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.
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.
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.
Risks/Harms of Implementing This Recommendation
Conditions of Application
Potential Costs Associated with Application
- Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.
- 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
- Risks/Harms of Implementing This Recommendation
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).
Ash S, Reeves MM, Yeo S, Morrison G, Carey D, Capra S. Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial. International Journal of Obesity. 2003; 27:797-802.
Banister NA, Jastrow ST, Hodges V, Loop R, Gillham MB. Diabetes self-management training program in a community clinic improves patient outcomes at modest cost. J Am Diet Assoc 2004;104(5):807-10.
Bray P, Thompson D, Wynn JD, Cummings DM, Whetstone L. Confronting Disparities in Diabetes Care: The clinical effectiveness of redesigning care management for minority patients in rural primary care practices. J Rural Health 2005; 21(4):317-21.
Chima CS, Farmer-Dziak N, Cardwell P, Snow S. Use of technology to track outcomes in a diabetes self-management program. J Am Diet Assoc 2005; 105(12):1933-8.
DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Brit Med J. 2002; 325:746-751.
The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977-986.
Franz MJ, Monk A, Barry B, McClain K, Weaver T, Cooper N, Upham P, Bergenstal R, Mazze RS. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized controlled clinical trial. J Am Diet Assoc 1995;95:1009-1017.
Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic disease. J Am Diet Assoc 2006;106(1):109-112.
Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Tristan ML, Nathan DM. Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care 2003; 26:24-29.
Graber AL, Elasy TA, Quinn D, Wolff K, Brown A. Improving glycemic control in adults with diabetes mellitus: shared responsibility in primary care practices. South Med J 2002; 95(7):684-90.
Laitinen JH, Ahola IE, Sarkkinen ES, Winberg RL, Harmaakorpi-Livonen PA, Uusitupa MI. Impact of intensified dietary therapy on energy and nutrient intakes and fatty acid composition of serum lipids in patients with recently diagnosed non-insulin-dependent diabetes mellitus. J Am Diet Assoc 1993;93(3):276-283.
Lemon CC, Lacey K, Lohse B, Hubacher DO, Klawitter B, Palta M. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes. J Am Diet Assoc 2004; 104(12):1085-15.
Maislos M, Weisman D, Sherf M. Western Negev Mobile Diabetes Care Program: a model for interdisciplinary diabetes care in a semi-rural setting. Acta Diabetol 2002; 39(1):49-53.
Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus:results from a randomized controlled trial. Prev Med 2002;34(2):252-9.
Wilson C, Brown T, Acton K, Gilliland A. Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian Health Service. Diabetes Care 2003; 26(6):2500-04.
Wolf AM, Conaway MR, Crowther JQ, Hazen KY, Nadler JL, Oneida B, Bovbjerg VE. Translating Lifestyle Intervention to Practice in Obese Patients with Type 2 Diabetes: Improving Control with Activity and Nutrition (ICAN) study. Diabetes Care, 2004; 27 (7): 1,570-1,576.
Delahanty LM, et al. Clinical Significance of medical nutrition therapy in achieving diabetes outcomes and the importance of the process. J Am Diet Assoc. 1998; 98: 28-30.
Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ. Practice guidelines for medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc 1995;95:999-1006.