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Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes

Published:January 31, 2019DOI:



      Clinical care for type 2 diabetes has improved but remains suboptimal. Collaborative, team-based models that maximize skills of different disciplines may improve care for individuals with diabetes, but few have been tested using rigorous research designs.


      To investigate the efficacy of a registered dietitian nutritionist–led telemedicine program compared with that of a control group in terms of diabetes optimal care goals.


      A randomized controlled trial in which participants were assigned to a control or intervention group.


      One hundred eighteen adults with type 2 diabetes (mean age, 60 years; 45% female) participated in the study between April 2016 and December 2017. Participants were recruited from separate primary care clinics in two rural Minnesota communities.


      For those assigned to the intervention, registered dietitian nutritionists used a treatment protocol to initiate and titrate therapies for blood glucose, hypertension, and lipid levels in addition to providing medical nutrition therapy; telemedicine visits supplemented usual care.

      Main outcome measures

      Primary outcomes included composite and individual diabetes optimal care goals: hemoglobin A1c, blood pressure, not using tobacco, and taking a statin and aspirin (as appropriate). Secondary measures included physical activity, breakfast, fruits and vegetables, whole grains, body mass index, low-density lipoprotein, and medication adherence.

      Statistical analysis

      Mixed-model regression was used to examine outcomes between baseline and 1-year follow-up.


      A modest but significantly greater improvement in the number of diabetes optimal care measures met at follow-up was found in the intervention group (3.7 vs 3.2 in the control group [P=0.017]). Among individual measures, the intervention group had significantly greater medication use, with 2.5 and 2.2 higher odds (compared with the control group) of taking a statin [95% CI, 1.0 to 6.24]) and aspirin [95% CI, 0.90 to 5.19] as appropriate, respectively.


      ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) findings suggest that registered dietitian nutritionists following medication treatment protocols can effectively improve care for adults with type 2 diabetes and can serve an instrumental role as part of the health care team in providing evidence-based, patient-centered care.


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      G. A. Benson is the population health program manager and a certified diabetes educator, Minneapolis Heart Institute Foundation, Minneapolis, MN.


      J. Hayes is a population health specialist and certified diabetes educator, Minneapolis Heart Institute Foundation, Minneapolis, MN.


      M. D. Miedema is a preventive cardiologist and researcher, Minneapolis Heart Institute Foundation, Minneapolis, MN.


      A. Sidebottom is principal research scientist, Allina Health, Care Delivery Research, Minneapolis, MN.


      M. Vacquier is a statistician, Allina Health, Care Delivery Research, Minneapolis, MN.


      A. Sillah is a data analyst, Allina Health, Care Delivery Research, Minneapolis, MN.


      J. Boucher is chief executive officer and a certified diabetes educator, Children’s HeartLink, Minneapolis, MN.


      S. Gamam is a health promotion specialist, Rally Health, San Francisco, CA; at the time of the study, she was a population health research associate, Minneapolis Heart Institute Foundation, Minneapolis, MN.


      J. J. VanWormer is a research scientist, Marshfield Clinic Research Institute, Marshfield, WI.