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Journal of Human Nutrition and Dietetics (1999), 12 (Suppl. 1), 7178
# 1999 Blackwell Science Ltd. 71
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The Sugar Buddies: an intervention
programme for obese patients with poorly
controlled diabetes
J. Hughes, V. Todorovic and H. KempDietetic and Nutrition Services, Bassetlaw Hospital, Worksop, Notts, UK
Background: Within the Bassetlaw Diabetes Clinic population a group of obese patients
with poorly controlled diabetes were identified, who appeared to be resistant to standard
intervention. An alternative approach, the Sugar Buddies programme, was developed,
focusing on gradual weight loss and improved glycaemic control. Development of self-care
behaviours such as healthy eating, following prescribed testing and medication routines
was encouraged. Programme participants attended either individual sessions or a
combination of individual sessions and group sessions provided jointly by a diabetes
specialist dietitian and diabetes specialist nurse.
Aims: To evaluate the effectiveness of the Sugar Buddies programme in achieving weight
loss and/or improved glycaemic contol in a group of obese patients with poorly
controlled diabetes.
Method: Measurements of weight and glycosylated haemoglobin (HbA1c)were made at 6,
12 and 18 months on 50 patients participating in the pilot programme. The programme
included patients with Type 1 and Type 2 diabetes. All patients had an initial body mass
index (BMI) 4 30 kg/m2 and HbA1c 4 7%.Outcome measures: The proportion of patients who were able to achieve gradual weight
loss (a minimum of 2.5 kg over 6 months) and sustain this minimum weight loss over 6, 12
and 18 months. The proportion of patients who were able to achieve a reduction in HbA1cof at least 1% against individual baseline measurements over 6 months, and sustain this
reduction over 6, 12 and 18 months.
Results: Patients who achieved an initial minimum weight loss of 2.5 kg at 6 months were
likely to sustain this weight loss at 12 and 18 months. Patients attending group sessions
were more likely to achieve weight loss. Some of the patients who did not achieve weight
loss at 6 months but continued in the programme achieved the minimum weight loss goal
at 12 and/or 18 months. Patients who achieved a reduction in HbA1c at 6 months were
likely to sustain these improvements at 12 and 18 months. Patients attending group
sessions were more likely to sustain improvements in HbA1c values. Length of
participation in sessions had no impact on HbA1c improvements. At 6 months, three
patients (6%) had achieved both a weight loss 5 2.5 kg and a reduction of at least1% in HbA1c.
Conclusions: The programmes focus on making lifestyle changes achieved a measure of
success in weight loss and/or improved glycaemic control among patients previously
resistant to intervention.
Key words: obese patients, diabetes, weight loss, glycaemic control.
Introduction and Background
While obesity, and in particular the increasing
prevalence of obesity, in the general population is
of concern (DH 1992; Knight 1994; Colhoun &Correspondence: Dr V. Todorovic.
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Prescott-Clarke 1996), there is a segment of the
population where obesity has a particularly
detrimental effect. Diabetes is the fourth leading
cause of death in the UK. Approximately 85% of
patients diagnosed with diabetes will be classi-
fied as having type 2 diabetes (Dowse et al. 1989).
Of these, 80% will be overweight or obese (BMI
4 25) and up to 50% will be dyslipidaemic ondiagnosis (De Grauw et al. 1995). Cardiovascular
disease is 24 times more prevalent than in the
general population and is the major cause of
death in Type 2 diabetes (De Grauw et al. 1995).
The Cardiovascular Disease Sub Group report
to the St Vincent Joint Task Force on Diabetes
concluded that weight loss is the most important
change necessary to improve or correct the risk
factors for Coronary Heart Disease in Diabetes
(DH/BDA 1995).
Other benefits of weight loss for obese patients
with type 1 or type 2 diabetes, range from
improvements in blood glucose control to pro-
longed survival (Lean et al. 1990; Ross et al. 1997).
Thus, weight loss becomes an important goal for
obese patients with diabetes. However, weight
loss and in particular sustained weight loss, is an
elusive goal for most patients with type 2
diabetes (Uusitupa et al. 1993).
The Diabetes Control and Complications Trial,
a large multicentre study in North America,
established that tight glycaemic control improved
health outcomes for patients with type 1 diabetes.
