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Recommendations Summary

DM: Medical Nutrition Therapy 2008

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    DM: MNT and Number/Length of Initial Series of Encounters

    Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with type 1 and type 2 diabetes. An initial series of three to four encounters each lasting from 45 to 90 minutes is recommended. This series, beginning at diagnosis of diabetes or at first referral to an RD for MNT for diabetes, should be completed within three to six months. The RD should determine if additional MNT encounters are needed after the initial series based on the nutrition assessment of learning needs and progress towards desired outcomes.  Studies based on a range in the number (1-5 individual sessions or a series of 6-12 group sessions) and length (45-90 minutes) report sustained positive outcomes at one year and longer. Studies implementing a variety of nutrition interventions report a reduction in A1C levels, and some studies also report improved lipid profiles, improved weight management, adjustments in medications, and reduction in the risk for onset and progression of comorbidities. 

    Rating: Strong
    Imperative

    DM: MNT Long-Term Follow-up Encounters

    At least one follow-up encounter is recommended annually to reinforce lifestyle changes and to evaluate and monitor outcomes that impact the need for changes in MNT or medication. The RD should determine if additional MNT encounters are needed.  Studies involving regular lifestyle intervention sessions (up to 1 per month) report sustained positive outcomes at one year and longer.

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      None.

    • Potential Costs Associated with Application

      • Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.

    • Recommendation Narrative

      • MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).
      • Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002; Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating the effectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to 2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or a series of 10 to 12 group sessions were employed.
      • A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydrate counting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchange lists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.
      • The number of initial and follow-up sessions varies in all the studies.
      • Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE Study Group, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al, 2005) report a variety in the number and type of MNT sessions that lead to improved outcomes. Therefore, the RD needs to determine what is appropriate for individual clients.
      • Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al, 2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months and longer. All involved regular sessions with an RD, ranging from monthly to three sessions per year.
      • Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemon et al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such as improved lipid profiles, weight management, decreased need for medications and reduced risk for onset and progression of comorbidities.

    • Recommendation Strength Rationale

      • Conclusion statement was Grade I

    • Minority Opinions

      Consensus reached.