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Recommendations Summary

T1DM: Monitoring and Evaluation: Medical Nutrition Therapy (2024)

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)

    T1DM: Effectiveness of Medical Nutrition Therapy

    In children and adolescents living with type 1 diabetes, it is reasonable for a registered dietitian nutritionist or international equivalent to assess/reassess the following areas during follow-up interventions/visits:

    • Diabetes-focused reassessment of dietary intake, nutrient needs, nutrition and/or carbohydrate management.
    • Growth trajectory of the child/adolescent relative to their personal growth history and the typical growth of other children/adolescents of the same age and sex.
    • Knowledge, skills, competencies of diabetes management tasks and need for additional training and education.
    • Progress on behavioral goals.
    • Monitor blood glucose and insulin dosing data to help optimize both food intake and related insulin dosing and timing with meals.
    • Readiness in a client’s ability to perform diabetes self-management tasks, particularly in an adolescent transition to self-care.
    • Effectiveness of strategies to address learning barriers and readiness to change.
    • Disordered eating behaviors.
    • Psychosocial needs or barriers.
    • Diabetes distress and depression.

    Rating: Consensus
    Imperative

    T1DM: Medical Nutrition Therapy Follow-Up Encounters

    The registered dietitian nutritionist or international equivalent should implement additional encounters to help children and adolescents and support persons adjust nutrition planning in concert with the changes and adjustments to insulin therapy until consistent goals are met (eg, blood glucose levels, time in range, A1C). More visits are likely to be needed in the first 6–12 months following diagnosis of type 1 diabetes. A minimum of one annual medical nutrition therapy follow-up encounter is needed. With growth and development, nutrition and insulin need to change frequently, so more encounters may be needed if diabetes care goals are not met. 

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are few adverse events reported with MNT interventions provided by RDNs for children and adolescents with T1DM. However, hypoglycemia, hyperglycemia or weight gain may result if the RDN does not select or the individuals with diabetes cannot implement the appropriate carbohydrate management strategy. Potential harms such as financial costs (Sheils 1999), time spent at clinic visits, psychological concerns and potential for anxiety related to MNT provided by RDNs are relatively minimal compared with the potential benefits of improved nutrition status and decreased disease progression. The cost-benefit ratio of MNT provided by the RDN is unlikely to be very high and if MNT is successful, the benefits may outweigh the financial costs. Coverage for services varies by state, payor, etc., and this can lead to varying out-of-pocket costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low number of RDNs. Cost is minimal compared to potential benefits, especially considering the long-term cost of ill-health to government, hospitals, etc. Prevention of additional illness could create moderate savings.

    • Conditions of Application

      Significant changes in disease treatment plans warrant full nutrition assessment and newly diagnosed individuals will have different needs compared to follow-up visits. There is the potential that individuals and families with lower socio-economic status will have more difficulty paying for additional expenses that they might incur while managing their children's condition. In these cases, practitioners may offer low-cost options to help them manage their needs.

    • Potential Costs Associated with Application

      Potential harms such as financial costs (Sheils 1999), time spent at clinic visits, psychological concerns and potential for anxiety related to MNT provided by RDNs are relatively minimal compared with the potential benefits of improved nutrition status and decreased disease progression. The cost-benefit ratio of MNT provided by the RDN is unlikely to be very high and if MNT is successful, the benefits may outweigh the financial costs. Coverage for services varies by state, payor, etc, and this can lead to varying out-of-pocket costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low number of RDNs. Cost is minimal compared to potential benefits, especially considering the long-term cost of ill-health to government, hospitals, etc. Prevention of additional illness could create a moderate saving.

    • Recommendation Narrative

      Evidence indicates that periodically evaluating growth, anthropometric parameters, and assessing the nutritional status should be considered during regular follow-up visits of children and adolescents living with T1DM (Grabia 2021, Hill-Briggs 2020). Managing diabetes during childhood and adolescence places a burden on the youth and family, and hence the RDN should conduct ongoing assessments of psychosocial status, social determinants of health, and diabetes distress in the youth and the parents/caregivers during routine diabetes visits (Hill-Briggs 2020, Hagger 2016).

      In children and adolescents with T1DM, low quality evidence reported that weekly MNT sessions for the first month after diagnosis and monthly sessions thereafter achieved significant reductions in A1C. For those receiving less frequent encounters with RDNs, evidence reports mixed findings on the effectiveness of MNT.

    • Recommendation Strength Rationale

      This recommendation is based on consensus of expert panel members.

    • Minority Opinions

      None.