Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes

Kathaleen Briggs Early; Kathleen Stanley

doi:10.1016/j.jand.2017.11.021

From the Academy Position Paper| Volume 118, ISSUE 2, P343-353, February 2018

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Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes

Kathaleen Briggs Early, PhD, RDN, CDE
Kathaleen Briggs Early
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Kathleen Stanley, MSEd, RD, LD, CDE, BC-ADM, MLDE
Kathleen Stanley
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Published:January 30, 2018DOI:https://doi.org/10.1016/j.jand.2017.11.021

Abstract

It is the position of the Academy of Nutrition and Dietetics that for adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective. MNT provided by RDNs is also successful and essential to preventing progression of prediabetes and obesity to type 2 diabetes. It is essential that MNT provided by RDNs be integrated into health care systems and public health programs and be adequately reimbursed. The Academy’s evidence-based nutrition practice guidelines for the prevention of diabetes and the management of diabetes document strong evidence supporting the clinical effectiveness of MNT provided by RDNs. Cost-effectiveness has also been documented. The nutrition practice guidelines recommend that as part of evidence-based health care, providers caring for individuals with prediabetes or type 2 diabetes should be referred to an RDN for individualized MNT upon diagnosis and at regular intervals throughout the lifespan as part of their treatment regimen. Standards of care for three levels of diabetes practice have been published by the Diabetes Care and Education Practice Group. RDNs are also qualified to provide additional services beyond MNT in diabetes care and management. Unfortunately, barriers to accessing RDN services exist. Reimbursement for services is essential. Major medical and health organizations have provided support for the essential role of MNT and RDNs for the prevention and treatment of type 2 diabetes.

Position Statement

It is the position of the Academy of Nutrition and Dietetics that for adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes, quality of life, and is cost effective. MNT provided by RDNs is also successful and essential to preventing progression of prediabetes and obesity to type 2 diabetes. It is essential that MNT provided by RDNs be integrated into health care systems and public health programs, and be adequately reimbursed.

Medical nutrition therapy (MNT) is an effective intervention for the management of obesity, prediabetes, and diabetes, which have all increased dramatically in the United States and worldwide over the last 30 years.

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MNT is defined as “Nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition professional…”.

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Clinical Effectiveness of MNT in the Management of Obesity, Prediabetes, and Type 2 Diabetes

Impact of MNT on Obesity

The Academy of Nutrition and Dietetics has analyzed compelling evidence supporting the effectiveness of MNT in a broad range of topics, including obesity, diabetes prevention, and type 2 diabetes.

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As obesity is a key risk factor for the development of prediabetes and type 2 diabetes, adult weight management MNT delivered by an RDN is both clinically and economically effective for prevention and management.

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MNT results in both statistically significant and clinically meaningful weight loss in overweight or obese adults, as well as reduced risk for diabetes and disorders of lipid metabolism and hypertension.

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The Academy’s Adult Weight Management Evidence-Based Nutrition Practice Guideline states: “For weight loss, the RDN should schedule at least 14 MNT encounters (either individual or group) over a period of at least 6 months.” To maintain weight loss, the nutrition practice guideline recommends “at least monthly MNT encounters over a period of at least 1 year.”

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The Academy’s Medical Nutrition Therapy Effectiveness Systematic Review also reviewed evidence supporting the effectiveness of frequent MNT visits.

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“Two to 12 visits (60-minute initial visit and 20- to 45-minute follow-ups) were associated with improved weight (−0.5 kg to −9.0 kg), body mass index (−0.2 to −7.8), waist circumference (−2.0 cm to −14 cm), fasting blood glucose (−5.2 mg to −9.5 mg/dL), total cholesterol (−4.3 mg to −59 mg/dL), low-density lipoprotein cholesterol (−15 mg to −47 mg/dL), low-density lipoprotein cholesterol (+2.0 mg to +11 mg/dL), and triglycerides (−12 mg to −60 mg/dL).”

Impact of MNT on Prediabetes

The primary goal of intervening in individuals with prediabetes, also known as “categories of increased risk for diabetes”

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is to prevent and/or delay progression to type 2 diabetes. Strong evidence supports the role of MNT provided by RDNs as being effective for managing prediabetes

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The Academy’s Prevention of Type 2 Diabetes Evidence-Based Nutrition Practice Guideline reports that lifestyle intervention delivered to individuals with prediabetes “over at least a 3-month period” has been shown to decrease fasting blood glucose by 2 to 9 mg/dL (0.11 to 0.5 mmol/L), body weight by 2.6 to 7.1 kg, and waist circumference by 3.8 to 5.9 cm.

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Greater improvements were found in metabolic and anthropometric outcomes with increased frequency of MNT visits. The systematic review of MNT interventions provided by an RDN reported that in the majority of the publications significant improvements in weight, glycemic outcomes, waist circumference, and blood pressure were doumented.

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Lifestyle interventions focused on healthy eating and physical activity and, when compared, improved clinical outcomes more than metformin. More recently, the positive impact of lifestyle interventions was reaffirmed by several studies: two among adults with impaired glucose regulation,

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—all indicated that small improvements in weight loss and waist circumference and/or glycemia can prevent the progression from prediabetes to type 2 diabetes over an extended period of time. Improvements in qualilty of life, an important measure of health-related outcomes, have also been reported in studies of MNT among adults and pediatric individuals with prediabetes.

