Running head: SELF-CONTROL DIETARY SELECTIONS 1. Self-Control Dietary Selections and Glycemic Control in Adults with Type II Diabetes:

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1 Running head: SELF-CONTROL DIETARY SELECTIONS 1 Self-Control Dietary Selections and Glycemic Control in Adults with Type II Diabetes: Evidence-Based Practice Yufang Gu Texas Woman s University NURS 6023 Dr. Janice Anderson August 11, 2010

2 SELF-CONTROL DIETARY SELECTIONS 2 Table of Contents Introduction 3 Purpose 3 Justification 4 Definition of Terms 5 Methodology 7 Review of the Literature 7 Conclusion 14 References 16

3 SELF-CONTROL DIETARY SELECTIONS 3 Self-Control Dietary Selections and Glycemic Control in Adults with Type II Diabetes Introduction The prevalence of type II diabetes mellitus in the adult population in the United States has increased dramatically over the last 30 years (Jeffreys, 2008). Almost 13 percent of the adults aged 20 years and above have diabetes. It has been estimated that another 5.7 million adults aged 20 and older have pre-diabetes. The burden of diabetes continues to increase as the number of people with diabetes rises (Jeffreys, 2008; Trapp, Barnard, & Katcher, 2010). In the United States, approximately 20 percent of health care dollars are spent on diabetes health care, and it counts for a total of $132 billion annually (Jeffreys, 2008). Type 2 diabetes is a major health concern, and uncontrolled diabetes is associated with a high morbidity and mortality rate (Jeffreys, 2008; Trapp et al., 2010). Diabetes is a complex chronic disease, and diet has been considered to be one of the most important behavioral aspects of preventing diabetes in both adults and children. Dietary compliance is a major factor promoting glycemic control in those with type II diabetes (Jeffreys, 2008). Adequate glycemic control in type II diabetes reduces complications, such as nephropathy and retinopathy, and it also helps slow down the progression of this chronic condition (Delahanty, McCulloch, Nathan, & Mulder, 2010; Sartorelli & Cardoso, 2006). Purpose The purpose of this evidence-based project is to evaluate current literature related to the association between self-control dietary selections and glycemic control in the adult population with type II diabetes. Nutritional education is well documented in the literature to prevent type II diabetes and promote hypoglycemic control in adults with type II diabetes (Jeffreys, 2008). As a result, one could assume that well controlled type II diabetes in adults could prevent many

4 SELF-CONTROL DIETARY SELECTIONS 4 diabetes-related complications and reduce the morbidity, mortality and financial cost in this population. Therefore, the question arises, in adults with type II diabetes, will education on selfcontrol dietary selections achieve better glycemic control? Justification Prevalence Diabetes is a major health issue in the United States and affects 23.6 million Americans, with 5.7 million with undiagnosed diabetes, and the numbers are still growing (Centers for Disease Control and Prevention [CDC], 2010; Rice, Kocurek, & Snead, 2010). In Texas, approximately 1.8 million adults have diagnosed diabetes, and it is estimated that another 460,000 have undiagnosed diabetes (CDC, 2010). According to the statistics for the state of Texas, diabetes rates were 12.9% among African Americans, 12.2% among Hispanics, 11.8% among other minorities, and 8.5% among whites (Rice et al., 2010, p. 230). Health Risks Diabetes causes high morbidity and mortality if it is uncontrolled (Rice et al., 2010). It is the seventh leading cause of death, and it is also a major cause of heart disease and stroke (Rice et al., 2010). Diabetes is also the leading cause of adult blindness, kidney failure, and other non-traumatic low-extremity amputations, which is responsible for $ 116 billion in direct medical costs in the United States and $58 billion more indirect costs, such as disability (Rice et al., 2010, p. 230). Behavioral Modification There are many factors affecting how well diabetes is controlled. Diet is one of the most critically important factors in the management of hemoglobin A1C, blood pressure and cholesterol in people with type II diabetes (Delahanty et al., 2010). This factor can be controlled