In the study report, it was recommended that
tight glycaemic control should be a goal for
patients with type 2 diabetes. The expectation is
that improved control will lead to improved
health outcomes (American Diabetes Association
1998). However, one of the risks of tight control is
weight gain (Wing et al. 1990).
Since 1994, The Bassetlaw Hospital Diabetes
Resource Centre has provided multidisciplinary
care and education to patients with diabetes
within a consultant-led clinic. Standard treat-
ment practice for obese patients with diabetes is
advice from the consultant to lose weight and a
referral for weight loss counselling to the
dietitian working in the clinic. Patients are seen
by the dietitian during the consultant clinic for
initial assessment and then are offered follow-up
care by the dietitian during a consultant clinic or
in their GP surgery, whichever is most appro-
priate for the patient.
Within the clinic population, there are a group
of patients who have been resistant to interven-
tion. These patients are obese, with a body mass
index (BMI) greater than 30 and have elevated
glycated haemoglobin (HbA1c 4 7.0). Thisdifficult group have been given guidance (includ-
ing dietetic counselling), on one or more occa-
sions, to reduce weight. Many have experienced
continued weight gain and/or a reduction in
blood glucose control over the past year with
standard practice. An efficient alternative ap-
proach was considered essential for this group.
Several studies have suggested that, in order to
achieve sustained weight loss and improvement
in metabolic control in diabetes, a continuous
care model with gradual lifestyle changes is likely
to be the most effective strategy (Goodrick &
Foreyt 1991; DCCT Research Group 1993).
In September 1995, The Sugar Buddies pro-
gramme was established to provide an alternative
treatment approach for a difficult cohort who had
not achieved satisfactory outcomes with the
standard treatment approach. The Sugar Buddies
programme encourages the development of self-
care behaviours, the tasks and activities that the
patient takes responsibility for to improve their
level of health care. The initial focus of the
programme, for the majority of patients, was to
stop weight gain and progress to weight loss.
Aim
This study was undertaken to evaluate the
effectiveness of The Sugar Buddies programme
in achieving weight loss and/or improved glycae-
mic control in a group of obese patients with
poorly controlled diabetes.
The Sugar Buddies Programme
The Sugar Buddies Programme is based on a
model of continuing care. It uses a team approach
with a relaxed environment, to assist in the
management and care of patients with diabetes
who have failed to achieve satisfactory outcomes.
The programme is based on current evidence of
effective chronic disease management and incor-
porates behaviour change strategies (DCCT
Research Group 1993; DEramo-Melkus et al.
1992). Weight loss theories that support the
concept of slow but sustained weight loss and
improved glycaemic control formed the basis for
programme development (Raz et al. 1988; Man-
ning et al. 1995; American Dietetic Association
1997; British Dietetic Association 1997).
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Group work was incorporated into the pro-
gramme, as an option, for both peer support and
to provide an efficient means of frequent on-going
contact for large numbers of patients (Wilson &
Pratt 1987; Jones et al. 1989; Campbell et al. 1990).
The main objectives of the programme are:
. to help patients achieve gradual weight lossthrough behaviour changes and to sustain or
improve weight loss over time (Goodrick &
Foreyt 1991; Harris et al. 1988; American
Dietetic Association 1997);
. to help patients achieve a reduction in HbA1cthrough behaviour changes, and sustain or
improve this reduction over time (American
Diabetes Association 1998; American Dietetic
Association 1997).
Programme structure
Process. The consultant diabetologist refers
patients to the programme. Patients typically
present with weight management concerns (BMI
4 30) and a high HbA1c (4 7.0%). Entry into theprogramme is open-ended. Initially, the diabetes
specialist dietitian and the diabetes specialist
nurse see each patient, on an individual basis, in
a combined clinic. A nursing and nutritional
history is completed at initial clinic attendance,
including information on blood glucose or urine
glucose self-monitoring, height, weight, medica-
tions, and usual food and activity patterns.
Patients are offered the option of individual
clinic appointments monthly (unless required
earlier for monitoring of medication therapy),
and/or weekly group education and support
sessions which patients may access as desired.
Patients are encouraged to attend group sessions
as they offer peer support, educational sessions
and increased contact frequency. However, pa-
tients are not required to attend group sessions.
The group sessions have an open continuing
format with topics developed on the basis of
patients need and request. The dietitian facil-
itates most group sessions with the nurse joining
in for the drop-in session. The programme is
flexible, enabling patients who initially may not
have attended group sessions to do so at any
point in their programme of care.