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In addition to reducing the progression of prediabetes to diabetes, lifestyle interventions in the DPP, including a weight loss of 3 kg from baseline, also improved cardiovascular risk factors—hypertension and lipid profiles—compared with placebo and metformin therapy.

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While the majority of evidence comes from studies in adults, there is also evidence that these efforts are effective in the general pediatric population.

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Therefore, reducing obesity and prediabetes prevalence is vital to prevent type 2 diabetes. Substantial evidence indicates that duration and intensity of lifestyle interventions matter. Of interest is the report from the Community Preventive Services Task Force.

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Impact of MNT on Type 2 Diabetes

Implementing MNT for the management of type 2 diabetes in adults is essential and the Academy’s Nutrition Practice Guidelines for Type 1 and Type 2 Diabetes in Adults documents the effectiveness of MNT on both clinical and quality of life outcomes.

¹⁷

Academy of Nutrition and Dietetics. 2015 diabetes type 1 and type 2 evidence-based nutrition practice guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5305&cat=5596. Accessed March 10, 2016.

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The nutrition practice guidelines recommend that RDNs, in collaboration with other members of the health care team, ensure that all overweight or obese adults at risk are screened for type 2 diabetes, and that all adults with type 2 diabetes be referred for MNT.

¹⁷

Academy of Nutrition and Dietetics. 2015 diabetes type 1 and type 2 evidence-based nutrition practice guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5305&cat=5596. Accessed March 10, 2016.

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RDNs should implement three to six MNT encounters during the first 6 months and, based on an individualized assessment, determine whether additional MNT encounters are needed. RDNs should implement a minimum of one annual MNT follow-up encounter based on strong evidence that continued MNT encounters produce maintenance and continued reductions of hemoglobin A1c (HbA1c) in adults with type 2 diabetes.

Strong evidence from the nutrition practice guidelines supports the role of MNT in the management of diabetes.

¹⁷

Academy of Nutrition and Dietetics. 2015 diabetes type 1 and type 2 evidence-based nutrition practice guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5305&cat=5596. Accessed March 10, 2016.

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In adults with type 2 diabetes, 21 study arms in 18 studies reported that MNT significantly lowered HbA1c by 0.3% to 2.0% at 3 months, and with ongoing MNT support, decreases were maintained or improved for more than 12 months. In studies with a control or usual care group, HbA1c remained unchanged or increased by 0.2%. Although MNT interventions were effective throughout the disease duration, the decreases in A1C were the largest when participants were newly diagnosed and/or had higher baseline HbA1c levels.

¹⁷

Academy of Nutrition and Dietetics. 2015 diabetes type 1 and type 2 evidence-based nutrition practice guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5305&cat=5596. Accessed March 10, 2016.

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Twelve study arms from 11 studies reported that MNT resulted in reductions in the dosing or the number of glucose-lowering medications used. However, due to the natural progression of type 2 diabetes, medication changes were needed to achieve glucose goals as study duration increased. Weight gain associated with medication use was also prevented by continued MNT support. Importantly, improvements in quality of life (improved self-perception of health status, increased knowledge and motivation, and decreased emotional stress) were reported.

¹⁷

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In these studies, implementing an individualized nutrition therapy intervention was of critical importance. A variety of interventions, such as individualized nutrition therapy, energy restriction, portion control, sample menus, carbohydrate counting, exchange lists, simple meal plans, and a low-fat vegan diet, were implemented and effective. All approaches resulted in a reduced energy intake.

Additional evidence further supports the Academy’s nutrition practice guideline recommendations. Intensive nutrition therapy interventions are reported to improve emotional distresss,

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found individuals who lost weight saw improvement not only in HbA1c, but also in lipid and blood pressure outcomes; similar findings were reported in a 2015 systematic review.

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In summary, MNT is essential for the achievement of treatment goals for both diabetes and prediabetes. Diagnostic criteria for prediabetes and type 2 diabetes, and desired treatment goals are provided by the American Diabetes Association (ADA) Standards of Medical Care in Diabetes, and these standards are updated annually.

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American Diabetes Association
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Cost-Effectiveness of MNT in the Prevention and Management of Diabetes

Cost effectiveness of lifestyle and MNT for the prevention and management of diabetes has been documented in a number of studies.

⁴⁶

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The Academy’s systematic review of cost effectiveness of MNT reported: “Based on six cost-effectiveness analyses, lifestyle interventions for diabetes prevention were cost effective in terms of cost per quality-adjusted life years gained compared to pharmacotherapy or no intervention.”

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In addition to the Academy’s review, the 10-year follow-up to the DPP, the Diabetes Prevention Program Outcomes Study, also reported lifestyle intervention to be cost-effective.

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Furthermore, among people aged 65 years and older, prediabetes lifestyle interventions were shown to be highly cost-effective and possibly cost-saving to a health care insurance payer such as Medicare.

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Costs were lower when diabetes prevention programs were delivered to individuals or groups in community or primary care settings.

⁴⁹

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These results suggest that it would be fiscally responsible for Medicare and similar payers to provide coverage for MNT for individuals with prediabetes to reduce diabetes risk. In a recent analysis, the Centers for Medicare & Medicaid Services and an independent actuary also found that lifestyle-based DPPs were cost-effective and are slated to cover DPP classes for Medicare enrollees starting in January 2018.

