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Seddigh Saedi M, Nachvak S M, Bagheri A, Sadeghi F. The Association between Therapeutic and Nutritional Care with the Control of Type 2 Diabetes Based on an Observational Study in Kermanshah, Iran. JNFS 2026; 11 (2) :269-278
URL: http://jnfs.ssu.ac.ir/article-1-1354-en.html
URL: http://jnfs.ssu.ac.ir/article-1-1354-en.html
Department of Nutritional Sciences, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Iran
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| Abstract (HTML) (331 Views)
1 Department of Nutritional Sciences, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Iran; 2 Research Center for Environmental Determinants of Health, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.
Introduction
.PNG)
In assessment of the relationship between diabetes control and disease history variables including the course of disease, family history and its degree, no significant association was observed between these variables and diabetes control (Table 4).
The association between self-monitoring blood glucose (by means of a glucometer), being aware of the normal range of blood glucose, and the consequences of uncontrolled levels with diabetes control is shown in Table 4. According to the results of this table, the patient's awareness of normal blood glucose levels and the consequences of uncontrolled diabetes showed a significant relationship with the control of this disease.
In assessing the effect of anthropometric indices and weight loss dieting on diabetes control, this control was significantly better in patients with weight assessment compared to patients without this assessment (approximately 33 vs. 15%) (P=0.004). Diabetes management was significantly better in the group receiving weight control recommendations than the others (29.3 vs. 16.8%) (P=0.037). Also, more than half of patients on a weight-loss diet showed a significant improvement in diabetes control, whereas this improvement was observed in fewer than 20% of those on a no-weight-control diet (P=0.001). Moreover, the period of adherence to the weight loss diet showed a significant difference in diabetes control in favor of patients with a longer period of adherence compared to a shorter period.
Evaluating the effect of variables related to diet on diabetes management showed a significant improvement in diabetes control in patients with complete adherence to the diet compared to those without full compliance (70 vs. 18.9%, P<0.001). Furthermore, a longer period of adherence caused a significant difference in diabetes control (80% in patients following the diet for more than one year versus 29.6% in those following the diet for one year or less) (P=0.002). Diabetes control was also significantly better in patients who received nutrition education compared to others (46.7 vs. 14.2%, P<0.001). Periodic follow-up by a nutritionist as well as increasing the frequency of anthropometric measurements led to a significant improvement in diabetes control (P=0.004). Controlled diabetes was reported in 80% of patients familiar with the exchange list of food groups and less than 20% of patients who did not know this list (P<0.001). Controlled diabetes was reported in 45% of patients familiar with portion sizes compared to less than 20% in others (P=0.004). Familiarity with glycemic terms showed a significant improvement in diabetes control (83.3 vs.15.1%, P<0.001, Table 4).
Discussion
As a chronic disease, diabetes is a major health problem which affects the quality of life and imposes a significant cost burden on society. So, any intervention or treatment with minimal side effects may significantly reduce the treatment costs (Franz et al., 1995). Various treatment methods are used for diabetes; however, their adverse effects have caused a shift towards educational approaches. Many studies have shown that education may play a significant role in diabetes management (Franz et al., 1995).
Moreover, educational approaches are less expensive than other methods, an issue that policy interventions are usually guarded against. Assessing the role of education and nutritional care in diabetes management, this study aimed to provide affordable treatment to improve blood glucose and diabetes control (Gaetke et al., 2006). Dysregulation of insulin signaling pathway or insulin resistance is the main cause of diabetes. Active insulin signaling reduces glucose production, increases glycogen synthesis and facilitates glucose uptake in peripheral tissues such as skeletal muscles and adipose tissue (Adu et al., 2019). Disruption of this signaling causes the complex metabolic disorder of insulin resistance, which is closely related to many pathways including lipid metabolism, energy expenditure and inflammation (Early and Stanley, 2018). Therapeutic approaches based on diet or pharmacological agents affect molecular signaling pathways and impaired glucose homeostasis (Marincic et al., 2017). Many studies showed that dietary components may affect glucose levels. For example, a mixed diet containing fiber, specific proteins or lipids may benefit type 2 diabetes patients by influencing the rate of carbohydrate digestion and absorption (Nam et al., 2011). Replacing saturated fat with monounsaturated fatty acids (MUFA) or polyunsaturated fatty acids (PUFA) may improve glucose or insulin tolerance. Different diets with various nutrient contents may lead to changes in metabolites and gut microbiome which are responsible for glucose metabolism in the body (Russell et al., 2016). Considering the role of nutrition in diabetes control, education of patients focusing on changing nutritional behaviors and lifestyle is one of the interventions that may be useful in achieving the goals of diabetes management. According to the results of this study, higher education level was positively associated with diabetes control; awareness of normal blood glucose levels and the consequences of uncontrolled diabetes as well as self-monitoring represented a remarkable relationship with diabetes management. Nutritional education including familiarity with portion sizes of foods, glycemic index, adherence to diet specially weight loss dieting and follow-up by a nutritionist was significantly associated with better control of diabetes (Qin et al., 2012). Moreover, this study showed that insurance coverage has a significant effect on management of this disease.
In a study by Aroke et al., evaluating the efficacy of medical nutrition therapy and weight-loss questionnaire in type 2 diabetes, a significant improvement was observed in triglyceride, waist circumference, (WC), glycemic control and blood pressure which was along with this study (Aroke and Powell-Roach, 2020). Similarly, in a study by Franz et al, medical nutrition therapy for 3-6 months reduced HbA1c up to 2% in type 2 diabetes, which was equal to or more than treatment medication (Chawla et al., 2019).