The length of time that patients continue to
come to group sessions is based on the patients
perception of their own needs and interest. The
length of attendance for the individual sessions is
generally a joint decision by the combined clinic
staff and patient.
Programme components
Individual sessions. The Sugar Buddies indivi-
dual sessions are based on work by Laurie
Ruggiero and her interpretation of Prochaska and
DiClementes Stages of Change Model for practical
application to help people with diabetes make
necessary changes (Prochaska & DiClemente 1986;
Ruggiero 1990). The stage of change is identified at
the initial session and barriers to progress and
temptations are discussed. Strategies such as role-
playing situational temptations may be employed
to identify coping strategies. Reducing temptation
and increasing the patients self-confidence in their
ability to make changes are the main focus of the
interventions thus; the program encourages pa-
tients to move through the stages of change.
Group sessions. The Sugar Buddies group
sessions are based on increasing knowledge,
developing skills, and improving attitudes to-
wards diabetes self-care. The sessions include a
mixture of interactive discussions, activities, and
lectures. Each session focuses on a single element
of diabetes self care and is either knowledge-
based or skill-based. During the group sessions,
patients are encouraged to interact, problem-
solve, and provide support and suggestions for
each other. The drop-in portion of the group
sessions provides an opportunity for individual
queries and a weight check.
Increasing knowledge. The educational compo-
nent of the programme focuses on increasing
knowledge of how diabetes affects the body, the
treatment and management of diabetes, the
principles of weight management, and healthy
eating for weight loss.
Developing skills. Group and individual activities
are planned in a manner designed to encourage
the development of skills. Activities such as a
supermarket tour help patients develop the skills
to select appropriate foodstuffs. Label-reading
exercises help patients choose foods with a lower
dietary fat content. Meal planning exercises
based on the patients usual meal habits help
identify areas for change and help patients plan
meals that meet their needs, their budgets, and
their tastes.
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Improving attitudes. Patients are encouraged to
develop confidence in their ability to make
dietary change by keeping records of food intake.
By assessing their own eating habits and accept-
ing recommended dietary changes to reduce
dietary energy intake, patients develop increased
confidence in their ability to manage their
self-care.
Through the process of monitoring blood
glucose or testing urine, patients are encouraged
to interpret tests and respond appropriately to
test results and follow prescribed medication
regimens. Patients begin to understand the
impact that activity and stress can have on
overall diabetes management.
Healthy eating for weight management. The
Healthy Eating for Weight Management compo-
nent of the programme is based on the Healthy
Eating Guidelines for Diabetes (British Diabetic
Association 1992). Throughout the programme, in
both individual and group sessions, patients are
encouraged to focus on lifestyle changes that may
lead to weight loss, rather than to focus on
weight loss.
Healthy eating stresses changing eating beha-
viours by reducing dietary fat intake and
increasing intake of fruit and vegetables. Studies
indicate that most patients with diabetes, con-
sume more than 40% of their energy from dietary
fat (Humphreys et al. 1994) rather than the 35%
recommended in current dietary guidelines (DH
1991). This high intake of fat may occur because
many patients with diabetes continue to focus on
reducing added sugar in the diet rather than
reducing and changing the type of dietary fat
(Pearson 1996). Recent work supports the concept
that reducing dietary fat may lead to sustained
weight loss (Carmichael et al. 1988).
Programme evaluation
In 1997, an evaluation of The Sugar Buddies
programme was undertaken to determine the
effectiveness of the overall programme and to
determine whether there were differences in
outcomes for patients attending both group and
individual sessions compared to those only
attending individual sessions.
The outcome measures used to determine
programme effectiveness were:
. the proportion of patients who achieved aminimum weight loss of at least 2.5 kg over
6 months and sustained this weight loss at
1 year and 18 months;
. the proportion of patients who reduced theirHbA1c by 1% against individual baseline
measurements over 6 months and sustained
this at 1 year and 18 months;
. the proportion of patients who achieved aminimum weight loss of at least 2.5 kg in 6
months and a reduction in HbA1c of at least
1% against individual baseline measurements
over 6 months and sustained this at 1 year and
18 months.
Methods
The patient population
The evaluation included all adult patients
(n=50) involved in The Sugar Buddies pro-
gramme from January 1996 to December 1997. All
patients had diabetes, a BMI greater than 30 and
glycosylated haemoglobin (HbA1c) greater than
7%. Characteristics of the patient group are
described in Table 1.
