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Recommendations Summary

AWM: Delivery of Medical Nutrition Therapy 2022

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)

    AWM: Telehealth and In-Person Care

    Registered dietitian nutritionists or international equivalents may use telehealth, in-person contacts, or a blend of these delivery methods when providing MNT interventions to adults with overweight or obesity. Outcomes may be optimized by including in-person contacts.

    Rating: Level 2(C)
    Conditional

    AWM: Group and Individual Contacts

    Registered dietitian nutritionists or international equivalents may use both individual and group delivery methods when providing MNT interventions to adults with overweight or obesity, as feasible and appropriate for each client.

    Rating: Level 2(C)
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Providing care via telehealth exclusively does not allow for in-person nutrition assessment and presents challenges with ensuring clients have adequate internet or phone access, communications are compliant with the Health Insurance Portability and Accountability Act (HIPAA), and services can be covered by public and private payers. The recommendation of a blended format appears to have no apparent harmful effects and would be important to provide the benefit of flexibility to clients and practitioners alike. For some adult clients, the expectation to share details of their weight loss in a group with other adults may be a barrier to participation, and delivery methods should be tailored to client preferences.

    • Conditions of Application

      An adult client’s ability to meet in person, their internet and/or phone access, and their preferences for in-person vs. telehealth MNT delivery methods are taken into consideration when determining types of contacts. The Academy provides tools and resources for providing nutrition care with telehealth (Academy of Nutrition and Dietitics 2021). Ensuring that MNT occurs at regularly prescribed intervals may need to take priority over the delivery method to continue providing adequate client support. If a variety of contact types are offered, dietitians may wish to solicit feedback from adult clients regarding their impressions of each type, and/or compare outcomes data based on delivery method.

      A significant challenge of telehealth interventions is the reduced ability to collect standardized anthropometric measurements. Adult clients can be trained to track weight or waist circumference using standardized methods, to document measures with digital images, and/or clients can be provided with a scale that can automatically sync electronically (i.e., Bluetooth capacity) with a database utilized by the dietitian.  However, at least periodic in-person contacts (i.e., every three months) are desirable to confirm weight status. Dietitians can utilize telehealth to improve insight into the clients’ home eating environment and can interact with clients while in their kitchens.

      Dietitians currently utilizing solely individual or solely group delivery methods can transition to a blended format that includes both individual and group delivery methods by either seeing clients on a one-to-one basis occasionally or creating groups with clients that are currently being counseled individually. When creating the client group, it may be ideal to have adult clients with similar experiences or backgrounds (e.g., parents, adults with type 2 diabetes mellitus) in the same group. Adults with overweight or obesity may value inclusion in a group of adults with similar issues and who have similar body types or personalities (Skea, Aceves-Martins et al. 2019). It is important for the dietitian to be flexible and to accommodate adult clients’ needs and their potentially changing levels of comfort with the group delivery method. Individual and/or group delivery methods can occur in-person, virtually, or with a blend of these delivery methods. For example, dietitians may find success using an in-person individual-level delivery method but then utilize telehealth for a group delivery method. Telehealth group delivery could happen via video conferencing platforms or in a discussion forum. The discussion forum may allow adult clients to have more freedom as they would have the ability to post on their own schedule.

      For dietitians providing MNT via telehealth, a variety of technologies and platforms are available. However, it is important that any medium for delivering MNT adheres to HIPAA standards to protect client privacy. Telehealth can take place via phone calls or video conferencing platforms that are HIPPA compliant (Center for Connected Health Policy 2021). When conducting sessions one-on-one via telehealth, dietitians should ensure they are in a private location, utilize a headset to limit noise interference and to ensure others can’t hear the client, and keep all records within a HIPAA compliant electronic health record. Client privacy can be more difficult when conducting sessions for groups, and dietitians should consider using informed consent with clients to outline confidentiality and behavior expectations within the group setting and potential risks.  

    • Potential Costs Associated with Application

      Lack of internet access may be a potential barrier to using telehealth for clients with low socio-economic status (Rozga, Handu et al. 2021), or living rurally. To reduce the barrier associated with internet access, traditional phone calls instead of or in addition to video conferencing may be effective for overweight and obesity management interventions. There was no evidence identified that examined the difference in cost-effectiveness between delivery methods for adults with overweight or obesity. Typically, a group delivery method is less time- and resource-intensive compared to an individual-level delivery method.

    • Recommendation Narrative

      Understanding effective techniques to deliver MNT is important to optimize care. The aim of telehealth is to facilitate access to care, and the motivation to increase telehealth options is becoming more prevalent among healthcare providers (Dorsey and Topol 2016). The COVID-19 pandemic accelerated the need for dietitians to deliver telehealth interventions (Rozga, Handu et al. 2021). In addition, telehealth technology has improved and become more accessible to clients. Telehealth interventions address major barriers to participation in overweight and obesity management, including time, cost and travel for appointments (Skea, Aceves-Martins et al. 2019), and exposure to others who may be ill. Offering telehealth as an option for MNT delivery may address health inequities by facilitating access to and feasibility of nutrition care. In the sub-group analysis of the systematic review supporting this EBPG, the influence of interventions on outcomes was similar for those with in-person delivery methods and those using a blend of delivery methods (i.e., a blend of in-person and telehealth contacts) for most outcomes examined (Academy of Nutrition and Dietetics' Evidence Analysis Center 2021, Morgan-Bathke M 2022). However, for the outcome of systolic blood pressure, interventions using in-person delivery methods resulted in significant improvement, while the effect of interventions using telehealth or blended delivery methods was not significantly different than to the control groups. Thus, telehealth can be an effective tool in providing overweight and obesity management, but in-person contacts may offer additional benefits.

      Interventions delivered via individual-level and/or group delivery methods are important considerations due to the impact on resources (e.g., space, time, staff) required. While the individual delivery method can focus attention on each adult client’s specific circumstances, developing relationships in groups with other adults who face similar circumstances and/or have similar physiques is also valued by adult clients.(Skea, Aceves-Martins et al. 2019) Adult clients may value social interactivity of in-person, individual and group counseling to improve sense of support (Skea, Aceves-Martins et al. 2019). In the systematic review supporting this EBPG, only interventions that used both individual and group delivery methods demonstrated that including both individual and group delivery methods may result in the most optimal outcomes. The recommendation of a blended format that includes both individual and group delivery methods will benefit practitioners and clients alike and allow for cost savings when using a group delivery method when appropriate.

      More information on the evidence supporting these recommendations can be found in the Summary of Findings Table and Relationships between Recommendation Statements and Evidence Table.

    • Recommendation Strength Rationale

      The recommendation of the interprofessional team was based on LOW level evidence from sub-group analyses examining efficacy of different intervention approaches.

    • Minority Opinions

      No minority opinion.