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<p>This thesis examined the biochemical role of skeletal muscle mitochondria and metabolic consequences of mitochondrial adaptations to exercise in individuals with poor glycemic control. Mitochondrial dysfunction and/or ectopic lipid accumulation has been implicated in the pathogenesis of metabolic-related diseases such as obesity and type 2 diabetes (T2D). However, whether mitochondrial dysfunction is the cause of insulin resistance and T2D or is a consequence of this disorder remains controversial. Alternatively, pro-inflammatory stress signals initiated through altered secretion of adipocytokines and oxidative stress may be a unifying mechanism underlying insulin resistance and T2D. Furthermore, the impact of exercise on muscle adaptation in insulin-resistant states is not well defined. At rest and prior to exercise training, no evidence of mitochondrial dysfunction or disproportionate intramyocellular lipid (IMCL) accretion was detected in obese, insulin-resistant skeletal muscle biopsy samples <em>vs.</em> healthy, lean age-, and fitness-matched men. In response to exercise training (12 weeks, consisting of 32 sessions of 30-60 min @ 50-70% maximal oxygen uptake [VO₂peak]), there was an increase in mitochondrial oxidative phosphorylation (OXPHOS) capacity, mitochondrial content, and IMCL deposition with sub-cellular specificity. Exercise training also reduced both skeletal muscle and systemic oxidative damage, already elevated in the obese. The improved adipocytokine profile associated with obesity after training also coincided with improvements in glycemic regulation. Patients with genetic mitochondrial mutations, resulting in skeletal muscle mitochondrial dysfunction have an increase prevalence of dysglycemia/T2D. However, when evaluated against age- and activity-matched normoglycemic myopathy controls, no differences in mitochondrial electron transport chain protein subunits, mitochondrial or IMCL density, or level of whole-body insulin resistance was detected. In fact, dysglycemic mitochondrial myopathy patients demonstrated <em>higher </em>skeletal muscle OXPHOS capacity and Akt activation, a key step in insulin-stimulated glucose transport activity as compared with normoglycemic mitochondrial myopathy patients. Interestingly, a significant impairment in β-cell function (defective insulin secretion), in the dysglycemic patients was observed coincident with elevated glucose levels during the oral glucose tolerance test (OGTT). These findings indicate that insulin resistance does not cause skeletal muscle mitochondrial dysfunction/IMCL accumulation or <em>vice versa</em> and provides evidence against a direct link between mitochondrial dysfunction and the development of insulin resistance/T2D. Perhaps, oxidative stress/inflammation and pancreatic β-cell erosion mediate the observed obesity-induced insulin resistance and mitochondrial myopathy-associated T2D, respectively? Twelve weeks of moderate endurance exercise is an effective strategy to improve mitochondrial capacity, oxidative damage, inflammation, and glycemic regulation in insulin-resistant, obese individuals, but an improvement in muscle insulin sensitivity did not appear to be required.</p> / Doctor of Philosophy (Medical Science)

Bakgrund: Diabetes mellitus typ 2 (DMT2) ökar globalt. Sjukdomstillståndet kan lindras med en sund livsstil och en god egenvård. En stor andel personer med sjukdomen har svårt att följa rekommendationer för egenvård. Sjuksköterskan har därav en viktig roll för att egenvården ska bli optimalt utformad utifrån individuella perspektiv.    Syfte: Att beskriva personers upplevelser av följsamhet till egenvård vid diabetes mellitus typ 2.   Metod: En kvalitativ litteraturöversikt med en induktiv ansats. Vetenskapliga artiklar hämtade från CINAHL och PubMed bearbetades med hjälp av Fribergs analyssteg.    Resultat: Nyckelfynden presenteras i tre kategorier med sex tillhörande subkategorier. Socioekonomiska faktorer presenteras som första kategori, med bostad, ekonomi, familjestöd och sociala aspekter som tillhörande subkategorier. Andra kategorin tar upp psykologiska faktorer, varav förnekelse, attityd och känslomässiga utmaningar benämns som subkategorier. Tredje kategorin är sjukvårdsinsatser, som redogör för relation, bemötande och informationsutbyte.   