⁵⁰

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MNT must be provided early in the diabetes disease process to aid in reducing the costs and burdens of this devastating condition. In an economic analysis of 12,308 patients with diabetes, the potential savings from MNT was measured, and the net cost to Medicare of covering these services for Medicare enrollees was estimated. MNT was associated with a 9.5% reduction in use of hospital services and a 23.5% reduction in use of physician services for individuals with diabetes.

⁵¹

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The authors concluded that after an initial period of implementation, coverage for MNT can result is a net reduction in health services use and costs. In individuals aged ≥55 years, the savings exceeds the cost of providing the MNT benefit. Furthermore, RDN visits were more strongly associated with reduced hospitalizations than diabetes classes. Each RDN visit was associated with a substantial reduction in hospital charges,

⁵¹

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suggesting that providing these services in the primary care setting may be highly cost effective for the health care system. More recently, Howatson and colleagues

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also demonstrated that dietetic interventions achieved a significant impact on a number of chronic health conditions, including diabetes, which results in economic benefits.

Roles and Responsibilities of RDNs in Diabetes Care

Implementation of MNT

As noted, the Academy has published evidence-based nutrition practice guidelines for prediabetes and diabetes that also review MNT implementation.

¹⁵

Academy of Nutrition and Dietetics. 2014 Prevention of Type 2 Diabetes Evidence-Based Nutrition Practice Guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 3, 2016.

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^,

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^,

¹⁹

MacLeod J.
Franz M.J.
Handu D.
Gradwell E.
Brown C.
Evert A.
Reppert A.
Robinson M.

Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition intervention evidence reviews and recommendations.

Nutrition practice guideline recommendations are incorporated into the Nutrition Care Process, a systematic problem-solving method for RDNs to think critically and make decisions that affect practice-related issues.

⁵³

Writing Group of the Nutrition Care Process/Standardized Language Committee
Nutrition care process and model part I: The 2008 update.

The Nutrition Care Process involves four key nutrition steps: assessment, diagnosis, intervention, and monitoring and evaluation,

⁵⁴

Academy of Nutrition and Dietetics. Nutrition Care Process: NCP 101. http://www.eatrightpro.org/resources/practice/nutrition-care-process/ncp-101. Accessed May 11, 2015.

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which promote evidence-based practice using the highest-quality evidence available to make practice decisions.

The implementation of the nutrition practice guidelines into practice must be individualized to assist the RDN to successfully integrate MNT into the overall management of diabetes and prediabetes.

⁵⁵

Franz M.J.
Boucher J.L.
Evert A.B.

Evidence-based diabetes nutrition therapy recommendations are effective: The key is individualization.

Individualization is a collaborative effort between the client and RDN. The goals of diabetes MNT are to achieve positive clinical outcomes including attaining individualized glycemic, lipid, and blood pressure goals, attaining and maintaining body weight goals, and delaying or preventing the complications of diabetes.

⁵⁶

Google Scholar

For those with prediabetes, the goals of MNT are a modest weight loss and moderate physical activity.

A 2015 joint position statement on self-management education and support in type 2 diabetes from the Academy, ADA, and American Association of Diabetes Educators (AADE) reviews an algorithm of care for adults with type 2 diabetes, which outlines the need and frequency for MNT interventions.

⁵⁷

Powers M.A.
Bardsley J.
Cypress M.
et al.

Diabetes self-management education and support in type 2 diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.

The algorithm defines four critical times to assess, provide, and adjust diabetes self-management education and support (DSMES), including MNT: at diagnosis; annually for assessment of education, nutrition, and emotional needs; when new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management; and when transitions in care occur.

The Diabetes Care and Education Practice Group of the Academy published revised “Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Diabetes Care,”

⁵⁸

Boucher J.L.
Evert A.
Daly A.
et al.

American Dietetic Association revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in diabetes care.

which define the three levels of practice in diabetes care.

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Bruening M.
Udarbe A.Z.
Yakes Jimenez E.
Stell Crowley P.
Fredericks D.C.
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Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition.

The standards are regularly reviewed, revised, and designed to promote the provision of safe, effective, and efficient RDN services. RDNs, and nutrition and dietetic technicians, registered under the direction of the RDN, are uniquely qualified to provide nutrition care for individuals with prediabetes and diabetes based on nutrition practice guidelines. Figures 1 and 2 summarize the roles and responsibilities of RDNs implementing nutrition practice guidelines into the three levels of practice in diabetes care.

¹⁵

Academy of Nutrition and Dietetics. 2014 Prevention of Type 2 Diabetes Evidence-Based Nutrition Practice Guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 3, 2016.

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^,

¹⁷

Academy of Nutrition and Dietetics. 2015 diabetes type 1 and type 2 evidence-based nutrition practice guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5305&cat=5596. Accessed March 10, 2016.

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Franz M.J.
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^,

¹⁹

MacLeod J.
Franz M.J.
Handu D.
Gradwell E.
Brown C.
Evert A.
Reppert A.
Robinson M.

Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition intervention evidence reviews and recommendations.

^,

⁵⁸

Boucher J.L.
Evert A.
Daly A.
et al.

American Dietetic Association revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in diabetes care.

Figure 1Roles and responsibilities of registered dietitian nutritionists (RDNs) providing medical nutrition therapy (MNT) for persons with prediabetes. (Adapted from reference

15

Academy of Nutrition and Dietetics. 2014 Prevention of Type 2 Diabetes Evidence-Based Nutrition Practice Guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 3, 2016.

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.)

