GSS cIRcle Open Scholar Award (UBCV Non-Thesis Graduate Work)

Effects of Nutritional Recommendations on Metabolic Control in Individuals with Type 2 Diabetes: A Systematic.. Bridge, Candice; Dunderdale, Sarah; Sarsfeld, Jocelyn; Skopac, Robyn; Tozer, Jamey 2009-07-31

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T2D is a metabolic disorder indicated by the presence of hyperglycemia as a result of insulin insensitivity3 million Canadians with diabetes, 246 million people worldwide2025 an estimated 380 million individuals worldwide will have diabetes90% of those have T2D $20 billion/year by 2020  DefinitionHbA1c: used as a marker for the amount of glucose in plasmathis reaction is irreversible therefore a stable marker to measure glucose valuesbest indicator of glycemic control2̊ complications: heart diseasekidney diseasestrokeblindness erectile dysfunctionleg amputation↓ QoL premature deathOnset of T2D may be delayed or prevented with a healthy lifestylephysical activity, healthy diet & weight 80% of individuals with T2D are overweight or obese 3-7x greater prevalence T2D in 	obese adultsFatty tissue ↑ insulin resistanceObesity is a critical modifiable risk factor for T2D & recent evidence suggests weight management to be the most important therapyDiet & weight lifestyle modifications require goal setting & pt centered care with follow upWeight loss of 5-10% = improved glycemic control & ↓ associated risk factors by ↓ lipid levels & BPNutrition therapy alone can improve glycemic control by1-2%HbA1C levels should be < 7%> 7.5% ↑ risk of micro & macro vascular complications ie. retinopathy & CV diseaseClinically significant change in HbA1C:HbA1C of 6- 7.5% or 10% ↓ from baseline in the first 4-6 wksA well supported nutritional regimen can effect positive change in metabolic parameters; however, there is little research on effects of nutritional advice provided by HCPs Weight loss with a well-balanced nutritional regimen can cure T2D & ↓ premature mortalityDieticians & nutritionists have specialized knowledge in prescribing nutritional plans; this needs to be supported & reinforced by other HCPs such as PTsCDA does not yet recognize PTs as members of a diabetic health care teamPTs are not recognized to be involved in reinforcing dietary recommendations patients who are obeseDean (2009) has advocated a major role for PTs in effecting multiple health behavior changeMorris & colleagues (2009) have outlined how PTs can incorporate such assessment & recommendations into daily practicePTs are primary HCPs that maximize function at the activity and participation levels of the ICFNeed for nutritional and dietary education groups integrated into PT management planThis review will enhance the PTs’ comprehensive knowledge of T2D and awareness of healthcare providers1. To examine the effectiveness of nutritional recommendations in improving metabolic control in people with T2D 2. To examine the role of physiotherapists in making nutritional recommendations that can be incorporated within the constraints of clinical practicePreliminary search:CINAHL, MEDLINE, FSTA & EMBASEgrey literature search:conference proceedings, theses & dissertations, government publications, clinical trials, reference lists of included articles Terms and MeSh headingsP: diabetes mellitus, diabetes mellitus type 2, overweight, obesityI: diet therapy, food habits, health promotion, health behavior, diabetic education, nutrition therapy, nutritionO: weight loss, body weight changes, body weights and measures, BMI, waist to hip ratio, body mass, waist circumference or body compositionFor further narrowing: dietetics, community health services, physical therapists, patient care team or allied healthInclusion criteria (1) aged 18 and older(2) T2D based on lab glucose test or physician diagnosis(3) measured : BMI, WHR and/or WC(4) RCT based on dietary intervention with minimum 1 session & six-month  follow up Exclusion criteria(1) absence of a control group or active control group(2) the length of follow up < 6 months(3) the presence of cardiac conditions or renal disease (4) animals as test subjects (5) written in languages other than EnglishInitial screening	2 people reviewed 598 titles Study selectionstandardized screening tool utilized3rd party consensus meeting where a consensus could not be met Quality Assessment: PEDro scaleCriterion was modified such that blinding  subjects, participants and HCPs were not used to calculate the final score Due to nature of the interventions blinding in these studies was not possibleInternal validity reduced from lack of blindingData extractionComparison groupsPurpose of the studyDescription of participantsDuration of studyDescription of intervention & non-intervention