Effects of Clinical Nutrition Education and Educator Discipline on Glycemic Control Outcomes in the Indian Health Service

Abstract

OBJECTIVE—We used the Indian Health Service (IHS) Diabetes Care and Outcomes Audit to assess the effectiveness of clinical nutrition education in reducing HbA1c levels and to test the relative effectiveness of clinical nutrition education when it was delivered by a registered dietitian (RD) compared with an educator from another discipline (non-RD). RESEARCH DESIGN AND METHODS—We examined clinical care data collected by the IHS Diabetes Care and Outcomes Audit of 7,490 medical records during 2001. Glycemic control was assessed by using the difference between the two most recent HbA1c levels during 2001. Age, BMI, duration of diabetes, type of treatment, proteinuria, and facility were included as covariates. Clinical nutrition education was defined as documentation in the record of any diet instruction and educator discipline classified as RD or non-RD. ANCOVA methods were used to assess the effects of diet education and educator discipline on differences between the two HbA1c measurements and to adjust for differences in the distribution of covariates among the education groups. RESULTS—After adjustment for age, sex, type of treatment, duration of diabetes, BMI, initial HbA1c level, and clinical facility, clinical nutrition education and educator discipline were each associated with changes in HbA1c levels (P < 0.001). Those receiving clinical nutrition education from an RD or from an RD as well as a non-RD had the largest improvements in HbA1c levels (−0.26 and −0.32, respectively) compared with those receiving either only non-RD or no clinical nutrition education (−0.19 and −0.10, respectively). CONCLUSIONS—Clinical nutrition education in the IHS is associated with favorable trends in glycemic control. To be effective, clinical nutrition education should be delivered by an RD or a team that includes an RD.