5 SELF-CONTROL DIETARY SELECTIONS 5 by the patients themselves, such as how much they should eat, what types of food they should choose, and how frequently the blood sugar should be monitored (Delahanty et al., 2010). Therefore, it is important to educate our diabetic patients about the self-control behavior regarding the proper dietary selections and other health behavioral change, such as their attitudes and beliefs of dietary change (Muchiri, Geriche, & Rheeder, 2009). Definition of Terms Diabetes Diabetes, also called diabetes mellitus, is defined as a fasting blood sugar of 126 milligrams per deciliter (mg/dl) or more. Impaired fasting glucose is defined as fasting glucose of mg/dl (American Heart Association [AHA], 2010). Impaired glucose tolerance means that when fasting glucose is less than 126 mg/dl, and a glucose level is between 140 and 199 mg/dl two hours after taking an oral glucose tolerance test. There are three main types of diabetes- type I diabetes, type II diabetes, and gestational diabetes. In type I diabetes, the pancreas makes little or no insulin, and it usually occurs in children and younger adults. In type II diabetes, the body does not make enough insulin or does not efficiently use the insulin it makes (AHA, 2010). Gestational diabetes means high blood sugar levels during pregnancy (CDC, 2010). Education Education is defined as any act or experience that has a formative effect on the mind, character or physical ability of an individual (Wikipedia, 2010). It is the process by which society deliberately transmits its accumulated knowledge, skills, and values from one generation to another (Wikipedia, 2010). Education on self-control dietary selections is to teach individuals the strategies of controlling themselves when making food selections. Education strategies are

6 SELF-CONTROL DIETARY SELECTIONS 6 organized around individually tailored achievable goals in eating behavior and sequenced manageable steps regarding daily dietary choices and responses to problematic eating circumstances (Yannakoulia, 2006, p. 15). Glycemic Control Glycemic control is a medical term meaning the typical levels of blood sugar in a person with diabetes (Wikipedia, 2010). Good glycemic control means that blood sugar is well controlled. Glycated hemoglobin (hemoglobin A1C) is the best measure of long-term glycemic control because it represents the average blood glucose levels over the last three months, although it can also be measured by post meal plasma glucose levels (Thomas & Elliott, 2009, p.2). The hemoglobin A1C goal for people with diabetes is less than 7 percent (CDC, 2010). Glycemic Index Glycemic index is a ranking of carbohydrate-containing foods, based on the food s effect on blood glucose compared with a standard reference food (Diabetes UK, 2008). Glycemic Load Glycemic load is defined as the product of the glycemic index value of a food and its carbohydrate content (Franz et al., 2002, p.152). It represents the overall glycemic effect of the diet and is calculated by multiplying the glycemic index by the grams of carbohydrates (Thomas & Elliott, 2009, p. 2). Self-control Self-control is defined as restraint exercise over one s own impulses, emotions, or desires (Wikipedia, 2010). Some critical indicators for self-control includes: lack of knowledge and understanding, lack of support from family members or friends, history of mental or psychiatric problems with behaviors, lack of faith in themselves and in their abilities in changing

7 SELF-CONTROL DIETARY SELECTIONS 7 their lifestyles, the belief that self-control or self-discipline limits the pleasure in their life (Wikipedia, 2010). Methodology A review of the literature was performed using a meta-database via Texas Woman s University library and Google search engine. Databases searched included the following: A SAGE Full-Text Collection, CINAHL Plus with Full Text, Cochrane Library, Medline with Full Text, ProQuest Nursing & Allied Health Source, and PubMed Remote. Websites searched included American Diabetes Association website, the AHA website, and the CDC website. Search terms included diabetes mellitus and diet, glycemic control and diet, diabetes and nutrition and adult, and diabetes and behavioral intervention. Using these terms, there were approximately 100 articles found to be relevant to the topic. Articles that are about the prevention of diabetes and were published prior to 2000 were not included in this literature review. Evidence-based recommendation guidelines, studies, systematic reviews, and metaanalysis were incorporated into this literature review. Review of the Literature There are studies, systematic reviews and meta-analysis, and evidence-based recommendation guidelines discussed about the association between the dietary selections and glycemic control in diabetes in the adult population, especially in adults with type II diabetes. Literature reviewed included dietary selections in general, according to glycemic index and glycemic load. This review of the literature also noted the investigation of the relationship of dietary supplements to carbohydrate content, fat content, fiber, sugar/sugar alcohol content, and starch. Some systematic review articles explored the association between glycemic control in diabetic adults and specific food or drink, such as red meat, preserved meat, and alcoholic

