Discussion
diabetic retinopathy, retinopathy, Type 2 diabetes, obese, diabetes’, diabetic education, overweight, diabetic, diabetes knowledge/awareness, weight loss, diabetes
DIABETIC RETINOPATHY, RETINOPATHY, TYPE 2 DIABETES, OBESE, COMPLICATIONS, DIABETES
Management of diabetes and its complications has become a major challenge for most countries. Lack of availability of information including a lack of a culturally appropriate education program, poor health literacy, poor compliance to treatment, and poor attendance to health care appointments all play a major role (Our first hypothesis was that participants who were trained in the intervention program present with significantly improved control of diabetes at the 3-month follow-up visit. The findings supported this hypothesis. The reduction in mean HbA1c levels from the baseline to the 3-month visit in the intervention group was significantly greater than in the control group. It is worth mentioning that mean HbA1c levels decreased significantly after three months from the baseline visit for both groups of participants, but the decline in HbA1c, from baseline to the 3-month visit was significantly higher for the intervention group (from 7.2% to 6.1%) compared to the control group (from 7.1% to 6.6%. The mean HbA1c level of 6.1% found in the intervention group after three months is below the recommended threshold value of 6.5%. However, the mean HbA1c level was 6.6% in the control group suggesting that the HbA1c levels were not adequately controlled at the three months follow-up visit in this group. Although our multidisciplinary intervention was found to be effective in controlling the total cholesterol levels, the effect of each of the individual components could not be ascertained with statistical certainty and is part of our future study with a larger number of participants. After three months, LDL levels reduced by 4.1% from the baseline value of 99.6 mg/dL to of 95.6 mg/dL in the intervention group, which was significantly lower than 107.5 mg/dL (an increase of 10%) in the control group. Clinical threshold values of <100 mg/dL LDL in adults are accepted as ‘within the normal range.’ A previous trial from the US called ‘action for health in diabetes’ evaluating the effects of an intensive lifestyle intervention (calorie control and increased physical activity for weight loss) in overweight and obese patients with Type 2 diabetes found that HbA1c levels decreased significantly by 8.3% after one year (Although systolic and diastolic blood pressure decreased, and HDL levels increased from baseline to three months in the intervention group, when compared to the control group, the differences were not found to be statistically significant. This was a surprising finding especially since the other parameters such as HbA1c data were significantly reduced. Fasting blood sugar and blood pressure readings tend to be affected by various parameters which are outside the control of the data collector, such as the size and content of the last meal patient had consumed and sodium intake (Also, participants in the intervention group were found to show evidence of improved diabetic self-care practice after three months, in which they self-reported less consumption of white rice and increased physical activity compared to those in the control group.Our study, however, also shows that participants from both groups would find it difficult to resist sweets and sugary food during festivals and social ceremonies. This agrees with previous studies reporting the importance of cultural beliefs, for example, the meal is not complete without eating rice, and social pressure to consume unhealthy food during festivals or social gatherings (All participants in the intervention group presented a diabetic retinopathy screening report at the 3-month follow-up visit compared to 0% in the control group. A hospital-based retrospective study conducted in Kathmandu valley reported that over 50% of the patients had already developed sight-threatening retinopathy at first presentation (A prior study from Nepal examining the effect of a diet-focussed diabetic education intervention, delivered in the form of PowerPoint presentations at the baseline visit, reported significantly lower calorie intake and improved plasma glucose levels from 8.6 mmol/L to 6.7 (1.2) mmol after six months in those who received the intervention compared to the controls in whom the change was from 8.1 mmol/L to 7.0 mmol/L (Findings from the present study must be interpreted in light of some limitations. Double blinding was not possible as participants would know the group they belonged to. The contribution of individual interventions such as diet control, physical activity, and pharmacologic treatment could not be discerned. Nonetheless, our findings suggest that clinical outcomes of diabetes control (more than twice in HbA1c levels) and diabetes knowledge/awareness can be significantly improved in as little as three months in newly diagnosed patients using standard treatment supplemented by a patient-centered diet and physical activity intervention program, and a video-based diabetic education training session provided at the baseline visit. This approach is important as the literature suggests no significant effect of a structured diabetic education intervention (developed in the UK by DESMOND) on improving blood glucose levels after three years (