Volume 13 Number 3, 2000, Page 122
The New Shape of Medical Nutrition Therapy
Melinda Downie Maryniuk, MEd, RD, CDE, FADA
"A patient can be treated successfully even though he does not know what a calorie is, what a gram represents or the meaning of the words carbohydrate, protein and fat. Indeed, many of my patients can not read or write. But I think if one has a disease, it is more fun to know something about it."
E.P. Joslin, MD, 19341
Nutrition is both a therapy and a topic for self-management education. While it is "more fun" to know something about it, it can be a frustrating challenge for patients and health care professionals given the wide array of nutrition messages that seem to make headlines on a weekly basis.
As Madelyn L. Wheeler, MS, RD, FADA, CDE, notes in her editorial in this issue (p. 116), medical nutrition therapy (MNT) for diabetes care has appeared in many different forms through the ages. Commonly described as the cornerstone of diabetes care, it might be better depicted as a lump of claycontinuously being reshaped, redesigned, and reformed.
Historically, one of the challenges to MNT commanding the respect it deserved was the lack of solid clinical research to support nutrition recommendations. This is slowly changing, as recent evidence has demonstrated the effectiveness of MNT in improving clinical outcomes and decreasing costs.2-4
A meta-analysis of 89 studies that looked at a wide variety of weight loss methods showed that diet alone had the largest statistically significant impact on weight loss and metabolic control.5
Still, people with diabetes report that nutrition therapy remains the most difficult part of their diabetes care plan. Lifelong behaviors are hard to change. Also, people with diabetes often get nutrition information not from registered dietitians or trained experts, but rather from well-intentioned but misinformed family members or friends. Thus, nutrition education first must focus on correcting any nutrition myths and misinformation that patients have learned.
Meanwhile, many health care providers have misconceptions of their own surrounding nutrition and meal planning. Consider the following two statements, which diabetes patients commonly hear from primary care providers.
"You'll need to get a diabetic diet. You can get one from a dietitian."
At least this provider did not tear off a sheet from a preprinted pad of diets, but the message still sounds like a diet is something that you can just pick up while running errands.
MNT is like pharmacotherapy. A physician would not order the same type and dose of insulin for all people with diabetes. Likewise, dietitians have many options to consider, and each can be effective in meeting goals. Determining the best approach requires a detailed assessment and understanding of each patient's lifestyle, usual intake, metabolic and personal goals, and readiness to change.
A meal plan can take many different forms, including a pyramid, a plate divided into quarters, a traditional exchange list approach, a set of carbohydrate goals for each meal and snack, a collection of suggested menus, or a list of personalized behavioral goals. Like pharmacotherapy, its effectiveness must be evaluated through blood glucose monitoring and follow-up, and adjustments must be made if necessary. The impact of MNT can usually be seen between 6 weeks and 3 months. Based on the dietitian's follow-up assessment, if therapeutic goals are not achieved, it is important to advance medication therapy.
"It's time to start on medication because the diet failed."
This is one more example of how health care professionals deliver judgmental messages to patients that can affect their belief in their ability to care for themselves. We should avoid talking about "good" and "bad" blood glucose numbers, "right" and "wrong" foods, "failed" diets, or blood glucose "testing" with "excellent" or "poor" results. It is no wonder that depression is three times more common in adults with diabetes.
For many people, diets don't "fail," but the disease progresses such that MNT alone can no longer achieve target goals for glycemic control. If there is a "failure"of diet or drug therapy, it is the failure of the health care provider to find the right therapeutic match for the patient in terms of the right meal planning approach or the right combination of medications.
In this From Research to Practice section, we feature three important areas of nutrition care: carbohydrate counting, the impact of protein on the diabetes meal plan, and current research findings on behavioral approaches to weight management. Since nutrition behaviors have always been recognized as the most difficult of all the diabetes-related skills to change, we begin with a special feature on readiness to change.
Adopting a Patient-Centered Approach to Nutrition
E.P. Joslin, 19341
In the early days of insulin when carbohydrate was being gradually reintroduced to the diet, a typical carbohydrate allowance, as described in Joslin's manual, included three medium size oranges, three slices of bread, four ounces of cream and four ounces of whole milk, and four portions of 5-percent vegetables (non-starchy vegetables, such as green beans, spinach, broccoli, and carrots). Today, we recognize the importance of a person being ready to change and empowered to adopt new behaviors rather than simply relying on "tactful wives."
We avoid labeling someone as "a diabetic," preferring instead the term "person with diabetes." We talk about "meal plans," rather than "diets." Meal plans are not designed for patients to "follow," but instead are developed with patients for their "use." Blood glucose is "checked" or "monitored" rather than "tested" to help us provide nonjudgmental feedback on the effectiveness of the meal plan. To quantify food intake and illustrate portion sizes, "exchanges" are not the only choice, but are instead one of several options available to dietitians.
Nutrition counseling sessions focus not so much on the facts of food composition, but on discussing obstacles to using a meal plan, identifying factors that have key effects on diabetes control, and learning how to modify those factors. This is done through problem-solving and goal-setting as well as incorporating an understanding of the patient's readiness to change.
