Medical Nutrition Therapy

Introduction:

The concept of medical Nutrition Therapy (MNT) was introduced in 1994 by the American Dietetic Association which is the world’s largest organization of food and nutrition professionals. MNT was formulated with the view to propagate the importance of therapeutic nutrition.
MNT or nutrition therapy is thus defined as nutritional diagnostic, therapy, and counselling services for the management of disease.
Research suggests that the health and the quality of life of the patients who received MNT intervention improved. Academy of Nutrition and Dietetics suggests that the MNT is an “integral component” of the health care and the management of the different diseases such as diabetes, heart diseases, osteoporosis, chronic kidney disease and cancer.

Thus, MNT is a tailored dietary prescription that involves diet counselling depending upon the person’s dietary requirements. It involves an individualized dietary assessment and can be offered to anyone who has an altered nutrition profile, including infants, children, adolescents and adults. It is also of significant importance in pregnant and nursing women and in different medical conditions (diabetes, obesity, hypertension, dyslipidaemia, and cardiovascular diseases).

Goals of MNT

  • Prevent and manage disease
  • Enhance medication effectiveness,
  • Maintain nutritional status
  • Prevent adverse complications associated with the disease
  • Help patients to recover quickly and spend less time in hospital

Process of MNT

MNT consists of 2 steps

  • Step 1 – Conduction of nutrition assessment
  • Step 2 – Development and implementation of the nutrition care plan

Step 1 – Conduction of nutrition assessment – The first step of MNT includes the complete analysis of the medical, nutrition and medication history of the patient. The data thus obtained help the Registered Dieticians) RDs to stratify the patients based on the risk of nutritional deficiencies. This step includes checking the person’s nutrition status, and providing the correct food or nutrients to manage the conditions such as diabetes, heart disease and cancer.5,7

Step 2 – Development and implementation of the nutrition care plan – The second step of MNT is to develop a nutrition plan based on the assessment. The nutrition plan may include providing simple changes in the diet of the patient. RDs ensure the implementation of the nutrition care plan. The nutrition therapies suggested by the RDs help the patients to manage the disease condition.5,7

MNT in chronic diseases

In chronic diseases such as diabetes mellitus, gestational diabetes, obesity, hypertension, disorders of lipid metabolism, heart failure, osteoporosis, celiac diseases, and chronic kidney diseases, adoption of MNT has proved beneficial.

  • Diabetes – In comparison to the pharmacotherapy, or no intervention, adoption of MNT has proven to be cost-effective in prevention of diabetes.8 In a study, in persons with diabetes, use of MNT for 3 to 6 months resulted in the reductions in HbA1c between 0.25% to 2.9% depending on the type and duration of diabetes. Persons who adhere to MNT also showed an improved lipid profile, weight management, and decreased need for medication.8
American Association of Clinical Endocrinologists(AACE)/American Diabetes Association(ADA) nutritional guidelines for the management of diabetes
Intake of hypocaloric (weight loss) diet: 250 to 1000 kcal/day deficit
Target: decrease weight by 5% to 10% for overweight/obese, 15% for class 3 obesity
Target: decrease BMI by 2 to 3 units
Intake of carbohydrates (preferably low-glycemic index): 45% to 65% daily energy intake and not less than 130 g/d in patients on low calorie diet
Intake of protein: 15% to 20% daily energy intake
Intake of dietary fat: <30% daily energy intake
Intake of saturated fat: <7% daily energy intake
Intake of cholesterol: <200 mg/day
Intake of fiber: 25 to 50 g/day
Intake of trans fats: minimize or eliminate
  • Gestational diabetes – The main objective of MNT in managing gestational diabetes is to maintain adequate pregnancy weight along with fetus growth while maintaining euglycemia and without ketosis, which overall improves glycemic control.9 In women with gestational diabetes, an analysis of the evidence recommended the implementation of MNT within 1 week of identification of impaired glucose tolerance. An early MNT implementation has proven to reduce hospital admissions and insulin use.8
  • Obesity – The measures of obesity used in the clinical practice are BMI and waist circumference.10
· Normal BMI: 18 to 22.9 kg/m2
· Overweight: 23 to 24.9 kg/m2
·  Obesity: >25 kg/m2