Table 1. Patient Characteristics at entry to the programme
Age, range in years 2249.9 5064.9 6575
Number (%) 14 (28%) 27 (54%) 9 (18%)
BMI Mean (range), kg/m2 36.6 (30.345.2) 35.5 (30.545.3) 35.0 (30.744.0)
HbA1c Mean (range),% 8.4 (7.39.8) 8.3 (7.011.1) 8.5 (7.110.8)
Sex M/F 8/6 14/13 3/6
Treatment:
Diet only 1 0 1
Oral hypoglycaemic agents (OHA) 2 10 1
OHA & insulin or insulin only 11 17 7
Type of Diabetes:
Type 1 4 2 0
Type 2 10 25 9
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Measures
Anthropometric. Patient heights and weights
were recorded at initial visit. BMI was calculated
from height and weight data. The clinic staff
nurse, using a Seca height meter attached to the
wall, measured height on all participants. Pa-
tients were weighed on Seca Alpha Model 770
scales on an uncarpeted floor. The scales are
under an annual maintenance contract.
Weights were also taken at 6, 12, and 18
months follow-ups.
Somatic. HbA1c assay measurements were
collected at the beginning of the programme.
Further HbA1c assay samples collections
were scheduled for patients at dates close to 6-,
12-and 18-month programme anniversaries.
HbA1c assay was measured using a Corning
Glycomat 765 Analyser with standardized
laboratory procedures.
In addition, telephone interviews were under-
taken to obtain qualitative data on experience of
group sessions and identify reported dietary
changes. These results are not presented in
this paper.
Data analysis
Analysis of quantitative data were completed
using SPSS for Windows (1993) Version 6.
Relative risk (RR) were calculated using Epi Info.
(Dean et al. 1994).
Results
The data were analysed according to the length of
time the patient had been involved in the
programme. Because the programme is open-
ended and continuing, separate results are
reported for 6 months, 12 months, and 18 months
of participation. At the point of evaluation, 22
patients had participated in the programme for
18 months, a further 16 had completed 12 months
and a further 12 patients had completed
6 months. This provides both a snapshot of
programme effectiveness after different lengths of
participation and also how well patients sus-
tained improvements over time.
Changes in weight and sustainability
The numbers and proportions of patients achiev-
ing a weight loss of 2.5 kg or more at 6, 12 and 18
months are shown in Table 2.
Analysis of the 38 patients who had been in the
programme for one year showed that of the nine
who had achieved weight loss at 6 months, seven
sustained weight loss at 12 months. A further
three who had not achieved weight loss at
6 months achieved a weight loss at 12 months.
Analysis of the 22 patients, who had been in
the programme for 18 months showed that of the
five patients who achieved a weight loss at
6 months, three had sustained weight loss at both
12 and 18 months. A further two achieved weight
loss by 18 months.
Changes in HbA1c and sustainability
Blood samples were routinely collected on or
within a few weeks of the patients initial visit.
However, failure to follow up collection of blood
samples at 6, 12 and 18 months from patient
visits that were cancelled, rescheduled or not
attended resulted in incomplete data collection. It
was not possible to obtain the HbA1c data on
eight out of 50 (16%) of patients at 6 months,
11 of 38 (29%) patients at 12 months and on
seven of 22 (32%) patients at 18 months.
The numbers and proportions of patients who
achieved a change in HbA1c of 1% or more at 6,
12 and 18 months is shown in Table 3.
Analysis of HbA1c assays of 27 patients, who
had been in the programme for 1 year showed
that, of the five who had achieved a reduction in
Table 2. Patients achieving weight loss 5 2.5 kg at 6, 12 and 18 months (WL)
Programme length n WL at 6 months n HbA1c n WL at 18 months
Count (%) Count (%) Count (%)
6 months 12 4 (33.3)
12 months 16 4 (25.0) 16 5 (31.3)
18 months 22 5 (22.7) 22 6 (27.3) 22 7 (31.8)
Total No. 50 13 (26.0) 38 11 (28.9) 22 7 (31.8)
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HbA1c at 6 months, three sustained a reduction
in HbA1c at 12 months. A further two who had
not achieved a reduction in HbA1c at 6 months
achieved a reduction in HbA1c at 12 months.