8 SELF-CONTROL DIETARY SELECTIONS 8 beverages. There are also studies discussing about the impact of dietary selections on weight loss, thus achieving better glycemic control in adult with diabetes. In addition, one review article and one research project investigated the eating behavior and barriers for dietary behavioral change in people with type II diabetes. Low/ High Glycemic Index/ Glycemic Load and Glycemic Control Thomas and Elliott (2009) conducted a systematic review of eleven randomized, controlled trials involving 402 participants, lasting 1 to 12 months. The authors found that there is no universal approach currently to the optimal dietary strategy for diabetes (p.2). However, they suggested that a diet with low glycemic index and low glycemic load, such as beans, oats, and lentils, may improve glycemic control in people with diabetes, compared to a diet with high glycemic index and high glycemic load (p.2). They further suggested that a low glycemic index diet promotes a decrease in the number of hypoglycemic episodes in diabetics. The authors conducted the systematic reviews from eleven randomized, controlled trials, and the participants in the included trials were both children and adults with diabetes (both type I and type II). Therefore, the results of their review are relevant to both types of diabetes across the life span. A limitation the authors identified in their review is their findings may only have relevance to diabetics in developed countries since trials were not conducted elsewhere. Strength of evidence is 1a. Sartorelli and Cardoso (2006) also compiled a literature review of several cross-sectional studies and a meta-analysis of randomized clinical trials on the association between diets with high or low glycemic index and glycemic control in type II diabetes. The authors concluded that consuming diets with low-glycemic index promotes better hemoglobin A1C in the adult population with type II diabetes. Sartorelli and Cardoso also concluded that high glycemic index

9 SELF-CONTROL DIETARY SELECTIONS 9 foods would be related to the increase in concentration post-prandial late free fatty acids, producing more insulin resistance (p.3). The authors conducted a literature review of a metaanalysis of the randomized clinical trials and epidemiological studies performed in Brazil. However, the authors did not specify how many studies were reviewed or how many participants were involved. Also, the results of their review may not be relevant to the type II diabetics in developed countries because all the studies were performed in developing countries Strength of evidence is 1c. Low and reduced Carbohydrate diets and low Caloric diets Nield et al. (2009) conducted a systematic literature review of 36 articles, reporting a total of 18 trials, with 1,467 participants included to assess the effectiveness of dietary advice for the treatment of type II diabetes in adults. The authors assessed five dietary approaches: lowfat/high-carbohydrate diets, high fat/low-carbohydrate diets, low caloric (1000 Kcal per day), very-low-calorie (500 Kcal per day), and modified fat diets. The conclusions showed no high quality data could be found on the efficacy of dietary selections alone for the treatment of type II diabetes. However, the authors did find that proper dietary selections, in addition to regular exercise, showed better glycemic control, especially in hemoglobin A1C levels for type II diabetic adults at six- and twelve- month- follow ups. The authors conducted their literature review of 18 randomized, controlled trials, each lasting six months or longer, in which dietary advice was the main intervention for participants with type II diabetes. The authors identified the need for well-designed studies which examine a range of interventions at various points during follow-up. Strength of evidence is 1a. Dyson (2008) also conducted a literature review of six studies investigating the effects of hypo-caloric reduced carbohydrate diets in people with type II diabetes. Only one randomized