Screening and referral: In collaboration with other health care team members, the RDN should ensure that:

•
All individuals are screened for risk of type 2 diabetes using a recognized screening tool, such as the American Diabetes Association Type 2 Diabetes Risk Test
•
Determine the appropriate actions to be taken based on the results of the screening

MNT encounters: For prevention in high-risk groups (individuals with prediabetes or metabolic syndrome), the RDN should:

•
Provide MNT encounters
•
Increase frequency of encounters to optimize outcomes

Nutrition assessment: For individuals at high risk for type 2 diabetes, the RDN should assess the following, but not limited to:

•
Glycemia (fasting blood glucose, 2-hour post-prandial blood glucose, and hemoglobin A1c)
•
Lipid and blood pressure risk factors
•
Anthropometrics
•
Physical activity
•
Medications and supplements
•
Dietary factors
•
History of depression
•
Obesigenic/diabetogenic environment
•
Socio-economic status
•
Food security

Nutrition intervention: For individuals at high risk of type 2 diabetes, the RDN should:

•
If overweight or obese, prescribe a weight-reducing eating plan and support weight loss using evidence-based practice guidelines
•
Individualize the nutrition prescription for macronutrients
•
Encourage fiber and whole-grain food intake
•
Encourage moderate intensity physical activity
•
If prescribed medication, educate on potential food and drug interactions and nutrition-related adverse effects
•
Counsel based on established, well-defined behavior changes

Coordination of care: Implement MNT and coordinate care with a multi-disciplinary team and important others (eg, family, friends, and colleagues) in a wide variety of settings

Nutrition monitoring and evaluation: Monitor and evaluate the following, but not limited to:

•
Glycemia
•
Anthropometrics
•
Lipid profile and blood pressure
•
Physical activity
•
Medications and supplements
•
Dietary factors

Advanced training: Seek specialized training as needed and noted in Figure 2.

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Figure 2Roles and responsibilities of registered dietitian nutritionists (RDNs) providing medical nutrition therapy (MNT) for persons with type 2 diabetes.

¹⁷

Academy of Nutrition and Dietetics. 2015 diabetes type 1 and type 2 evidence-based nutrition practice guideline. Evidence Analysis Library website. http://andeal.org/topic.cfm?menu=5305&cat=5596. Accessed March 10, 2016.

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Franz M.J.
Evert A.
Brown C.
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Reppert A.
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^,

¹⁹

MacLeod J.
Franz M.J.
Handu D.
Gradwell E.
Brown C.
Evert A.
Reppert A.
Robinson M.

Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition intervention evidence reviews and recommendations.

^,

⁵⁸

Boucher J.L.
Evert A.
Daly A.
et al.

American Dietetic Association revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in diabetes care.

Screening and referral: In collaboration with other health care team members, the RDN should ensure that:

•
All overweight/obese adults at risk are screened for type 2 diabetes
•
Individuals with type 2 diabetes are referred for MNT

MNT encounters: The RDN should implement:

•
A minimum of three to six MNT encounters during the first 6 months; determine whether additional MNT encounters are needed
•
A minimum of one annual MNT follow-up encounter

Nutrition assessment: The RDN should assess the following to formulate the nutrition care plan:

•
Biochemical data, medical tests, and medication usage
•
Nutrition-focused physical findings
•
Client history
•
Food/nutrition-related history, including food behavior and habits
•
Dietary supplement and complementary and alternative medicine practices.
•
Client’s psychological and social situation

Nutrition intervention: The RDN should individualize the nutrition prescription and implement evidence-based guidelines in collaboration with the adult with diabetes:

•
A variety of eating patterns are acceptable
•
A healthful eating plan is encouraged for appropriate-weight persons with diabetes; a reduced energy healthful eating plan is encouraged for overweight and obese persons with diabetes
•
Individualize the macronutrient intake composition within the appropriate energy intake
•
Educate on carbohydrate management strategies including fiber, glycemic index, and sweetener (nutritive and non-nutritive) recommendations
•
Educate on the role of protein intake in diabetes management
•
Encourage consumption of a cardio-protective eating pattern within the recommended energy intake
•
Advise there is no clear evidence of benefit from vitamin, mineral, and/or herbal supplementation in people who do not have underlying deficiencies
•
If choice is to drink alcohol, it should be done in moderation (one drink/day or less for adult women and two drinks/day or less in adult men)
•
Encourage an individualized physical activity plan
•
Educate on self-monitoring of blood glucose and using data to adjust therapy

Coordination of care: Care systems should support team-based care and community involvement to meet person’s needs: implement and coordinate care with an interdisciplinary health care team, the person with diabetes, and important others (eg, family, friends, and colleagues).

Nutrition monitoring and evaluation: The RDN should monitor and evaluate to determine effectiveness of MNT:

•
Biochemical data, medical tests, and medication usage
•
Nutrition-focused physical findings
•
Client history
•
Food/nutrition-related history
•
Dietary supplement and complementary and alternative medicine practices
•
Client’s psychological and social situation

Generalist (competent): Implements Nutrition Practice Guidelines for type 1 and type 2 diabetes using the nutrition care process.

Specialty (proficient): Implements education and training on diabetes self-care tasks/skills/topics such as instruction on self-monitoring of blood glucose; hypoglycemia recognition and treatment; blood glucose targets; assesses blood glucose monitoring results and needs for MNT and medication adjustments; calculates insulin-to-carbohydrate ratios and insulin sensitivity factors; assesses other metabolic outcomes.

