Nutrition Counselling for Cardiometabolic Multimorbidity

Introduction Cardiometabolic multimorbidity (CMM), commonly involving T2DM and hypertension, represents the most prevalent and burdensome cluster of chronic diseases (1-3). These conditions are interrelated through shared lifestyle risk factors, and their co-occurrence significantly increases the risk of cardiovascular complications, disability, and premature mortality (4, 5). Nutrition plays a central role in the prevention and management of these conditions, yet dietary adherence among patients remains poor, contributing to uncontrolled blood glucose and blood pressure(6, 7). Nutrition counselling may improve patients' dietary behaviors by enhancing knowledge, self-management skills, and adherence to recommended diets(7); however, evidence on its effect among patients with multiple chronic conditions is limited.

In Ethiopia, national NCD guidelines do not provide specific dietary recommendations for patients with coexisting diabetes and hypertension, and nutrition counselling is poorly integrated into routine chronic care services (8-10). Patients are often managed mainly with medications, with limited structured dietary support, resulting in poor disease control and increased risk of complications, polypharmacy, and hospital utilization(9, 10). Generating context-specific evidence on the effect of nutrition counselling on clinical outcomes is therefore essential to strengthen nutrition care integration and inform guideline development.

Beyond clinical outcomes, patients with CMM frequently experience emotional distress, dietary limitations, and social challenges that negatively affect their well-being and functional capacity (11, 12). Nutrition-related quality of life (NQoL) is particularly compromised in this group due to the complexity of managing multiple dietary restrictions alongside heavy medication loads and symptom burden (13, 14). Structured nutrition counselling might have the potential to improve self-efficacy, psychosocial well-being, and patient satisfaction by addressing the multidimensional impact of diet on daily life. No study has evaluated the effect of nutrition counselling on NQoL among patients with CMM. Generating such evidence is vital to demonstrate the broader value of nutrition counselling, support its integration into Ethiopia's routine NCD services, and inform policies aimed at improving patient-centered outcomes.

Methods This study will be conducted in South Wollo Zone, Amhara Regional State, Northeast Ethiopia, involving all 14 public hospitals as study clusters.

A two-arm parallel cluster randomized controlled trial will be conducted to evaluate the effect of nutrition counselling on dietary adherence, clinical outcomes (blood pressure, fasting blood glucose (FBG), and low-density lipoprotein (LDL), and NQoL among patients with CMM. Fourteen public hospitals will be included, with seven randomly assigned to the intervention group and seven to the control group. A total of 308 adults with coexisting type 2 diabetes and hypertension will be recruited using systematic random sampling.

Participants in the intervention group will receive six individualized nutrition counselling sessions over three months, guided by the COM-B Model, while the control group will receive routine care. Intervention fidelity will be assessed using the five domains of the NIH Behavior Change Consortium framework. Data will be collected at baseline and post-intervention. Perceived dietary adherence will be assessed using a questionnaire adapted from the Perceived Dietary Adherence Questionnaire (PDAQ) and aligned with DASH diet principles. Clinical outcomes, including blood pressure, FBG, and LDL levels, will be measured using standardized national and laboratory procedures. Fasting venous blood samples will be collected and analyzed following established specimen handling and quality assurance protocols. Mixed-effects regression models will be used to evaluate intervention effects while accounting for clustering and relevant covariates.