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Medical Nutrition Therapy-MNT in Diabetes PowerPoint Presentation

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Medical Nutrition Therapy (MNT) in Diabetes, A Consensus Report by the American Diabetes Association Part 1: ADA MNT Consensus Report 2019: The Evidence and Practice Guidance
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Janice MacLeod MA, RDN, LD, CDE, FAADE Head of Clinical Advocacy @ Companion Medical San Diego, CA
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Alison Evert MS, RDN, CDE UW Medicine – UW Neighborhood Clinics Manager, Nutrition and Diabetes Programs Seattle, WA
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Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: Presenter: Alison Evert, MS, RD, CDE – N/A Presenter: Janice MacLeod, MA, RDN, CDE, FAADE – Employee of Companion Medical Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration.
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What’s new in the 2019 Nutrition Therapy for Adults with Diabetes or Prediabetes Consensus Report? Prevention/Prediabetes Eating Patterns – such as Ketogenic and VLC, Intermittent Fasting and Very Low-fat (Ornish) and Paleo Emphasis on options for weight loss & management Diabetes Remission Gastroparesis Protein/Fat effect on insulin dosing Personalized nutrition Linking MNT to medical management -organization approved protocols Technology-Enabled tools
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One-Size-Fits-All does not fit
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People make decisions, not evidence SHARED DECISION MAKING BMJ 2002;324:1350 | Evidence based practice | Research enhanced health care | Person Centered Care
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Bridging the Gap:What we know vs. what we do Katz D, JAND, 2012;XX:313
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Goals of nutrition therapy
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Are nutrition and diabetes education interventions effective in improving outcomes?
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Sorting through the acronyms *AADE Practice Synopsis Healthy Eating, 2015 **AADE. The scope of practice, standards of practice, and standards of professional performance for diabetes educators. 2011
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Consensus Recommendations Refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT at diagnosis and as needed throughout the life span and during times of changing health status to achieve treatment goals. Coordinate and align the MNT plan with the overall management strategy, including use of medications, on an ongoing basis. Refer adults with diabetes to comprehensive diabetes self-management education and support (DSMES) services according to national standards. Diabetes-focused MNT is preferably provided by an RDN who has comprehensive knowledge and experience in diabetes care. Diabetes MNT is a covered Medicare benefit and should be adequately reimbursed by insurance and other payers, or bundled in evolving value-based care and payment models.
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Consensus Recommendations Refer adults with diabetes to comprehensive diabetes self-management education and support (DSMES) services according to national standards.
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Is MNT clinically and cost effective?
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How should MNT be implemented?
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Key Considerations One –Size-Fits-All does not fit Not once and done but continuous and evolving Must be aligned with medical management CHW/Peer Coach for ongoing support Technology-enabled solutions needed to extend access and reach Digital health enables data-driven, on-demand encounters virtually or FTF
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Refer to MNT: With newly diagnosed diabetes/pre-diabetes as component of comprehensive evaluation Experiencing change in therapy With a new diagnosis or other change in health status affecting nutritional status Source: AADE. The scope of practice, standards of practice, and standards of professional performance for diabetes educators. 2011 Diabeteseducator.org/JPStoolkit
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Potential of Digital Health in Diabetes 24/7 Individualized, automated coaching and support Analyzed, Actionable Patient-Generated Health Data Connection to the individual’s own care team Engaged patients Engaged care teams
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Digital Health in Diabetes: The Evidence Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management and Support 265 articles reviewed, 25 selected for data abstraction Reductions in A1C ranged from 0.1% to 0.8% Interventions that were most effective included the full Technology Enabled Self-Management (TES) Feedback Loop Analyzed Patient Generated Health Data (PGHD) Tailored individualized feedback Two-way communication Individualized education Greenwood D, Gee P, Fatkin K, Peeples M. A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support. Journal of Diabetes Science and Technology. DOI:10:117711193226817713506 1-13. Technology-Enabled Self-Management (TES) Feedback Loop
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What needs to happen to assure PWD have access to quality MNT/DSMES?
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Reducing barriers to referrals MNT integrated with Medical Management and embedded at the POC Technology-enabled Use of CHW/Peer coaches to facilitate ongoing support Higher quality research Ongoing cost-effectiveness research
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Hope To Answer The Question For Those Who Seek Our Care:What Can I Eat?
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Issues with Nutrition Research Large, rigorous clinical trials lacking Most studies short-term Controlling intervention arms difficult &/or costly Can study outcomes be implemented long-term?
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To Complicate Matters…. Nutrition recommendations change over time, just like other fields of medicine. “It is easier to change a man’s religion than his diet.” Margaret Mead, anthropologist For example:
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Consensus Recommendations Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes, therefore macronutrient distribution should be based on an individualized assessment of eating patterns, preferences, and metabolic goals.
