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Recommendations Summary

T1DM: Macronutrient Composition (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: Individualize Macronutrient Composition

    It is reasonable for a registered dietitian nutritionist or international equivalents, in collaboration with youth living with type 1 diabetes and their families to individualize the macronutrient composition of a healthy, energy appropriate eating plan to optimize glycemic outcomes.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      There are few adverse events reported with MNT interventions provided by an RDN 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

      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 an RDN 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 with diabetes, families, caregivers, RDN’s, 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 RDNs 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 RDNs 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.

      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, the RDN should 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.

    • Potential Costs Associated with Application

      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.

    • Recommendation Narrative

      There were no randomized controlled trials that clearly evaluated consumption of differing amounts of macronutrients compared to usual dietary intake, however, there were some observational studies that evaluated the association of total carbohydrate intake and outcomes of interest. These studies did not meet the inclusion criteria for answering this research question. The lack of evidence on this topic is likely related to the fact that clinical practice is focused on appropriately managing insulin to carbohydrate ratio rather than focusing on differing amounts of carbohydrate. There is a lack of evidence to study the effect of differing amounts of macronutrient consumption in youth with T1DM on nutrition-related outcomes.

    • Recommendation Strength Rationale

      There was no evidence evaluating the effect of differing amounts of macronutrient consumption.

    • Minority Opinions

      None.