Slutsats: Egenvård vid DMT2 är utmanande. Socioekonomiska faktorer var förutsättningar för att kunna prioritera egenvård, där en stabil boendesituation och ekonomisk trygghet i kombination med stöd från både familj och samhälle gynnade en god följsamhet till egenvård. Psykologiska faktorer kunde skapa utmaningar kring förmågan att hantera egenvården. Det är av stor vikt att hälso- och sjukvårdspersonal ger adekvat information och skapar individualiserade behandlingsplaner. Ett tillräckligt stöd från hälso- och sjukvården sågs kunna stärka personens motivation till att upprätthålla en god egenvård. Det är betydelsefullt att vårdpersonal och samhälle får en ökad förståelse för faktorer som påverkar följsamhet till egenvård för att kunna ge rätt stöd. / Title: People´s experiences of adherence to self-care in diabetes mellitus type 2. Background: Type 2 Diabetes Mellitus (T2DM) is increasing globally. The condition can be alleviated with a healthy lifestyle and considerable self-care. A large proportion of individuals with the disease struggle to adhere to self-care recommendations. Therefore, nurses play a vital role in optimizing self-care tailored to individual perspectives.  Aim: To describe people´s experiences of adherence to self-care in type 2 diabetes mellitus.  Method: A qualitative litterature review with an inductive approach. Scientific articles were retrieved from CINAHL and PubMed and analyzed using Friberg´s analysis steps.  Results: Key findings are presented in three categories with six associated subcategories. Socioeconomic factors are presented as the first category, with housing, economy, family support and social aspects as its subcategories. The second category addresses psychological factors, including denial, attitude and emotional challenges as subcategories. The third category pertains to healthcare interventions, detailing relationship, treatment and information exchange.  Conclusion: Self-care in T2DM is challenging. Socioeconomic factors are prerequisites for prioritizing self-care, where a stable housing situation and financial security, combined with support from both family and the community promote good adherence to self-care practices. Psychological factors can create challenges in managing self-care. It is crucial for healthcare professionals to provide adequate information and create individualized treatment plans. Adequate support from the healthcare system has been shown to strengthen a person´s motivation to maintain effective self-care. It is important for healthcare personal and the community to gain better understanding of the factors that influence adherence to self-care in order to provide appropriate support.

Type 2 Diabetes Mellitus (T2D) is a major public health issue. Diabetes prevalence is growing and is the 7th leading cause of death in the US. Virginia has a slightly higher prevalence than the national average. Community-based diabetes lifestyle management programs that include a physical activity component are effective at improving glycemic control and influencing lifestyle behavior changes among people with T2D. The Balanced Living with Diabetes (BLD) program uses an active learning approach to improve glycemic control and healthful lifestyles. The Lifelong Improvements through Fitness Together (LIFT) program uses behavioral strategies to improve functional fitness, participant engagement, and program adherence. Participant retention is a challenge for community-based program. Participants may start the program, but then fail to complete the program and/or adhere to program recommendations. Two pilot studies were conducted to evaluate strategies for increasing participant retention and improving outcomes. The first evaluated the implementation and impact of a retention plan implemented in BLD programs conducted from 2015-2017. There were more participants returned to the reunion class session prior the development of the retention plan. There were improvements in some health behavior and self-efficacy indicators in programs that used the retention materials, however, impacts on outcomes were mixed. Preliminary findings showed that the retention plan could be a tool for providing additional support to participants, however strategies for dissemination of the retention plan needs to be reevaluated. The second study evaluated the impact on participant engagement and program outcomes when the LIFT program is incorporated with the BLD program. There was an increase in participant retention, self-efficacy and one health behavior for physical activity and health behaviors related to diet in BLD+LIFT programs. Extension Agents are willing to implement the BLD+LIFT programs, however, clarity of program logistics is needed prior to implementation. Extension Agents indicated that implementation of these programs in locations with older adults that have greater disability may not be the best locations. Having larger studies on the effect of incorporation of LIFT with the BLD with older adult populations that have fewer co-morbidities are needed to determine the impact of addition of the LIFT program with the BLD program on program outcomes. / Doctor of Philosophy / Type 2 Diabetes is a chronic disease in which the body does not use insulin as it