10 SELF-CONTROL DIETARY SELECTIONS 10 controlled trial was identified in these six studies. Low carbohydrate diets were defined as any diet providing equal or less than 50 grams of carbohydrate per day, and reduced carbohydrate referred to any dietary management designed to lower usual carbohydrate intake. Dyson went on to suggest that the conclusions were limited because of study design and small numbers. However, data from these six studies indicated that reduced carbohydrate diets in people with type II diabetes appeared to reduce both body weight and hemoglobin A1C levels. Low carbohydrate diets were associated with reducing plasma glucose levels, increasing insulin sensitivity, and reducing post-absorptive glycogenolysis for short term in type II diabetic adults (Dyson, 2008, p. 532). The author identified that the conclusion of his review was limited because of small numbers of subjects, lack of a control group, and short follow-up periods. He further identified that the studies were heterogenous, and no studies were done on low carbohydrate diets (<50 g per day). The author suggested that more research would be needed to explore the long-term effects of these diets on weight loss, glycemic control, lipid levels, and nutritional adequacy in people with diabetes (p.537). Strength of evidence is 1c. Fiber, starch, dietary fat, alcohol Franz et al. (2002) performed a literature review of the evidence from randomized controlled trials, cohort and case controlled studies, and observational studies and presented position statements on evidence-based nutrition principles and recommendations for the treatment of diabetes and diabetes-related complications. The authors suggested that a diet supplemented with large amounts of water soluble fibers, such as guar gum, decreased post meal blood sugar levels. The authors or Franz et al. further concluded that consumption of food high in dietary fiber improved glycemic control, reduced hyperinsulinemia, and decreased plasma lipids in diabetic adults (p.152).

11 SELF-CONTROL DIETARY SELECTIONS 11 In addition, Franz et al. (2002) suggested that consumption of resistant starch, such as legumes, may help modify postprandial glycemic response, prevent hypoglycemia and reduce hyperglycemia (p. 154). They also found that restricting dietary fat, in addition to self-control eating behaviors, may promote glycemic control, reduce plasma lipids, and/or lose weight in people with diabetes. Data from 1989 to 1991 were further reviewed on alcoholic beverages in relation to glycemic control in diabetic patients and the findings suggest that alcoholic beverages could cause both hypo-and hyperglycemia in people with diabetes, depending on the amount of alcohol consumed (franz et al.). Consumption of light to moderate amounts of alcohol lowered blood glucose levels. However, alcohol induced hypoglycemia can not be corrected by glucagon because of the indirect impairment of gluconeogenesis instead of excessive insulin secretion. These evidence-based nutritional principles and recommendations for the treatment of diabetes contain rich information regarding different dietary selections, physical activity, and behavioral intervention for people with type I, type II, or both. Strength of evidence is 1c. Red and Processed Meat Micha, Wallace and Mozaffarian (2010) conducted a systematic review and metaanalysis of 20 studies to investigate the effect of the red and processed meat consumption on coronary heart disease, stroke and diabetes. The 20 studies included 17 prospective cohorts and 3 case-control studies, with a total of 10,797 diabetic cases, 23,889 coronary heart disease cases, and 2280 stroke cases (Micha et al., 2010). The authors concluded that consumption of red meat did not significantly cause hyperglycemia in people with diabetes. However, consumption of processed meats (per 50-gram serving per day) was associated with increased incidence of coronary heart disease and hyperglycemia in adults with diabetes. The authors explained that hyperglycemia in diabetic adults occurred after consuming processed meats is because the nitrite

12 SELF-CONTROL DIETARY SELECTIONS 12 and its byproducts in the processed meats reduce insulin secretion, thus increasing serum glucose levels. The authors identified some limitations in their review. For instance, all studies were observational, and several studies did not adjust for other dietary habits. Some studies did not provide data on cooking methods. Micha et al. also identified that future research needs to distinguish between the different types of meats. Strength of Evidence is 3a. Dietary Selections in Relation to Weight Loss and Glycemic Control Norris et al. (2005) conducted a systematic review and meta-analysis of 22 studies, with a total of 4,659 participants, on weight loss strategies using dietary, physical activity or behavioral interventions. The participants were followed up for one to five years. The authors found that most people with diabetes, especially type II diabetes, are obese or overweight. Glycemic control was greatly improved with weight loss (Norris et al., 2005). Self-control food selections alone, such as low caloric diets, were not very effective in long-term weight loss. Regular physical activity and behavioral interventions in addition to appropriate dietary selections, could achieve improved weight loss in diabetic people, thus promoting more effective glycemic control. The authors used randomized controlled trials to conduct their systematic review and meta-analysis on the effect of weight loss strategies on glycemic control in people with diabetes. The follow- up period lasted up to 5 years. Strength of evidence is 1a. Dietary behavior and barriers to Dietary Behavioral Change Yannakoulia (2006) conducted a literature review of the studies on eating behavior among type 2 diabetic patients. The author found that adoption of healthy and balanced diet requires a series of behavioral changes in eating patterns (p. 14). She also found that although people with diabetes receive a lot of information and recommendations regarding their diet, it is still difficult for them to follow these recommendations. Yannakoulia then explored the factors

