Ajee’lon Boyd

Shaun Hui

Lauren Nickerson

Brenna Robinson

Preventing Diabetes in Medicare Act of 2017

Research question: How are medical nutrition therapy services beneficial to individuals with pre-

diabetes or who are at risk of developing diabetes?

Barakatun Nisak MY, Ruzita AT, Norimah AKl. Medical nutrition therapy administered by a

dietitian yields favourable diabetes outcomes in individual with type 2 diabetes mellitus. Med J

Malays. doi: 2013;68:18-23

This study hypothesized that MNT intervention led by a registered dietitian will improve an

individual’s clinical outcomes, for example glycemic control and metabolic parameters.

Researchers followed 100 subjects with uncontrolled type 2 diabetes mellitus for twelve weeks.

In addition, 90% of the patients were already on a single or dual oral diabetic agent. At the end

of the study HbA1c levels were reduced by a mean of 7.2% to 7.6%. The participants who began

with a high HbA1c had the biggest reduction by the end of the twelve weeks. At the end of the

study, body weight, BMI, and waist circumference were reduced. Lipid profiles remained

unchanged. This study supports the Preventing Diabetes in Medicare Act of 2017 by providing

evidence that MNT interventions by a registered dietitian leads to positive clinical outcomes in

patients with T2DM, especially those with a very high HbA1c.

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

(DPP): Description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-2171.

This study evaluated the effectiveness of the Diabetes Prevention Program (DPP) lifestyle

intervention on help participants to achieve and maintain a 7% weight loss and increase physical

activity to a minimum of 150 mins of physical activity/week. The goal of the study was to

determine whether lifestyle intervention or pharmacological therapy (metformin) would prevent

or delay the onset of diabetes in individuals with impaired glucose tolerance (IGT) who are at

high risk for the disease. The study resulted in a 58% decrease in the incidence of diabetes in the

lifestyle intervention group.

This study supports the fact that lifestyle interventions (a form of Medical Nutrition Therapy-

MNT) can reduce or delay the onset and diagnosis of Diabetes. In addition to an overall

reduction in the incidence of diabetes, the participants also increased their physical activity

which has also been known to reduce the risk of other chronic diseases such as heart disease

Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes

with lifestyle intervention or metformin. New Engl J Med. 2002;346(6):393-403.

doi:10.1056/NEJMoa012512.

This study evaluated the effects of lifestyle changes and treatment with metformin on reducing

the incidence of diabetes in those who are at high risk for diagnosis. The 3,234 nondiabetic

participants were randomly placed into 3 groups: placebo, metformin (participants received 850

mg of metformin twice a day), and a lifestyle modification group. The goal of the lifestyle

modification group was to lose at least 7% of their body weight and increase physical activity to
a minimum of 150 minutes of physical activity a week. Baseline characteristics were similar

amongst all three groups. 50% of the participants in the lifestyle intervention group had reached

their goal weight loss of 7% or more at 24 weeks into the study.

The study resulted in an incidence of diabetes of 11.0, 7.8, and 4.8 cases per 100 person-years in

the placebo, metformin, and lifestyle groups, respectively. The lifestyle intervention group

program reduced the incidence by 58% and metformin by 31%, as compared with placebo; the

lifestyle intervention group program was significantly more effective than metformin. The

overall conclusion of the study was that type 2 diabetes can be prevented or delayed in persons at

high risk for the disease through various forms of Medical Nutrition Therapy such as lifestyle

intervention and pharmaceutical drugs.

If Congress approved the bill, Medical Nutrition Therapy would be more readily available to

diabetic patients. Providing such care would decrease the incidence of diabetes and thus lead to a

decrease in the total cost that is spent by Medicare on diabetes. This study shows that Medical

Nutrition Therapy like lifestyle changes, increase in physical activity, and the use of

pharmaceutical drugs can decrease the incidence of diabetes.

Franz M, Monk A, Barry B, McClain K, Weaver T, Cooper N, Upham P, Bergenstal R, Mazze

R. Effectiveness of medical nutrition therapy provided by dietitian in the management of non-

insulin dependent diabetes mellitus. J Acad Nutr Diet. 1995 95(9): 1009-17. doi:10.1016/S0002-

8223(95)00276-6.

This study was conducted to observe in influence MNT services provided by registered

dietitians had on diabetes management. To conduct this study, researchers asked patients recently
diagnosed non-insulin dependent diabetes from three different state outpatient clinics to join. The

patients were then divided up randomly up into two groups. The two groups consisted of two

interventions. The PGC ( practice guidelines nutrition care) or BC (basic nutrition care). The

interventions were taught through a dietitian. The sessions were an hour long for initials and 30-

45 minutes long for follow ups. BC consisted of one nutrition intervention at entry. PCG was

three nutrition visits during a 6-week period. Outcomes were measured at 3 and 6 months after

initial intervention. A comparison group was used during the study to create an even baseline.

This group had no nutrition intervention.

As a result, after six months, glycemic control was achieved by more than half the PCG group

(63%). The BC group returned back to baseline at six months. Lipids also improved for the PCG

group, they either maintained or achieved target cholesterol. Both groups saw weight loss but

the largest change in weight loss was seen in the PGC group who lost >4.5kg after six months.