Full-Text: (13 Views)
The Association between Therapeutic and Nutritional Care with the Control of Type 2 Diabetes Based on an Observational Study in Kermanshah, Iran
Mohammad Seddigh Saedi; MSc1, Seyed Mostafa Nachvak; PhD*1, 2, Amir Bagheri; PhD1 &
Fatemeh Sadeghi; PhD1
Mohammad Seddigh Saedi; MSc1, Seyed Mostafa Nachvak; PhD*1, 2, Amir Bagheri; PhD1 &
Fatemeh Sadeghi; PhD1
1 Department of Nutritional Sciences, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Iran; 2 Research Center for Environmental Determinants of Health, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| ARTICLE INFO | ABSTRACT | |
| ORIGINAL ARTICLE | Background: The measures and interventions which contribute to the control of diabetes may play an important role in the disease prognosis. This study was conducted with the aim of evaluating the effect of medical and nutritional care in the control of type 2 diabetes. Methods: This work as retrospective cohort, was conducted on 200 patients diagnosed with type 2 diabetes, utilizing medical records of those receiving medical care. The participants completed the Diabetes Self-Management Questionnaire (DSMQ), which assesses self-care activities pertaining to glycemic control. Additionally, demographic information, disease history, treatment monitoring, self-monitoring of blood sugar, diet data, physical activity, and biochemical tests were obtained for analysis. Results: Out of the 200 patients with type 2 diabetes studied, 45% were male and 55% were female. The majority of patients (90%) lived in urban areas. The study found that patients who received nutritional education, including information on portion sizes, glycemic index, and adherence to weight loss diets, and who were followed up by a nutritionist, had better control of their diabetes. Patients who were aware of normal blood glucose levels and the consequences of uncontrolled diabetes also showed a significant relationship with better control of the disease. Conclusion: Overall, these findings highlight the importance of incorporating nutritional education into the management plan for patients with type 2 diabetes, as it can have a significant impact on both short-term and long-term health outcomes. | |
| Article history: Received: 31 May 2025 Revised: 27 Dec 2025 Accepted: 20 Jan 2026 |
||
| *Corresponding author: smnachvak@hotmail.com Department of Nutritional Sciences, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Iran. Fax: +98 8337102002 Tel: +98 8337102009 |
||
| Keywords: Diabetes self-management; Medical nutrition therapy; Type 2 diabetes; Glycemic control.. |
Introduction
Diabetes mellitus is a chronic and progressive disease that affects the function of various organs, causing long-term complications and reducing the quality of life. Over 90% of diabetes cases are type 2 diabetes, characterized by defective insulin secretion from pancreatic islet β-cells, insulin resistance and lack of adequate compensatory insulin response (Singh et al., 2018). The global prevalence of diabetes is over 10% and future prediction estimate that by 2045 the number of persons with diabetes will have reached by 46% worldwide. The prevalence of diabetes in Iran varies from 2.4-19.1% for men and 3.2-19.8% for women (Adab et al., 2019). Diabetes has various complications. Macrovascular complications such as peripheral vascular disease, stroke and coronary heart disease as well as microvascular complications including neuropathy, nephropathy, retinopathy and lower-extremity amputations are accountable for the most burden related to diabetes.
Diabetes also imposes a remarkable burden on society in terms of higher healthcare and medical costs. Various anti-diabetes agents including thiazoledinediones, alpha glucosidase inhibitors, sulphonylureas, DPP-4 (Dipeptidyl peptidase-4) inhibitors and GLP-1 (Glucagon-like peptide-1 receptor) agonists as well as bariatric surgery were used for the control of this disease. However, these treatment options have several adverse effects and clinical limitations (Cruz-Jentoft et al., 2019).
Nowadays, adherence to medical nutrition therapy (MNT) has dramatically increased in popularity. According to existing evidence, MNT is an effective approach for improving the clinical outcomes of diabetes and reducing the medical costs. Many studies indicate the fifty-fifty role of MNT in medical treatment of diabetes and the American Diabetes Association considers MNT as the basis of all diabetes management programs. In a study to assessment the effect of registered dietitian interventions on diabetic dyslipidemia and glycemic control, Glycated Hemoglobin A1c (HbA1c) was significantly decreased to target values (≤7%) in 62% of patients by following MNT; Also, a significant improvement was observed in High-Density Lipoprotein Cholesterol (HDL-c), Triglyceride (TG) and TG-to- HDLc ratio (P<0.05). In another study, the efficacy of follow up and supervision of dietitians in improvement of biochemical indices of patients with type 2 diabetes was significant. Several studies have highlighted the prominent effects of MNT in control of diabetes (Guariguata et al., 2011). The measures and interventions which contribute to the control of diabetes may play an important role in the disease prognosis, reducing the pain as well as the burden of disease in the society. In patients with diabetes without being affected by any intervention studies, the disease control status has a wide range. Some patients are successful in disease management and others are unsuccessful (Zheng et al., 2018). One of the types of studies investigating how some patients have been able to control their disease are observational studies. This observational study was conducted with the aim of evaluating the effect of medical and nutritional care in the control of type 2 diabetes.
Materials and Methods
Study design and participants
The present study is a retrospective cohort study conducted on 200 patients with type 2 diabetes who referred to the Taleghani Diabetes Clinic in Kermanshah between April 2017 and March 2019. The data was collected using medical record information of patients. The patient files were selected based on inclusion and exclusion criteria. Inclusion criteria: Confirmed diagnosis of type 2 diabetes according to the American Diabetes Association (ADA) criteria; Age between 30 and 75; Both sexes (male and female); Ability to communicate and provide information for completing questionnaires; At least two HbA1c test results recorded during the past 12 months; No change in diabetes treatment type (oral medication or insulin) during the previous 6 months and Ability to read or have basic literacy to complete the self-management questionnaire (DSMQ).
Exclusion criteria: Type 1 diabetes, gestational diabetes, or other secondary forms of diabetes; Severe comorbid diseases that could affect glycemic control (e.g., chronic kidney disease stage ≥3, cardiovascular disease, malignancy, or advanced liver disease); Use of corticosteroids or other drugs influencing glucose metabolism; Incomplete medical records or missing laboratory data; Cognitive or psychiatric disorders preventing valid participation; Pregnancy or lactation during the study period; Refusal to participate in interviews or follow-up and Patients who did not meet the above criteria were excluded from the study.
