0.064 vs. UC:-0.5 ± 0.5 cm, p=1.000). Percentage body fat decreased
significantly in tDNA-MI group (-1.3 ± 0.4%, p=0.002) and tDNA-CC group (-1.5 ±
0.5%, p=0.017) but unchanged in the UC group (0.4 ± 0.3%, p=1.000). The systolic
blood pressure decreased significantly in tDNA-MI and tDNA-CC groups but
unchanged in the UC group (tDNA-MI: -9 ± 2 mmHg, p<0.001 vs. tDNA-CC: -9 ±
2 mmHg, p=0.001 vs. UC: -1 ± 2 mmHg, p=1.000). The diastolic blood pressure
decreased significantly in tDNA-CC group (-6 ± 2 mmHg, p=0.008) but unchanged
the tDNA-MI group (-3 ± 1 mmHg, p=0.566) and UC group (-1 ± 1 mmHg,
iii
p=1.000). Lipid profile was unchanged in the tDNA-MI and tDNA-CC groups, but
the UC group had significant reduction in total cholesterol (-0.3 ± 0.1 mmol/L,
p=0.001) and low-density lipoprotein cholesterol (-0.26 ± 0.07 mmol/L, p=0.005).
Dietary energy, carbohydrate, protein and fat intake decreased significantly more in
the tDNA-MI group (-574 ± 43 kcal, p<0.001; -69.5 ± 6.0 g, p<0001; -25.8 ± 2.4 g,
p<0.001; and -21.9 ± 2.1 g, p<0.001, respectively) than tDNA-CC group (-458 ± 47
kcal, p<0.001; -56.4 ± 6.5 g, p<0.001; -18.5 ± 2.6 g, p<0.001; and -17.8 ± 2.3 g,
p<0.001, respectively) and UC group (-171 ± 46 kcal, p=0.002; -25.1 ± 6.7 g,
p=0.002; -3.6 ±1.9 g, p=0.586; and -6.1 ± 2.1 g, p=0.031, respectively). Exercise
improved significantly in the tDNA-MI but unchanged in tDNA-CC and UC groups
(tDNA-MI: 188 ± 16 min/week, p<0.001 vs. tDNA-CC: 149 ± 14 min/week,
p=0.471 vs. UC: 106 ± 14 min/week, p=1.000). At 12 months, weight loss sustained
significantly in the tDNA-MI group (-5.8 ± 1.3 kg, p<0.001) but not in the tDNACC
group (-3.3 ± 1.2 kg, p=0.086) and UC group (0.5 ± 0.6 kg, p=1.000). Similarly,
significant decrease in HbA1c retained in the tDNA-MI group (-0.5 ± 0.2%,
p=0.006) but not in the tDNA-CC group (0.1 ± 0.2%, p=1.000) and UC group (0.02
± 0.1%, p=1.000) at 12 months.
Conclusion: Lifestyle intervention that includes structured MNT and physical
activity following customised tDNA care was effective in achieving and sustaining
weight loss, lowering of metabolic outcomes and dietary intake and improving
exercise levels in this study. Motivational interviewing delivered by dietitian can
enhance outcomes in patients with overweight/obesity with T2DM following
intervention with structured MNT, such as the tDNA.
Description
Keywords
Life Style, Weight Loss, Diabetes Mellitus, Nutrition Therapy, Motor Activity, Diabetes Mellitus, Type 2, Risk Factors