Advanced (expert): Implements education and training on devices (monitors, insulin pumps, pods, continuous glucose monitors); recommends meal plan and diabetes medication adjustments, if needed; evaluates management (evaluation of trends, review of glucose data) and other diabetes self-management behaviors; drives and directs clinical practice; conducts and collaborates in research; leads in the advancement of diabetes care.

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Role of RDNs beyond MNT

As a team member, the RDN possesses unique skills in the real-world application of food and nutrition, in addition to specialized training in diabetes care. This positions RDNs to adeptly facilitate the overall care of the individual with diabetes in a primary care practice, clinic, hospital, or other facility. As noted in the Standards of Practice, other activities that RDNs may be involved with include self-blood glucose monitoring training and interpretation, and device training and adjustments (glucose meters, insulin pumps, insulin delivery systems, continuous blood glucose monitoring devices).

⁵⁸

Boucher J.L.
Evert A.
Daly A.
et al.

American Dietetic Association revised standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in diabetes care.

^,

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American Association of Diabetes Educators. Diabetes Education Services: Reimbursement Tips for Primary Care Practice. 2009. https://www.diabeteseducator.org/docs/default-source/practice/Entrepreneurial-DE/reimbursement-tips-2009.pdf?sfvrsn=0. Accessed May 11, 2015.

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RDNs are also diabetes education program coordinators. According to data in 2015, 34% of current ADA Education Recognition Programs have an RDN program coordinator. Recognition refers to diabetes education programs who have met or exceeded established guidelines and quality measures as written by the recognition requirements developed by the ADA.

⁶²

American Diabetes Association. Education Recognition Requirements. 2015. http://professional.diabetes.org/content/recognition-requirement. Accessed January 21, 2016.

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RDNs also are coordinators of diabetes education programs accredited by the AADE Diabetes Education Accreditation Program Diabetes Education Program.

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American Association of Diabetes Educators. Diabetes Education Accreditation Program (DEAP). https://www.diabeteseducator.org/practice/diabetes-education-accreditation-program-(deap)/applying-for-accreditation. Accessed January 21, 2016.

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Other responsibilities include the facilitation of medication adjustments, being disease case managers for insurers and employees, and involvement in corporate and facility wellness programs. RDNs are also important in DPPs serving as instructors and/or as coordinators.

RDNs are uniquely positioned to fulfill key needs, and the roles of the RDN continue to expand.

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Warshaw H.S.
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Goody C.M.

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Van Horn L.

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They are involved in patient-centered medical homes within physician offices where individuals have a team of providers for care, and accountable care organizations.

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Furthermore, RDNs can participate in shared medical appointments (also known as shared medical visits, group medical visits, or groups clinics)

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Van Horn L.

Diabetes, diet, and dietitians: An urgent public health problem requiring multi-disciplinary decisions.

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^,

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Kirsh S.
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Ridge T.

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Hodorowicz M.A.

Reimbursement for shared medical appointments incorporating diabetes self-management education/training or diabetes medical nutrition therapy.

by providing expertise to small groups in partnership with a primary care provider. Nutrition counseling via technology is another expanded role with the data supporting the use of frequent MNT via face-to-face, online, or telephone.

⁷¹

Rollo M.E.
Hutchesson M.J.
Burrows T.L.
et al.

Video consultations and virtual nutrition care for weight management.

^,

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Academy of Nutrition and Dietetics. RDNs in the New Primary Care: A Toolkit for Successful Integration. American Academy of Nutrition and Dietetics, ed. http://www.eatrightstore.org/product/65BAFEC1-40CE-4D2B-91E3-84A03CE2C8032015. Accessed January 21, 2016.

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Because RDNs possess a variety of attributes that include training in communications, counseling, food science, pathophysiology, biochemical sciences, clinical nutrition and diabetes care skills, cultural and psychosocial awareness, and the ability to use collaborative approaches to providing patient care, they are well-suited to provide value added programs of all types. RDNs also take roles in non−patient-centered arenas. Worksite wellness programs, which are becoming more common throughout the United States, are a venue opportune to the RDN skillset.

⁷³

Kooi K.
Acosta S.
Hunnicutt M.

Registered dietitian on the go: The evolving role of a dietitian in a workplace wellness setting.

^,

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Aneni E.C.
Roberson L.L.
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A systematic review of internet-based worksite wellness approaches for cardiovascular disease risk management: Outcomes, challenges & opportunities.

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Breaux-Shropshire T.L.
Whitt L.
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Shropshire A.T.
Calhoun D.A.

Characterizing workers participating in a worksite wellness health screening program using blood pressure control, self-monitoring, medication adherence, depression, and exercise.

^,

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Mincher J.L.
Leson S.M.

Worksite wellness: An ideal career option for nutrition and dietetics practitioners.

Program, patient care, and data and resource management coordination, whether at the level of an insurance company or within a primary care clinic, are other employment opportunities that lend themselves to the unique skillsets of RDNs. Additional programs RDNs are involved in as coordinator or as a health care professional on the health care team include the Medicare Special Needs Plan, Medicare’s Everyone with Diabetes Counts Program, Lower Extremity Amputation Prevention Programs, Chronic Disease Self-Management Program, We Can! Initiatives, Indian Health Services Special Diabetes Programs for Indians, and state government-supported programs.