Analysis of HbA1c assays of the 15 patients,
who had been in the programme for 18 months
showed that of the three patients who achieved a
reduction in HbA1c at 6 months, three had
sustained a reduction in HbA1c at 18 months.
Data was only available for one of these patients
at 12 and 18 months.
Sustainability of both weight loss and HbA1c
Three patients achieved both a reduction in
HbA1c of 1% or more and a reduction in weight
of 2.5 kg or more at 6 months.
One patient achieved a sustained weight loss
and a sustained reduction in HbA1c at 1 year.
This same patient had sustained weight loss and
a reduction in HbA1c at 18 months.
Table 4 shows the numbers and proportions
who achieved either or both a reduction in HbA1cand weight of 2.5 kg or more according to
whether they attended group sessions or not.
Whilst only 19 (38%) of patients attended group
sessions, a higher proportion of these reduced
their HbA1c by 1% or more than those who did
not attend group sessions (32% and 19%,
respectively). Likewise a higher proportion of
those attending group sessions reduced their
weight by 2.5 kg or more than those not attending
group sessions (37% and 19%, respectively).
Discussion
As all patients had been referred to the pro-
gramme due to failure to achieve satisfactory
outcomes in standard treatment protocols, any
positive outcome in this group was viewed as
success. Patients did not come to the programme
because they had decided to lose weight, or
improve their blood glucose control but because
they were referred to the programme by the
consultant. In some instances patients were
pleased to be offered a new source of help, but
most initial appointments were viewed with
suspicion. Many patients felt that any effort to
control their blood sugar or manage their weight
would be futile. At the point of evaluation the
pilot programme has been running for 18 months.
Despite initial scepticism, only two patients were
no longer attending the sessions demonstrating
that a good level of commitment to the programme
had been achieved. However, it must be noted that
due to the nature of diabetes care, annual clinic
visits are scheduled for patients so there is some
pressure to attend if only to assure the consultant
an effort was made to comply with advice!
Half of the patients involved in the programme
experienced either weight loss greater than 2.5 kg
in 6 months or a reduction in HbA1c of one
percentage against baseline measurements. For a
group that had not achieved success previously,
this seemed a slow but impressive start, particu-
larly since 72% of the group were over the age of
50 years and had very reduced or impaired
physical activity on initial interviews.
Table 4. Changes in weight, HbA1c at 6 months by attendance at group sessions
Criteria Attended group sessions Did not attend group
RR
n Count (%) n Count (%)
HbA1c drop 5 1% 19 6 (32) 31 6 (19) 1.63Weight loss 5 2.5 kg 19 7 (37) 31 6 (19) 1.9Both HbA1c drop 5 1%and Weight loss 5 2.5 kg 19 2 (11) 31 1 (3) 3.26
Table 3. Patients achieving a reduction in HbA1c by 1% or more at 6, 12 and 18 months (c Hb).
Programme length Na/n* cHb at 6 months n cHb n cHb at 18 months
Count (%) Count (%) Count (%)
6 months 11/12 3 (27)
12 months 15/16 5 (33) 13/16 5 (38)
18 months 16/22 4 (25) 14/22 2 (14) 15/22 5 (33)
Total Nos. 42/50 12 (28) 27/38 7 (26) 15/22 5 (33)
*Na=number of HbA1c assays available, n=number of patients in programme
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As one would expect with a patient group,
whose blood glucose values were significantly
higher than recommended, the first effect of
dietary intake reduction was to reduce blood
glucose rather than reduce weight. Only three
patients were able to fulfil both criteria of weight
loss and improvement in HbA1c. It often seemed to
both patients and staff alike that patients, whose
diabetes control was poor, required an almost
impossibly high level of co-ordination to achieve
both goals. Many patients had experienced fre-
quent episodes of hypoglycaemia as well as
hyperglycaemia prior to entry into the programme.
There was considerable reluctance on the part of
the patient to run any risk of hypoglycaemia and
there was often a lack of awareness of warning
signs prior to the onset of hypoglycaemia.
The small sample size made it unlikely that
statistically significant results would be found
even with large effects. The impact of the group
sessions, although not significant statistically,
was noticeable. Patients attending groups were
1.9 times more likely to experience weight loss
than those who did not attend group sessions.
Also, although not significant statistically,
those who attended group sessions were 1.6
times more likely to achieve an improvement in
HbA1c values.
