Diabetes Spectrum
Volume 9, Number 2, 1996, Pages 97-98

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The Art of Nutrition: Multiple Aspects of Diabetes Medical Nutrition Therapy

Introduction
Madelyn L. Wheeler MS, RD, CDE, Co-Guest Editor

Alfred Harper, a world renowned nutritional biochemist, has described nutrition as both a science and a practice.^l,2 As a science, nutrition is multi-disciplinary, drawing many of its methods and concepts from physics, chemistry, biochemistry, physiology, pathology, genetics, and other areas. In the early part of the century, nutrition research resulted in a number of discoveries (vitamins, for example). More recently, results of nutrition research have been used as the scientific basis for making recommendations to the general population (lowering saturated fats in the diet to reduce risk of heart disease, for example).

The practice, or art, of nutrition is the application of this scientific knowledge when treating individual patients/ clients. Diabetes Medical Nutrition Therapy (MNT) is an example. (MNT is the general term for the practice of nutrition. Diabetes MNT is a more specific term used when relating the practice of nutrition specifically to people with diabetes. In more concrete terms, Tinker and associates³ represent diabetes MNT as a four-step, repeating process involving assessment, goal setting, intervention, and evaluation.)

Not only are the science and the practice of nutrition intimately related, but they also represent a process that is cyclical in nature. The science of nutrition provides the basis upon which to develop nutrition practice recommendations. The practice of nutrition reveals new problems and provides opportunities for new discoveries and further expansion of basic knowledge by the science of nutrition.

Diabetes nutrition science and practice provide a wonderful paradigm for this cyclical relationship. In 1993, the American Diabetes Association (ADA) convened a panel of experts to review the science of diabetes nutrition.^4,5 Based on these scientific reviews, practice recommendations,⁶ hereafter known as the 1994 Recommendations, were made. Because of the inherent nature of the cyclical process, the 1994 Recommendations generated a number of diabetes nutrition practice issues, which needed to be addressed. In this FROM RESEARCH TO PRACTICE section, authors who have been closely involved in this process discuss, explain, or interpret some of these practice issues.

One nutrition practice issue was that the 1994 Recommendations apply primarily to people receiving diabetes MNT on an outpatient basis and living in a home setting. Can these recommendations be implemented in settings such as hospitals or long-term care facilities, and if so, how? Becky Schafer, chair of the ADA task force charged with translating 1994 Recommendations for health-care facilities, and Sue McLaughlin, a member of that task force, provide information on the current status of implementation and the process the task force is using to develop recommendations for implementation (p. 118).

Another issue was the need to update current diabetes educational materials and develop new materials to reflect the 1994 Recommendations. To address this task, a steering committee representing both the ADA and The American Dietetic Association and its Diabetes Care and Education Practice Group was formed. After two years, which involved hundreds of dedicated hours and hundreds of volunteer dietitians, other health professionals, and people with diabetes, the task was completed.⁷ Included here are articles about some of the resulting new products. (In addition to the resources described below, the Exchange Lists for Meal Planning were updated by a subcommittee chaired by Harold Holler. )

. Brenda Broussard, chair of the subcommittee responsible for developing "The First Step in Diabetes Meal Planning" (sometimes better known as the Diabetes Food Guide Pyramid) provides suggestions for using this stand-alone resource. (p. 103)

.Hope Warshaw and LeaAnn Holzmeister, co-chairs of the subcommittee responsible for developing the "Single-Topic Diabetes Resources," describe how to take advantage of these helpful, interactive reproducible handouts and corresponding professional information. (p. 105)

· Anne Daly, chair, and Sandy Gillespie and Karmeen Kulkarni, members of the subcommittee responsible for creating the popular new "Carbohydrate Counting" patient education booklets, provide examples from their own experiences of issues and problems to be solved using that meal-planning method. (p. 114)

These new resources provide new options for diabetes meal planning. Now the challenge for practitioners is to determine the best diabetes MNT approach to take for each patient/client. Joyce Green Pastors, chair of the subcommittee to develop Facilitating Lifestyle Change: A Resource Manual shows us how to effectively use nutritional assessment for this purpose.(P. 99).

The ADA and The American Dietetic Association will publish later this year another diabetes nutrition resource: a comprehensive guide to diabetes MNT for professionals. Although not yet available for review, Diabetes Medical Nutrition Therapy: A Guide for Professionals,⁸ promises to be an invaluable tool, not only for dietitians, but also for diabetes nurses and all other members of the diabetes health-care team. It is edited by Joyce Green Pastors and Harold Holler.