13 SELF-CONTROL DIETARY SELECTIONS 13 affecting food consumption and eating patterns in diabetic patients and concluded that there were three main factors affecting their eating behavior- personal dimensions, behavior patterns, and environmental characteristics. Personal eating history, such as food selections, weight control efforts, emotional eating, and nutritional-related knowledge, not only has great influence on these patients daily diabetic management but also impacts their behavioral response to diet challenges. In addition, the author identified the barriers against the dietary selections among these diabetic patients. These barriers included eating out and social events, temptations, need for food planning, need for constant self-care, knowledge deficits of diet-disease associations, misinformation, lack of appropriate family and social support, feelings of dietary deprivation, depression, the loss of pleasure in eating, and a sense of losing freedom and autonomy. The author provided a thorough summarization of the dietary behaviors and barriers to the dietary behavioral change among the adults with type II diabetes. However, she did not identify how many studies were included in her review, nor did she identify the methodology of the studies. In addition, she did not state the strengths and weakness of her review. Strength of evidence is 3a. Abbott, Davison, Moore, and Rubinstein (2010) also conducted a research in Australia on the barriers and enhancers to dietary behavioral change in a group of diabetic people who were attending a diabetes cooking course. Twenty-six participants were involved in this research project. Most of the participants identified the barriers against change in their dietary behavior. The barriers against change included lack of family support for dietary change, lack of knowledge of healthier food choices, a sense of isolation from their social group if they changed their dietary habits, medical and psychological problems, such as poor health and depression, inability to afford healthier food, and unwillingness to overcome personal and generational food preferences. In this research project, the authors identified some limitations, such as small

14 SELF-CONTROL DIETARY SELECTIONS 14 number of participants, and the participants were those who were enrolled in the cooking course. The barriers reported by the participants in this research project may not apply to other diabetic adults. Strength of evidence is 4. Conclusions The prevalence of diabetes is increasing globally and dramatically. It is being referred to as an epidemic (Muchiri et al., 2009, p. 1). Uncontrolled diabetes leads to a lot of serious complications and is also associated with considerable mortality and loss of quality of life (Jeffreys, 2008). Diabetes also adds a significant economic burden on the individuals, family, community, as well as the whole health care systems (Jeffreys, 2008; Roberts & Liu, 2009). Dietary education, such as self-control dietary selection and dietary behavior changes, play an important role in the management in people with diabetes (Delahanty et al., 2010). Since most people with diabetes, especially type II diabetes, are overweight or obese, studies stressed the importance of self-control dietary selections and dietary compliance, as well as regular exercise, and other behavioral interventions, in order to promote weight loss, thus achieving better glycemic control in diabetic patients (Delahanty et al., 2010; Dyson, 2008; Norris et al., 2005). There were nine articles reviewed including seven systematic reviews with one evidence-based nutritional recommendation guideline for diabetes and its complication. One article is a research project, and another article is a review of studies. There were six systematic reviews discussing the association between dietary supplements and glycemic control in diabetic patients. One systematic review article discussed the effect of dietary selections on weight loss and glycemic control in type II diabetic patients. There was a research project and a review of studies explored the dietary behavior among the people with type II diabetes and barriers against their dietary behavioral changes. In the review of studies, the author did not state the methodology of the

15 SELF-CONTROL DIETARY SELECTIONS 15 studies, nor did she describe how many studies included in her review. Since dietary education is one of the most critically important factors in the management of diabetes, especially hemoglobin A1C levels, it is important for the health care providers to assess the diabetic patients individually and identify the specific concerns and barriers against their dietary behavior change. Then by utilizing the evidence-based nutritional principles and recommendations for the treatment of diabetes and its complications, the health care providers design and implement patient-specific dietary education program to assist the diabetic patients to change their dietary behavior. No studies were found to compare dietary selections and food portion size on the effect of glycemic control in adults with diabetes. In addition, no studies were found to explore the impact of family s participation in the dietary education programs on individual diabetic patient s dietary behavioral change regarding food selections and meal planning. Therefore, further studies are warranted which include the comparison between the self-control dietary selections and self-control food portion size on the effect of glycemic control in adults with type II diabetes, and family members participation in the dietary education program on the effect of the dietary behavioral change of the diabetic patients.