groupsPrimary/secondary outcome measuresConclusionsStudy selection598 titles         ↓		76 selected for abstract review              ↓          17 selected for full text review              ↓           4 articles met final criteriaReasons for exclusion     i) active control groups were used     	      ii) studies were not RCTs             iii) anthropometric measures were not includedQuality Assessmentmean methodological quality of the studies was 6.75±1.26 out of 8Ranging between 5 – 83 high quality,1 moderate qualityCommon flaws: lack of concealed allocation and inadequate number of participants for follow up1 study differed significantly at baseline for 1  primary outcome measureCharacteristics of participants 1408 total:844 underwent nutritional interventions 564 controls who continued basic medical care395 men & 449 womenAge: 55.43±2.84 yr (53-59)HbA1c: 7.9 - 8.3%, average 8.15±0.19%Weight: 91.8 - 107.1 kg, average 96.69±7.02 kgCharacteristics of InterventionsDuration 3 studies of 12 months, 1 study of 6 monthsTotal timewith HCP 3–12 hrs, average 6.25±4.03 hrsFranz et al., 1995BC: single visit with dieticianPGC: 3 visits with dietician, (1hr, 2 X 30-45min)Davies, 20086 hrs of structured group education in community in 1 or 2 sessions by trained HCPWolf, 20046 individual & 6 small group sessions with dietician lasting 1 hr, brief monthly phone callsChristian, 2008initial 10-minute computer Ax , 3 subsequent sessions with physician every 3 monthsStatistical significanceWolf et al., (2004) reported a difference between control & intervention groups (p=0.02 Wolf)greatest difference at 4 months (-0.57%, p=-.008) compared with 12 months (-0.20%, p=0.45) Franz et al., (1995) reported a reduction from baseline to 6 months (p< 0.001)BC: -0.7% 	PGC: -0.9% greatest ↓ in HbA1c for both intervention groups occurred between baseline & 6 wks, this reduction was maintained up to 3 monthsFrom 3 - 6 months, HbA1c  ↑Clinical Significance A reduction of 10% from baseline or an HbA1c  less than 7.5% is considered clinically significantOnly the PGC intervention group in Franz et al.,1995 achieved a clinically significant change in HbA1c mean HbA1c 7.4% at 6 monthsDavies et al., 2008 reported a clinically significant reduction in HbA1c in both control and intervention groups: ↓ to 6.7% & 6.8%, respectivelyAfter adjusting for baseline and cluster effects results not sig (p=0.52)Wolf et al., 2004 reported a sig diff in mean weight change between groups4, 6 & 8 months p< 0.001, 12 months  p≤ 0.05 in intervention group8 months was greatest ↓ in weight in intervention group (-4.0 kg) & greatest net weight ↓ between groups (-5.0 kg)12 months control group gained 0.6 kg & intervention group lost 2.4 kgDavies et al., 2008 reported sig diff between control & intervention groups at 4 & 12 months (p=0.024 and p=0.027)	Control -1.86 kg 	Intervention -2.98 kg   (12 months)Difference between groups not sig at 8 months; however, greatest weight loss for control & intervention groups at this timeFranz et al., 1995 reported a sig weight loss from baseline to 6 months in both intervention groupsWeight reduction at 6 wks maintained at 6 months (p< 0.001)BC & PGC groups lost 1.7 kg (p<0.01) and 1.4 kg (p<0.001) Clinical SignificanceA weight loss > 5% from the initial visit was considered clinically significant (CDA)None of the studies included in this review had clinically significant findings  Results of this study indicate nutritional therapy is a viable option Even without clinically significant weight loss, glycemic control was positively influenced in individuals with T2D who were also obese with smaller, gradual amounts of weight loss Support from health care providers is important for maintaining weight lossPhysiotherapists are in a prime position to provide basic nutritional recommendations To the best of our knowledge there is no entry level or post graduate training specific to PTEriksson et al, 2006 conducted a study utilizing PTs,  in an activity program & to support diet counselling to ↓ CV risk factorsfound differences among weight, BMI, physical activity & other outcomesThose with T2D for longer than 6 months achieved better results with more advanced dietary careOptimally , nutritional recommendations can result in significant weight loss and effective metabolic control reducing or eliminating the need for pharmacological interventionMetabolic control & weight loss tended to regress toward baseline valuesIndividuals who are obese and who have had T2D for some time require the same intensity if not more support from HCPs as T2D progressesPTs have an important role in providing basic nutritional recommendationsChange can be implemented, supported, and sustained with brief