About 20% of the PCG group achieved this weight loss. Only 16% of BC had reached a >4.5kg

loss after six months.

This study suggests that increased amount of intensive MNT sessions were more beneficial for

patients with diabetes for a longer duration. For example glycemic control may be easier to

achieve during the first few months after diagnosis without assistance. Another consideration is

that there may be psychological issues that stem from being newly diagnosed with diabetes.

Those issues may influence compliance with recommendations. Untimely both groups

benefited from the nutrition interventions even though the PGC group experienced more change.

Weight can often predict an individual’s risk for developing diabetes. The group who received

MNT from providers lost more weight. This can answer the question of are MNT services
beneficial for those with prediabetes or at risk for diabetes. The expansion of Medicare coverage

for MNT services, could have positive influences for those at risk for diabetes.

Huang MC, Hsu CC, Wang HS, Shin SJ. Prospective randomized controlled trial to evaluate

effectiveness of registered dietitian-led diabetes management on glycemic and diet control in a

primary care setting in Taiwan. Diabetes Care. 2009;33(2):233-239. doi:10.2337/dc09-1092.

This randomized control trial evaluated the effectiveness of diabetes management on glycemic

control with the help of a registered dietitian. The control group received basic nutrition guides

by nurses, while the intervention group received individualized nutrition counseling and dietary

plans every 3 months by a registered dietitian. By the end of the one year study, participants in

the intervention group had an average 13.4 mg/dl reduction in their mean fasting plasma

glucose. The control group had a 16.9mg/dl increase in their fasting glucose.This study showed

that RD-led diabetes management programs in primary care clinics can improve fasting plasma

glucose in T2DM patients.

Katula JA, Vitolins MZ, Rosenberger EL, et al. One-year results of a community-based

translation of the diabetes prevention program: healthy-living partnerships to prevent diabetes

(HELP PD) project. Diabetes Care. 2011;34(7):1451-1457. doi:10.2337/dc10-2115.

This study determined the effects of a first-year results of a community-based translation of the

DPP lifestyle weight loss (LWL) intervention on fasting glucose, insulin resistance, and

adiposity. 301 overweight and obese participants were randomly assigned to 1 of 2 groups: an

enhanced usual- care group or lifestyle weight loss intervention group that was administered

through a diabetes education program (DEP) and delivered by community health workers. The
study concluded that the participants in the lifestyle weight loss intervention group experienced

the greatest decrease in blood glucose levels, insulin, homeostasis model assessment of insulin

resistance, weight, BMI, and waist circumference. The study also concluded that fasting insulin

levels and homeostasis model assessment of insulin resistance (HOMA-IR) were affected in a

positive manner. These are important measures to the overall research question as they are

markers of insulin resistance.

Laitinen J, Ahola A, Sarkkinen E, Winberg R, Harmaakorpi-livonen P, Uustupa M. Impact of

intensified dietary therapy on energy and nutrient intakes and fatty acid composition of serum

lipids in patients with recently diagnosed non-insulin-dependent diabetes mellitus. J Acad Nutr

Diet. 1993 93(3): 276-83. doi:10.1016.j.jada.1993

The purpose of this study was to examine the effect of intensified dietary therapy on nutrient

intake of newly diagnosed non-insulin dependent diabetes mellitus. They were more specifically

looking at energy intake and fatty acid composition of serum lipids in obese patients. The

patients were subject to three months of basic education or intervention treatment. The

conventional group received basic education from health clinics. The intervention treatment

group visited the outpatient clinic every second month for 6 times total. The education was

provided by a physician, nurses specializing in diabetes, or clinical nutritionist. The intervention

lasted 12 months. At different monthly intervals (3,6,or 9 months), measurements were taken.

These measurements were fasting glucose, A1c, blood pressure, lipids, and fatty acid profile.

At the end of the intervention phase, the intervention group saw increased changes compared to

the conventional group. Both groups saw weight loss during the basic education part, but the

intervention group continued to see weight loss compared to the conventional group patients,
who gained weight. The average weight loss in the intervention was 7kg. Hemoglobin A1c was

lower in the intervention group and there was an increase in the conventional group. Both

groups’ dietary cholesterol intake remained within the recommended limits. However the

intervention group tended to decrease their energy intake and the conventional group increased

their intake.

Authors conclude that slight changes in quality and amount of dietary fat and energy restriction

can result in weight loss, improve glycemic control and serum lipid profiles in patients that were

recently diagnosed with non-insulin dependent diabetes mellitus. Although these individuals are

recently diagnosed with type 2 diabetes, it is revisable. This article supports the idea that

individuals at risk for diabetes or prediabetes can receive positive outcomes from interventions

provided by registered dietitians. If the Medicare bill were to pass, the interventions provided by

registered dietitians would be expanded for many beneficiaries.

Lemon CC, Lacey K, Lohse B, Hubacher DO, Klawitter B, Palta M. Outcomes monitoring of

health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes. J

Am Diet Assoc. 2004;104(12):1805-1815. doi:10.1016/j.jada.2004.09.024.

