## 5 Discussion
Continuity among dietitians is somewhat different, since the indices show no major discrepancies between the segments but do demonstrate variations in terms of adherence to the protocol. According to the guidelines, all patients should visit the dietitian with the same frequency as a physician or nurse. However, during the period of analysis, approximately 50% of the patients failed to visit the dietitian, with the greatest adherence being in the improved patient segment, and the least in the worsened segment. Previous studies have presented quantitative evidence on the link between the participation of a dietitian within a clinical team, which is to ensure the provision of balanced treatment among the three professionals of a care team, and a positive evolution in HbA1c levels [18]. We should consider the possibility that patients with a lower adherence to dietitian appointments could also have a lower adherence to medication or a recommended behavior that could explain the differences. Future studies will need to analyze the causality of this relationship in greater detail. Regarding the general context, Chile is a high-income country according to The World Bank data, as are the countries of the studies reviewed in this discussion [57]. The income level of the country has been associated with diabetes prevalence and diabetes-related complication risk [2,3]. This condition, in addition to the demographic characteristics of the population, allows us to compare our results with previous literature. However, in our particular setting, patients belong to the lowest income population, which may be related to a higher risk of diabetes-related complications [58]. Because of that, even when relative differences presented in each work are comparable with our results, one should be cautious with absolute comparisons between metrics. Among the strengths of our study is the size of the population, which is comparable with the sample size in related work, and the fact that medical decisions are based on a protocol based on HbA1c test results, which allows for the comparison of patients with similar evolutions, assuming similar treatments. At the same time, the fact that a common protocol is being followed can also be considered as a weakness of this study, because patients are treated under particular conditions that might limit the universality of the results. Another limitation of this study is that it only considered HbA1c measurements as an outcome with which to segment the patients. More thorough analysis should consider other variables, e.g., blood pressure, cholesterol, weight, BMI, which were not available for our study. Also, we considered the last 12-24 months of data for each patient, without considering the time of diagnosis. Although most patients had already been under treatment for some time, some patients might have been recently diagnosed, and healthcare professionals might be willing to try different courses of action with patients who had been previously unsuccessful, even if the guidelines and health programs establish similar actions for all patients, according to the last HbA1c test result. Our results show that, as expected from previous research, physician continuity of care is related to patient evolution, but also that nurse continuity of care has a similar relevance. Even though dietitians are too few to evaluate the impact of their continuity, patients who adhere to nutritional treatment have better outcomes. These results may help healthcare centers with little resources and high physician turnover to focus their protocols and guidelines towards maintaining nurse continuity and improving adherence to nutritional treatment.