The proportion of patients who achieved the
modest weight loss goal was small. However,
those who achieved weight loss were likely to
sustain their weight loss up to 12 and 18 months.
It is also of note than success in weight loss for
some patients was achieved with greater length
of contact, achieving goals in 12 months rather
than 6 months.
Patient commitment to the programme is
evident, as after 18 months only two patients
are no longer participating in the programme.
Continued patient participation is hopefully a
step towards responsibility for self-care and thus
the behaviour changes required for continued
and sustained weight loss.
Conclusions
Study results indicate that for a sector of this
population, group sessions are an acceptable
method of maintaining contact and, thus perhaps,
promoting adherence and assisting in sustaining
weight loss. Study numbers are too small at this
time to provide any conclusive answers. The
programme will need to be re-evaluated when
patient numbers are greater.
Pre-programme tests of self-care behaviours, as
well as dietary records should be incorporated
into the programme. HbA1c assays should be
scheduled at regular intervals. The present
practice left gaps in available data.
The programmes focus on making lifestyle
changes achieved a measure of success in weight
loss and/or improved glycaemic control despite
working with patients resistant to intervention.
Although it is a slow method of achieving weight
loss, there appears to be good potential for not
only sustained weight loss but also further
weight loss for this patient group. As diabetes
is a lifelong condition, a programme that sup-
ports and encourages appropriate self-care beha-
viours in a continuous model appears to offer
potential for long-term weight management and
thus improved health outcomes for patients
with diabetes.
Acknowledgements
The Department of the Health for the grant which
made it possible to carry out an evaluation of
The Sugar Buddies programme. Mark Myatt,
consultant epidemiologist for his invaluable help
and advice. The Sugar Buddy team Gill French,
diabetes specialist nurse and Dr Roger Blandford,
consultant for his tremendous support of the
programme; Diane, who always tracked down the
records, Judy for assistance with the typing, and
all the staff of the Diabetes Centre.
References
American Diabetes Association (1998) Clinical
Practice Recommendations: Implications of the
Diabetes Control and Complications Trial.
Diabetes Care 21 (Suppl. 1).
American Diabetes Association. (1990) Position
Statement: Blood Glucose Control in Diabetes.
Diabetes Care 13, 1617.
American Dietetic Association (1997) Position of
the American Dietetic Association: Weight
Management. J. Am. Diet. Assoc. 97, 71.
British Diabetic Association. (1992) Dietary recom-
mendations for people with diabetes.AnUpdate for
the 1990s. London: British Diabetic Association.
British Dietetic Association. (1997) Obesity Treat-
ment. Position Paper. British Dietetic Association.
Campbell, L.V., Barth, R., Gosper, J.K., Jupp, J.J.,
Simons, L.A. & Chisholm, D.J. (1990) Impact of
intensive educational approach to dietary change
in NIDDM. Diabetes Care 13, 841847.
Paper 12 Disc
78 J. Hughes et al.
# 1999 Blackwell Science Ltd, J Hum Nutr Dietet 12 (Suppl. 1), 7178
Carmichael, H.E., Swinburn, B.A. & Wilson, M.R.
(1988) Lower fat intake as a predictor of initial and
sustained weight loss in obese subjects consuming
an otherwise ad libitum diet. J. Am. Diet. Assoc.
98, 3539.
Colhoun, H. & Prescott-Clarke, P. (1996) Health
Survey for England, 1994. A survey carried out
on behalf of the Department of Health, Vol. 1.
London, HMSO.
DEramo-Melkus, G.A., Wylie-Rosett, J. & Hagan, J.A.
(1992) Metabolic impact of education in NIDDM.
Diabetes Care, 15, 864869.
DCCT (Diabetes Control and Complications Trial)
Research Group. (1993) Expanded Roles of the
Dietitian in the Diabetes Control and
Complications Trial: Implications for Clinical
Practice. J. Am. Diet. Assoc. 7, 758764 , 767.
De Grauw, et al. (1995) Cardiovascular Morbidity
and Mortality in Type 2 Diabetes in General
Practice. Diabetic Med. 12, 117122.
Dean, A.G., Dean, J.A., Coulombier, D., Brendal, K.A.,
Smith, D.C., Burton, A.H., Dicken, R.C., Sullivan, K.,
Fagan, R.F. & Anner, T.G. (1994) Epi Info: A Word
processing, database and statistics program for
epidemiology on microcomputers. Centers for Dis-
ease Control and Prevention, Atlanta, Georgia, USA.