This study was a non-controlled descriptive study aiming to examine the changes in health and

lifestyle indicators over 6 months in persons with type 2 diabetes receiving nutrition counseling

from a registered dietitian. Participants were required to have a diagnosis of type 2 diabetes

mellitus as defined by the ADA, no interventions by a dietetics professional for diabetes mellitus

within 1 year of baseline session, 20 years of age or over, sufficient cognitive awareness, no

acute or chronic renal failure, no chemotherapy within the past 60 days, no major unplanned

surgery requiring more than an overnight stay in the hospital within the previous week. Positive
health, behavior, and quality-of-life outcomes were demonstrated between 3 to 6 months of

nutrition counseling for type 2 diabetes. Biochemical and anthropometric outcomes were

significantly related to either the amount of time with an RD, the number of visits, or both. These

findings are congruent with recommendations in ADA’s MNT Evidence-Based Guides for

Practice. By passing the bill, it would allow for diabetics who utilize Medicare to get even more

MNT.

Lindstrom J, Louheranta A, Mannelin M. The finnish diabetes prevention study (DPS): lifestyle

intervention and 3-year results on diet and physical activity. Diabetes Care. 2003;26(12):3230-

3236. doi:10.2337/diacare.26.12.3230.

This randomized controlled trial study was conducted to describe the lifestyle intervention used

in the Finnish diabetes prevention study. It also showed the short and long term changes in diet

and exercise behavior, and the effect of the intervention on glucose and lipid metabolism.

Participants were suggested to the study from a screening of high risk groups, for example first-

degree relatives of type 2 diabetics. Participants had to be 40-64 years of age with a BMI of over

25.0kg/m2. Within the dietary intervention, the participants had in person consultation sessions

ranging from 30 minutes to 1 hour with the nutritionist at weeks 0, 1-2, 5-6, and at months 3, 4,

6, 9. Seven sessions altogether. The first year had preplanned topics to discuss about diabetes

risk factors. Interventions focused on behavior changes and included trips to the grocery store,

cooking classes, and group sessions. Exercise intervention included being guided to increase

overall levels of physical activity. This was done by the nutritionist during sessions.

The intensive lifestyle intervention induced several beneficial changes in diet, physical activity,

blood glucose, and lipid concentrations and a highly significant reduction in diabetes incidence.
The intervention program was most intensive during the first year, and consequently the changes

in clinical characteristics were most prominent after the first year. It is evident that lifestyle

intervention can prevent or at least postpone type 2 diabetes and should therefore be

implemented in primary health care.

Liu H, Min Z, Xuesen W, Chunhua W, Zhong L. Effectiveness of a public dietitian-led diabetes

nutrition intervention on glycemic control in a community setting in China. Asia Pac J Clin.

2015;24(3):525-32. doi: 10.6133/apjcn.2015.24.3.07.

This study evaluated the effectiveness of nutrition intervention provided by a public dietitian on

glycemic control in a community setting in China. The study concluded that there were

significant improvements in fasting plasma glucose, total cholesterol, triglycerides, and HbA1c

in the intervention group in comparison to the control subjects. There was also a significant

decrease in weight and BMI in the intervention group. This study provides evidence of a positive

correlation between medical nutrition therapy services and a reduction in the biomarkers

associated with type 2 diabetes. Furthermore, this study shows that counseling from a dietitian

and a personalized nutritional assessment are effective in reducing biomarkers related to type 2

diabetes. The passing of the bill would increase the availability of Medical Nutrition Therapy.

This care would lead to an overall reduction in these biomarkers and thus lead to a decrease in

other comorbidities related to diabetes. An overall reduction in diabetes and other related

comorbidities would decrease the total cost spent on healthcare each year.
Marincic PZ, Hardin A, Salazar MV, Scott S, Fan SX, Gaillard PR. Diabetes self-management

education and medical nutrition therapy improve patient outcomes: A Pilot Study Documenting

the efficacy of registered dietitian nutritionist interventions through retrospective chart review. J

Acad Nutr Diet. 2017;117(8):1254-1264. doi:10.1016/j.jand.2017.01.023.

This study utilized a retrospective chart review design to interpret the efficacy of diabetes self-

management education (DSME) and medical nutrition therapy on patient outcomes. The

population group observed was diagnosed with Type 2 diabetes mellitus and completed a

comprehensive ADA-recognized program. This program included DSME, group nutrition

education classes, and individualized MNT services. Biomarkers, specifically HbA1c, were

significantly reduced from a mean of 8.74% to 6.2% and were sustained at the one year mark.

This reduction in HbA1c can help reduce hospital admissions and healthcare costs. Overall, the

outcome data presented in this study proves the importance of registered dietitians in preventing

the onset or risk of developing diabetes. This supports the bill that extending MNT services

coverage to Medicare beneficiaries will reduce the occurrence.

Morris SF, Wylie-Rosett J. Medical nutrition therapy: a key to diabetes management and

prevention. Clinical Diabetes. 2010;28(1):12-18. doi:10.2337/diaclin.28.1.12.

