Background: The Transcultural Diabetes Nutrition Algorithm (tDNA) was created by an international task force and culturally customized for Malaysian population. 
Aims: This study was designed to evaluate its effectiveness versus usual diabetes care in primary care settings. 
Methods:  We randomized 230 patients with overweight/obesity, type 2 diabetes and A1C>7% to receive usual care (UC) or UC with tDNA for 6 months.  The tDNA intervention consisted of a structured low-calorie meal plan, diabetes-specific meal replacements, and increased physical activity. Patients randomized to the tDNA group were randomly assigned to be counselled either through motivational interviewing (tDNA-MI) or conventional counselling (tDNA-CC). The UC group received standard dietary and exercise advice through conventional counselling. All patients were followed for 6 months after intervention.
Results: At 6 months, A1C decreased significantly from baseline in tDNA-MI (-1.1±0.1%, p<0.001 ) and tDNA-CC (-0.5±0.1%, p=0.001), but not in UC (-0.2±0.1%,p=NS) patients. Body weight decreased significantly from baseline in tDNA-MI (-6.9±1.3 kg, p<0.001) and tDNA-CC (-5.3±1.2 kg, p<0.001), but not in UC (-0.8±0.5 kg, p=NS).  tDNA-MI patients had the lowest fasting plasma glucose (tDNA-MI -1.1±0.3 mmol/L, p<0.001; tDNA-CC -0.6±0.3, p=0.951; UC : 0.1±0.3, p=NS) and systolic blood pressure (tDNA-MI: -9±2 mmHg, p<0.001;  tDNA-CC: -9±2 mmHg, p=0.001; UC: -1±2 mmHg, p=NS). tDNA-MI patients ate the least calories (tDNA-MI: -574 ± 43 kcal/day, p<0.001; tDNA-CC -458 ± 47 kcal/day, p<0.001; UC -171 ± 46 kcal/day, p<0.05) and engaged in the highest exercise duration (188 ± 16 min/week, p<0.001, tDNA-CC group 149 ± 24 min/week, p=NS; UC group 106 ± 14 min/week, p =NS).  The tDNA-MI patients also had the highest eating self-efficacy scores (155 ± 1, p<0.001) compared to tDNA-CC patients (146 ± 2, p<0.001) and UC patients (116 ± 1, p<0.05). At one year, tDNA-MI patients best maintained the reduction in A1C (tDNA-MI: -0.5±0.2%, p=0.006 vs. tDNA-CC: 0.1±0.2, p=NS and UC 0.02±0.01, p=NS) and weight loss (tDNA-MI: -5.8±1.3 kg p<0.001 vs. tDNA-CC: -3.3±1.2 kg, p=0.086 and UC: 0.5±0.6 kg, p=NS). 
Discussion: Structured lifestyle intervention through the use of a culturally adapted nutrition algorithm significantly improves diabetes control and body weight in a primary care setting. Incorporating behavioural counselling, such as motivational interviewing, as part of a structured lifestyle intervention can further lead to significantly better outcomes.

Transcultural diabetes-specific nutrition algorithm in type 2 diabetes: better outcomes with motivational interviewing