interventions  Holistic practice & valuable, cost-effective method of providing ongoing nutritional support for individuals with T2D to maintain weight loss or continue weight loss to positively effect glycemic controlThe intensity and frequency of contact with HCPs appear to be key factors in metabolic controlThere is no clear guideline for recommendations on frequencyThere was a positive relationship between follow-up frequency and maintenance of changeProblematic methodological issuesPotential performance biasInternal validity: lack of blinding assessors, patients, and health care providersBasic care control groups were poorly definedNot ethical to withhold care to create a ‘true’ control which minimizes the measured effects of the interventions  Variable effectiveness of a nutritional recommendations on individuals who are obese with T2DOngoing support is important for long term metabolic controlBasic care is insufficient for long term management of T2DThank you Dr. Elizabeth Dean for your wisdom and guidance throughout the past yearDr. Darlene Reid for guidance in the early stagesCharlotte Beck for guidance with our search Fellow classmates for general support and discussion over the year An hour is allocated to each presentation so each presentation begins on the  hour. Presentations however are limited to 30 minutes followed by 15 to 20 minutes of questions and a 10 to 15 minute break.     It goes without saying that attendance is required for the entire session on both days as you will be both learning from the presentations as well as evaluating them.    As I finalize the schedule for each day (I have the office order them randomly however I put similarly themed ones sequentially as we may have clinicians attend who would need to come for a block of time), I need confirmation from each group for (have one person in the group please provide the following information):    1. The final title for each systematic review (usually there is tweaking of the title over time, if not, please still provide it so I can ensure I have exactly the same)  2. The names of all the students who completed each review.     Please provide this by Monday June 22nd. I look forward to seeing you at the Mini Symposium. The final schedule is circulated to the clinical community province wide and others who are interested. All are certainly invited to attend but they also will have ipod access later.     Usually each member of the SR group contributes in some way to the presentation. However, if some have contributed to the writing and analysis more, then allowances can be made. Discuss this with your supervisor who I recommend runs through your presentation a few times with you. Structure the presentation as follows (or a format that you have selected with your supervisor for publication in a specific journal):    Introduction/Background Literature/Rationale/Question 8-10 minutes  Methods 5 - 6 minutes (this you have done exhaustively in your proposal so highlight the primary points)  Results 8 minutes  Discussion - 5 minutes  Conclusion and Implications - 0.5 - 1 minute  Acknowledgments - 0.5 minute    The final report can be submitted to me on either day of the Symposium or placed in my mail box no later than the end of the day on the 24th. If you have it put in mailbox, please have one member of your group indicate this by e-mail so I can respond that it has been received.*leptin, cytokines and substrates are released affecting the regulatory control of glucose homeostasis 5, ADA 2008leptin, cytokines and substrates are released affecting the regulatory control of glucose homeostasis 5, ADA 2008leptin, cytokines and substrates are released affecting the regulatory control of glucose homeostasis 5, ADA 2008pt centered care (pt + medical mgt goals) *glycemic target of glycated hemoglobin (HbA1C) levels less than 7%*CPG’s= clinical practice guidelines*enhance the physiotherapists’ working knowledge of T2D management, and increase awareness of other health care providers of the physiotherapist’s role in comprehensive diabetes management*A search of the literature was conducted in CINAHL, MEDLINE, FSTA & EMBASE, with the last search on conducted on Feb 10th 2009(Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Food Science and Technology Abstracts (FSTA) and the European Medical Database (EMBASE). )To minimize publication bias, a search of grey lit was also conducted in conference proceedings, theses & dissertations, government publications, clinical trials, reference lists of included articles *The search included keywords and medical subject headings with the terms commonly used for our Population (type 2 diabetics): diabetes mellitus, diabetes mellitus type 2, overweight, obesityIntervention (dietary education session): diet therapy, food habits, health promotion, health behaviour, diabetic education, nutrition therapy, nutritionOutcomes (Anthropometric measures): weight loss, body weight changes, body weights and measures, BMI, waist to hip ratio, body mass, waist circumference or body compositionFor further narrowing: dietetics, community health services, physical therapists, patient care team or allied healthInclusion criteria: (1) aged 18 and older(2) Diagnosis of T2D based on lab glucose test or by physician diagnosis(3) measured one of BMI, waist to hop ratio or Waist circumference(4) RCT based on dietary intervention with a minimum of 1 session & a six-month  follow up Exclusion criteria(1) absence of a control group or active control group (receiving Rx)(2) the length of follow up < 6 months(3) the presence of cardiac conditions or renal disease (4) animals as test subjects (5) the papers were written in languages other than English*Initial screening based on key terms produced 598 titles 2 independent reviewers screened titles for relevance. where doubt existed the abstract was screened for inclusion/exclusion criteriaIf relevant, the full text article was included; As new titles were uncovered the same two reviewers proceeded to screen as above until no further studies were included. .  *The PEDro scale was selected as an appropriate tool to assess methodological quality and to examine internal and external validity of each study.  Due to nature of the interventions blinding in these studies was not possible therefore the Criterion was modified such that blinding subjects, participants and therapists were not used to calculate the final score.  Blinding is a procedure used to reduce result bias, therefore a lack of blinding results in reduced internal validity. Data was extracted to summarize relevant data on:what kind of comparison group/ groups were usedThe Purpose of the studyDescription of participantsDuration of studyDescription of intervention & non-intervention groupsPrimary/secondary outcome measures And Study ConclusionsFrom 4 electronic databases, 598 titles were identified.  Of these, 60 titles were selected and 17 other titles were identified in grey literature for abstract reviewAfter abstract screening, 17 titles remained eligible for full text review.When the exclusion criteria were applied, 4 articles met the criteria for inclusion with the most common reasons for exclusion being The use of an active control group    studies were not RCTs     anthropometric measures were not includedUsing the modified PEDro scale, the mean methodological quality of the sourced studies was 6.75±1.26 out of 8, with scores between 5 and 83 were of high quality (scoring greater than 6) and 1 was of moderate quality (scoring between 3 and 5)The most common flaws were: lack of concealed allocation and inadequate number of participants for follow up1 study differed significantly at baseline for 1  primary outcome measureCharacteristics of participants 1343 total:779 underwent nutritional interventions 564 controls who continued basic medical care345 men & 449 womenAge: averaging 55.43±2.84 yr (53-59)HbA1c: 7.9 - 8.3%, with an average of 8.15±0.19% (similar at baseline)Weight: 91.8 - 107.1kg, with an average of 96.69±7.02 (varied at baseline)Characteristics of InterventionsDuration of each study: 12 months, (1 study 6 months)Total time with health care providers 3 – 12hrs, with a mean of 6.25±4.03 hrsCharacteristics of each individual study include: Franz, 1995Had 2 intervention groups:One titled Basic nutritional care (BC): single visit with dietician And the Practice guidelines nutrition care (PGC) group : which had 3 visits with a dietician, first lasting an hour then 2 subsequent visits lasting 30-45mins, Davies, 2008Provided 6 hrs of structured group education in the community in either 1 or 2 sessions by trained health care providersWolf, 2004Provided 6 individual & 6 small group sessions with dietician lasting 1 hr, brief monthly phone calls.  Christian, 2008initial 10-minute computer Ax , 3 subsequent sessions with physician every 3 monthsKey Intervention Components:  developing a nutrition care plan, daily blood glucose testing, and individualized goals based on reducing risk factors, group education, brief check in phone calls. 2 studies had statistically sig. difference:Wolf and Colleagues reported significant differences between the control and intervention groups at 4 and 12 monthsThe greatest difference occurs at 4 months (-0.57%, p=-.008) compared with 12 months (-0.20%, p=0.45) Only Franz and colleagues, reported a sig decrease in HbA1c from baseline to 6 mos (p< 0.001): the BC group reported a 0.7% reduction & -0.9% reduction in the PGC groupThe greatest reduction in HbA1c for both intervention groups occurred between baseline & 6 wks, this reduction was maintained up to 3 months although there was a trend to where both intervention groups increased HbA1c values increased slightly.  