Despite the increasing availability of medications for managing type 2 diabetes mellitus (T2DM), a significant proportion of patients fail to achieve optimal glycemic control.
Objective
This study aimed to evaluate adherence to treatment and lifestyle recommendations and their association with achieving diabetes management goals after a 12-month structured follow-up program.
Methods
In this retrospective cohort study, adults with poorly controlled T2DM (baseline HbA1c ≥ 10%) who completed a 12-month follow-up were analyzed. The program included close monitoring, structured education, and lifestyle guidance. The Mediterranean Diet Adherence Screener (MEDAS) was employed to evaluate participants’ adherence to the Mediterranean diet. The primary outcomes were overall adherence to lifestyle recommendations and its association with variations in HbA1c and body weight.
Results
The study included 127 patients (58.3% male) with a mean age of 55.4 ± 10.6 years, and baseline HbA1c of 12.1 ± 1.8%. At 12 months, 92.1% of patients achieved an HbA1c reduction, with a mean change of −3.8 ± 2.8% (p < 0.001). Weight loss was observed in 52.8% of patients, with a mean change of −0.9 ± 8.2 kg (p = 0.064). Medication adherence increased from 52.8% to 84%, but only 22.8% of patients consulted a diabetes specialist dietitian. The mean MEDAS score was 6.4 ± 1.9, with 26% of patients categorized as low, 66.7% as moderate, and 6.3% as high. MEDAS scores were not associated with changes in HbA1c or body weight (p = 0.248 and p = 0.732 respectively).
Conclusion
While promoting healthy lifestyle behaviors and medication adherence improves glycemic control in poorly controlled diabetes, adherence to the Mediterranean diet and achieving substantial weight loss remain challenging.
GBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet2023; 402: 203–234.
2.
DaviesMJArodaVRCollinsBS, et al.Management of hyperglycemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European association for the study of diabetes (EASD). Diabetes Care2022; 45: 2753–2786.
3.
PowersMABardsleyJKCypressM, et al.Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American diabetes association, the association of diabetes care & education specialists, the academy of nutrition and dietetics, the American academy of family physicians, the American academy of PAs, the American association of nurse practitioners, and the American pharmacists association. Diabetes Care2020; 43: 1636–1649.
4.
DrazninBArodaVRBakrisG, et al.American diabetes association professional practice committee. 5. Facilitating behavior change and well-being to improve health outcomes: standards of Medical Care in Diabetes–2022. Diabetes Care2022; 45: 60–82.
5.
EstruchRRosESalas-SalvadóJ, et al.; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. N Engl J Med2018; 378: 34.
6.
CarterPAchanaFTroughtonJ, et al.A Mediterranean diet improves HbA1c but not fasting blood glucose compared to alternative dietary strategies: a network meta-analysis. J Hum Nutr Diet2014; 27: 280–297.
7.
ZhengXZhangWWanX, et al.The effects of Mediterranean diet on cardiovascular risk factors, glycemic control and weight loss in patients with type 2 diabetes: a meta-analysis. BMC Nutr2024; 10: 59.
8.
Celada RoldanCTarraga MarcosMLMadrona MarcosF, et al.Adhesion to the Mediterranean diet in diabetic patients with poor control. Clin Investig Arterioscler2019; 31: 210–217.
9.
ErbakanANArslan BahadirMKayaFN, et al.The effect of close and intensive therapeutic monitoring of patients with poorly controlled type 2 diabetes with different glycemic background. Medicine (Baltimore)2023; 102: e36680.
10.
BeckATWardCHMendelsonM, et al.An inventory for measuring depression. Arch Gen Psychiatry1961; 4: 561–571. PMID: 13688369.
11.
HisliNH. A reliability and validity study of beck depression inventory in a university student sample. J Psychol1989; 7: 3–13.
12.
FramsonCKristalARSchenkJM, et al.Development and validation of the mindful eating questionnaire. J Am Diet Assoc2009; 109: 1439–1444.
13.
KöseGTayfurMBirincioğluI, et al.Adaptation study of the mindful eating questiionnare (MEQ) into turkish. J Cognitive-Behav Psychother Res2018; 5: 125–134.
14.