This position paper presents research that shows the effectiveness of Medical Nutrition Therapy

in treating of both type 1 and type 2 diabetes. The paper is a review of 18 studies that involved

MNT by a registered dietitian as part of treatment for type 1 and type 2 diabetes. Studies varied

from randomized controlled trials to observational studies. Studies ranged from 3 months in

length to 9 years in length. Although Medicare and other third-party payers cover diabetes

screening for patients who have been diagnosed with prediabetes, Medicare does not currently
cover MNT for patients with prediabetes. The Diabetes Prevention Program study has done

much to underscore the effectiveness and cost-effectiveness of lifestyle interventions, including

MNT, in preventing or delaying the onset of type 2 diabetes.

Findings show that MNT by a registered dietitian lowered HbA1c levels and lowered the

prevalence for the onset of diabetes in prediabetes patients. It should be noted that the registered

dietitians were key to lowering HbA1c levels in these studies. MNT is an effective and

increasingly affordable method to prevent type 2 diabetes and to treat both type 1 and type 2

diabetes. It is endorsed for the treatment of diabetes by the Institute of Medicine, the American

Dietetic Association, and the ADA and is covered by Medicare. The provision of MNT by RDs,

who are experts in offering individualized nutrition counseling, will improve the quality of

counseling offered to patients and alleviate the burden on physicians to provide nutrition

education. Primary care physicians should refer patients with symptoms of pre-diabetes and

diabetes for MNT services, to be provided by an RD, to ensure the best care for their patients.

Parker AR, Byham-Gray L, Denmark R, Winkle PJ. The effect of medical nutrition therapy by a

registered dietitian nutritionist in patients with prediabetes participating in a randomized

controlled clinical research trial. J Acad Nutr Diet. 2014;114(11):1739-1748.

doi:10.1016/j.jand.2014.07.020.

This study showed that medical nutrition therapy services can lower a patient’s Diabetes Risk

Score and HbA1c. Participants in this study were overweight or obese, aged 18 or older, and had

a HbAlc of 5.7% to 6.4%. The study compared two groups, one receiving MNT services and the

other receiving usual care for diabetes, for 12 weeks. The MNT services included 4 sessions with
a registered dietitian about moderate weight loss of 5-7% of starting weight, regular physical

activity, and counseling on reducing calories and fat intake. Researchers reported the mean

HbA1c in the MNT group reduced from 5.99% to 5.79%, while the usual care group had an

increase of 6.01%. In addition, the MNT group had a sharper decline in the Diabetes Risk Score

as compared to that of the usual care group. These results show MNT services by a registered

dietitian can improve clinical outcomes, particularly with the prediabetes population. This bill

can increase availability to resources, such as MNT services by a registered dietitian, for

Medicare beneficiaries.

Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K. The evidence for the effectiveness of

medical nutrition therapy in diabetes management. Diabetes Care. 2002;25(3):608-613.

doi:10.2337/diacare.25.3.608.

The purpose of this study was to determine the clinical and cost effectiveness of Medical

Nutrition Therapy as a potential preventative benefit in a diabetes management program. To

determine the clinical and cost effectiveness of MNT in the Medicare program, the 105th U.S

Congress, in the balanced budget act of 1997, requested that a study be conducted by the Institute

of Medicine. The study looked at data reported from multiple other studies done including

randomized controlled trials, randomized controlled trials of MNT combined with DSMT,

observational studies, and meta-analyses.

Evidence based research strongly suggests that MNT provided by a registered dietitian, who is

experienced in the management of diabetes, is clinically effective. The randomized controlled

nutrition therapy outcome studies have documented decreases in HbA1c levels of ~1-2 % in
newly diagnosed diabetics. Reductions in these biomarkers from this study show how this bill

can be successful if implemented.

Robbins, J M, Thatcher G, Webb D, Valdmanis G. Nutritionist visits, diabetes classes and

hospitalization rates and charges. Diabetes Care. 2008; 31(4):655-660. doi: 10.2337/dc07-1871

This study analyzed patient’s records to see if diabetic patients went to any form of education

and if the patient benefited from the education. The authors wanted to compare nutrition visits to

the number of hospital rates and charges. Patients from the Philadelphia health care centers, who

were recently diagnosed with diabetes were included. The different forms of education were

nutrition education, diabetes classes, and health classes. The patient had the option of choosing a

class. Nutrition visits were one on one and included nutrition counseling, instruction for

managing insulin or other medications. Some nutritionists were RDs and CDEs. Health

education visits were one on one and addressed diabetes management, smoking cessation or

other topics. Health educators had a degree in the field or relevant training. Diabetes classes

covered all topics above and were led by a nurse, nutritionist, or health educator. The material

used was developed by RNs with masters and that were CDEs. Those who taught the class had

different areas of expertise.

Data was collected for 7 years. The most significant findings were in both the diabetes class and

nutritionist visits. These interventions were strongly associated with reduced hospitalizations and

hospital charges. The average annual hospital charge for patients who received any education

was $6,244. This cost is 39% less than the $10,258 per average for patients who had no visits.

