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Recommendations Summary

DM: 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: Initial Series of Medical Nutrition Therapy Encounters

    The registered dietitian nutritionist (RDN) should implement three to six medical nutrition therapy (MNT) encounters during the first six months, and determine if additional MNT encounters are needed. In studies reporting on the implementation of an initial series of RDN encounters (three to 11; total of two to 16 hours), MNT significantly lowered HbA1c by 0.3% to 2.0% in adults with type 2 diabetes and by 1.0% to 1.9% in adults with type 1 diabetes during the first six months, as well as optimization of medication therapy and improved quality of life.
     

    Rating: Strong
    Imperative

    DM: Medical Nutrition Therapy Follow-Up Encounters

    The registered dietitian nutritionist (RDN) should implement a minimum of one annual medical nutrition therapy (MNT) follow-up encounter. Studies longer than six months report that continued MNT encounters resulted in maintenance and continued reductions of A1C for up to two years in adults with type 2 diabetes, and for up to 6.5 years in adults wtih type 1 diabetes. 
     

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      Considerations for Determination of the Necessity for Additional MNT Encounters

      • Implementation of carbohydrate counting and insulin-to-carbohydrate ratios
      • Weight management interventions
      • Physical activity
      • Self-monitoring of blood glucose (SMBG)
      • Medication usage.