AhmadSHarrisTLimbE, et al.Evaluation of reliability and validity of the General Practice Physical Activity Questionnaire (GPPAQ) in 60–74 year old primary care patients. BMC Fam Pract2015; 16: 13.
15.
SchröderHFitóMEstruchR, et al.A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J. Nutr2011; 141: 1140–1145.
16.
RoebuckMCKaestnerRJDoughertyJS. Impact of medication adherence on health services utilization in Medicaid. Med Care2018; 56: 266–273.
17.
RaumEKrämerHRüterU, et al.Medication non-adherence and poor glycaemic control in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract2012; 97: 377–384.
18.
AzharuddinMAdilMSharmaM, et al.A systematic review and meta-analysis of non-adherence to anti-diabetic medication: evidence from low- and middle-income countries. Int J Clin Pract2021; 75: e14717.
19.
SaudiRAAbbasRANour-EldeinH, et al.Illness perception, medication adherence and glycemic control among primary health-care patients with type 2 diabetes mellitus at Port Said City, Egypt. Diabetol Int2022; 13: 522–530.
20.
GowKRashidiAWhitheadL. Factors influencing medication adherence among adults living with diabetes and comorbidities: a qualitative systematic review. Curr Diab Rep2024; 24: 19–25.
21.
FarmerAJRodgersLRLonerganM, et al.Adherence to oral glucose-lowering therapies and associations with 1-year HbA1c: a retrospective cohort analysis in a large primary care database. Diabetes Care2016; 39: 258–263.
22.
LeanMELeslieWSBarnesAC, et al.5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study. Lancet Diabetes Endocrinol2024; 12: 233–246.
23.
SmithAGSingletonJR. Obesity and hyperlipidemia are risk factors for early diabetic neuropathy. J Diabetes Complications2013; 27: 436–442.
24.
Look AHEAD Research Group, et al.Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med2013; 369: 145–154.
25.
LeanMELeslieWSBarnesAC, et al.Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet2018; 391: 541–551.
26.
FranzMJBoucherJLRutten-RamosS, et al.Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Diet2015; 115: 1447–1463.
27.
YingZFuMFangZ, et al.Mediterranean Diet lowers risk of new-onset diabetes: a nationwide cohort study in China. Nutr J2024; 23: 31.
28.
AhmadSDemlerOVSunQ, et al.Association of the Mediterranean diet with onset of diabetes in the women's health study. JAMA Netw Open2020; 3: e2025466.
29.
LongoMScappaticcioLCaputoM, et al.Mediterranean Diet in type 2 diabetes: an updated overview of pharmacological activities of cardiometabolic and reproductive outcomes. Curr Opin Pharmacol2021; 60: 27–33.
30.
EspositoKMaiorinoMIBellastellaG, et al.A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses. BMJ Open2015; 5: e008222.
31.
García-ConesaMTPhilippouEPafilasC, et al.Exploring the validity of the 14-item Mediterranean diet adherence screener (MEDAS): a cross-national study in seven European countries around the Mediterranean region. Nutrients2020; 12: 2960.
32.
PapadakiAJohnsonLToumpakariZ, et al.Validation of the English version of the 14-item Mediterranean diet adherence screener of the PREDIMED study, in people at high cardiovascular risk in the UK. Nutrients2018; 10: 138.
33.
HashimMRadwanHIsmailLC, et al.Determinants for Mediterranean diet adherence beyond the boundaries: a cross-sectional study from Sharjah, the United Arab Emirates. J Transl Med2024; 22: 513.
34.
ShatwanIMAlhinaiEAAlawadhiB, et al.High adherence to the Mediterranean diet is associated with a reduced risk of obesity among adults in gulf countries. Nutrients2021; 13: 995.
35.
SerrettiAMandelliL. Antidepressants and body weight: a comprehensive review and meta-analysis. J Clin Psychiatry2010; 71: 1259–1272.
36.
NouwenAAdriaanseMCvan DamK, et al.Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis. Diabet Med2019; 36: 1562–1572.
37.
MillerCKKristellerJLHeadingsA, et al.Comparison of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a randomized controlled trial. Health Educ Behav2014; 41: 145–154.
38.
ColbergSRSigalRJFernhallB, et al.Exercise and type 2 diabetes: the American college of sports medicine and the American diabetes association: joint position statement. Diabetes Care2010; 33: e147–e167.