Initially, 275 files which met the inclusion criteria were reviewed. After completing the information that was not in the files through interviews, 200 files were included.
General information
Demographic information and socio-economic status including level of education, position in the family, marital status, household population, type of residence, occupation, access to basic infrastructure, insurance coverage, access to food market, monthly income and history of smoking were recorded.
Medical information
The data was collected using medical record information of patients. The diabetes self-management questionnaire (DSMQ) is a sixteen-item questionnaire evaluating self-care activities related to glycemic control which was completed for all the participants. The validity and reliability of this questionnaire has been confirmed in many studies (Schmitt et al., 2013). Disease history including the time and method of diagnosis, family history of diabetes, history of death due to diabetes and its complications in relatives, history of gestational diabetes, miscarriage, polycystic ovary and birth of a macrosomic baby were also recorded. Disease status was monitored by the physician every 3 months through evaluation of laboratory tests and physical examinations (such as cardiovascular, eye, foot, oral and dental examinations). Also, patients were educated about normal blood glucose levels and how to deal with its fluctuations. Biochemical indices including HbA1c, lipid profiles, serum creatinine and urine test were recorded.
Physical activity, anthropometry and nutritional information
Anthropometric indices, including weight, height and body mass index (BMI), physical activity level, dietary intake and nutritional behaviors were recorded by a nutritionist. Dietary status was monitored by the nutritionist every month and the nutritional recommendations were provided.
Definition of study groups
To assess the relationship between nutritional and medical care with glycemic control, patients were categorized into two main groups based on HbA1c levels:
- Controlled group: HbA1c ≤ 7%
- Uncontrolled group: HbA1c > 7%
Ethical considerations
This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences and registered at the deputy of Research and Technology (IR.KUMS.REC.1400.316).
Data analysis
Data were analyzed by SPSS Software (version 22), and two independent t-tests were used to compare the quantitative variables between groups. Nominal variables were then compared using the Chi-square test between groups and Spearman correlation coefficient was used for correlation analysis. The value of P-value less than 0.05 was significant.
Results
In this study, 275 files meeting the inclusion criteria were examined. Finally, 200 files were studied due to the lack of cooperation of some patients (Figure1). Of these, 90 (45%) were men and 110 (55%) were female, 180 (90%) were urban and 20 (10%) were rural. The variables including age, weight, height, BMI, marital status, education level, residence, insurance coverage, the course of diabetes and glycosylated hemoglobin percentage were compered between the two sexes at baseline. There was no significant difference between the two sexes regarding the course of diabetes, age, BMI, glycosylated hemoglobin percentage, residence and insurance coverage (P≥0.05). However, a significant difference was observed between the two sexes in terms of weight, height, education level and marital status (P<0.05, Table 1).
Referral of the patient to the nutritionist by the physician was evaluated based on sex, BMI, education level, use or non-use of insulin and HbA1c. No significant difference was observed in the referral based on the mentioned variables (P≥0.05. Table 2). Moreover, the association between diabetes control and demographic variables based on HbA1c (≤7%: controlled diabetes and 7%<: uncontrolled diabetes) was assessed. There was no significant association between sex and marital status with diabetes control. Otherwise, higher education level was significantly associated with better diabetes control (P<0.001, Table 3).
In evaluating the association between socio-economic variables including residence, employment status and insurance coverage and diabetes control based on HbA1c, only insurance coverage was significantly associated with diabetes control (Table 4).
Diabetes also imposes a remarkable burden on society in terms of higher healthcare and medical costs. Various anti-diabetes agents including thiazoledinediones, alpha glucosidase inhibitors, sulphonylureas, DPP-4 (Dipeptidyl peptidase-4) inhibitors and GLP-1 (Glucagon-like peptide-1 receptor) agonists as well as bariatric surgery were used for the control of this disease. However, these treatment options have several adverse effects and clinical limitations (Cruz-Jentoft et al., 2019).
Nowadays, adherence to medical nutrition therapy (MNT) has dramatically increased in popularity. According to existing evidence, MNT is an effective approach for improving the clinical outcomes of diabetes and reducing the medical costs. Many studies indicate the fifty-fifty role of MNT in medical treatment of diabetes and the American Diabetes Association considers MNT as the basis of all diabetes management programs. In a study to assessment the effect of registered dietitian interventions on diabetic dyslipidemia and glycemic control, Glycated Hemoglobin A1c (HbA1c) was significantly decreased to target values (≤7%) in 62% of patients by following MNT; Also, a significant improvement was observed in High-Density Lipoprotein Cholesterol (HDL-c), Triglyceride (TG) and TG-to- HDLc ratio (P<0.05). In another study, the efficacy of follow up and supervision of dietitians in improvement of biochemical indices of patients with type 2 diabetes was significant. Several studies have highlighted the prominent effects of MNT in control of diabetes (Guariguata et al., 2011). The measures and interventions which contribute to the control of diabetes may play an important role in the disease prognosis, reducing the pain as well as the burden of disease in the society. In patients with diabetes without being affected by any intervention studies, the disease control status has a wide range. Some patients are successful in disease management and others are unsuccessful (Zheng et al., 2018). One of the types of studies investigating how some patients have been able to control their disease are observational studies. This observational study was conducted with the aim of evaluating the effect of medical and nutritional care in the control of type 2 diabetes.
Materials and Methods
Study design and participants
The present study is a retrospective cohort study conducted on 200 patients with type 2 diabetes who referred to the Taleghani Diabetes Clinic in Kermanshah between April 2017 and March 2019. The data was collected using medical record information of patients. The patient files were selected based on inclusion and exclusion criteria. Inclusion criteria: Confirmed diagnosis of type 2 diabetes according to the American Diabetes Association (ADA) criteria; Age between 30 and 75; Both sexes (male and female); Ability to communicate and provide information for completing questionnaires; At least two HbA1c test results recorded during the past 12 months; No change in diabetes treatment type (oral medication or insulin) during the previous 6 months and Ability to read or have basic literacy to complete the self-management questionnaire (DSMQ).