The article by Laurie Ruggerio, PhD, (p. 125) provides useful tips for enhancing behavior change and nutrition counseling skills through an understanding of the transtheoretical model of change. Her detailed case study will help readers apply these concepts in practical situations.
Protein Recommendations: From Practice to Research to
John Rollo's diet for Captain David Meredith, 17977
High-protein, high-fat, low-carbohydrate diets were the recommended therapy in the pre-insulin era. Today, the "benefits" of high-protein diets are being touted everywhere you look. At the same time, people with diabetes have been receiving all kinds of messages about protein: when to eat it, how much to eat, what it will or won't do to blood glucose, and whether high intakes will or won't hasten the development of renal disease.
A true investigative scientist, Marion Franz, MS, RD, LD, CDE, has spent that past few years researching what published evidence there is to uphold the recommendations that have been commonly given to patients. She has discovered that many of these messages are not supported by scientific data.
Her excellent article (p. 132) provides food for thought about the way we practice and the common messages we give to patients. She stimulates us to review the research, examine the data, and think about how we might reframe our messages.
Weight Control: A Focus on Key Behaviors
E.P. Joslin, 19341
Obesity is an epidemic. Despite a decrease in the total fat content of the American diet, the rising numbers of low-calorie foods, and the proliferation of weight-loss programs and health clubs, more people than ever are overweight. The incidence of type 2 diabetes and obesity in children is also increasing at an alarming rate. And weight-loss efforts continue to yield poor long-term results.
For many years, a meal plan for someone with diabetes might have been described as a weight-loss diet. One might think of a 1,200-calorie diet for women and a 1,500-calorie plan for men. Unfortunately, the idea of a restricted-calorie diet was carried into meal plans for children, who need additional calories to grow.
This emphasis on low-calorie diets has had a negative effect on many people with diabetes. Some did not get adequate calories, while others felt they had "failed" if they were not able to meet weight-loss goals. Today, we focus patient efforts not on weight loss, but rather on blood glucose control. Treatment objectives should not focus on pounds lost but on behaviors changed that will lead to improved glycemic control.
Cheryl F. Smith, PhD, and Rena R. Wing, PhD, (p. 142) have summarized a strong collection of research studies that demonstrate key behaviors closely related to improved outcomes in weight control and glycemic control. Readers will find numerous practical tips for enhancing the success of weight-control interventions based on the research results described in this article.
Carbohydrate Counting: A Return to the Basics
E.P. Joslin, 19341
In the Joslin historical collection, there is an organized, pocket-sized notebook that was once owned by a young man with type 1 diabetes. Back in about 1929, he was carefully recording each food he ate, the grams of carbohydrate that portion of food contained, and the amount of regular insulin he injected. These early records of carbohydrate and insulin intake show that the carbohydrate-to-insulin ratio concept is not new. But like much of MNT, the research demonstrating its effectiveness is only now being done.
While carbohydrate counting gained recognition from the Diabetes Control and Complications Trial, it is not just for individuals with intensively managed type 1 diabetes. Details on using carbohydrate counting in clinical practice are described elsewhere.8 Here, we offer (p. 149) a collection of case studies illustrating the application of this approach to different population groups and in institutional settings.
There is no evidence indicating that one approach to meal planning is more effective than another. Identify-ing what an individual is willing and able to do and what specific behaviors will be addressed is crucial. Whether those behaviors involve knowing exchange lists, counting servings of carbohydrate, determining a carbohydrate-to-insulin ratio, or keeping track of fat grams matters not, as long as the patient achieves the desired results.
The Shape of Things to Come
But perhaps more important than the recommendations themselves is their translation into actual meal planning for people with diabetes. Ultimately, it is the people with diabetes who face decisions every few hours of every single day regarding exactly what, when, and how much to eat. As nutrition therapy and education focuses more on problem-solving skills, flexible meal planning options, and making informed choices, people with diabetes should be more successful in achieving their desired metabolic and behavioral goals.
2Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ: Practice guidelines for medical nutrition therapy by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc 95:999-1008, 1995.
3Franz MJ, Monk A, Barry B, McLain K, Weaver T, Cooper N, Upham P, Bergenstal R, Mazze RS: Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. J Am Diet Assoc 95:1009-17, 1995.
4Kulkarni K, Castle G, Gregory R, Holmes A, Leontos C, Powers M, Snetselaar L, Splett P, Wylie-Rosett J: Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. J Am Diet Assoc 98:62-70, 1998.
5Brown SA, Upchurch S, Anding R, Winter M, Ramirez G: Promoting weight loss in type II diabetes. Diabetes Care 19:613-24, 1996.
6Rabasa-Lhoret R, Garon J, Langelier H, Poisson D, Chiasson J-L: Effects of meal carbohydrate content on insulin requirements in type 1 diabetic patients treated intensively with the basal-bolus (ultralente-regular) insulin regimen. Diabetes Care 22:667-73, 1999.
7Leeds AR: The dietary management of diabetes in adults. Proc Nutr Soc 38:365-71, 1979.
8Gillespie SJ, Kulkarni KK, Daly AE: Using carbohydrate counting in clinical practice. J Am Diet Assoc 98:897-905, 1998.
Copyright © 2000 American Diabetes Association
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