DH/BDA (1995) St. Vincent Joint Task Force on
Diabetes. The Report. London: DH/BDA.
Department of Health (1992) The Health of the Nation.
A Strategy for Health in England. London, HMSO.
Dowse, G.D., Zimmet, P.Z. (1989) The prevalence and
incidence of non-insulin-dependent diabetes. In:
Frontiers in Diabetes Research: Current Trends in
Non-Insulin-Diabetes. eds. Alberti, K. G. M. M.
And Mazze, R. Amsterdam: Elsevier.
Goodrick, G.K. & Foreyt, J.P. (1991) Why Treatments
for Obesity Dont Last. J. Am. Diet. Assoc. 91,
12431247.
Guare, J.C., Wing, R.R. & Grant, A. (1995)
Comparison of obese NIDDM and non diabetic
women: short-and long-term weight loss. Obes.
Res. 3, 329335.
Harris, M.D., Davidson, M.B. & Bush, M.A. (1988)
Exogenous insulin therapy slows weight loss in
type 2 diabetic patients. Int. J. Obes. 12, 149155.
Henry, R.R. (1996) Glucose control and insulin
resistance in non-insulin-dependent diabetes
mellitus. Ann. Intern. Med. 24, 97103.
Humphreys, M., Cronin, C.C., Barry, D.G. & Ferris,
J.B. (1994) Are Nutritional Recommendations
Being Met? Diabetic Med. 11, 7984.
Jones, K., Bone, A., Gill, G. et al. (1989) Factors
affecting weight loss in obese Type 2 diabetes the
vital role of the dietitian. Pract Diabetes 6, 18.
Knight, I. (1994) The Heights and Weights of Adults
in Great Britain. London, HSMO.
Lean, M.E.G., Powne, J.K., Anderson, A.S. &
Garthwaite, P.H. (1990) Obesity, weight loss and
prognosis in Type 2 diabetes. Diabetic Med. 7,
228233.
Manning, R.M., Jung, R.T., Leese, G.P. & Newton,
R.W. (1995) The Comparison of Four Weight
Reduction Strategies Aimed at Overweight
Diabetic Patients. Diabetic Med. 12, 409415.
Nutrition and Physical Activity Task Forces. (1995)
Obesity: Reversing the Increasing Problem of
Obesity in England. London: Department of Health.
Pearson, G. (1996) The Diabetic Diet: are We Getting
it Right? Pract Diabetes. 13, 153154.
Prochaska, J. & DiClemente, C. (1986) Towards a
comprehensive model of change. In: Miller,
W.R.Heather, N., eds. Treating Addictive
Behaviour: Process of Change. New York: Plenum.
Raz, I., Soskolne, V. & Stein, P. (1988) Influence of
smallgroup education sessions on glucose
homeostasis in NIDDM. Diabetes Care 11, 6771.
Ross, C., Langer, R.D. & Barrett-Connor, E. (1997)
Given Diabetes, is Fat Better than Thin? Diabetes
Care 20, 650652.
Ruggiero, L. (1990) Helping People with Diabetes
Change: Practical Application of the Stages of
Change Model. Canadian Diabetes Educator
Section. Canadian Diabetes Association.
Toobert, D.J. & Glasgow, R.E. (1994) Assessing
Diabetes Self-Management: The Summary of
Diabetes Self-Care Activities Questionnaire. In:
Handbook of Psychology and Diabetes Ed. C.
Bradley. Harwood Academic Publishers, 351378.
Uusitupa, M., Laitinen, J., Siitonen, O., Vanninen, E.
& Pyorala, K. (1993) The maintenance of improved
metabolic control after intensified diet therapy in
recent type 2 diabetes. Diabetes Res. Clin. Prac. 19,
227238.
Wilson, W. & Pratt, C. (1987) The Impact of diabetes
education and peer support upon weight and
glycaemic control of elderly persons with non
insulin dependent diabetes (NIDDM). Am. J. Public
Health. 77, 634635.
Wing, R.R., Klein, R. & Moss, S.E. (1990) Weight gain
associated with improved glycaemic control in
population-based sample of subjects with type 1
Diabetes. Diabetes Care 3, 11061109.
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