# Effectiveness of a Nutrition Education Program for Patients with Type 2 Diabetes Mellitus
## 4 Discussion  
In this study, the nutritional and lifestyle recommendations given to diabetic patients appeared to cause significant changes in anthropometric characteristics and biochemical markers 3 months after a face-to-face meeting with a specialized dietitian. This is due to dietary instructions and changes in their physical activity (Tables 1 and 2). Main role in achieving and maintaining an appropriate body weight, preventing complications of the disease (Figure 1) and improving the overall clinical picture play also the appropriate dietary changes (Figure 2). Other studies have also examined a similar research topic [37, 38, 39]. In most of them, a significant trend of a decrease in the recorded anthropometric characteristics and biochemical indices was observed [40]. In our study, body weight decreased from 81.8 to 77.8 kg after 3 months, and BMI also decreased from 28.8 to 27.1 kg/m\({}^{2}\). There was also a significant reduction in the average fasting blood glucose from 110.7 to 99.5 mg/dL and in the mean value of lipids (total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides). The greatest change was observed in the mean total cholesterol and the mean triglyceride values. According to a recent study with a 3-month intervention to improve glucose control in individuals with type 2 diabetes through education, the HbA1c value was reduced by 1.1% [41]. In the ANODE study (2017), other secondary endpoints in the intention-to-treat analysis with web-based nutritional coaching were fasting blood glucose 1.46 mmol/L, total cholesterol 0.21 mg/dL, LDL-c 0.2 mg/dL, HDL-c 0.05 mg/dL, triglycerides 1.05 mg/dL and uric acid 45.45 umol/L [42]. In our study, the changes in the other biomarkers were higher, with the exception of fasting blood glucose and uric acid, which were the same: fasting blood glucose 1.12 mmol/L, total cholesterol 17.2 mg/dL, LDL-c 6.8 mg/dL, HDL-c 1.1 mg/dL, triglycerides 35 mg/dL and uric acid 30 umol/L. Other studies had positive results [41, 42], as our study has. A possible explanation is the multi-layered strategies such as a personalized diet plan, written instructions with healthy food choices and personal contact with the dietician. Some studies found varying effects of nutritional education [43, 44, 45]. For example, one study of 100 patients with type 2 diabetes found no significant effects on BMI or daily intake of fruit and vegetables, but there were positive changes in fasting blood glucose and HbA1c as well as weekly consumption of fruit and vegetables. Weekly moderate physical activity also improved [46]. Awareness about diabetes complications and consequent improvements in dietary knowledge, attitude and practices lead to better control of the  
Figure 5: How often the patients communicated (either through calling, messaging or visiting) with the dietician during the three-month intervention. disease [47]. Different medications may also have different effects [48] and it is important to provide appropriate motivation for physical activity [49]. Our study did not find any significant change in HbA1c values, although significant changes occurred in fasting blood glucose levels. The biggest change was found in those who followed the dietitian's nutritional advice. Our results agree with other studies that both dietary guidelines and nutritional interventions contribute to the reduction in anthropometric characteristics and biochemical indicators of people with type 2 diabetes. Following specific dietary interventions also gives better results for weight loss than are found in people who follow more general dietary recommendations [50]. Our sample consisted of patients admitted to the hospital due to uncontrollable diabetes. It is possible that being admitted to the hospital and being given information about the possible complications that can occur if T2 DM is not controlled contributed to their more positive attitude toward making changes in their behavior, both in terms of diet and physical activity (Figure 3).