should or does not produce enough insulin. The Centers for Disease Control and Prevention (CDC) indicates that the prevalence of diabetes was 23.1 million among US adults in 2015. The prevalence of diabetes in Virginia is slightly higher than the national average. Community-based diabetes lifestyle management programs that include a physical activity component are effective in improving glycemic control and influencing lifestyle behavior changes among people with T2D. The Balanced Living with Diabetes (BLD) program uses an active learning approach to influence better glycemic control and healthful lifestyles. The Lifelong Improvements through Fitness Together (LIFT) program uses behavioral strategies to improve functional fitness, participant engagement, and program adherence. The challenge with implementing community-based programs is retention. Participants may initially agree to participate in a program, but then fail to complete the program and/or follow program recommendations. Two pilot studies were conducted to evaluate strategies for increasing participant retention and program outcomes. The first evaluated the implementation and impact of a retention plan implemented in BLD programs conducted from 2015-2017. There were more participants returned prior to the development of the retention plan. There were improvements in some health behavior and self-efficacy indicators in programs that used the retention materials, however, impacts on outcomes were mixed. Findings showed that the retention plan could be a useful tool for providing additional support to participants, however distribution of the retention plan needs to be reevaluated. The second study evaluated the impact of program outcomes when the LIFT program is combined with the BLD program. There was an increase in participants' self-confidence to perform physical activity and making changes in their diet in BLD+LIFT groups. Extension Agents were enthusiastic about conducting more BLD+LIFT programs, however, program procedures and the time commitment needs to be understood before doing so. Expanding the conduct of BLD programs that incorporate the LIFT program can be effective in improving glycemic control and increasing physical activity, however, working with organizations that service people that have diabetes with fewer health conditions that limit physical activity may be more effective.

Bakgrund Diabetes mellitus typ 2 är en sjukdom vars prevalensen ökar i världen. Behandlingen består av läkemedel och egenvårdsåtgärder, innehållande bland annat hälsosam kost och ökad fysisk aktivitet. Stöttande anhöriga kan öka följsamheten för behandlingen.     Syfte Att undersöka effekter av fysisk träning för personer med DMT2. Metod En kvantitativ litteraturanalys genomfördes. Databassökning i Pubmed och Cinahl. Nio randomiserade kontrollerade studier granskades enligt Olsson och Sörensens mall för kvantitativa studier. Analysen av studierna gjordes i enlighet med Popenoes mall. Resultat Interventionerna bestod av tre olika typer av träning: Aerob fysisk aktivitet, muskelstärkande fysisk aktivitet och högintensiv intervallträning. Studierna varierade i längd mellan 10 veckor och ett år och mätvärdena var bland annat hba1c, olika typer av kroppsfett och plasmaglukos. Minskning av fettmassa var signifikant i alla studier förutom en och hba1c minskade signifikant i tre studier.   Konklusion Resultatet kan tyda på att en minskning av fett kan ske vid träningsinterventioner, att MFA kan öka den fettfri massa och att HIIT och AFA kan öka kondition för personer med DMT2. / Background Type 2 diabetes mellitus is a disease whose prevalence is increasing worldwide. Treatment consists of medication and self-care measures, including a healthy diet and increased physical activity. Supportive family members can increase adherence to treatment. Aim To investigate the effects of physical exercise on people with diabetes mellitus type 2 Methods A quantitative literature analysis was conducted. Database search in PubMed and Cinahl. Nine randomised controlled trials were reviewed according to Olsson and Sörensens template for quantitative studies.  The studies were analysed according to the Popenoe template. Results The interventions consisted of three different types of exercise: Aerobic physical activity, muscle-strengthening physical activity and high-intensity interval training. The studies varied in length from 10 weeks to one year and the measurements included hba1c, fat mass and plasma glucose. Reduction in fat mass was significant in all but one study and hba1c decreased significantly in three studies. Conclusion The results may indicate that a reduction in fat can occur with exercise interventions, that MFA can increase fat-free mass and that HIIT and AFA can increase fitness for people with DMT2.

