• Increase Font Size
  • Decrease Font Size
  • View as PDF

Recommendations Summary

DM: Screening and Referral for 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: Screening for Type 2 Diabetes

    The registered dietitian nutritionist (RDN), in collaboration with other members of the health care team, should ensure that all overweight or obese adults at risk are screened for type 2 diabetes. Testing to assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI 25kg/m2 or more or 23kg/m2 or more in Asian Americans) and who have one or more additional risk factors for diabetes.
     

    Rating: Fair
    Imperative

    DM: Referral for Medical Nutrition Therapy

    The registered dietitian nutritionist (RDN), in collaboration with other members of the health care team, should ensure that all adults with type 1 diabetes and type 2 diabetes are referred for medical nutrition therapy (MNT). Individuals who have diabetes should receive individualized MNT to achieve treatment goals, preferably provided by a registered dietitian nutritionist (RDN) familiar with the components of diabetes MNT.
     

    Rating: Strong
    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, 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 not available within past three months
      • If not performed or available within 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 or 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

      Classification and Diagnosis of Diabetes

      • Testing to assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI 25kg/m2 or more or 23kg/m2  or more in Asian Americans) and who have one or more additional risk factors for diabetes. For all patients, particularly those who are overweight or obese, testing should begin at age 45 years. Grade B
      • If tests are normal, repeat testing carried out at a minimum of three-year intervals is reasonable. Grade C
      • To test for pre-diabetes, the A1C, FPG and two-hour PG after 75g OGTT are appropriate. Grade B
      • In patients with pre-diabetes, identify and, if appropriate, treat other cardiovascular disease (CVD) risk factors. Grade B
      • Testing to detect pre-diabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. Grade E
      • Inform the relatives of patients with type 1 diabetes of the opportunity to be tested for type 1 diabetes risk, but only in the setting of a clinical research study. Grade E
      • Testing to detect type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI 25kg/m2  or more or 23kg/m2 or more in Asian Americans) and who have one or more additional risk factors for diabetes. For all patients, particularly those who are overweight or obese, testing should begin at age 45 years. Grade B
      • If tests are normal, repeat testing carried out at a minimum of three-year intervals is reasonable. Grade C
      • To test for diabetes, the A1C, FPG, and two hour PG after 75g OGTT are appropriate. Grade B
      • In patients with diabetes, identify and, if appropriate, treat other CVD risk factors. Grade B
      • Testing to detect type 2 diabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors for diabetes. Grade E
      • Test for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria. Grade B
      • Test for GDM at 24 weeks to 28 weeks of gestation in pregnant women not previously known to have diabetes. Grade A
      • Screen women with GDM for persistent diabetes at 6–12 weeks postpartum, using the OGTT and clinically appropriate non-pregnancy diagnostic criteria. Grade E
      • Women with a history of GDM should have lifelong screening for the development of diabetes or pre-diabetes at least every three years. Grade B
      • Women with a history of GDM found to have pre-diabetes should receive lifestyle interventions or metformin to prevent diabetes. Grade A
      • Annual screening for cystic fibrosis–related diabetes (CFRD) with OGTT should begin by age 10 years in all patients with cystic fibrosis who do not have CFRD. Grade B
      • A1C as a screening test for CFRD is not recommended. Grade B
      • Patients with CFRD should be treated with insulin to attain individualized glycemic goals. Grade A
      • In patients with cystic fibrosis and IGT without confirmed diabetes, prandial insulin therapy should be considered to maintain weight. Grade B
      • Annual monitoring for complications of diabetes is recommended, beginning 5 years after the diagnosis of CFRD. Grade E
       Initial Evaluation and Diabetes Management Planning
      • Consider screening those with type 1 diabetes for autoimmune diseases (e.g., thyroid dysfunction, celiac disease) as appropriate. Grade E
      • 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
      • Nutrition therapy is recommended for all people with type 1 diabetes and type 2 diabetes as an effective component of the overall treatment plan. Grade A
      • Individuals who have diabetes should receive individualized MNT to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. Grade A
      • Because diabetes nutrition therapy can result in cost savings (Grade B) and improved outcomes (e.g., A1C reduction) (Grade A), MNT should be adequately reimbursed by insurance and other payers. Grade E
      • People with diabetes should receive diabetes self-management education (DSME) and diabetes self-management support (DSMS) according to the national standards for DSME and DSMS when their diabetes is diagnosed and as needed thereafter. 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/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 older than 65 years) with diabetes should be considered a high-priority population for depression screening and treatment. Grade B
       Prevention or Delay of Type 2 Diabetes
      • Patients with impaired glucose tolerance (IGT) (Grade A), impaired fasting glucose (IFG) (Grade E), or an A1C 5.7–6.4% (Grade E) should be referred to an intensive diet and physical activity behavioral counseling program targeting loss of 7% of body weight and increasing moderate-intensity physical activity (such as brisk walking) to at least 150 minutes per week.
      • Follow-up counseling may be important for success. Grade B
      • Based on the cost-effectiveness of diabetes prevention, such programs should be covered by third-party payers. Grade B
      • Metformin therapy for prevention of type 2 diabetes may be considered in those with IGT (Grade A), IFG (Grade E), or an A1C 5.7–6.4% (Grade E), especially for those with BMI >35 kg/m2, aged <60 years, and women with prior gestational diabetes mellitus (GDM). Grade A
      • At least annual monitoring for the development of diabetes in those with pre-diabetes is suggested. Grade E
      • Screening for and treatment of modifiable risk factors for cardiovascular disease is suggested. Grade B
      • Diabetes self-management education (DSME) and support (DSMS) programs are appropriate venues for people with pre-diabetes to receive education
        and support to develop and maintain behaviors that can prevent or delay the onset of diabetes. Grade C
        Cardiovascular Disease and Risk Management
      • Blood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure confirmed on a
        separate day. Grade B
      • In adults, a screening lipid profile is reasonable at the time of first diagnosis, at the initial medical evaluation, and/or at age 40 years and periodically (e.g., every 1–2 years) thereafter. Grade E
      • In asymptomatic patients, routine screening for coronary artery disease (CAD) is not recommended because it does not improve outcomes as long as CVD risk factors are treated. Grade A
        Microvascular Complications and Foot Care
      • At least once a year, quantitatively assess urinary albumin (e.g., urine albumin to-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes duration of more than five years and in all patients with type 3 diabetes. Grade B
      • Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within five years after the onset of diabetes. Grade B
      • Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. Grade B
      • Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy (NPDR) or any proliferative diabetic retinopathy (PDR) to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy. Grade A
      • All patients should be screened for diabetic peripheral neuropathy (DPN) starting at diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes, and at least annually thereafter, using simple clinical tests such as a 10g monofilament. Grade B
      • Screening for signs and symptoms (e.g., orthostasis, resting tachycardia) of cardiovascular autonomic neuropathy (CAN) should be considered with more advanced disease. Grade E
      Older Adults
      • Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to
        functional impairment. Grade E
      • Older adults (aged older than 65 years) with diabetes should be considered a high-priority population for depression screening and treatment. Grade B

    • Recommendation Strength Rationale

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

    • Minority Opinions

      Consensus reached.