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Recommendations Summary

T1DM: Medical Nutrition Therapy Intervention (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: Medical Nutrition Therapy

    Medical nutrition therapy provided by a registered dietitian nutritionist or international equivalent is recommended for children and adolescents living with type 1 diabetes to manage A1C, as appropriate and desired by each client.

    Rating: Level 1(C)
    Imperative

    T1DM: Medical Nutrition Therapy-Initial Encounters

    In children and adolescents living with type 1 diabetes, it is reasonable for a registered dietitian nutritionist or an international equivalent to collaborate with individuals with type 1 diabetes, their families, and interdisciplinary healthcare teams to design individualized medical nutrition therapy based upon the individual’s diabetes treatment plan, overall health and nutritional status, personal preferences, psychological and psychosocial factors, and physiological needs. Medical nutrition therapy for individuals with type 1 diabetes should focus on comprehensive nutrition assessment that includes considerations for insulin planning/administration, reducing short-term adverse events (hyperglycemia, hypoglycemia) and appropriate interventions, including individualized modification of diet, to maintain or improve nutrition status, and monitoring over time.

    Rating: Consensus
    Imperative

    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

      Barriers to Implementing 

      Access to RDN services may be limited by the number of professionals, the availability of these individuals and physical access to schedule. Families may experience burden due to the volume of appointments they are required to attend, despite the need/desire for the information provided by the service (and the support). Appointments may mean missing school (children/adolescents) and work (parents/caregivers) and lost wages. Also, increased travel costs, and childcare costs can be barriers to accessing care. Telehealth options can mitigate some of these issues.

      Recommendations focusing on dietary patterns, diet quality, and making appropriate changes in dietary intake without addressing food insecurity may inadvertently have potential risks and harms in some populations as implementation of this recommendation may not be accessible to underserved and vulnerable populations. Underserved and vulnerable populations are populations that face health, financial, educational, and/or housing disparities (Serving Vulnerable and Underserved Populations. Accessed January 17, 2023). Access to supermarkets and convenience stores that have a variety of foods is known to be limited in neighborhoods with high minority populations and low population density, which could limit access to lower, healthier food choices (Larson 2009). Underserved and vulnerable populations with limited health literacy may not have access to nutrition education and resources that would facilitate making this change. Food insecurity may also serve as a potential barrier to following this guideline, as provision of adequate food and nutrients may take priority. 

      Acceptability

      There is limited research on the acceptability of MNT provided by RDNs among children and adolescents with T1DM. However, this limited evidence indicates that children and adolescents living with T1DM understand that food plays a central role in the management of diabetes (Ye 2017). Stakeholders for these recommendations included children and adolescents with diabetes, families, caregivers, RDNs, health professionals, educators, and support services. Findings from Ye 2017 mention that teens are not only concerned about outcomes like management of their blood glucose, but also their interactions with peers, and emotional well-being, to name a few. Based on the results from these articles, it is clear that children and adolescents living with T1DM and their parents/caregivers do value MNT from RDNs and understand that dietary knowledge and behavior are important for management of their blood glucose. Chalmers 2022 indicated that developing social media related tools or education materials to discuss T1DM might be helpful. Overall, evidence indicates that stakeholders desired a personalized approach, not just focusing on A1C management but also other outcomes like emotional and physical well-being, access to dietetic services, and a shared decision-making relationship with the RDN.

      Implementation Considerations

      RDNs should work within interdisciplinary teams to promote the implementation of nutrition care. Interdisciplinary team protocols should include nutrition screening and referral to RDNs for individualized MNT. Incorporation of nutrition screening and referral to RDNs requires coordination of administrators, and organizational policies and procedures. Issues like feasibility of implementation, values of interventions, and equity issues should be considered while developing care plans for clients.

      The primary goal of implementing these recommendations is improving client outcomes while individualizing care to your client’s preferences and health status. Although the costs of MNT sessions and reimbursement vary, MNT is significantly associated with improved client outcomes. MNT can be considered cost-effective when considering the benefits of nutrition interventions on the onset and progression of comorbidities versus the cost of the interventions. The dietary recommendation can be implemented in numerous ways and hence is easy to incorporate into practice. This recommendation can be incorporated into ongoing counseling sessions and does not require any extra resources. However, there can be some barriers to providing care and the RDN should consider these when planning interventions for their clients. Issues like lack of insurance or higher out-of-pocket costs are more likely to impact the ability of certain demographics/groups to obtain care. Diabetes complications, both short and long-term, could be more frequent for those who have access problems, costing more for the individual, family, and the health-care system as a whole. Limited services by RDNs in some areas (eg,  rural) can also be a barrier.

      The RDN should work with both children and adolescents with T1DM and their parents/caregivers, as they play a critical part in self-management in youth. The treatment plan should focus on normal growth and development of the individual along with dietary management. The RDN should screen and assess the educational, psychological, emotional, behavioral, and access to food status of children and work with parents/caregivers to help implement the treatment plan.