Master of Public Health / Human Nutrition / Richard R. Rosenkranz / Background: Type 2 diabetes mellitus (T2DM) is a costly and burdensome lifelong disease, and without proper glycemic control, severe life-threatening complications result. In Southeast Asia, the prevalence of T2DM is forecast to increase markedly from 2000 to 2030. Although literature reviews on lifestyle modification for glycemic control are available, these are mainly for the Western context, and there is a dearth of evidence for Southeast Asians who are at greater risk of T2DM and have differing patterns of diet, physical activity and body composition than Western populations. Objective: To systematically review literature on the effectiveness of lifestyle modification interventions for glycemic control in T2DM patients from Southeast Asia. Methods: Randomized controlled trials (RCT) with interventions ≥ 8 weeks that compared HbA1c or blood glucose for intervention (lifestyle modification) versus control groups were identified from searches in Cochrane Library, CINAHL, PubMed, ProQuest, Science Direct, SPORTDiscus, Scopus and Web of Science. Results: Seven RCTs (679 participants) meeting inclusion and exclusion criteria were identified. There was a significant reduction in HbA1c% (MD = -0.56%; 95% CI = -0.95,-0.16%; p = 0.006; n = 5 studies) and in blood glucose mg/dl (MD = -16.76 mg/dl; 95% CI = -31.36, -2.17 mg/dl; p = 0.02; n = 4 studies) over 3 months for lifestyle modification intervention groups. Lifestyle interventions included diet (n = 2), exercise (n = 2), and general lifestyle interventions (n = 3). Duration of interventions ranged from 12 weeks to 6 months. Studies included populations from Thailand (n = 5) and Malaysia (n = 2). Conclusion: Overall, lifestyle modification interventions are effective for the glycemic control of T2DM patients in countries of Southeast Asia.

The aim of the study was to evaluate type 2 diabetes mellitus (DM) medicine management in Government Clinics in Maseru, Lesotho. A two-dimensional research method was employed, consisting of a literature review and an empirical investigation. The objective of the literature review was to provide information on the pathophysiology, signs and symptoms, diagnosis, treatment and clinical management of DM. The empirical investigation consisted of a descriptive pharmacoepidemiological study, in which data for analysis was collected retrospectively from patients‘ medical records (―bukanas‖) at dispensing points, a using data collection tool. The selected study sites were Domiciliary Health Center, Mabote, Likotsi, and Qoaling filter clinics in Maseru district of Lesotho. Data on costs of antidiabetic agents was collected from purchase invoices provided by the pharmacy department of Domiciliary Health Center. Results showed that the overall ratio of males to females was 1.3. There were no statistical difference in DM prevalence between males and females in the different clinics (p = 0.48). The mean age of males and females was 57.5 ± 14.2 years and 58.6 ± 11.3 years, respectively (Cohen‘s d = 0.07). DM was more prevalent in patients 59 to 69 years for both males and females, with the exception of Mabote and Qoaling filter clinics, where DM was more prevalent in patients 49 to 59 years. These differences in prevalence were not statically significant. Overall, 20% (n = 69) of the study sample had DM alone, while 80.0% of patients had DM concurrently with hypertension. The odds ratio implicated that women were 1.7 times more likely to have hypertension concurrently with Type 2 Diabetes Mellitus. The mean blood glucose level at 95% confidence interval for females and males were 10.1 ± 5.9 mmol/L (95% CI: 10.1–11.7) and 10.9 ± 6.2 mmol/L (95% CI: 11.0–14.0) respectively. The difference in the mean blood glucose levels of males vs. females was not statistically significant (p = 0.07). In both males and females there were outliers as high as 33.3 mmol/L. Metformin 850 mg given three times, metformin 500 mg three times a day, glibenclamide 10 mg daily and glibenclamide 5 mg twice daily are oral hypoglycaemic agents that were first, second, third and fourth choice treatment of DM at all four study sites at a frequency of 54.2% (n = 160), 27.7% (n = 82), 4% (n = 12) and 2.7% (n = 27), respectively. Actraphane® 20 units in the morning and 10 units in the evening was prescribed at a frequency of 11.6% (n = 432) in comparison to other Actraphane®-containing regimens. The frequencies of prescribing metformin and Actraphane® as combination therapies represented 10.6% (n = 40), 7.1% (n = 27), and 6.6% (n = 25), respectively, for Actraphane® 20 units in the morning and 10 units in the evening, plus metformin 500 mg three times per day; Actraphane® 20 units in the morning and 10 units in the evening plus metformin 850 mg three times