Exclusion criteria: Type 1 diabetes, gestational diabetes, or other secondary forms of diabetes; Severe comorbid diseases that could affect glycemic control (e.g., chronic kidney disease stage ≥3, cardiovascular disease, malignancy, or advanced liver disease); Use of corticosteroids or other drugs influencing glucose metabolism; Incomplete medical records or missing laboratory data; Cognitive or psychiatric disorders preventing valid participation; Pregnancy or lactation during the study period; Refusal to participate in interviews or follow-up and Patients who did not meet the above criteria were excluded from the study.
Initially, 275 files which met the inclusion criteria were reviewed. After completing the information that was not in the files through interviews, 200 files were included.
General information
Demographic information and socio-economic status including level of education, position in the family, marital status, household population, type of residence, occupation, access to basic infrastructure, insurance coverage, access to food market, monthly income and history of smoking were recorded.
Medical information
The data was collected using medical record information of patients. The diabetes self-management questionnaire (DSMQ) is a sixteen-item questionnaire evaluating self-care activities related to glycemic control which was completed for all the participants. The validity and reliability of this questionnaire has been confirmed in many studies (Schmitt et al., 2013). Disease history including the time and method of diagnosis, family history of diabetes, history of death due to diabetes and its complications in relatives, history of gestational diabetes, miscarriage, polycystic ovary and birth of a macrosomic baby were also recorded. Disease status was monitored by the physician every 3 months through evaluation of laboratory tests and physical examinations (such as cardiovascular, eye, foot, oral and dental examinations). Also, patients were educated about normal blood glucose levels and how to deal with its fluctuations. Biochemical indices including HbA1c, lipid profiles, serum creatinine and urine test were recorded.
Physical activity, anthropometry and nutritional information
Anthropometric indices, including weight, height and body mass index (BMI), physical activity level, dietary intake and nutritional behaviors were recorded by a nutritionist. Dietary status was monitored by the nutritionist every month and the nutritional recommendations were provided.
Definition of study groups
To assess the relationship between nutritional and medical care with glycemic control, patients were categorized into two main groups based on HbA1c levels:
- Controlled group: HbA1c ≤ 7%
- Uncontrolled group: HbA1c > 7%
Ethical considerations
This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences and registered at the deputy of Research and Technology (IR.KUMS.REC.1400.316).
Data analysis
Data were analyzed by SPSS Software (version 22), and two independent t-tests were used to compare the quantitative variables between groups. Nominal variables were then compared using the Chi-square test between groups and Spearman correlation coefficient was used for correlation analysis. The value of P-value less than 0.05 was significant.
Results
In this study, 275 files meeting the inclusion criteria were examined. Finally, 200 files were studied due to the lack of cooperation of some patients (Figure1). Of these, 90 (45%) were men and 110 (55%) were female, 180 (90%) were urban and 20 (10%) were rural. The variables including age, weight, height, BMI, marital status, education level, residence, insurance coverage, the course of diabetes and glycosylated hemoglobin percentage were compered between the two sexes at baseline. There was no significant difference between the two sexes regarding the course of diabetes, age, BMI, glycosylated hemoglobin percentage, residence and insurance coverage (P≥0.05). However, a significant difference was observed between the two sexes in terms of weight, height, education level and marital status (P<0.05, Table 1).
Referral of the patient to the nutritionist by the physician was evaluated based on sex, BMI, education level, use or non-use of insulin and HbA1c. No significant difference was observed in the referral based on the mentioned variables (P≥0.05. Table 2). Moreover, the association between diabetes control and demographic variables based on HbA1c (≤7%: controlled diabetes and 7%<: uncontrolled diabetes) was assessed. There was no significant association between sex and marital status with diabetes control. Otherwise, higher education level was significantly associated with better diabetes control (P<0.001, Table 3).
In evaluating the association between socio-economic variables including residence, employment status and insurance coverage and diabetes control based on HbA1c, only insurance coverage was significantly associated with diabetes control (Table 4).
| Table 1. Demographic characteristics of the participants. | |||
| Variable | Male | Female | P-value |
| Age (y) | 58.11±9.98a | 55.90±8.85 | 0.111 |
| Weight (kg) | 85.41±18.86 | 84.87±12.07 | <0.001 |
| Height (cm) | 1.71±0.68 | 1.60±0.62 | <0.001 |
| BMI (kg/m2) | 29.16±6.26 | 29.09±4.64 | 0.178 |
| HbA1c (%) | 8.21±1.92 | 8.14±1.70 | 0.275 |
| Course of diabetes (y) | 7.27±5.95 |
8.35±5.70 |
0.834 |
| Marital status Married |
88 (97.7)b |
85 (77.27) |
<0.001 |
| Single | 2 (2.3) | 25 (22.73) | |
| Education level Illiterate |
19 (21.11) |
62 (56.36) |
<0.001 |
| Elementary | 26 (28.89) | 18 (16.38) | |
| Junior high school | 16 (17.77) |
12 (10.9) |
|
| Senior high school | 18 (20.00) |
16 (14.55) |
|
| University | 11 (12.23) | 2 (1.81) | |
| Residence Urban |
79 (87.77) |
101 (91.82) |
0.343 |
| Rural | 11 (12.23) | 9 (8.18) | |
| Insurance Public |
75 (83.33) |
96 (87.27) |
0.923 |
| Supplementary | 24 (26.66) |
30 (27.27) |
|
| a: Mean±SD; b: n (%);BMI: Body mass index; HbA1c: Hemoglobin A1c.. | |||
In assessment of the relationship between diabetes control and disease history variables including the course of disease, family history and its degree, no significant association was observed between these variables and diabetes control (Table 4).