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Macronutrients Difficult to put foods in precise categories People eat food not individual macronutrients
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Macronutrients: “What Do You Notice?”Emmy Suhl, MS, RD, CDE DCE: On the Cutting Edge1 What happens after you eat a meal or a particular food to your glucose?1 Less about rules and formulas, more about “trial and error” Important to develop individualized troubleshooting skills Glucose monitoring2 Valuable tool for assessing food, activity, and medications when data used for decision-making. Can provide insights into the influence of macronutrients on meal-time glucose response. 2Lyons L, et al. ADA Guide to Diabetes Nutrition Therapy. 3rd Edition, 2017
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Macronutrients: “What Do You Notice?”Emmy Suhl, MS, RD, CDE DCE: On the Cutting Edge What would you do differently next time? Change an amount? Change an ingredient? Enjoy the food or meal, understanding how it impacts glucose?
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What’s the best eating plan for people with diabetes and prediabetes?
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Eating Plans to Manage Prediabetes and Reduce Risk of Type 2 Most robust research: Mediterranean-style (Med-style), low-fat, and low-carb PREDIMED trial, compared Med-style vs low-fat, found 30% lower relative risk with the Med-style Epidemiologic studies correlate Med-style, vegetarian, DASH eating plans with lower risk, with no effect for low carb Given limited evidence, unclear which eating plan is best
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Eating Plans to Manage Type 2 Diabetes Evaluated in ADA Report: Mediterranean-Style Vegetarian or Vegan Low-fat Very-Low Fat Ornish or Pritikin Low-Carb & Very-Low Carb DASH Intermittent Fasting Paleo
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Guiding Principles Emphasize non-starchy vegetables. Minimize added sugars and refined grains. Choose whole grains over highly processed foods to the extent possible What the individual is able to follow
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Bottom line: Evidence does not support a clear preference for a specific eating pattern Diabetes Care. 2019; 42(5):731-754 MacLeod J, et al. JAND. 2017; 117:1637–1658
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Consensus Recommendations Refer people with prediabetes and overweight/obesity to an intensive lifestyle intervention program that includes individualized goal-setting components, e.g. DPP
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Setting Realistic Expectations 45 million Americans go on diets every year, most fail to meet their goals Unfortunately our goals and our patient goals – may be unrealistic The Science of Obesity Management: An Endocrine Society Scientific Statement: Endocrine Reviews. 2018, 39(2):1–54
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In Type 2 Diabetes, For Individuals That Are Overweight Or Obese At least 5% weight loss is recommended to achieve clinical benefit. Benefits are progressive too! Goal for optimal outcomes 15% or more when needed and can be feasibly and safely accomplished. Diabetes Care. 2019; 42(5):731-754
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For Individuals that are Overweight or Obese Diabetes Care. 2019; 42(5):731-754
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As a frame of reference: 7% (or) 15% Weight Loss
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Additional Weight Loss & MaintenanceTake-aways Diabetes Care. 2019; 42(5):731-754
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Progressive Nature of T2D Because of the pathophysiology of type 2 diabetes: β-cell decline Insulin resistance “Diet & exercise” don’t fail It’s not a personal failure, it’s a pancreatic failure
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Natural History of Type 2 Diabetes Adapted from: International Diabetes Center (Minneapolis, Minnesota). Insulin resistance RelativeFunction (%) 250 200 150 100 50 0 Years of Diabetes -10 -5 0 5 10 15 20 25 30 Insulin secretion Glucose (mg/dL) 350 300 250 200 150 100 50 -10 -5 0 5 10 15 20 25 30 FPG PPG Diabetes Insulin Deficiency
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Diabetes Remission Evidence indicates that intensive lifestyle interventions that result in ≥ 5-10 % of body weight, have varying rates of diabetes remission studies in T2D report reduction at ~ 60% Remission defined by ADA in report, glucose in prediabetes range and no diabetes medications for up to one year
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Until Evidence Strengthens Focus On:Lifestyle intervention strategies with ongoing support – in person or onlineWhat the person is able to follow
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Resources Beck J, Greenwood DA, Blanton L, Bollinger ST, Butcher MK, Condon JE, Cypress M, Faulkner P, Fischl AH, Francis T, Kolb LE, Lavin-Tompkins JM, MacLeod J, Maryniuk M, Mensing C, Orzeck EA, Pope DD, Pulizzi JL, Reed AA, Rhinehart AS, Siminerio L, Wang J; 2017 Standards Revision Task Force. 2017 National Standards for Diabetes Self-Management and Support. Diabetes Care. 2017; 40(10):1409-1419, Jul 28. pii: dci170025. Franz MJ, MacLeod J, Evert A, Brown C, Gradwell E, Handu D, Reppert A, Robinson M. Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet. 2017;117(10):1659-1679. MacLeod J, Franz, MJ, 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. J Acad Nutr Diet. 2017;117(10):1637-1658. Powers MA, 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. Diabetes Care 2015;38:1372–1382.