per day; and Actraphane® 30 units in the morning and 15 units in the evening plus metformin 850 mg three times per day. The combination therapy of metformin and glibenclamide were prescribed at frequencies of 24.6% (n = 172), 22.9% (n = 160), and 13.4% (n = 94) respectively for glibenclamide 10 mg daily plus metformin 850 mg three times per day, glibenclamide 5 mg daily plus metformin 850 mg three times per day, and glibenclamide 5 mg once a day plus metformin 500 mg three times per day as first, second and third choice treatments at all study sites. The total cost incurred for all the oral drugs prescribed alone within different regimens was M75.6 with the weighted average cost per patient of M0.81 ± 2.06 per day compared to the cost of Actraphane® which was M40 660.52 per month at a weighted average daily cost of M21.43 ± 6.23 per patient. The overall cost of Actraphane® and metformin combination therapy amounted to M50 676.50, at an average cost per patient of M21.77 ± 6.80 per day. The cost of combination therapy consisting of metformin and glibenclamide amounted to M377.10, at a weighted average cost amounting to M0.49 ± 0.16 per patient, per day. Based on the results of this study some conclusions were reached on the prevalence of DM, prescribing patterns and the cost of antidiabetic agents. Recommendations pertaining to the clinics and further research were made. / MPham (Pharmacy Practice), North-West University, Potchefstroom Campus, 2014

The aim of the study was to evaluate type 2 diabetes mellitus (DM) medicine management in Government Clinics in Maseru, Lesotho. A two-dimensional research method was employed, consisting of a literature review and an empirical investigation. The objective of the literature review was to provide information on the pathophysiology, signs and symptoms, diagnosis, treatment and clinical management of DM. The empirical investigation consisted of a descriptive pharmacoepidemiological study, in which data for analysis was collected retrospectively from patients‘ medical records (―bukanas‖) at dispensing points, a using data collection tool. The selected study sites were Domiciliary Health Center, Mabote, Likotsi, and Qoaling filter clinics in Maseru district of Lesotho. Data on costs of antidiabetic agents was collected from purchase invoices provided by the pharmacy department of Domiciliary Health Center. Results showed that the overall ratio of males to females was 1.3. There were no statistical difference in DM prevalence between males and females in the different clinics (p = 0.48). The mean age of males and females was 57.5 ± 14.2 years and 58.6 ± 11.3 years, respectively (Cohen‘s d = 0.07). DM was more prevalent in patients 59 to 69 years for both males and females, with the exception of Mabote and Qoaling filter clinics, where DM was more prevalent in patients 49 to 59 years. These differences in prevalence were not statically significant. Overall, 20% (n = 69) of the study sample had DM alone, while 80.0% of patients had DM concurrently with hypertension. The odds ratio implicated that women were 1.7 times more likely to have hypertension concurrently with Type 2 Diabetes Mellitus. The mean blood glucose level at 95% confidence interval for females and males were 10.1 ± 5.9 mmol/L (95% CI: 10.1–11.7) and 10.9 ± 6.2 mmol/L (95% CI: 11.0–14.0) respectively. The difference in the mean blood glucose levels of males vs. females was not statistically significant (p = 0.07). In both males and females there were outliers as high as 33.3 mmol/L. Metformin 850 mg given three times, metformin 500 mg three times a day, glibenclamide 10 mg daily and glibenclamide 5 mg twice daily are oral hypoglycaemic agents that were first, second, third and fourth choice treatment of DM at all four study sites at a frequency of 54.2% (n = 160), 27.7% (n = 82), 4% (n = 12) and 2.7% (n = 27), respectively. Actraphane® 20 units in the morning and 10 units in the evening was prescribed at a frequency of 11.6% (n = 432) in comparison to other Actraphane®-containing regimens. The frequencies of prescribing metformin and Actraphane® as combination therapies represented 10.6% (n = 40), 7.1% (n = 27), and 6.6% (n = 25), respectively, for Actraphane® 20 units in the morning and 10 units in the evening, plus metformin 500 mg three times per day; Actraphane® 20 units in the morning and 10 units in the evening plus metformin 850 mg three times per day; and Actraphane® 30 units in the morning and 15 units in the evening plus metformin 850 mg three times per day. The combination therapy of metformin and glibenclamide were prescribed at frequencies of 24.6% (n = 172), 22.9% (n = 160), and 13.4% (n = 94) respectively for glibenclamide 10 mg daily plus metformin 850 mg three times per day, glibenclamide 5 mg daily plus metformin 850 mg three times per