Values remained significantly reduced at 6 months as compared with baseline. According to the Canadian Diabetes Association: A reduction of 10% from baseline or an HbA1c  less than 7.5% is considered clinically significant Only the PGC intervention group in Franz,1995 achieved a clinically sig change in HbA1c : mean HbA1c 7.4% at 6 monthsDavies et al., 2008 reported a clinically significant reduction in HbA1c in both control and intervention groups: with a reduction to 6.7% & 6.8%, respectivelyAfter adjusting for baseline and cluster effects results were not significant (p=0.52)This graph shows the trends in HBA change over the course of the interventionWith the greatest reduction between 3-4 months and a trend increasing towards baseline values at followupDavies values were not statistically sig at 12 months.   Wolf et al., 2004 reported a sig diff in mean weight change between groups at 4, 6 & 8 months p< 0.001, 12 months  p≤ 0.05 in intervention groupAt 8 months there was the greatest decrease in weight in the intervention group with a total of a 4.0 kg loss as well as the greatest weight loss between the control and intervention groups of 5.0 kgA 12 months control group gained 0.6 kg & intervention group lost 2.4 kgDavies et al., 2008 reported sig diff between control & intervention groups at 4 & 12 months (p=0.024 and p=0.027)The control and intervention groups had a net weight loss of 1.86 kg and -2.98 kg at 12 months respectively. While the difference between groups not sig at 8 months, the greatest weight loss for control & intervention groups at this time.Franz et al., 1995 reported a sig weight loss from baseline to 6 months in both intervention groupsWeight reduction at 6 wks maintained at 6 months (p< 0.001)The BC & PGC groups lost 1.7 kg (p<0.01) and 1.4 kg (p<0.001) respectivelyFor the purposes of this review a weight loss > 5% from the initial visit was considered clinically significantNone of the studies included in this review had clinically significant findings  This graph depicts the trend occurring in the percent weight change over the intervention period of 6 or 12 months.  Christian had no sig. weight lossFranz, Wolf and Davies show a trend towards significant weight loss early in the study and then a challenge to maintain the weight loss until follow up where the values begin to regress towards baseline. No intervention groups gained weight, based on baseline values, over the intervention period. Regaining weight lost six months post-intervention due to absence of support from HCP indicates necessity of participation & support *Why: As an adjunct to support the efforts of a nutritionist referralsee patients regularly to set Rx goalsPara 1&2 discussionBasic nutritional counselling could easily be incorporated into PT practice *Ongoing support : d/t reversion during periods with decreased contact with the health care professional È  T2D is a metabolic disorder indicated by the presence of hyperglycemia as a result of insulin insensitivity i  3 million Canadians with diabetes, 246 million people worldwide  o  2025 an estimated 380 million individuals worldwide will have diabetes › 90% of those have T2D  e  $20 billion/year by 2020  Definition G  HbA1c: › used as a marker for the amount of glucose  in plasma › this reaction is irreversible therefore a stable  marker to measure glucose values › best indicator of glycemic control  o  2  complications:  › heart disease › kidney disease › stroke › blindness › erectile dysfunction › leg amputation › ↓ QoL › premature death  Œ  Onset of T2D may be delayed or prevented with a healthy lifestyle › physical activity, healthy diet & weight y  80% of individuals with T2D are overweight or obese  l  3-7x greater prevalence T2D in obese adults  v  Fatty tissue ↑ insulin resistance  ¬  Obesity is a critical modifiable risk factor for T2D & recent evidence suggests weight management to be the most important therapy r  Diet & weight lifestyle modifications require goal setting & pt centered care with follow up  t  Weight loss of 5-10% = improved glycemic control & ↓ associated risk factors by ↓ lipid levels & BP  È  Nutrition therapy alone can improve glycemic control by1-2% y  HbA1C levels should be < 7%  e  > 7.5% ↑ risk of micro & macro vascular complications ie. retinopathy & CV disease  .  