The association between self-monitoring blood glucose (by means of a glucometer), being aware of the normal range of blood glucose, and the consequences of uncontrolled levels with diabetes control is shown in Table 4. According to the results of this table, the patient's awareness of normal blood glucose levels and the consequences of uncontrolled diabetes showed a significant relationship with the control of this disease.
In assessing the effect of anthropometric indices and weight loss dieting on diabetes control, this control was significantly better in patients with weight assessment compared to patients without this assessment (approximately 33 vs. 15%) (P=0.004). Diabetes management was significantly better in the group receiving weight control recommendations than the others (29.3 vs. 16.8%) (P=0.037). Also, more than half of patients on a weight-loss diet showed a significant improvement in diabetes control, whereas this improvement was observed in fewer than 20% of those on a no-weight-control diet (P=0.001). Moreover, the period of adherence to the weight loss diet showed a significant difference in diabetes control in favor of patients with a longer period of adherence compared to a shorter period.
Evaluating the effect of variables related to diet on diabetes management showed a significant improvement in diabetes control in patients with complete adherence to the diet compared to those without full compliance (70 vs. 18.9%, P<0.001). Furthermore, a longer period of adherence caused a significant difference in diabetes control (80% in patients following the diet for more than one year versus 29.6% in those following the diet for one year or less) (P=0.002). Diabetes control was also significantly better in patients who received nutrition education compared to others (46.7 vs. 14.2%, P<0.001). Periodic follow-up by a nutritionist as well as increasing the frequency of anthropometric measurements led to a significant improvement in diabetes control (P=0.004). Controlled diabetes was reported in 80% of patients familiar with the exchange list of food groups and less than 20% of patients who did not know this list (P<0.001). Controlled diabetes was reported in 45% of patients familiar with portion sizes compared to less than 20% in others (P=0.004). Familiarity with glycemic terms showed a significant improvement in diabetes control (83.3 vs.15.1%, P<0.001, Table 4).
Discussion
As a chronic disease, diabetes is a major health problem which affects the quality of life and imposes a significant cost burden on society. So, any intervention or treatment with minimal side effects may significantly reduce the treatment costs (Franz et al., 1995). Various treatment methods are used for diabetes; however, their adverse effects have caused a shift towards educational approaches. Many studies have shown that education may play a significant role in diabetes management (Franz et al., 1995).
Moreover, educational approaches are less expensive than other methods, an issue that policy interventions are usually guarded against. Assessing the role of education and nutritional care in diabetes management, this study aimed to provide affordable treatment to improve blood glucose and diabetes control (Gaetke et al., 2006). Dysregulation of insulin signaling pathway or insulin resistance is the main cause of diabetes. Active insulin signaling reduces glucose production, increases glycogen synthesis and facilitates glucose uptake in peripheral tissues such as skeletal muscles and adipose tissue (Adu et al., 2019). Disruption of this signaling causes the complex metabolic disorder of insulin resistance, which is closely related to many pathways including lipid metabolism, energy expenditure and inflammation (Early and Stanley, 2018). Therapeutic approaches based on diet or pharmacological agents affect molecular signaling pathways and impaired glucose homeostasis (Marincic et al., 2017). Many studies showed that dietary components may affect glucose levels. For example, a mixed diet containing fiber, specific proteins or lipids may benefit type 2 diabetes patients by influencing the rate of carbohydrate digestion and absorption (Nam et al., 2011). Replacing saturated fat with monounsaturated fatty acids (MUFA) or polyunsaturated fatty acids (PUFA) may improve glucose or insulin tolerance. Different diets with various nutrient contents may lead to changes in metabolites and gut microbiome which are responsible for glucose metabolism in the body (Russell et al., 2016). Considering the role of nutrition in diabetes control, education of patients focusing on changing nutritional behaviors and lifestyle is one of the interventions that may be useful in achieving the goals of diabetes management. According to the results of this study, higher education level was positively associated with diabetes control; awareness of normal blood glucose levels and the consequences of uncontrolled diabetes as well as self-monitoring represented a remarkable relationship with diabetes management. Nutritional education including familiarity with portion sizes of foods, glycemic index, adherence to diet specially weight loss dieting and follow-up by a nutritionist was significantly associated with better control of diabetes (Qin et al., 2012). Moreover, this study showed that insurance coverage has a significant effect on management of this disease.
In a study by Aroke et al., evaluating the efficacy of medical nutrition therapy and weight-loss questionnaire in type 2 diabetes, a significant improvement was observed in triglyceride, waist circumference, (WC), glycemic control and blood pressure which was along with this study (Aroke and Powell-Roach, 2020). Similarly, in a study by Franz et al, medical nutrition therapy for 3-6 months reduced HbA1c up to 2% in type 2 diabetes, which was equal to or more than treatment medication (Chawla et al., 2019).