A third major practice issue for nutrition, just as for other health disciplines, centers around development of a logical system for providing care, and then the evaluation of that care. What are the practice guidelines for diabetes MNT? As provided, is diabetes MNT cost effective?

In the early part of this decade, The American Dietetic Association identified as a priority developing practice guidelines for nutrition care and conducting studies to evaluate how the use of these guidelines affects the clinical outcomes and cost-effectiveness of nutrition care. Non-insulin- dependent diabetes mellitus (NIDDM) was chosen to be the first area studied, and a contract was awarded to develop, field-test, and evaluate practice guidelines for MNT for NIDDM.⁹ The rest is history.^l0-l3

. Marion Franz, principal investigator of the NIDDM practice guidelines study described above, and associates provide a summary of the study design, the results, and the cost-effectiveness data. They also provide a primer on types of evaluations, and pull it all together by providing a proposed cost-effective model for the management of NIDDM. (p. 122)

. Patricia Splett, a nationally known authority in the field of cost-effectiveness techniques for evaluating nutrition care, critically reviews and provides thought-provoking commentary on the published report of the study by Franz and associates and another research article about the effectiveness of diabetes MNT. (p. 131 and p. 133)

. What about insulin-dependent diabetes mellitus? Diabetes Care and Education, a Practice Group of The American Dietetic Association, took on the challenge of developing these practice guidelines, using the NIDDM guidelines mentioned above as a prototype. Carolyn Leontos and Patricia Splett, members of the committee charged with this task, describe the development and field testing of nutrition practice guidelines for this subgroup of people with diabetes. (p. 128) (Coguest editor Karmeen Kulkarni chaired this committee).

A final nutrition practice issue was determining and overcoming barriers to providing diabetes MNT for people with diabetes.

. Sandy Gillespie, an expert on reimbursement and lobbying issues, finds a parallel in the issues of reimbursement for diabetes self-management training and for MNT. She describes the problems and the challenges, and eloquently makes the point that we (nurses, dietitians, doctors, and other members of the health-care team) all need to be active advocates for reimbursement, as it is ultimately in the best interest of our patients/ clients with diabetes. (p. 135)

· Finally, although diabetes treatment is a team approach and there is cross-training at a basic level, few non-dietitian health practitioners have the desire or the training to provide diabetes MNT. Margaret Powers describes how to access dietitians who can provide the whole spectrum of diabetes MNT. (p. 119)

We hope this FROM RESEARCH TO PRACTICE section not only illustrates the cyclical nature of diabetes nutrition science and practice, but also provides you with helpful information and new resources to use in your practice today.

References

¹Harper AK: Nutrition: Where are we? Where are we going? Am J Clin Nutr 22:87-98, 1969.

²Harper AK: 1990 Atwater lecture. The science and the practice of nutrition: reflections and directions. AmJ Clin Nutr 53 :413-20, 1991.

³Tinker LF, Heins JM, Holler HJ: Commentary and translation: 1994 nutrition recommendations for diabetes. J Am Diet Assoc 94: 507-11, 1994.

⁴Franz MJ, Horton ES, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, Henry RR, Hoogwerf BJ, Stacpoole PW: Nutrition principles for the management of diabetes and related complications. (Technical Review) Diabetes Care 17:490-518, 1994.

⁵Henry RR: Protein content of the diabetic diet. (Technical Review) Diabetes Care 17: 1502-13, 1994.

⁶American Diabetes Association: Position Statement: Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care. 19 (Suppl l):S16-19, 1996.

⁷Wheeler ML: New diabetes nutrition resources available. Diabetes Spectrum 8:254-55, 267, 1995.

⁸Green Pastors J, Holler HH (Eds): Diabetes Medical Nutrition Therapy: A Guide for Professionals. Alexandria Va: American Diabetes Association and The American Dietetic Association, 1996. In preparation

⁹Carey M: Diabetes guidelines, outcomes, and cost-effectiveness study: a protocol, prototype, and paradigm. J Am Diet Assoc 95:976-78, 1995.

¹⁰Franz MJ: Practice guidelines for nutrition care by dietetics practitioners for outpatients with non-insulin-dependent diabetes mellitus: Consensus Statement. J Am Diet Assoc 92: 1136-39, 1992.

¹¹Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ: Practice guidelines for medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc 95:999-1006, 1995.

¹²Franz MJ, Monk A, Barry, B, McClain 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.

¹³Franz MJ, Splett PL, Monk A., Barry B, McClain K, Weaver T, Upham P, Bergenstal R, Mazze R: Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc. 95:1018-24, 1995.

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