day, and glibenclamide 5 mg once a day plus metformin 500 mg three times per day as first, second and third choice treatments at all study sites. The total cost incurred for all the oral drugs prescribed alone within different regimens was M75.6 with the weighted average cost per patient of M0.81 ± 2.06 per day compared to the cost of Actraphane® which was M40 660.52 per month at a weighted average daily cost of M21.43 ± 6.23 per patient. The overall cost of Actraphane® and metformin combination therapy amounted to M50 676.50, at an average cost per patient of M21.77 ± 6.80 per day. The cost of combination therapy consisting of metformin and glibenclamide amounted to M377.10, at a weighted average cost amounting to M0.49 ± 0.16 per patient, per day. Based on the results of this study some conclusions were reached on the prevalence of DM, prescribing patterns and the cost of antidiabetic agents. Recommendations pertaining to the clinics and further research were made. / MPham (Pharmacy Practice), North-West University, Potchefstroom Campus, 2014

Bakgrund: I den systematiska litteratur studien Mat vid diabetes (SBU 2010) framgår det att lågkolhydratkost har likartade metabola effekter hos personer med diabetes i jämförelse med en traditionell lågfettskost. Trotts dessa råd visar en undersökning ifrån samma studie att endast 18 % av de tillfrågade sjuksköterskorna kliniskt tillämpade denna typ av kostintervention. Detta tycks vara problematiskt vilket nyligen uttryckts i en rad olika mediala sammanhang. Utöver denna debatt har vi idag också en epidemiskt stor utbredning av patienter med typ 2 diabetes mellitus vilket ställer krav på de allt mer begränsade resurser som finns inom vård och omsorg.  Syfte: Syftet var att beskriva lågkolhydratkostens metabola påverkan hos patienter med Diabetes Mellitus typ 2. Metod: Den elektroniska sökningen av artiklar utfördes i PubMed, CINAHL, Academic Search Elite, Scopus, Web of Science, PsycINFO (2009-2014) samt PMC (2011-2014). 13 artiklar bedömdes utifrån studiedesign, metabola markörer, intervention/kontrollgrupp, inklusions och exklusionskriterer vara lämpliga för studien. Resultat: En övergripande majoritet studierna visade på att lågkolhydratkosten gav signifikant förbättrade metabola markörer och framförallt gällande HbA1c och HDL-kolesterol. Endast en studie visade på ett negativt icke-signifikant resultat. Konklusion: Lågkolhydratkost förefaller utifrån studiens syfte och resultat som ett fullgott alternativ till den traditionella diabeteskost som utgör stora delar av den kostbehandling som patienter med T2DM får idag. Men kan innebära ett stort ansvar i det arbetsätt som sjuksköterskan tillämpar för att stödja och hjälpa en patient med T2DM att nå en god egenvård, hälsa och metabolkontroll  Nyckelord: Typ 2 diabetes mellitus. Lågkolhydratkost. Traditionell diabeteskost. Chronic Care Model. Egenvård. Empowerment. / Background: The systematic literature review Mat vid diabetes (SBU 2010) indicates that a low carbohydrate diet possesses similar metabolic effects in people with diabetes compared to a traditional low-fat diet. Contrary to this advice, a review from the same study portrayed that only 18% of the surveyed nurses clinically applied this type of diet intervention. This seems to be problematic, as was recently expressed in a variety of media. In addition to this debate, health care now also face a widespread epidemic of patients with type 2 diabetes mellitus which in turn puts the increasingly diminished and limited resources in health care under additional pressure.  Aim: The aim of this study was to describe a low-carbohydrate diet and its metabolic effects in patients with Diabetes Mellitus type 2. Method: Included articles in this review was found by searching PubMed, CINAHL, Academic Search Elite, Scopus, Web of Science, PsycINFO (2009-2014) and PMC (2011-2014). 13 articles were assessed to be eligible for this review by assessing study-design, metabolic markers, intervention / control group, inclusion and exclusions criteria.  Results: An overall majority of studies proved that a low carbohydrate diet could result in significantly improved metabolic markers, and in particular the HbA1c and HDL cholesterol. Only one study showed a negative non-significant result. Conclusion: A low-carbohydrate diet seems based on our findings as a viable alternative to the traditional diabetic diet which constitute a large part of the diet treatment that patients with T2DM receives from current healthcare. But this in turn implies that a greater responsibility is taken by the nurse in order to support and help a patient with T2DM to achieve a good self-care, health and metabolic control. Keywords: Type 2 diabetes mellitus. Low carbohydrate diets. Traditional diabetic diet. Chronic Care Model. Self-care. Empowerment.