Clinically significant change in HbA1C: › HbA1C of 6- 7.5% or › 10% ↓ from baseline in the first 4-6 wks  ¬  A well supported nutritional regimen can effect positive change in metabolic parameters; however, there is little research on effects of nutritional advice provided by HCPs b  Weight loss with a well-balanced nutritional regimen can cure T2D & ↓ premature mortality Dieticians & nutritionists have specialized knowledge in prescribing nutritional plans; this needs to be supported & reinforced by other HCPs such as PTs  Ì  CDA does not yet recognize PTs as members of a diabetic health care team c  PTs are not recognized to be involved in reinforcing dietary recommendations patients who are obese  d  Dean (2009) has advocated a major role for PTs in effecting multiple health behavior change  l  Morris & colleagues (2009) have outlined how PTs can incorporate such assessment & recommendations into daily practice  è  PTs are primary HCPs that maximize function at the activity and participation levels of the ICF Need for nutritional and dietary education groups integrated into PT management plan d  This review will enhance the PTs’ comprehensive knowledge of T2D and awareness of healthcare providers  1. To examine the effectiveness of nutritional recommendations in improving metabolic control in people with T2D 2. To examine the role of physiotherapists in making nutritional recommendations that can be incorporated within the constraints of clinical practice  ¬  Preliminary search: › CINAHL, MEDLINE, FSTA & EMBASE grey literature search: › conference proceedings, theses & dissertations, government publications, clinical trials, reference lists of included articles  ,  Terms and MeSh headings › P: diabetes mellitus, diabetes mellitus type 2, overweight,  obesity › I: diet therapy, food habits, health promotion, health behavior,  diabetic education, nutrition therapy, nutrition › O: weight loss, body weight changes, body weights and  measures, BMI, waist to hip ratio, body mass, waist circumference or body composition › For further narrowing: dietetics, community health services,  physical therapists, patient care team or allied health  Inclusion criteria (1) aged 18 and older (2) T2D based on lab glucose test or physician diagnosis (3) measured : BMI, WHR and/or WC (4) RCT based on dietary intervention with minimum 1 session & six-month follow up Exclusion criteria (1) absence of a control group or active control group (2) the length of follow up < 6 months (3) the presence of cardiac conditions or renal disease (4) animals as test subjects (5) written in languages other than English  È  Initial screening › 2 people reviewed 598 titles d  Study selection › standardized screening tool utilized › 3rd party consensus meeting where a consensus  could not be met  n  Quality Assessment: PEDro scale › Criterion was modified such that blinding  subjects, participants and HCPs were not used to calculate the final score › Due to nature of the interventions blinding in  these studies was not possible › Internal validity reduced from lack of blinding  ¬  Data extraction › Comparison groups › Purpose of the study › Description of participants › Duration of study › Description of intervention & non-  intervention groups › Primary/secondary outcome measures › Conclusions  ˆ  Study selection › 598 titles  ↓ 76 selected for abstract review ↓ 17 selected for full text review ↓ 4 articles met final criteria i  Reasons for exclusion i) active control groups were used ii) studies were not RCTs iii) anthropometric measures were not included  ð  Quality Assessment › mean methodological quality of the studies was  6.75±1.26 out of 8 Ranging between 5 – 8  › 3 high quality,1 moderate quality Common flaws: lack of concealed allocation and inadequate number of participants for follow up r 1 study differed significantly at baseline for 1 primary outcome measure  p  Characteristics of participants › 1408 total: T 844 underwent nutritional interventions t 564 controls who continued basic medical care › 395 men & 449 women › Age: 55.43±2.84 yr (53-59) › HbA1c: 7.9 - 8.3%, average 8.15±0.19% › Weight: 91.8 - 107.1 kg, average 96.69±7.02 kg  L  Characteristics of Interventions › Duration T 3 studies of 12 months, 1 study of 6 months  › Total time T with HCP 3–12 hrs, average 6.25±4.03 hrs  h  t  i  Franz et al., 1995 › BC: single visit with dietician › PGC: 3 visits with dietician, (1hr, 2 X 30-45min) Davies, 2008 › 6 hrs of structured group education in community in 1 or 2 sessions by trained HCP Wolf, 2004 › 6 individual & 6 small group sessions with dietician lasting 1 hr, brief monthly phone calls Christian, 2008 › initial 10-minute computer Ax , 3 subsequent sessions with physician every 3 months  Statistical significance i  Wolf et al., (2004) reported a difference between control & intervention groups (p=0.02 Wolf) › greatest difference at 4 