16 SELF-CONTROL DIETARY SELECTIONS 16 References Abbott, P., Davison, J., Moore, L., & Rubinstein, R. (2010). Barriers and enhancers to dietary behavior change for Aboriginal people attending a diabetes cooking course. Health Promotion Journal of Australia, 21, American Heart Association (AHA) (2010, August 1). Diabetes Mellitus. Retrieved from Centers for Disease Control and Prevention (CDC) (2010, August 2). Diabetessuccesses and opportunities for population-based prevention and control: At a glance Retrieved from Delahanty, L. M., McCulloch, D. K., Nathan, D. M., & Mulder, J. E. (2010 July 29). Patient information: Type 2 diabetes mellitus and diet. UpToDate. Retrieved from Diabetes UK (2008, August 2). The glycemic index. Retrieved from Dyson, P. A. (2008). A review of low and reduced carbohydrate diets and weight loss in type 2 diabetes. Journal of Human Nutrition and Dietetics. 21, doi: /j X x Franz, M., Bantle, J. P., Beebe, C. A., Brunzell, J. D., Chiasson, J. L., Garg, A., Wheeler, M. (2002). Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care, 25 (1), Jeffreys, H. L. (2008, August 1). Hemoglobin A1C value for evaluating a community

17 SELF-CONTROL DIETARY SELECTIONS 17 diabetes education series. The Internet Journal of Advanced Nursing Practice, 9(2). Retrieved from Micha, R., Wallace, A. K., & Mozaffarian, D. (2010). Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus. Circulation, 121, doi: /circulationha Muchiri, J. W., Gericke, G., & Rheeder, P. (2009). Elements of effective nutrition education for adults with diabetes mellitus in resource-poor settings: A review. Journal of Interdisciplinary Health Sciences, 14(1), 1-9. doi: /hsag.v14i1.413 Nield, L., Moore, H., Hooper, L., Cruickshank, K., Vyas, A., Whittakeer, V., & Summerbell, C. D. (2009). Dietary advice for treatment of type 2 diabetes mellitus in adults. Cochrane Database of Systematic Review 2009 (3), Art. No.:CD doi: / cd pub4 Norris, S., Zhang X., Avenell, A., Gregg, E., Brown, T. J., Schmid, C. H., & Lau, L. (2005). Long-term non-pharmacologic weight loss interventions for adults with type 2 diabetes. Cochrane Database of Systematic Review 2005(2), Art. No.: CD doi: / CD pub2 Rice, D., Kocurek, B., & Snead, C. A. (2010). Chronic disease management for diabetes: Baylor health care system s coordinated efforts and the opening of the diabetes health and wellness institute. Baylor University Medical Center Proceedings, 23(3), Robert, C. K., & Liu, S. (2009). Effects of glycemic load on metabolic health and type 2 diabetes mellitus. Journal of Diabetes Science Technology, 3(4), Sartorelli, D. N., & Cardoso, M. A. (2006). Association between carbohydrate diet and

18 SELF-CONTROL DIETARY SELECTIONS 18 diabetes mellitus type 2: epidemiological evidence. Arq Bras Endocrinol Metab, 50(3), doi: /s Thomas, D., & Elliott, E. J. (2009). Low glycemic index, or low glycemic load, diets for diabetes mellitus (review). Cochrane Database of Systematic Reviews 2009 (1), Art. No. : CD doi: / CD pub2. Trapp, C., Barnard, N, & Katcher, H. (2010). A plant-based diet for type 2 diabetes: Scientific support and practical strategies. The Diabetes Educator, 36 (1), doi: / Wikipedia Encyclopedia. (n.d.) Retrieved August 2, 2010, from Wikipedia Encyclopedia. (n.d.) Retrieved August 1, 2010, from Wikipedia Encyclopedia. (n.d.) Retrieved August 2, 2010, from Yannakoulia, M. (2006). Eating behavior among type 2 diabetic patients: A poorly recognized aspect in a poorly controlled disease, The Review of Diabetic Studies, 3, doi: /rds