| Table 2. Referral to a nutritionist based on some study variables. | |||
| Variable | Referral | No referral | P-value |
| Sex Male |
30 (15.0) |
60 (30.0) |
0.40 |
| Female | 43 (21.5) | 67 (33.5) | |
| Weight status Underweight |
2 (2.7) |
1 (0.8) |
0.59 |
| Normal | 11 (15.1) | 25 (20.0) | |
| Overweight | 30 (41.1) | 47 (37.6) | |
| Obese | 30 (41.1) | 52 (41.6) | |
| Education level Illiterate |
26 (13.0) |
55 (27.5) |
0.26 |
| Elementary | 16 (8.0) | 28 (14.0) | |
| Junior high school | 15 (7.5) | 13 (6.5) | |
| Senior high school | 13 (6.5) | 21 (10.5) | |
| University | 3 (1.5) | 10 (5.0) | |
| Insulin therapy Yes |
19 (9.5) |
36 (18.0) |
0.72 |
| No | 54 (27.0) | 91 (45.5) | |
| Hemoglobin A1c (%) ≤7 |
17 (8.5) | 28 (14.0) | 0.74 |
| 7.1-8 | 21 (10.5) | 46 (23.0) | |
| 8.1-9 | 16 (8.0) | 25 (12.5) | |
| 9.1˂ | 19 (9.5) | 28 (14.0) | |
| Table 3. Frequency distribution of diabetes control status according to demographic variables. | |||
| Variable | Controlled | Uncontrolled | P-value |
| Sex Male |
19 (21.1) |
71 (78.9) |
0.9 |
| Female | 24 (21.8) | 86 (78.2) | |
| Education level Illiterate |
11 (13.6) |
70 (86.4) |
0.001 |
| Elementary | 8 (18.4) | 36 (81.6) | |
| Junior high school | 4 (14.3) | 24 (85.7) | |
| Senior high school | 16 (41.7) | 18 (58.3) | |
| University | 4 (30.8) | 9 (69.2) | |
| Marital status Single |
40 (23.1) |
133 (76.9) |
0.158 |
| Married | 3 (11.1) | 24 (88.9) | |
| Table 4. Frequency distribution of diabetes control status according to study variables. | |||
| Socio-economic variables. | Controlled | Uncontrolled | P-value |
| Residence Urban |
39 (21.7) |
141 (78.3) |
0.863 |
| Rural | 4 (20.0) | 16 (80.0) | |
| Employment status Employee |
2 (13.3) |
13 (87.7) |
0.464 |
| Retired | 13 (32.5) | 27 (67.5) | |
| Housewife | 22 (21.4) | 81 (78.6) | |
| Others | 3 (12.0) | 22 (88.0) | |
| Unemployed | 3 (17.6) | 14 (82.4) | |
| Insurance coverage Insured |
42 (24.6) |
129 (75.4) |
0.01 |
| No insurance | 1 (3.4) | 28 (96.9) | |
| Disease history variables | |||
| Course of diabetes (y) | 5.67 ± 4.39 | 8.47 ± 6.03 | 0.172 |
| Family history of diabetes Yes |
32 (24.6) |
98 (75.4) |
0.144 |
| No | 11 (15.7) | 59 (84.3) | |
| Degree of family history of diabetes Grade 1 |
28 (23.3) |
92 (76.7) |
0.161 |
| Grade 2 | 4 (36.4) | 6 (63.6) | |
| Blood glucose monitoring variables | |||
| Having a glucometer Yes |
25 (20.3) |
98 (79.7) |
0.731 |
| No | 17 (22.4) | 59 (77.6) | |
| Recording glucometer results Yes |
3 (20.0) |
12 (80.0) |
0.883 |
| No | 40 (21.6) | 145 (78.4) | |
| Being aware of the normal range of blood glucose | 14 (43.8) |
18 (56.2) |
0.001 |
| Yes | |||
| No | 29 (17.3) | 139 (82.7) | |
| Being aware of the consequences of Uncontrolled levels with diabetes control | ˂0.001 | ||
| Yes | 18 (50.0) | 18 (50;0) | |
| No | 25 (15.2) | 139 (84.8) | |
| HbA1c values with anthropometric indices and weight loss diet | |||
| Overweight Yes |
35 (22.0) |
124 (78.0) |
0.839 |
| No | 8 (20.5) | 31 (79.5) | |
| Weight assessment in clinic Yes |
24 (32.4) |
50 (67.6) |
0.004 |
| No | 19 (15.1) | 107 (84.9) | |
| Receiving weight control recommendations Yes |
22 (29.3) |
53 (70.7) |
0.037 |
| No | 21 (16.8) | 104 (83.2) | |
| Weight loss diet Yes |
9 (52.9) |
8 (47.1) |
0.001 |
| No | 26 (17.8) | 120 (82.2) | |
| Adherence to diet More than a year |
2 (66.7) |
1 (33.3) |
0.029 |
| One year or less | 4 (44.4) | 5 (55.6) | |
| No diet | 29 (19) | 124 (81) | |
| Complete adherence to diet Yes |
5 (71.4) |
2 (28.6) |
0.001 |
| No | 30 (19.0) | 128 (81.0) | |
| Weight assessment times in one 1 or two years None |
19 (14.7) |
110(85.3) |
˂0.001 |
| Once | 17 (27.4) | 45 (72.6) | |
| Twice and more | 7 (77.8) | 2 (22.2) | |
| Diet change after diabetes Yes |
14 (41.2) |
20 (58.8) |
0.002 |
| No | 29 (17.5) | 137 (82.5) | |
| Nutrition education Yes |
21 (46.7) |
24 (53.3) |
<0.001 |
| No | 22 (14.2) | 133 (85.8) | |
| Complete adherence to recommended diet Yes |
7 (70.0) |
3 (30.0) |
<0.001 |
| No | 36 (18.9) | 154 (81.1) | |
| Period of adherence to diet More than a year |
4 (80.0) |
1 (20.0) |
0.002 |
| One year or less | 8 (29.6) | 19 (70.4) | |
| No diet | 31 (18.5) | 137 (81.5) | |
| Periodic follow-up by a nutritionist Yes |
5 (62.5) |
3 (37.5) |
0.004 |
| No | 38 (19.8) | 154 (80.2) | |
| Familiarity with the exchange list of food groups | <0.001 | ||
| Yes | 8 (80.0) | 2 (20.0) | |
| No | 35 (18.4) | 155 (81.6) | |
| Familiarity with portion sizes Yes |
10 (45.5) |
12 (54.5) |
0.004 |
| No | 33 (18.5) | 145 (81.5) | |
| Frequency of anthropometric measurements by a nutritionist in 1or 2 years | |||
| None | 35 (20.2) | 138 (79.8) | 0.031 |
| Once | 5 (21.7) | 18 (78.3) | |
| Twice and more | 3 (75.0) | 1 (25.0) | |
| Familiarity with glycemic terms Yes |
5 (83.3) |
1 (16.7) |
<0.001 |
| No | 38 (19.6) | 156 (80.4) | |
Likewise, in the study by Dobrow et al., assessing the effect of registered dietitian nutritionists in healthy behavior interventions in older people with type2 diabetes, a significant improvement was observed in fasting blood glucose, HbA1c, blood pressure, low-density lipoprotein cholesterol (LDLc), BMI, lean body mass and self-efficacy (Dobrow et al., 2022).