Barriers to Access for RDN Services

The role of MNT and the RDN is important in both the management and prevention of diabetes. Unfortunately, national data indicate that only about half of those individuals with diabetes actually receive any diabetes education,

⁷⁷

Ali M.K.
Bullard K.M.
Saaddine J.B.
Cowie C.C.
Imperataorie G.
Gregg E.W.

Achievement of goals in the U.S. diabetes care, 1999-2010.

and even fewer see an RDN. In a study of 28,404 individuals with diabetes, only 9.1% had at least one nutrition visit within a 9-year period.

⁷⁸

Robbins J.M.
Thatcher G.E.
Webb D.A.
Valdmanis V.G.

Nutritionists visits, diabetes classes, and hospitalization rates and charges: The Urban Diabetes Study.

Some of the potential barriers to accessing RDN services include geographic accessibility; variable health insurance benefits for MNT; lack of understanding of benefits and coverage among consumers and health care providers, including RDNs; inability to provide MNT and Diabetes Self-Management Education on the same day; and limitations of provider directories. Those populations at highest risk for obesity, prediabetes, and type 2 diabetes are also often more likely to have difficulties accessing MNT services.

⁷⁹

Galasso P.
Amend A.
Melkus G.D.
Nelson G.T.

Barriers to medical nutrition therapy in black women with type 2 diabetes mellitus.

Despite the evidence of effectiveness of RDN services and diabetes education and support, underutilization of RDN services for DSMES is evident in both acute care and outpatient settings.

⁵⁷

Powers M.A.
Bardsley J.
Cypress M.
et al.

Diabetes self-management education and support in type 2 diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.

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Torres E.A.
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This is true also of referrals for DSMES, as in one study only 6.8% of privately insured individuals with type 2 diabetes diagnosed within the last 12 months received DSMES,

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Li R.
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Burrows N.R.
Kolb L.E.
Rutledge S.

Diabetes self-management education and training among privately insured persons with newly diagosed diabetes—United States, 2011-2012.

and only 4% of Medicare individuals received DSMES or MNT services.

⁸²

Duncan I.
Birkmeyer C.
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Effectiveness of RDN services to individuals with prediabetes and diabetes and to the health care team providing diabetes care/management and education/support is of proven effectiveness, and reducing barriers to RDN services is essential.

Reimbursement for MNT

Medicare Reimbursement

A physician referral is needed for MNT for Medicare reimbursement. Providers need to follow local and national regulations to be eligible for reimbursement, and qualifications require obtaining a National Provider Identifier number. Current Procedural Terminology and billing procedures for MNT within government-funded programs and private sector insurance plans are varied and have been widely interpreted by carriers and billing agencies. The regulations for billing Medicare Part B for MNT are defined by Centers for Medicare & Medicaid Services. Since January 1, 2002, RDNs have been able to bill Medicare Part B for MNT provided to individuals with diabetes and/or renal disease using Current Procedural Terminology codes 97802, 97803, or 97804. This Medicare benefit allows 3 hours of MNT in the first referral year and 2 hours in each subsequent calendar year. Medicare may cover additional visits for MNT when there is a documented change in medical condition; however, a new referral is needed using codes G0270 or G0271 for these additional hours beyond the annual benefit.

⁸³

Centers for Medicare & Medicaid Services HHS. 42 CFR Ch. IV. 2007. https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol2/pdf/CFR-2007-title42-vol2-sec410-134. Accessed July 16, 2017.

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The Medicare benefit also allows 10 hours of DSME the first year of diagnosis and then 2 hours of continuing education thereafter; however, Centers for Medicare & Medicaid Services mandates that DSMES cannot occur on the same day as MNT. (Note that Medicare uses the term diabetes self-management training for reimbursement, not DSME or DSMES).

Other Reimbursement for Nutrition Therapy

As of 2016, forty-six states and the District of Columbia had some law that requires health insurance policy coverage for diabetes treatment. These laws impact both the private market place, as well as state Medicaid programs. The US Preventative Services Task Force recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese.

⁸⁵

US Preventative Services Task Force (USPSTF). Abnormal blood glucose and type 2 diabetes mellitus: Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes. Accessed May 4, 2017.

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Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.

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The recommendation does not guarantee coverage by all plans and does not guarantee RDNs as providers of such services.

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Burge M.R.
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Nutrition services, including diabetes education by an RDN, are also generally part of the bundled payment system in acute care settings.

⁸⁸

Academy of Nutrition and Dietetics. Nutrition Services Delivery and Payment: The Business of Every Academy Member. HOD (House of Delegates) Backgrounder. 2013. http://www.cnmdpg.org/docs/Delegate/2013/F2013%20-%20HOD-BACKGROUNDER-FINAL. Accessed July 14, 2017.

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Nutrition services for individuals receiving Medicare benefits may be included in long-term care settings as part of bundled payment. MNT provided to Medicare beneficiaries in the home setting could be a component of a bundled payment, or it might be a separately billable service under part Medicare Part B.

⁹⁰

Department of Health and Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS). Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies, 82 FR 4504. 2017. https://www.federalregister.gov/d/2017-00283. Accessed July 18, 2017.

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The growing adoption of alternative payment models presents an opportunity to support nutrition services provided by RDNs to individuals with diabetes and prediabetes in multiple settings, based on the cost-effectiveness of MNT and stakeholder focus on improving quality and outcomes, and decreasing the total cost of care.

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Nutrition therapy is an integral component of the National Standards for DSMES programs.