    • 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

      • In adults with type 2 diabetes, 21 study arms from 18 studies reported that MNT provided by RDNs significantly lowered HbA1c levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Bastiaens et al, 2009; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Goldhaber-Fiebert et al, 2003; Franz et al, 1995; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; Takahashi et al, 2004; UKPDS 1990; UKPDS 2000; Wolf et al, 2004). At three months, HbA1c levels decreased by 0.3% to 2.0% and with ongoing MNT support, decreases in HbA1c levels were maintained or improved for more than 12 months. An initial series of RDN encounters (three to 11; total of two to 16 hours) with continued RDN encounters throughout the studies were reported. Although nutrition therapy interventions were effective throughout disease duration, the decrease in HbA1c was largest in studies in which participants were newly diagnosed or had higher baseline HbA1c levels. RDNs implemented a variety of nutrition therapy interventions all resulting in a reduced energy intake.
      • In adults with type 1 diabetes, three studies reported that MNT provided by RDNs contributed to significantly decreased HbA1c levels (DAFNE 2002; DCCT 1993; Laurenzi et al, 2011). At six months, HbA1c levels decreased by 1.0% to 1.9%. An initial series of RDN encounters (four to six) were reported. Ongoing MNT support resulted in maintenance of the reduced HbA1c levels at one year and in the Diabetes Control and Complications Trial (DCCT) throughout the 6.5 years of the trial.
      • In adults with type 1 and type 2 diabetes, nine studies reported that MNT provided by RDNs decreased fasting blood glucose levels at three months by 18mg to 61mg per dL (Al-Shookri et al, 2012; Barnard et al, 2006; Coppell et al, 2010; DCCT 1993; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Laitinen et al, 1993; Lemon et al, 2004; UKPDS 1990). With ongoing MNT support, decreased levels were maintained to 12 months and in the DCCT throughout the 6.5 years of the trial. Grade I
      • In adults with type 2 diabetes, 12 study arms from 11 studies reported that MNT provided by RDNs resulted in decreases in doses or the number of glucose-lowering medications used (Al-Shookri et al, 2012; Andrews et al, 2011; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). An initial series of RDN encounters (three to ten; total two to six hours) with continued RDN encounters throughout the studies were reported. The United Kingdom Prospective Diabetes Study (UKPDS) reported significantly improved glucose outcomes for approximately two years. However, due to the normal progression of type 2 diabetes, additional medications were needed to achieve optimal glycemic control. Weight gain with medication use can be ameliorated by an intensive intervention provided by RDNs.
      • In two studies of adults with type 1 diabetes, RDNs implemented carbohydrate counting for the adjustment of pre-meal insulin doses (DAFNE 2002, Laurenzi et al, 2011). In both studies, a series of RDN encounters (four to six) were reported. Although the number of insulin injections increased, HbA1c improved without an increase in total insulin doses. Grade I
      • In six studies in which RDNs implemented MNT, improvements in quality of life were reported (Bastiaens et al, 2009; DAFNE 2002; DCCT 1993; Laurenzi et al, 2011; Lemon et al, 2004; Wolf et al, 2004). An initial series of three to six RDN encounters (2.5 hours to six hours) with long-term RDN encounters were reported. Grade I
      • In adults with type 2 diabetes, body weight outcomes from MNT provided by RDNs were mixed (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Laitinen et al, 1993; Lemon et al, 2004; Takahashi et al, 2004; UKPDS 1990). At study end, 11 study arms reported MNT provided by RDNs significantly decreased baseline body weights by 2.4kg to 6.2kg, whereas, six study arms reported non-significant weight changes at study end. In persons with type 1 diabetes, weight outcomes were also mixed (DAFNE 2002, DCCT 1993).
      • In adults with type 2 diabetes, body mass index (BMI) outcomes from MNT provided by RDNs were mixed (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010, Izquierdo et al, 2010; Wolf et al, 2004). At study end, nine study arms reported significant decreases in baseline BMIs by 0.3kg/m2 to 2.1kg/m2, whereas eight study arms reported non-significant changes in BMI at study end. In persons with type 1 diabetes, one study reported a significantly decreased BMI of 0.3kg/m2 from MNT provided by RDNs (Laurenzi et al, 2011).
      • In adults with type 2 diabetes, waist circumference outcomes from MNT provided by RDNs were mixed (Al-Shookri et al, 2012; Andrews et al, 2011; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Bastiaens et al, 2009; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert 2003; Imai et al, 2011; Izquierdo et al, 2010; Lemon et al, 2004; UKPDS 1990, UKPDS 2000). At study end, nine study arms reported decreases of 1.0cm to 5.5cm, whereas three study arms reported non-significant changes in waist circumference at study end. In persons with type 1 diabetes, one study reported a significantly decreased waist circumference of 1.0cm from MNT provided by RDNs (Laurenzi et al, 2011). Grade II
      • In adults with type 2 diabetes and normal to mildly elevated cholesterol levels, 19 study arms in 16 studies reported that MNT provided by RDNs had mixed effects on cholesterol levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; Takahashi et al, 2004; UKPDS 2000; Wolf et al, 2004). Eight study arms reported significant decreases in cholesterol ranging from 8.0mg to 28mg per dL.
      • In adults with type 2 diabetes and normal to mildly elevated LDL-cholesterol levels, 17 study arms in 15 studies reported that MNT provided by RDNs had mixed effects on LDL-cholesterol levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). Seven study arms reported significant decreases in LDL-cholesterol ranging from 8.0mg to 22mg per dL.
      • In adults with type 2 diabetes and normal to mildly low HDL-cholesterol levels, 19 study arms in 16 studies reported that MNT provided by RDNs had mixed effects on HDL-cholesterol levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). Three studies reported significant increases in HDL-cholesterol ranging from 2.4mg to 6.0mg per dL.
      • In adults with type 2 diabetes and normal to elevated triglyceride levels, 19 study arms in 16 studies reported that MNT provided by RDNs had mixed effects on triglyceride levels (Al-Shookri et al, 2012; Andrews et al, 2011; Ash et al, 2003; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Franz et al, 1995; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Laitinen et al, 1993; Lemon et al, 2004; UKPDS 2000; Wolf et al, 2004). Seven study arms reported significant decreases in triglycerides ranging from 15mg to 153mg per dL.
      • In adults with type 2 diabetes and with near-normal blood pressure levels, 12 study arms in 10 studies reported that MNT provided by RDNs had mixed effects on blood pressure levels (Andrews et al, 2011; Barakatun Nisak et al, 2013; Barnard et al, 2006; Barratt et al, 2008; Battista et al, 2012; Coppell et al, 2010; Davis et al, 2010; Goldhaber-Fiebert et al, 2003; Imai et al, 2011; Lemon et al, 2004). Seven study arms reported significant decreases in systolic BP and diastolic BP of 3.2 to 9.0mm Hg/2.5 to 5.3mm Hg.
      • In adults with type 1 diabetes and near-normal lipid and blood pressure levels, two studies reported that MNT provided by RDNs led to non-significant changes in total cholesterol, HDL-cholesterol, triglycerides and blood pressure (DAFNE 2002, DCCT 1993). The Diabetes Control and Complications Trial (DCCT), at five years, reported that LDL-cholesterol was significantly decreased.
      • Subjects did not have or were not described as having any disorders of lipid metabolism or hypertension. The effectiveness of MNT may have been confounded by lipid-lowering or anti-hypertensive medications. Additional long-term studies are needed to ascertain the effectiveness of MNT on lipid profiles and blood pressure in adults with diabetes and disorders of lipid metabolism and hypertension. Grade II
      From the 2013 American Diabetes Association Nutrition Therapy Recommendations
      • 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 as needed to achieve treatment goals, preferably provided by an RDN familiar with the components of diabetes MNT. Grade A
      • People with diabetes should receive DSME according to national standards and diabetes self-management support when their diabetes is diagnosed and as needed thereafter. Grade B
      • Because diabetes nutrition therapy can result in cost savings (Grade B) and improved outcomes such as reduction in A1C (Grade A), nutrition therapy should be adequately reimbursed by insurance and other payers. Grade E
      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Strategies for Improving Care
      • A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy and addresses cultural barriers to care should be used. Grade B
      • Treatment decisions should be timely and founded on evidence-based guidelines that are tailored to individual patient preferences, prognoses and co-morbidities. 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
      • Effective self-management and quality of life are the key outcomes of DSME and DSMS and should be measured and monitored as part of care. Grade C
      • DSME and DSMS should address psychosocial issues, as emotional well-being is associated with positive diabetes outcomes. Grade C
      • DSME and 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
      • Because DSME and DSMS can result in cost-savings and improved outcomes (Grade B), DSME and DSMS should be adequately reimbursed by third-party payers. Grade E

    • Recommendation Strength Rationale

      • Conclusion Statements in support of these recommendations were given Grades I and II
      • The 2013 American Diabetes Association Nutrition Therapy Recommendations received Grades A, B and E
      • The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades A, B, C and E.

    • Minority Opinions

      Consensus reached.