The present study has several limitations: 1) The retrospective observational design precludes causal inference; only associations between nutritional/therapeutic care and glycemic control can be reported, not cause–effect relationships; 2) All patients are from a single diabetes clinic in Kermanshah, which may limit generalizability to other regions, healthcare systems, and ethnic or socio-economic populations; 3) Reliance on medical records and self-reported questionnaires (e.g., DSMQ, diet adherence) introduces possible recall bias, reporting bias, and missing or incomplete data.
Conclusion
This study shows that evaluating the disease process through focusing on nutritional care and education will provide the basis for better and more effective care services in diabetes management from both quantitative and qualitative aspects.
Acknowledgments
This article extracted from the MSc thesis of Mohammad Seddigh Saedi. The authors wish to thank the Vice-Chancellor for research, Kermanshah University of Medical Sciences, for financially supporting this project
Authors’ contributions
All authors contributed to study design, writing, and interpretations of data; they agreed to be responsible for all aspects of this study.
Funding
This study was extracted from the MSc thesis of Mohammad Seddigh Saedi. The authors wish to thank the Vice-Chancellor for research, Kermanshah University of Medical Sciences, for financially supporting this project.
Conflicts of interests
The authors had no conflicts of interest.
References
Adab Z, et al. 2019. Effect of turmeric on glycemic status, lipid profile, hs‐CRP, and total antioxidant capacity in hyperlipidemic type 2 diabetes mellitus patients. Phytotherapy research. 33 (4): 1173-1181.
Adu MD, Malabu UH, Malau-Aduli AE & Malau-Aduli BS 2019. Enablers and barriers to effective diabetes self-management: A multi-national investigation. PloS one. 14 (6): e0217771.
Aroke EN & Powell-Roach KL 2020. The metabolomics of chronic pain conditions: a systematic review. Biological research for nursing. 22 (4): 458-471.
Chawla SPS, et al. 2019. Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. Journal of family medicine and primary care. 8 (1): 261-268.
Cruz-Jentoft AJ, et al. 2019. Sarcopenia: revised European consensus on definition and diagnosis. Age and ageing. 48 (1): 16-31.
Dobrow L, Estrada I, Burkholder-Cooley N & Miklavcic J 2022. Potential effectiveness of registered dietitian nutritionists in healthy behavior interventions for managing type 2 diabetes in older adults: a systematic review. Frontiers in nutrition. 8: 737410.
Early KB & Stanley K 2018. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes. Journal of the Academy of Nutrition and Dietetics. 118 (2): 343-353.
Franz MJ, et al. 1995. Effectiveness of medical nutrition therapy provided by dietitians in the management of non–insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. Journal of the American Dietetic Association. 95 (9): 1009-1017.
Gaetke LM, Stuart MA & Truszczynska H 2006. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. Journal of the American Dietetic Association. 106 (1): 109-112.
Guariguata L, Whiting D, Weil C & Unwin N 2011. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults. Diabetes research and clinical practice. 94 (3): 322-332.
Marincic PZ, et al. 2017. 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. Journal of the Academy of Nutrition and Dietetics. 117 (8): 1254-1264.
Nam S, Chesla C, Stotts NA, Kroon L & Janson SL 2011. Barriers to diabetes management: patient and provider factors. Diabetes research and clinical practice. 93 (1): 1-9.
Qin J, et al. 2012. A metagenome-wide association study of gut microbiota in type 2 diabetes. Nature. 490 (7418): 55-60.
Russell WR, et al. 2016. Impact of diet composition on blood glucose regulation. Critical reviews in food science and nutrition. 56 (4): 541-590.
Schmitt A, et al. 2013. The diabetes self-management questionnaire (DSMQ): Development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health and quality of life outcomes. 11 (1): 138.
Singh AK, Talwalkar PG, Ahluwalia A, Modi KD & Saboo B 2018. Expert group recommendations on detection and management of hypoglycemia in routine clinical practice in insulin treated patients with diabetes. Journal
of association of physicians of India. 66 (12): 90-97.
Zheng Y, Ley SH & Hu FB 2018. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature reviews endocrinology. 14 (2): 88-98.
The present study has several limitations: 1) The retrospective observational design precludes causal inference; only associations between nutritional/therapeutic care and glycemic control can be reported, not cause–effect relationships; 2) All patients are from a single diabetes clinic in Kermanshah, which may limit generalizability to other regions, healthcare systems, and ethnic or socio-economic populations; 3) Reliance on medical records and self-reported questionnaires (e.g., DSMQ, diet adherence) introduces possible recall bias, reporting bias, and missing or incomplete data.
Conclusion
This study shows that evaluating the disease process through focusing on nutritional care and education will provide the basis for better and more effective care services in diabetes management from both quantitative and qualitative aspects.
Acknowledgments
This article extracted from the MSc thesis of Mohammad Seddigh Saedi. The authors wish to thank the Vice-Chancellor for research, Kermanshah University of Medical Sciences, for financially supporting this project
Authors’ contributions
All authors contributed to study design, writing, and interpretations of data; they agreed to be responsible for all aspects of this study.
Funding
This study was extracted from the MSc thesis of Mohammad Seddigh Saedi. The authors wish to thank the Vice-Chancellor for research, Kermanshah University of Medical Sciences, for financially supporting this project.
Conflicts of interests
The authors had no conflicts of interest.
References
Adab Z, et al. 2019. Effect of turmeric on glycemic status, lipid profile, hs‐CRP, and total antioxidant capacity in hyperlipidemic type 2 diabetes mellitus patients. Phytotherapy research. 33 (4): 1173-1181.
