Screening and Referral
- The primary goals of medical nutrition therapy (MNT) for adults with type 1 and type 2 diabetes include glycemic control as well as prevention and treatment of cardiovascular disease.
- Secondary goals include improvement of quality of life, optimization of medication usage, and weight management.
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 ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and who have one or more additional risk factors for diabetes. (Fair, Imperative)
DM: Referral for MNT
- The 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 MNT. Individuals who have diabetes should receive individualized MNT to achieve treatment goals, preferably provided by a RDN familiar with the components of diabetes MNT. (Strong, Imperative)
DM: Initial Series of MNT Encounters
- The RDN should implement three to six 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 (3–11; total of 2–16 hours), MNT significantly lowered HbA1c by 0.3%–2.0% in adults with type 2 diabetes and by 1.0%–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. (Strong, Imperative)
DM: MNT Follow-Up Encounters
- The RDN should implement a minimum of one annual MNT follow-up encounter. Studies longer than six months report that continued MNT encounters resulted in maintenance and continued reductions of A1C for ≤2 years in adults with type 2 diabetes, and for ≤6.5 years in adults with type 1 diabetes. (Strong, Imperative)
DM: Nutrition Assessment
- The RDN should assess the following in adults with type 1 diabetes and type 2 diabetes, to formulate the nutrition care plan:
Biochemical data, medical tests and medication usage:
- Type of diabetes
- Glycemic control (target glucose and A1C levels are noted in the annual American Diabetes Association Standards of Medical Care in Diabetes)
- Lipid profiles
- Blood pressure
- Stage of chronic kidney disease
- Use of glucose-and lipid-lowering medications, anti-hypertensive medications, prescription and other over-the-counter medications, herbal supplements and complementary or alternative medications.
Nutrition-focused physical findings:
- Height, weight, BMI and waist circumference
- Injection sites
- Relative importance of weight management.
- General health and demographic information
- Social history
- Cultural preferences
- Health literacy and numeracy
- Education and occupation
- Knowledge, beliefs, attitudes, motivation, readiness to change, self-efficacy and willingness and ability to make behavioral changes
- Physical activity
- Patient or family nutrition-related medical and health history
- Other medical or surgical treatments
- Previous nutrition care services and MNT recommendations.
Food and nutrition-related history:
- Food, beverage and nutrient intake including energy intake, serving sizes, meal-snack patterns, carbohydrate, fiber, types and amounts of fat, protein, micronutrient intake and alcohol intake
- Experience with food, previous and current food and nutrition history, eating environment, access to healthy foods and eating out.
Assessment of the patient’s psychological and social situation should be included as an ongoing part of the medical management of diabetes, which may include, but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect and mood, general and diabetes-related quality of life, resources (financial, social and emotional), and psychiatric history, as well as addressing common co-morbid conditions that may complicate diabetes management. (Fair, Imperative)