# Effectiveness of a Nutrition Education Program for Patients with Type 2 Diabetes Mellitus
## 1 Introduction  
The prevalence of type 2 diabetes mellitus (T2 DM) worldwide is increasing at epidemic proportions [1]. Chronic hyperglycemia is considered a major risk factor for cardiovascular and kidney disease, retinopathy and neuropathy [2]. The Center for Disease Control (CDC) estimates that almost 33% of adults in the U.S. have prediabetes; therefore, preventing or delaying T2 DM is a public health imperative to help extend and improve the lives of millions of people [3]. The increase in the prevalence of T2 DM is paralleled with the increase in overweight/obesity, and it has become particularly evident in the last decade [4]. Undoubtedly, as a person's body mass index (BMI) increases, the risk of developing T2 DM increases in a \"dose-dependent\" manner. The prevalence of T2 DM is 3-7 times higher in obese than in normal-weight adults [4], and people with a BMI \(>\) 35 kg/m\({}^{2}\) are 20 times more likely to develop T2 DM than those with a BMI between 18.5 and 24.9 kg/m\({}^{2}\)[5]. Obesity also complicates the management of T2 DM by increasing insulin resistance and bloodglucose concentrations [6]. Obesity is also an independent risk factor for dyslipidemia, hypertension and cardiovascular complications and cardiovascular mortality in patients with T2 DM [2]. Attaining and maintaining a healthy body weight is a major therapeutic target in the management of T2 DM. Governments are looking to identify the most effective services to support overweight/obese patients with T2 DM to lose weight and improve their health status and quality of life [7]. Data from the Diabetes Prevention Program (DPP) showed that weight loss (7% of weight lost in the first year), increased physical activity (150 min of walking per week) and improvements in other lifestyle behaviors (e.g., dietary behavior) decreased the 4-year incidence of T2 DM by 58% in men and women with glucose tolerance disorders [8]. Some strategies associated with successful long-term weight loss include lifestyle modification, specifically the adoption of low-caloric diets, frequent body weight monitoring, and participation in regular physical activity. Successful weight loss is accompanied by a reduction in the portion size of meals, foods and snacks, daily breakfast consumption, and 3 or less hours of screen-watching (television, computer, tablets/smartphone) per week on average [9; 10]. The link between overweight and obesity and many non-communicable diseases is well known [11]. Weight loss has a major impact on improving glycemic control and reducing the risk of cardiovascular disease [12]. Dietary recommendations need to be based on personal choices, access to food and the patient's culture and ability to make behavioral changes [13]. Interventions in the patient's lifestyle to increase physical activity and reduce caloric intake aim to reduce body weight by 5%, as this can improve HbA1c and cholesterol and reduce cardiovascular risk [14]. The American Diabetes Association emphasizes the importance of educating the patient to make conscious food choices that take into account personal preferences, culture and religion and individualized metabolic goals. The diet patterns with the most beneficial effect on the metabolic profile have been mentioned as the Mediterranean diet and the vegetarian diet [15; 16]. Long-term improvements to lifestyle, especially nutrition and physical activity, are challenging for most patients. The role of healthcare professionals working with diabetic patients is to encourage, monitor and support them in this effort [17]. Several techniques can be used to promote behavioral change. First, behaviors need to be screened, and personalized goals need to be set by the healthcare professional in agreement with the patient. Setting realistic and achievable goals allows patients to achieve success, which can be a starting point for further lifestyle change [18; 19]. Strategies such as self-monitoring, avoidance of situations that trigger food intake and problem-solving (to the extent possible) may support self-regulation over time.