months (-0.57%, p=-.008) compared with 12 months (-0.20%, p=0.45) Franz et al., (1995) reported a reduction from baseline to 6 months (p< 0.001) ) BC: -0.7%  PGC: -0.9%  › greatest ↓ in HbA1c for both intervention groups occurred  between baseline & 6 wks, this reduction was maintained up to 3 months › From 3 - 6 months, HbA1c ↑  Clinical Significance A reduction of 10% from baseline or an HbA1c less than 7.5% is considered clinically significant c  Only the PGC intervention group in Franz et al.,1995 achieved a clinically significant change in HbA1c › mean HbA1c 7.4% at 6 months  s  Davies et al., 2008 reported a clinically significant reduction in HbA1c in both control and intervention groups: ↓ to 6.7% & 6.8%, respectively › After adjusting for baseline and cluster effects results not  sig (p=0.52)  Glycemic Control change over intervention period. Time (M onths) 0  2  4  6  8  10  12  14  0  -0.2  -0.4  -0.6 Franz -0.8  Christan Wolf  H e g n a h c 1 A )b (%  -1  -1.2  -1.4  -1.6  -1.8  Davies  0  Wolf et al., 2004 reported a sig diff in mean weight change between groups › 4, 6 & 8 months p< 0.001, 12 months p≤ 0.05 in intervention group › 8 months was greatest ↓ in weight in intervention group (-4.0 kg) & greatest net weight ↓ between groups (-5.0 kg) › 12 months control group gained 0.6 kg & intervention group lost 2.4 kg l  Davies et al., 2008 reported sig diff between control & intervention groups at 4 & 12 months (p=0.024 and p=0.027) Control -1.86 kg Intervention -2.98 kg (12 months) › Difference between groups not sig at 8 months; however, greatest weight loss for control & intervention groups at this time  ¨  Franz et al., 1995 reported a sig weight loss from baseline to 6 months in both intervention groups › Weight reduction at 6 wks maintained at 6 months (p< 0.001) › BC & PGC groups lost 1.7 kg (p<0.01) and 1.4 kg (p<0.001)  Clinical Significance A weight loss > 5% from the initial visit was considered clinically significant (CDA) f  None of the studies included in this review had clinically significant findings  È  Results of this study indicate nutritional therapy is a viable option s  Even without clinically significant weight loss, glycemic control was positively influenced in individuals with T2D who were also obese with smaller, gradual amounts of weight loss Support from health care providers is important for maintaining weight loss  ì  Physiotherapists are in a prime position to provide basic nutritional recommendations  To the best of our knowledge there is no entry level or post graduate training specific to PT Eriksson et al, 2006 conducted a study utilizing PTs, in an activity program & to support diet counselling to ↓ CV risk factors  found differences among weight, BMI, physical activity & other outcomes a  p  Those with T2D for longer than 6 months achieved better results with more advanced dietary care r  Optimally , nutritional recommendations can result in significant weight loss and effective metabolic control reducing or eliminating the need for pharmacological intervention  Ð  Metabolic control & weight loss tended to regress toward baseline values a  Individuals who are obese and who have had T2D for some time require the same intensity if not more support from HCPs as T2D progresses  p  PTs have an important role in providing basic nutritional recommendations m  Change can be implemented, supported, and sustained with brief interventions  r  Holistic practice & valuable, cost-effective method of providing ongoing nutritional support for individuals with T2D to maintain weight loss or continue weight loss to positively effect glycemic control  ¬  The intensity and frequency of contact with HCPs appear to be key factors in metabolic control e  There is no clear guideline for recommendations on frequency › There was a positive relationship between follow-up frequency and maintenance of change  l  Problematic methodological issues › Potential performance bias mInternal validity: lack of blinding assessors, patients, and health care providers › Basic care control groups were poorly  defined › Not ethical to withhold care to create a ‘true’  control which minimizes the measured effects of the interventions  l  Variable effectiveness of a nutritional recommendations on individuals who are obese with T2D o  Ongoing support is important for long term metabolic control  l  Basic care is insufficient for long term management of T2D  0  Thank you Dr. Elizabeth Dean for your wisdom and guidance throughout the past year  o  Dr. Darlene Reid for guidance in the early stages Charlotte Beck for guidance with our search  o  Fellow classmates for general support and discussion over the year  

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