Trial Analyzes Impacts of Nutrition Education Programs on Patients With T1D

Results of a prospective randomized trial show that nutrition education using a food-based approach (FBA), carbohydrate counting (CC), or routine care (RC) is equivalent in terms of glycated hemoglobin (A1C) change and cardiovascular risk factors among individuals with type 1 diabetes (T1D) and moderately impaired glycemic control.

However, findings, published in BMJ Open Diabetes Research & Care, do show that an FBA resulted in benefits regarding food choices when compared with CC and RC.

Although nutrition is critical in the prevention of complications in T1D and nutrition education can lead to immediate implications for blood glucose control and quality of life, “evidence on the effects of structured nutrition education is weak in adults with T1D with moderately impaired glycemic control,” authors wrote.

To address this knowledge gap, researchers assessed the effects of group education with an FBA—including food with low glycemic index (GI)—compared with group education in CC (2 intervention groups) on long-term glycemic control, cardiovascular risk factors, quality of life, and diet. RC was carried out in a third arm of the trial (control group), which consisted of individual counseling sessions.

Patients recruited from 9 Swedish specialist diabetes centers took part in the randomized controlled multicenter study. All participants had a T1D diagnosis at least 3 years prior to enrollment, had an A1C between 7.4% and 9.3%, had a body mass index of 35 kg/m² or greater and were between the ages of 20 and 70 years. The last subject completed the trial in 2015 and all patients were followed up for 12 months.

FBA program groups were led by dieticians, and participants were instructed to set their own goals to incorporate food groups such as seeds, vegetables, legumes and others into their diets. Participants kept a specific food diary to keep track of results and were also informed of goals to strive for, such as recommendation of daily intake.

The CC program groups were led by diabetes specialist nurses; the program was inspired by the Dose Adjustment for Normal Eating (DAFNE) trial. Patients were supervised on home assignments conducted between meetings as opposed to doing practical exercises during meetings.

“In the RC program, also led by diabetes specialist nurses, the instruction to the nurses were regular counseling. Subjects in the RC program were individually scheduled to attend 4 education sessions by a specialist nurse, with each session lasting up to 1 hour,” researchers explained.

FBA and CC interventions lasted 30 hours total, with 10 meetings lasting 3 hours each.

A total of 159 patients were randomized to FBA (n = 51), CC (n = 52), and RC (n = 55); they had a mean (SD) age of 48.6 (12) years. The majority of participants (57.9%) were female, and mean A1C level was 63.9 (7.9) mmol/mol or 8% (0.7%) at baseline. Twenty-seven subjects withdrew from the trial during the study period (23% from FBA, 14% from CC, and 20% from RC).

After 3 months, patients in the FBA and CC groups exhibited improved A1C compared with those receiving RC. Analyses conducted after 12 months revealed:

• No significant differences in A1C; FBA vs RC (−0.4 mmol/mol [1.3]; 0.04% [0.1%]), CC vs RC (−0.8 mmol/mol [1.2]; 0.1% [0.1%]), FBA vs CC (0.4 mmol/mol [0.3]; 0.04% [0.01%]).
• Intake of legumes, nuts, and vegetables was improved in FBA vs CC and RC.
• The FBA group reported higher intake of monounsaturated and polyunsaturated fats compared with RC, and dietary fiber and monounsaturated and polyunsaturated fats compared with CC (all P <.05).
• There were no differences in blood pressure levels, lipids, body weight, or quality of life.

“One unexpected finding was that all 3 groups decreased their intake (in portions, measured by food diary) of wholegrain products with low GI, this even though the FBA group was encouraged to increase their intake,” researchers wrote.

Despite FBA participants converting to more healthy foods, this shift was not of a sufficient magnitude to influence cardiovascular risk factors measured. Authors hypothesize that a combination of education in CC with continuous glucose monitoring (CGM) or insulin pumps, and education in healthy eating with FBA could constitute a more complete and effective method in this population.

Self-estimated documentation of hypoglycemia marks a limitation to the study, as actual glucose levels were not measured. CGM was also not used in this study.

“An FBA may, tentatively, have beneficial effects on food choices and nutrient quality,” researchers concluded. “The results point toward several options in terms of nutrition programs to achieve health goals and quality of life and, thus, more ways to tailor the nutritional management of T1D to each individual’s needs and preferences.”

Reference

Isaksson SS, Bacos MB, Eliasson B, et al. Effects of nutrition education using a food-based approach, carbohydrate counting or routine care in type 1 diabetes: 12 months prospective randomized trial. BMJ Open Diabetes Res Care. Published online March 31, 2021. doi:10.1136/bmjdrc-2020-001971