The authors saw a strong association between nutrition education and hospital costs. It is

suggested that any type of education can be beneficial on hospital costs for individuals with
diabetes. About 10 million dollars in hospital charges and 10,000 hospitalizations can be avoided

with a primary care system that includes nutrition education. Many diabetics find themselves in

the hospital due to the complications of diabetes. It can cost individuals thousands for a hospital

stay. This article shows that nutrition education can prevent possible hospitalizations for

diabetics. If this education prevents hospitalizations for diabetics it can be applicable to those

with prediabetes. Expansion of Medicare coverage can help provide these classes to those at risk

for diabetes or have prediabetes.

Wolf A, Conaway M, Crowther J, Hazen K, Nadler J, Oneida B, Bovberg V. Translating lifestyle

intervention to practice in obese patients with type 2 diabetes. Diabetes Care. 2004; 27(7): 1570-

76. doi:10.2337/diacare.27.7.1570

This study was conducted to see if lifestyle intervention programs were effective for obese type 2

diabetic patients. Participants were randomly put into groups. These groups were lifestyle case

management (received a dietitian manager) group or usual care group. The case management

consisted of individual or group education, support, and referral by registered dietitians. The goal

of the research was to see if the group that was in the lifestyle case management group had

improved outcomes in reduced waist circumference, A1c, fasting lipids, use of medication and

quality of life. An RD would meet with the patients individually, in groups, or by phone. Each

was coached in setting individual goals. The sessions occurred six times throughout a year.

Health variables; weight, waist circumference, fasting lipids, and A1c, were measured at

different monthly intervals. The case management group saw larger weight loss. (-4kg). The

usual care group had gained 0.6kg. The A1c levels between the two groups was not statistically

significant. Overall quality of life scores were higher in the case management group.
It is suggested that interventions from a registered dietitian can improve indicators of health

including weight, A1c, fasting lipids and quality of life. Those who were still medically managed

for their type 2 diabetes gained weight, had reduce quality of life and sustained need for

medication. This study concludes that there are several benefits from interventions provided by

a registered dietitian. Individuals with diabetes or prediabetes have their A1C checked to see

how well they are managing their diabetes. This article illustrates the positive impact MNT

interventions can have on an individual’s A1c level. If the Medicare bill passed, MNT services

could help lower an A1c, which is the biomarker that ultimately diagnoses an individual with

diabetes.

Discussion:

Preventing Diabetes in Medicare Act of 2017 is bill that would allow for Medicare coverage for

people who are at risk for diabetes or have prediabetes to receive Medical Nutrition Therapy

(MNT). Diabetes is a nationwide epidemic and the population size is increasing each day. The

annotated bibliography above provides research that shows the positive outcomes MNT can have

on this population.

The established research question: How are medical nutrition therapy services beneficial to

individuals with pre-diabetes or who are at risk of developing diabetes?, explores all the possible

benefits that come from MNT services. MNT services can be dietary or lifestyle related. These

benefits include but are not limited to; lowering A1c and lowering body weight. Obesity is one

of the biggest contributors to diabetes in the United States. Many of the studies above have

concluded that MNT services provided to diabetics leads to a decrease in body weight. One study

in particular involved 301 obese patients with high fasting blood sugars. The intervention

involved lifestyle weight loss inventions and diabetes education. Participants in the lifestyle
weight loss and education group experienced the greatest decrease in in blood glucose levels,

insulin, homeostasis model assessment of insulin resistance, weight, BMI, and waist

circumference.6 To determine if someone has diabetes or is at risk for diabetes, a hemoglobin

A1c level is established. The higher the A1c level is, the higher the risk is for diabetes. In one

study, participants saw a reduction in their personal A1c levels. The participants were given

dietary advice by a dietitian for twelve weeks. The reduction was close to 10% in just twelve

weeks.1

The cost of diabetes should also be noted. Complications of diabetes can increase need for

medical attention. In one study, diabetics who received one on one care from a nutritionist had

reduced number of hospital visits. Having had at least one nutritionist visit was associated with

11 (95% CI 6–16) fewer hospitalizations per 100 person-years and $13,872 (95% CI $7,799 to

$19,945) less in hospital charges in the adjusted model. This is a significant decrease in hospital

stays just by receiving a single person visit with a nutritionist.15 If the bill passes, it is possible

for these costs to decrease significantly.

The research gathered provides evidence that MNT services provided by dietitians or health care

providers can help treat diabetes. It can also lower the cost of treating the complications which

may arise with diabetes. If the Preventing Diabetes in Medicare Act passes, MNT services will

be more accessible and more affordable for the diabetes population.