²²

American Diabetes Association
Standards of medical care in diabetes—2017.

^,

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^,

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Bardsley J.
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Multidisciplinary teams are recommended to provide care for people with diabetes.

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Jortberg B.T.
Fleming M.O.

Registered dietitian nutritionists bring value to emerging health care delivery models.

Multiple studies have found that DSMES is associated with improved diabetes knowledge, improved self-care behavior, improved clinical outcomes, such as lower HbA1c, lower self-reported weight, improved quality of life, healthy coping, and lower costs.

⁹³

Chrvala C.A.
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Better outcomes were reported from DSMES interventions that were longer and included follow-up support, that were culturally and age-appropriate, that were tailored to individual needs and preferences, and that addressed psychosocial issues and incorporated behavioral strategies. Both individual and group approaches have been found to be effective. Ultimately, however, individualization is the most important aspect of DSME and MNT for diabetes management and prevention.

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Brown C.
Evert A.
Reppert A.
Robinson M.

Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition intervention evidence reviews and recommendations.

^,

⁵⁵

Franz M.J.
Boucher J.L.
Evert A.B.

Evidence-based diabetes nutrition therapy recommendations are effective: The key is individualization.

^,

⁹⁴

American Association of Diabetes Educators
Individualization of diabetes self-management education.

^,

⁹⁵

American Association of Diabetes Educators
Position Statement: Individualization of diabetes self-management education.

^,

⁹⁶

Muller G.
Weser G.
Schwarz P.E.

The European perspective of diabetes prevention: The need for individualization of diabetes prevention.

Typically, programs involve both an RDN and a registered nurse as instructors and/or coordinators of the DSME program. The ADA and the AADE recognize that RDNs can also function as a diabetes instructor to deliver DSME in a single discipline education program. Instructors in recognized programs must achieve ongoing continued education hours specific to diabetes to maintain their role as a qualified instructor per recognition standards.

⁶²

American Diabetes Association. Education Recognition Requirements. 2015. http://professional.diabetes.org/content/recognition-requirement. Accessed January 21, 2016.

Google Scholar

^,

⁶³

American Association of Diabetes Educators. Diabetes Education Accreditation Program (DEAP). https://www.diabeteseducator.org/practice/diabetes-education-accreditation-program-(deap)/applying-for-accreditation. Accessed January 21, 2016.

Google Scholar

^,

⁹⁷

American Association of Diabetes Educators. Board Certified-Advanced Diabetes Management (BC-ADM). https://www.diabeteseducator.org/education-career/certification/bc_adm. Published November 15, 2015. Accessed April 7, 2016.

Google Scholar

RDNs have achieved comprehensive education and training and may pursue additional validating professional certification in treating individuals with prediabetes and diabetes. Some RDNs who choose to specialize in diabetes care may become a Certified Diabetes Educator (CDE) and/or become Board Certified in Advanced Diabetes Management (BC-ADM).

⁹⁷

American Association of Diabetes Educators. Board Certified-Advanced Diabetes Management (BC-ADM). https://www.diabeteseducator.org/education-career/certification/bc_adm. Published November 15, 2015. Accessed April 7, 2016.

Google Scholar

Within their scope of practice, CDEs and BC-ADMs can engage in adjusting medications, treating and monitoring acute and chronic complications, counseling individuals on lifestyle modifications, addressing psychosocial issues, and participating in research and mentoring. According to a 2015 survey report by AADE, approximately 91% of the RDNs who responded were CDEs and 2% were BC-ADMs; and 36% reported volunteering time to diabetes-related activities, which demonstrates significant professional engagement.

⁹⁸

Sherr D.
Lipman R.D.

The diabetes educator and the diabetes self-management education engagement: The 2015 National Practice Survey.

RDNs were 35% of the AADE membership respondents, demonstrating the number of RDNs who are involved in diabetes management and education. In addition, in 2015, 5,924 RDNs were members of Diabetes Care and Education Practice Group. Professionals involved in diabetes care contribute to community events and charitable organizations related to diabetes as well.

⁹⁸

Sherr D.
Lipman R.D.

The diabetes educator and the diabetes self-management education engagement: The 2015 National Practice Survey.

Support for the Role of Nutrition Therapy and/or RDNs

Guidelines from major medical and health organizations have recognized the essential role of MNT for the prevention and treatment of type 2 diabetes and/or the important role of RDNs.

²²

American Diabetes Association
Standards of medical care in diabetes—2017.

^,

⁵⁷

Powers M.A.
Bardsley J.
Cypress M.
et al.

Diabetes self-management education and support in type 2 diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.

^,

⁹⁹

Inzucchi S.E.
Bergenstal R.M.
Buse J.B.
et al.

Management of hyperglycemia in type 2 diabetes: A patient-centered approach: Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

^,

¹⁰⁰

European Federation of the Associations of Dietitians. Position Paper on the Role of the Dietitian in the Prevention and Management of Gestational and Type 2 Diabetes. 2012. http://www.idf.org/sites/default/files/Position%20Paper%20on%20the%20Role%20of%20the%20Dietitian%20in%20the%20Prevention%20and%20Management. Accessed October 7, 2015.

Google Scholar

^,

¹⁰¹

Garber A.J.
Abrahamson M.J.
Barzilay J.I.
et al.

Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm—2016 Executive Summary.

^,

¹⁰²

Jensen M.D.
Ryan D.H.
Apovian C.M.
et al.

2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.

