Recommendations Summary

DM: Monitor and Evaluate Effectiveness of Medical Nutrition Therapy (2015)

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: Monitor and Evaluate Effectiveness of Medical Nutrition Therapy

  The registered dietitian nutritionist (RDN) should monitor and evaluate the following in adults with type 1 diabetes and type 2 diabetes, to determine the effectiveness of medical nutrition therapy (MNT):

  • Biochemical data, medical tests and medication usage:
    • Glycemic control (target glucose and A1C levels are noted in the annual American Diabetes Association Standards of Medical Care in Diabetes)
    • Results of glucose monitoring
    • Lipid profiles
    • Blood pressure
    • Stage of chronic kidney disease
    • Use of glucose-and lipid-lowering medications, anti-hypertensive medications, prescription and other over-the-counter medications, herbal supplements and complementary or alternative medications.
  • Nutrition-focused physical findings:
    • Height, weight, BMI and waist circumference
    • Injection sites
    • Relative importance of weight management.
  • Client history:
    • Knowledge, beliefs, attitudes, motivation, readiness to change, self-efficacy and willingness and ability to make behavioral changes
    • Physical activity
    • Other medical or surgical treatments.
  • Food and nutrition-related history:
    • Food, beverage and nutrient intake including energy intake, serving sizes, meal-snack patterns, carbohydrate, fiber, types and amounts of fat, protein, micronutrient intake and alcohol intake
    • Eating environment, access to healthy foods and eating out.

  Monitoring and evaluation of the patient’s psychological and social situation should be included as an ongoing part of the medical management of diabetes, which may include but are not limited to attitudes about the illness, expectations for medical management and outcomes, affect or mood, general and diabetes-related quality of life, resources (financial, social and emotional) and psychiatric history, as well as addressing common co-morbid conditions that may complicate diabetes management.

  Rating: Fair
  Imperative

  • Risks/Harms of Implementing This Recommendation

    None.

  • Conditions of Application

    Components of the Comprehensive Diabetes Evaluation (Table 3.1 of American Diabetes Association Standards of Medical Care in Diabetes–2015)
    
    Medical History

    • Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding)
    • Eating patterns, physical activity habits, nutritional status and weight history; growth and development in children and adolescents
    • Presence of common co-morbidities, psychosocial problems and dental disease
    • Diabetes education history
    • Review of previous treatment regimens and response to therapy (A1C records)
    • Current treatment of diabetes, including medications, medication adherence and barriers thereto, meal plan, physical activity patterns and readiness for behavior change
    • Results of glucose monitoring and patient’s use of data
    • DKA frequency, severity and cause
    • Hypoglycemic episodes:
      • Hypoglycemia awareness
      • Frequency and cause of any severe hypoglycemia.
    • History of diabetes-related complications:
      • Microvascular: Retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
      • Macrovascular: Coronary heart disease, cerebrovascular disease and peripheral arterial disease.

    Physical Examination

    • Height, weight, BMI
    • Blood pressure determination, including orthostatic measurements when indicated
    • Fundoscopic examination
    • Thyroid palpation
    • Skin examination (for acanthosis nigricans and insulin injection sites)
    • Comprehensive foot examination:
      • Inspection
      • Palpation of dorsalis pedis and posterior tibial pulses
      • Presence or absence of patellar and Achilles reflexes
      • Determination of proprioception, vibration and monofilament sensation.

    Laboratory Evaluation

    • A1C, if results are not available within the past three months
    • If not performed or available within the past year:
      • Fasting lipid profile, including total cholesterol, LDL-cholesterol and HDL-cholesterol and triglycerides, as needed
      • Liver function tests
      • Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
      • Serum creatinine and calculated GFR
      • TSH in type 1 diabetes, dyslipidemia, or women over age 50 years.

    Referrals

    • Eye care professional for annual dilated eye exam
    • Family planning for women of reproductive age
    • Registered dietitian for medical nutrition therapy
    • DSME and DSMS
    • Dentist for comprehensive periodontal examination
    • Mental health professional, if needed.

  • Potential Costs Associated with Application

    Costs of medical nutrition therapy (MNT) sessions and reimbursement vary, however, MNT sessions are essential for improved outcomes.

  • Recommendation Narrative

    From the 2015 American Diabetes Association Standards of Medical Care in Diabetes
    
    Initial Evaluation and Diabetes Management Planning
    
    Consider assessing for and addressing common co-morbid conditions (e.g., depression, obstructive sleep apnea) that may complicate diabetes management. Grade B
    
    Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization

    • Include assessment of the patient’s psychological and social situation as an ongoing part of the medical management of diabetes. Grade B
    • Psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect and mood, general and diabetes-related quality of life, resources (financial, social, and emotional) and psychiatric history. Grade E
    • Routinely screen for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders and cognitive impairment. Grade B
    • Older adults (aged 65 years or older) with diabetes should be considered a high-priority population for depression screening and treatment. Grade B
    • Patients with co-morbid diabetes and depression should receive a stepwise collaborative care approach for the management of depression. Grade A

    Glycemic Targets

    • When prescribed as part of a broader educational context, SMBG results may help guide treatment decisions and self-management for patients using less frequent insulin injections B or non-insulin therapies. Grade E
    • When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique, SMBG results and their ability to use SMBG data to adjust therapy. Grade E
    • Patients on multiple-dose insulin or insulin pump therapy should perform SMBG prior to meals and snacks, occasionally post-prandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normo-glycemic and prior to critical tasks such as driving. Grade B
    • When used properly, CGM in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years or older) with type 1 diabetes. Grade A
    • Although the evidence for A1C lowering is less strong in children, teens and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. Grade B
    • CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness or frequent hypoglycemic episodes. Grade C
    • Given variable adherence to CGM, assess individual readiness for continuing use of CGM prior to prescribing. Grade E
    • When prescribing CGM, robust diabetes education, training and support are required for optimal CGM implementation and ongoing use. Grade E
    • Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). Grade E
    • Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. Grade E
    • Use of point-of-care testing for A1C provides the opportunity for more timely treatment changes. Grade E
    • Lowering A1C to approximately 7% or less has been shown to reduce microvascular complications of diabetes, and, if implemented soon after the diagnosis of diabetes, it is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal for many non-pregnant adults is less than 7%. Grade B
    • Providers might reasonably suggest more stringent A1C goals (such as less than 6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy or no significant cardiovascular disease (CVD). Grade C
    • Less stringent A1C goals (such as less than 8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive co-morbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring and effective doses of multiple glucose-lowering agents including insulin. Grade B
    • Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. Grade C
    • Glucose (15g to 20g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. Grade E
    • Glucagon should be prescribed for all individuals at an increased risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed on its administration. Glucagon administration is not limited to health care professionals. Grade E
    • Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re-evaluation of the treatment regimen. Grade E
    • Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. Grade A
    • Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient and caregivers if low cognition or declining cognition is found. Grade B

  • Recommendation Strength Rationale

    The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades A, B and E.

  • Minority Opinions

    Consensus reached.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  • References
  • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

    American Diabetes Association. Standards of medical care in diabetes–2015. Diabetes Care. 2015; 38(1): S1-S94.