Authors Purpose Population Intervention Results Limitations

Barakatun The purpose 100 subjects Subjects were The results Some did not
Nisak MY, of this study treated with given dietary showed follow the
Ruzita AT, was to see if diet and on advice by a significant guidelines to
Norimah MNT a stable dietitian for a reduction for the end of the
AK, 2013 provided by dose of oral twelve week subjects with intervention.
a registered anti-diabetic period. high HbA1c The exact
dietitian had agents. levels. The mean location of
 any reduction was 7.2 the
significant % to 7.6%. population
impact on an was not
individual’s stated.
clinical
outcomes.
The This study 3,234 3 groups: Baseline The rate of
Diabetes evaluated the nondiabetic Standard characteristics GI symptoms
Prevention effects of participants lifestyle were similar was the
Program lifestyle with recommendatio amongst all three highest in the
Research changes and elevated ns plus groups. metformin
Group, 2002 treatment fasting and metformin At the end of the group in
with post-load (Glucophage) study 99.6 comparison
metformin on plasma at a dose of percent of the to that of
reducing the glucose 850 mg twice participants were lifestyle-
incidence of concentratio daily, standard alive and of that, intervention
diabetes in ns. Average lifestyle 92.5% had group and the
those who age of 51 recommendatio attended a placebo
are at high years old. ns plus placebo scheduled visit group. The
risk for Average twice daily, or within the rate of
diagnosis. BMI of 34 an intensive previous 5 musculoskele
kg/m2. 68% program of months. tal symptoms
women and lifestyle 50% of was the
45% of a modifications. participants in the highest in the
minority lifestyle lifestyle-
group. intervention intervention
group had group in
reached their goal comparison
weight loss of 7% to the
or more at 24 metformin
weeks into the and the
study. placebo
The average group.
follow-up was
2.8 years. The
incidence of
diabetes was
11.0, 7.8, and 4.8
cases per 100
person-years in
the placebo,
metformin, and
lifestyle groups,
respectively. The
lifestyle
intervention
 reduced the
incidence by 58
% and metformin
by 31%, as
compared with
placebo; the
lifestyle
intervention was
significantly
more effective
than metformin.

Diabetes To determine 3,234 Intensive 58% decrease in Participants

Prevention whether participants, training in diet, the incidence of received
Program lifestyle 1,079 physical diabetes. BMI individual
Coordinatin intervention participants activity, and decreased by coaching
g Center, or randomly behavior 2.4%, weight loss from the
Biostatistics pharmacolog placed in modifications. decreased by 6% lifestyle
Center, ical therapy the lifestyle of bodyweight, coaches, so
George (metformin) intervention improved the coaching
Washington would group. physical activity received was
University, prevent or Average of level. different to
Rockville, delay the 51 years old meet the
Maryland, onset of at baseline needs of each
2002 diabetes in (20% ≥60 participant
individuals years, 68% (no standard
with women, amongst all
impaired 55% participants).
glucose Caucasian, Each
tolerance 20% participant
(IGT) who African had $100
are at high American, available to
risk for the 16% them each
disease. Hispanic year to help
American, them
5% implement
American the toolbox
Indian, 4% strategies.
Asian This type of
American). income may
Education: not be readily
25.8% <13 available
years of after
education, completing
48.1% 13– the program
16 years, to help them
 26.1% ≥17 achieve their
years. goals.

Franz M, This study 179 newly Intervention At six months The majority
Monk A, was diagnosed included 3 63% of the PGC of the
Barry B, conducted to with non- nutrition group achieved or participants
McClain K, look to see insulin consults for the maintained tended to be
Weaver T, what dependent Practice successful middle class
Cooper N, influence diabetes Guidelines glucose with at least a
Upham P, MNT mellitus Nutrition Care outcome. At 6 high school
Bergenstal provided by between the group and one months glycemic education so
R, Mazze R, registered ages of 38- consultation control returned the results
1995 dietitians had 76 years for the Basic to baseline for may not
on diabetes old. Nutrition Care BC group. 46% apply to all
management. group. There of the PGC group non-insulin
was also a had achieved or dependent
control group. maintained target diabetes
cholesterol. BC mellitus. The
lipid levels registered
returned. 19% of dietitians
PGC group providing
achieved target MNT were
outcome (>4.5kg CDE and
weight loss). well versed
Only 16% of BC in overall
group achieved management
successful weight of diabetes.
loss of 4.5kg. Entry level
dietitians
may not be
experienced
and may need
additional
training to
integrate
MNT into
overall
diabetes
management.
Huang M-C, The purpose 154 adults The Participants in the The study
Hsu C-C, of this study who were intervention intervention noted that 24-
Wang H-S, was to show newly group received group had an hr recalls are
Shin S-J, the diagnosed on-site average 6.8 mg/dl not always
2009 effectiveness with type 2 diabetes self- reduction in their accurate in
of registered diabetes management mean fasting some
dietitian-led from education plasma glucose. settings. This
management various every 3 months In addition, the study did not
of glycemic clinics in over 12 months overall energy analyze
control in Kaohsiung, by a registered intake and insulin
patients with Taiwan. dietitian. carbohydrate sensitivity at
type 2 intake were all.
diabetes. reduced.