The ADA states that MNT is an integral component of diabetes prevention, management, and self-management education.

²²

American Diabetes Association
Standards of medical care in diabetes—2017.

^,

⁵⁷

Powers M.A.
Bardsley J.
Cypress M.
et al.

Diabetes self-management education and support in type 2 diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.

In addition, all individuals with diabetes should receive individualized MNT, preferably provided by a RDN who is knowledgeable and skilled in providing diabetes MNT. In individuals with diabetes, individualized education sessions and comprehensive group diabetes education programs including nutrition therapy effectively improve blood glucose levels.

²²

American Diabetes Association
Standards of medical care in diabetes—2017.

^,

⁹⁴

American Association of Diabetes Educators
Individualization of diabetes self-management education.

One of the founding principles of the Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinologists on the Comprehensive Type 2 Diabetes Management Algorithm

¹⁰¹

Garber A.J.
Abrahamson M.J.
Barzilay J.I.
et al.

Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm—2016 Executive Summary.

is lifestyle optimization, which should begin with MNT counseling and education. The American College of Cardiology, the American Heart Association, and The Obesity Society also support the role of the RDN in the management of overweight and obesity in adults.

¹⁰²

Jensen M.D.
Ryan D.H.
Apovian C.M.
et al.

2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.

These professional organizations authenticate the importance of MNT and interventions of the RDN for diabetes care, as well as interventions for associated risk factors leading to the development of the disease.

Summary

Analysis of current research and evidence strongly supports the role of MNT and RDNs in the treatment and prevention of diabetes. Fundamental to the management of type 2 diabetes is the inclusion of MNT into the treatment plan for the individual with diabetes. MNT provided by RDNs can prevent progression of obesity to prediabetes, and from prediabetes to type 2 diabetes. RDNs are uniquely trained and have the skills to practice independently or as a team member in health care systems or public health programs. They have the ability to individualize care based on the person’s needs, abilities, and resources and to work collaboratively with individuals and health care providers to improve outcomes. MNT provided by RDNs must be deliberately integrated into diabetes management, diabetes prevention, and diabetes self-management education and support programs. Furthermore, evidence demonstrates the cost-effectiveness of MNT interventions. Diverse MNT interventions should be adequately reimbursed by third-party payers in current and future health care system environments for the treatment and prevention of prediabetes and diabetes.

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Published online: January 30, 2018

Footnotes

This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on October 19, 2017. This position is in effect until December 31, 2025. Position papers should not be used to indicate endorsement of products or services. All requests to use portions of the position or republish in its entirety must be directed to the Academy at [email protected]

Authors: Kathaleen Briggs Early, PhD, RDN, CDE, Pacific Northwest University of Health Sciences, Yakima, WA; Kathleen Stanley, MSEd, RD, LD, CDE, BC-ADM, MLDE, Baptist Health Lexington, Lexington, KY.

Both authors share equal authorship.

STATEMENT OF POTENTIAL CONFLICT OF INTEREST Kathaleen Briggs Early is a former Medtronic pump trainer/contractor (2006-2013). No potential conflict of interest was reported by Kathleen Stanley.

FUNDING/SUPPORT There is no funding to disclose.

Reviewers: Catherine Brown, MS, RD, CDE (WellDoc, Columbia, MD); Patricia Davidson DCN, RDN, CDE, LDN, FAND (West Chester University of PA, West Chester, PA); Sarah Picklo Halabu, RDN, LDN, CDE (Academy Publications and Resources, Chicago, IL); Carolyn C. Harrington, RD, LDN, CDE (Consultant, Venice, FL); Research dietetic practice group (Swarna Mandali, PhD, RDN, LD, University of Central Missouri, Warrensburg, MO); Lisa Moloney, MS, RDN (Academy Research, International and Scientific Affairs, Chicago, IL); Diabetes Care and Education dietetic practice group (Elizabeth Quintana, EdD, RD, LD, CDE, Sandia National Laboratories, Albuquerque, NM); Mary Pat Raimondi, MS, RD (retired, formerly Academy Policy Initiatives & Advocacy, Washington, DC); Weight Management dietetic practice group (Anne Wolf, MS, RD, NutritionFirst, Charlottesville, VA).

Academy Positions Committee Workgroup: Nurgul Fitzgerald, PhD, MS, RDN Rutgers, The State University of New Jersey, New Brunswick, NJ (chair); Tamara L. Randall, MS, RDN, LD, CDE, FAND, Case Western Reserve University, Cleveland, OH; Marion J. Franz, MS, RDN, CDE, Nutrition Concepts by Franz, Inc., Minneapolis, MN (content advisor).

We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the supporting paper.

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DOI: https://doi.org/10.1016/j.jand.2017.11.021

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Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes

Abstract

Clinical Effectiveness of MNT in the Management of Obesity, Prediabetes, and Type 2 Diabetes

Impact of MNT on Obesity

Impact of MNT on Prediabetes

Impact of MNT on Type 2 Diabetes

Cost-Effectiveness of MNT in the Prevention and Management of Diabetes

Roles and Responsibilities of RDNs in Diabetes Care

Implementation of MNT

Role of RDNs beyond MNT

Barriers to Access for RDN Services

Reimbursement for MNT

Medicare Reimbursement

Other Reimbursement for Nutrition Therapy

Nutrition Therapy and Diabetes Self-Management Education and Support

Support for the Role of Nutrition Therapy and/or RDNs

Summary

References

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Footnotes

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