      RDNs can play a central role in helping individuals obtain the skills needed to balance dietary intake, quality of life, and glycemic goals. Potential skills to assist with:

      • Identifying and quantifying carbohydrate foods.
      • Understanding average carbohydrate intake for age, weight, activity level.
      • Calculating insulin dosages based on carbohydrate intake from foods and beverages.
      • Quantifying carbohydrate quantities in foods when dining away from home.
      • Choosing foods on a limited budget.
      • Choosing foods to promote a healthy growth pattern.
      • Defining healthy eating attitudes and behaviors to reduce the risk of disordered or dysfunctional eating.
      • Managing hypoglycemia.
      • Understanding nutrition guidelines for sick days.
      • Understanding nutrition recommendations for religious/ethnic considerations (eg,  fasting, foods avoided, etc.).
      • Navigating eating and glycemic management while traveling.
      • Understanding nutrition recommendations for exercise and physical activity to optimize glycemic goals, prevent hypoglycemia, and optimize performance through nutrition.
      • For those interested in technology, introducing the use of apps to assist with tasks related to identifying and quantifying carbohydrate foods, tracking food intake, understanding the impact on different variables, including food, on blood glucose.
      • Understanding the use of continuous glucose monitoring, insulin smart pen, and/or insulin pump data as diabetes self-management tools to aid in optimal post-prandial glycemia, management of hypoglycemia, and sports performance.

      Additional information to consider when determining the best methods of implementing recommendations:

      • Consider client's age, socio-economic status, cultural membership, psychological and mental health status, health history, and other individual and health conditions. 
      • Dietary pattern-focused interventions may have small to moderate benefits for individuals with diabetes and little to no harm. Benefits would include changes in diet that show an improvement in A1C and quality of life. Secondary benefits could be seen with improvements in lipid profiles, blood pressure, and optimizing of BMI through growth and development. 
      • Changes in diet quality or intake may result in hypoglycemia. Thus, practitioners must ensure families know how to treat low blood glucose and discuss insulin adjustments should there be a pattern of hypoglycemia. Insulin adjustments should always be considered before suggesting it.
      • While providing counseling and care for individuals regarding dietary interventions, evaluate for signs of disordered eating.
      • At present there are no guidelines for best practice recommendations on vitamin D supplementation. Practitioners should use their own clinical expertise and individualize based on patients’ needs. 
      • Consider all types of learning in teaching methods, including visual, kinesthetic, audible, and written, and include demonstrations and teaching back skills when appropriate.
      • The Academy has developed Implementing Evidence: from Guidelines to Daily Practice, a new resource which aims to assist nutrition and dietetics practitioners with implementing evidence-based practice recommendations and clinical practice innovations into daily practice.

      RDNs are encouraged to incorporate inclusion, diversity, equity, and access (IDEA) in their practice when working with individuals living with T1DM. Addressing health inequities extends beyond providing individualized advice that considers social determinants of health and other barriers to healthy lifestyle behaviors. The Academy’s member website, eatrightPRO.org, includes a section titled “IDEA Hub” that provides resources for RDNs aiming to advance IDEA principles in their practices and professions. For example, providing dietary counseling on diet quality would probably create more equity, as some cultures do not value fruit, vegetables, and high fiber in the diet. Providing this education could help to improve overall health for all populations, thus improving health equity.

    • 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

      Five randomized controlled trials (RTCs) (Bakir et al. 2021, Dluzniak et al. 2020 and 2019, Donzeau et al. 2020, Majumdar et al. 2015, Spiegel et al. 2012) and one non-randomized trial (Kostopoulou et al. 2020) reported on the effectiveness of MNT provided by an RDN. Majority of the studies included participants who had diabetes for more than one year before study entry (Dluzniak 2020 and 2019, Donzeau 2020, Kostopoulou 2020, Spiegel 2012). One study included newly diagnosed children and adolescents with T1DM (Majumdar 2015) and one (Bakir 2021) included participants with a T1DM diagnosis established at least six months ago. Duration of intervention in these studies ranged from 3.25 months to 12 months. The number of contacts between these studies varied; Bakir had thirteen contacts over the intervention period, Kostopoulou had nine contacts, Majumdar had six contacts, Donzeau had five contacts, and Dluzniak had four contacts. Five RCTs demonstrated low risk of bias (Bakir 2021, Dluzniak 2020 and 2019, Donzeau 2020, Majumdar 2015, Spiegel 2012), and one non-randomized controlled trial demonstrated moderate risk of bias (Kostopoulou 2020).

      These studies examined the effectiveness of MNT on A1C. All studies included RDNs as a provider of MNT for the intervention group and the comparator group received standard care. Not all six studies could be included in the pooled analysis due to data reporting issues. Three studies (Bakir 2021, Donzeau 2020, Kostopoulou 2020) reported a significant reduction in A1C at the end of the intervention. Three other studies (Dluzniak 2020 and 2019, Majumdar 2015, Spiegel 2012) reported a reduction in A1C at the end of intervention. However, the A1C difference between the intervention group and the control group was not statistically significant. Pooled analysis of three studies (Bakir 2021, Dluzniak 2020 and 2019, Spiegel 2012) indicated that MNT intervention did reduce HbA1c levels, however the findings were not statistically significant [MD (95% CI):-0.323% (-0.708, 0.062); I=73.63%] and heterogeneity was moderate. However, the certainty of evidence was low.

      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

      The recommendation was based on LOW level evidence from examining the efficacy of medical nutrition therapy interventions.

    • Minority Opinions

      None.