Katula JA, Determine 301 Lifestyle Lifestyle weight This

Vitolins the effects of overweight weight loss loss intervention intervention
MZ, a first-year and obese intervention participants study was
Rosenberger results of a volunteers and diabetes experienced the conducted in
EL, 2011 community- (BMI 25–40 education greatest decrease only one
based kg/m2) with program. (of about 4.3 community
translation of fasting mg/dL) in blood located in the
the DPP blood glucose levels, southeastern
lifestyle glucose insulin, U.S. It is
weight loss values homeostasis unknown
(LWL) between 95 model assessment whether this
intervention and 125 of insulin approach can
on fasting mg/dL resistance, be effectively
glucose, Average age weight, BMI, and disseminated
insulin of 57.9 waist to other
resistance, years old. circumference. communities.
and 78 of the There was no
adiposity. 301 were formal
from a training for
race/ethnic the personnel
group other involved in
than white. the study.
Participants
were of
different
age,
weights,
BMI, and
had
different
glucose
levels.
Laitinen J, The purpose Participants Subjects were The intervention Although the
Ahola A, of this study were to be randomly group had a (- intervention
Sarkkinen E, was to see if recently assigned to two 0.4mmol/L) group was
Winberg R, dietary diagnosed treatment decrease in more
Harmaakorp therapy with groups an fasting glucose successful
i-livonen P, influenced NIDDM and intervention level during the only a small
Uustupa M, intake of fat had a group and a intervention portion of the
1993 of those who fasting conventional period (3-15 group was
were recently blood group. The months). At the able to
diagnosed glucose convention end of the study achieve with
with non- level of group received a1c was lower in the strict
insulin 6.7mmol/L the usual the intervention goals.
dependent or greater in education group than the
diabetes. repeated given out at conventional
measures health centers. group. Serum
(n=86). They visited at lipids were lower
2-3 month in the invention
intervals. The group then the
intervention convention but
group visited serum cholesterol
the outpatient did not change
clinic every for either group.
second month
6 times total.
The
intervention
lasted 12
months. Each
time the
intervention
group met with
a physician,
nurse in
diabetes or
clinical
nutritionist.
Measurements
 (fasting
glucose, A1c,
blood pressure)
were measured
at each visit.
Lipids were
checked at
baseline,
3,9,15. Fatty
acid
composition
was analyzed
at baseline 3
months and 15
months.

Lemon CC, To examine 213 Nutrition Positive health, Health,

Lacey K, the changes Participants counseling and behavior, and behavior, and
Lohse B, in health and had a education. quality-of-life quality of life
Hubacher lifestyle diagnosis of outcomes were outcomes
DO, indicators type 2 demonstrated were not
Klawitter B, over 6 diabetes following defined nor
Palta M, months in mellitus as nutrition described
2016 persons with defined by counseling for completely.
type 2 the ADA, type 2 This would
diabetes no diabetes. Bioche- vary per
receiving intervention mical and person.
nutrition by a anthropometric
counseling dietetics outcomes were
from a professional significantly
registered for diabetes related to either
dietitian. mellitus the amount of
within 1 time with an RD,
year of the number of
baseline visits, or both.
session, 20
years or
over,
sufficient
cognitive
awareness,
no acute or
chronic
 renal
failure, no
chemothera
py within
the past 60
days, no
major
unplanned
surgery
requiring
more than
an overnight
stay in the
hospital
within the
previous
week.

Lindstrom J, To describe High risk Within the The intensive Done on the
Louheranta the lifestyle groups such dietary lifestyle Finnish
A, Mannelin intervention as first- intervention, intervention population,
M, 2003 used in the degree the participants induced several not
Finnish relatives of had in person beneficial American.
diabetes type 2 consultation changes in diet,
prevention diabetics. sessions physical activity,
study and Participants ranging from blood glucose,
show the had to be 30 minutes to 1 and lipid
short and 40-64 years hour with the concentrations
long term of age with nutritionist at and a highly
changed in a BMI of weeks 0, 1-2, significant
diet and over 25. 5-6, and at reduction in
exercise months 3,4,6,9. diabetes
behavior, and Seven sessions incidence.
the effect of altogether. The
the first year had
intervention preplanned
on glucose topics to
and lipid discuss about
metabolism. diabetes risk
factors etc.
Liu H, Min To identify 117 Chinese Routine care There were There were
Z, Xuesen the diabetic group of 59 significant no significant
W, Chunhua effectiveness patients. (46 participants an improvements in improvement
W, Zhong L, of nutrition men, 71 d a public fasting plasma s in systolic
2015 intervention women) dietitian-led glucose, total blood
provided by Average age group of 58 cholesterol, pressure or
public of 62. participants triglycerides, and diastolic
dietitian on Participants in HbA1c in the blood
glycemic the public intervention pressure
control in a dietitian-led group in between the
community group received comparison to the intervention
setting in a nutrition control subjects. and control
China. education There was also a patients.
program while significant
those in the decrease in
routine care weight and BMI
group received in the
routine care intervention
that was group.
practiced at
their
community
health service
centers.
Marincic The purpose 88 adults This study The study group The study
PZ, Hardin of this study diagnosed observed the had significant had a small
A, Salazar was to with type 2 intervention weight loss of an sample size
MV, Scott demonstrate diabetes that was the average 2.6 kg by in Alabama,
S, Fan SX, the who were comprehensive the end of the so the results
Gaillard PR, effectiveness completing program at the study. There was may not
2017 of a the clinic in also a significant represent
registered comprehens Alabama. This reduction in other states.
dietitian ive ADA- program HbA1c from In addition,
 intervention recognized included baseline of 8.74% the sample
for patients program at diabetes self- to 6.82% on population
with type 2 an management average. was higher in
diabetes. outpatient education and African
clinic in individualized Americans
Alabama. MNT by an than the
. RD. national
average.
Since this
study was a
retrospective
chart review,
information
for all
patients were
not available.
Morris SF, This position Type 1 and Studies varied Findings show Position
Wylie- paper aims to type 2 from that MNT by a paper
Rosett J, show how diabetics. randomized registered combining
2010 research has controlled dietitian lowered multiple
shown trials to HbA1c levels and studies. Not
Medical observational lowered the one
Nutrition studies. Studies prevalence for individual
Therapy to ranged from 3 diabetes within study.
be effective months in prediabetes. It
for the length to 9 should be noted
treatment of years in length that the registered
both type 1 including dietitian was key
and type 2 nutrition to lowering
diabetes. counseling and HbA1c levels in
education. these studies.
MNT is an
effective and
increasingly
affordable
method to
prevent type 2
diabetes and to
treat both type 1
and type 2
diabetes.