Adu MD, Malabu UH, Malau-Aduli AE & Malau-Aduli BS 2019. Enablers and barriers to effective diabetes self-management: A multi-national investigation. PloS one. 14 (6): e0217771.
Aroke EN & Powell-Roach KL 2020. The metabolomics of chronic pain conditions: a systematic review. Biological research for nursing. 22 (4): 458-471.
Chawla SPS, et al. 2019. Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. Journal of family medicine and primary care. 8 (1): 261-268.
Cruz-Jentoft AJ, et al. 2019. Sarcopenia: revised European consensus on definition and diagnosis. Age and ageing. 48 (1): 16-31.
Dobrow L, Estrada I, Burkholder-Cooley N & Miklavcic J 2022. Potential effectiveness of registered dietitian nutritionists in healthy behavior interventions for managing type 2 diabetes in older adults: a systematic review. Frontiers in nutrition. 8: 737410.
Early KB & Stanley K 2018. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes. Journal of the Academy of Nutrition and Dietetics. 118 (2): 343-353.
Franz MJ, et al. 1995. Effectiveness of medical nutrition therapy provided by dietitians in the management of non–insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. Journal of the American Dietetic Association. 95 (9): 1009-1017.
Gaetke LM, Stuart MA & Truszczynska H 2006. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. Journal of the American Dietetic Association. 106 (1): 109-112.
Guariguata L, Whiting D, Weil C & Unwin N 2011. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults. Diabetes research and clinical practice. 94 (3): 322-332.
Marincic PZ, et al. 2017. 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. Journal of the Academy of Nutrition and Dietetics. 117 (8): 1254-1264.
Nam S, Chesla C, Stotts NA, Kroon L & Janson SL 2011. Barriers to diabetes management: patient and provider factors. Diabetes research and clinical practice. 93 (1): 1-9.
Qin J, et al. 2012. A metagenome-wide association study of gut microbiota in type 2 diabetes. Nature. 490 (7418): 55-60.
Russell WR, et al. 2016. Impact of diet composition on blood glucose regulation. Critical reviews in food science and nutrition. 56 (4): 541-590.
Schmitt A, et al. 2013. The diabetes self-management questionnaire (DSMQ): Development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health and quality of life outcomes. 11 (1): 138.
Singh AK, Talwalkar PG, Ahluwalia A, Modi KD & Saboo B 2018. Expert group recommendations on detection and management of hypoglycemia in routine clinical practice in insulin treated patients with diabetes. Journal
of association of physicians of India. 66 (12): 90-97.
Zheng Y, Ley SH & Hu FB 2018. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature reviews endocrinology. 14 (2): 88-98.
Type of article: orginal article |
Subject:
public specific
Received: 2025/05/31 | Published: 2026/05/30 | ePublished: 2026/05/30
Received: 2025/05/31 | Published: 2026/05/30 | ePublished: 2026/05/30
References
1. Adab Z, et al. 2019. Effect of turmeric on glycemic status, lipid profile, hs‐CRP, and total antioxidant capacity in hyperlipidemic type 2 diabetes mellitus patients. Phytotherapy research. 33 (4): 1173-1181.
2. Adu MD, Malabu UH, Malau-Aduli AE & Malau-Aduli BS 2019. Enablers and barriers to effective diabetes self-management: A multi-national investigation. PloS one. 14 (6): e0217771.
3. Aroke EN & Powell-Roach KL 2020. The metabolomics of chronic pain conditions: a systematic review. Biological research for nursing. 22 (4): 458-471.
4. Chawla SPS, et al. 2019. Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. Journal of family medicine and primary care. 8 (1): 261-268.
5. Cruz-Jentoft AJ, et al. 2019. Sarcopenia: revised European consensus on definition and diagnosis. Age and ageing. 48 (1): 16-31.
6. Dobrow L, Estrada I, Burkholder-Cooley N & Miklavcic J 2022. Potential effectiveness of registered dietitian nutritionists in healthy behavior interventions for managing type 2 diabetes in older adults: a systematic review. Frontiers in nutrition. 8: 737410.
7. Early KB & Stanley K 2018. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes. Journal of the Academy of Nutrition and Dietetics. 118 (2): 343-353.
8. Franz MJ, et al. 1995. Effectiveness of medical nutrition therapy provided by dietitians in the management of non–insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. Journal of the American Dietetic Association. 95 (9): 1009-1017.
9. Gaetke LM, Stuart MA & Truszczynska H 2006. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. Journal of the American Dietetic Association. 106 (1): 109-112.
10. Guariguata L, Whiting D, Weil C & Unwin N 2011. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults. Diabetes research and clinical practice. 94 (3): 322-332.
11. Marincic PZ, et al. 2017. 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. Journal of the Academy of Nutrition and Dietetics. 117 (8): 1254-1264.
12. Nam S, Chesla C, Stotts NA, Kroon L & Janson SL 2011. Barriers to diabetes management: patient and provider factors. Diabetes research and clinical practice. 93 (1): 1-9.
13. Qin J, et al. 2012. A metagenome-wide association study of gut microbiota in type 2 diabetes. Nature. 490 (7418): 55-60.
14. Russell WR, et al. 2016. Impact of diet composition on blood glucose regulation. Critical reviews in food science and nutrition. 56 (4): 541-590.
15. Schmitt A, et al. 2013. The diabetes self-management questionnaire (DSMQ): Development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health and quality of life outcomes. 11 (1): 138.
16. Singh AK, Talwalkar PG, Ahluwalia A, Modi KD & Saboo B 2018. Expert group recommendations on detection and management of hypoglycemia in routine clinical practice in insulin treated patients with diabetes. Journal of association of physicians of India. 66 (12): 90-97.
17. Zheng Y, Ley SH & Hu FB 2018. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature reviews endocrinology. 14 (2): 88-98.
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