Parker AR, The purpose The The MNT The MNT group The study
Byham- of this study population group received had significantly was a short-
Gray L, was the was RD-led lower HbA1c term study
Denmark R, evaluate the overweight education that levels than the that lasted 12
Winkle PJ, effectiveness or obese emphasized usual care group weeks at the
2014 of medical adult men moderate after 12 weeks of same clinical
nutrition and women weight loss, intervention. site.
therapy with a regular Diabetes risk Participants
(MNT) HbA1c of physical score also most likely
compared to 5.7-6.4% activity, and decreased more had similar
usual care of from the guidelines to significantly in income
fasting Anaheim reduce the MNT group levels,
plasma Clinical calories. This (mean of 17.54 to characteristic
glucose Trials in education was 15.31) than that s, and
values, California. spread across 4 of the usual care behaviors
HbA1c, lipid visits with the group (mean of from going to
profiles, and initial session 17.23 to 16.83). the same
Diabetes lasting 60 Both groups had clinic.
Risk Score. minutes and reduced total
the following 3 cholesterol and
lasting 30-45 LDL-C levels by
minutes each. the end of 12
weeks.

Pastors JG, To determine Type 1 and The study Evidenced based Position
Warshaw H, the clinical type 2 looked at data research strongly paper
Daly A, and cost diabetics from multiple suggests that combining
Franz M, effectiveness other studies MNT provided multiple
Kulkarni K, of Medical done including by a registered studies. Not
2002 Nutrition. randomized dietitian who is one
controlled experienced in individual
trials, the management study.
randomized of diabetes is
controlled clinically
trials of MNT effective. The
combined with randomized
DSMT, controlled
observational nutrition therapy
studies, and outcome studies
meta-analyses. have documented
Intervention decreases in
was using HbA1c levels of
nutrition ~1-2 % in newly
education and diagnosed
counseling. diabetics.

Robbins, J The purpose Diabetic Nutrition The most There was no

M, Thatcher of this study patients who education, significant data on how
G, Webb. was to were diabetes findings were the many patients
2008 compare diagnosed classes, health diabetes class and were offered
nutrition between classes were nutritionist visits education but
visits and the March 1993 offered to were strongly did not take
number of and newly associated with it. Retaining
hospital December diagnosed reduced patients in
rates/charges 2001 diabetes hospitalizations diabetes
(n=18,404) patients. The and hospital education
interventions charges. The programs that
included these average annual involve
classes. The hospital charge multiple
patient had an for patients who sessions may
option to received any be difficult.
choose one. education was
$6,244. That is
about 39% less
than the $10, 258
per average for
patients who had
no visits.

Wolf A, The purpose The An RD case Mean weight was The main
Conaway M, of this study population manager would greatly shown in limitations of
Crowther J, was to group meet with the case ICAN
Hazen K, examine the included participants management include
Nadler J, efficacy of a 118 eligible individually, in group. p (–4.0 kg, generalizabili
Oneida B, lifestyle participants groups and by 95% CI 5.6 to ty, lack of a
Bovberg V. intervention from the phone for 2.5) and net strong
program for southern assessment. weight loss physical
obese health They also met between groups activity
patients with services in with (5.0 kg, 7.2 to component,
type 2 Virginia. participants for 2.9) occurred at 8 and no long-
diabetes. Subjects had goal setting, months. By the term
to have type education and end of the maintenance
2 diabetes, support. interventions
use of Individual participants in the
diabetes sessions intervention
medications, occurred six group lost an
BMI times average of 2.4kg
>27Kg/m ,2
throughout the whereas the usual
age > 20 year totaling 4 care gained
years, hours. Interve 0.6kg. The 12
ability to ntions cost month mark for
comprehend $350.00 per A1c between
English and person, this both groups was
membershi- included not statistically
ps in SHS. interventions significant.
and written Quality of life
material. scores were
higher in the case
management
group.