 

Studies in persons with obesity have suggested that MNT can statistically and significantly reduce the body weight.8 A dietician can help in making definitive lifestyle changes such as including regular exercise in daily regime, moderation in alcohol consumption, abstaining from smoking, stress reduction, and modifications in diet such as lowering the intake of total and saturated fatty acids, increasing plant based diets along with monitoring the sodium content in the diet.11

  • Disorders of lipid metabolism – MNT has proved to be a cost-effective method to prevent and treat lipid disorders in patient. The combination of medications and MNT for managing severe forms of lipid disorders has resulted in lower dosage and lesser side-effects.8
  • Chronic kidney failure – Renal diseases are often the complication of diabetes and hypertension. . In patients with renal disease, the diet therapy helps to maintain good nutrition, slows down the progression of disease, and helps to treat complications. The main diet constituents that slows down the progression of disease are8,12:
    1. Blood pressure should be controlled (less than 140/90 mm Hg) by limiting sodium intake to 2300 mg a day and by delimiting the potassium intake if serum potassium is greater than 5 mEq/L.
    2. Albuminuria should be controlled by reducing the dietary protein intake
      For nondiabetic: 0.8 g protein/kg/day
      For diabetic: 0.8 to 1 g protein/kg/day
    3. By controlling diabetes

 

Integrating MNT and Pharmacotherapy

In cases where optimal management of specific disease states and conditions cannot be achieved with MNT alone and pharmacotherapy is required, a team approach with active collaboration among registered dieticians and other health care team members should be promoted.8

Role of dietician in management of MNT for patients receiving pharmacotherapy8

  • Prepares a customized nutrition prescription depending upon the patient’s energy, macronutrient, mineral, vitamin, fibre and fluid requirements, and the effect of medicines.
  • Intervenes with foods, supplemental nutrients, parenteral and enteral nutrition, and also basic lifestyle and exercise adjustments.
  • Collaborates with pharmacists and gains information on potential drug-nutrient interactions, and adjusts patient’s diet accordingly to achieve optimal therapeutic benefit.

Need for Nutrition Supplementation

As the nutritional professionals possess the expertise in the composition of food and nutrient metabolism, as MNT providers they customize food intake in collaboration with food preferences and lifestyle habits of an individual.8
Nutrition supplements are not intended to substitute food and cannot replicate all the nutrients present in whole foods; however supplements are a useful and effective way to obtain essential nutrients that might otherwise be lacking in routine diet.13

Use of supplements is recommended in the following situations13,14:

  • There is an increased demand of nutrients in the body during pregnancy, especially of protein, iron, folate and calcium.
  • People who are vegan or vegetarians eat a limited variety of foods and may suffer from nutritional deficiencies.
  • People who consume less than 1600 calories a day.
  • Older adults have higher requirements of vitamin B12 and Vitamin D.
  • Women who experience heavy bleeding during menstrual cycles.
  • People who have a medical condition which affects the metabolism of nutrients.
  • People who have had a surgery and are unable to digest and absorb nutrients adequately.
  • Children who are picky eaters and consume a diet deficient in nutrients such as proteins, DHA, vitamins and minerals (especially calcium and iron).

 

Summing up

MNT is a tailored dietary prescription that involves diet counselling depending upon the person’s dietary requirements. MNT is of significant importance in pregnant and nursing women and in different medical conditions. In chronic diseases adoption of MNT has proved beneficial and is an “Integral component” of the health care and management of different diseases such as diabetes, heart diseases, osteoporosis, chronic kidney disease and cancer. Active collaboration among registered dieticians and other health care team members including pharmacists should be promoted in cases where optimal management of specific disease conditions requires pharmacotherapy along with MNT. Nutrition supplements are recommended for those who lack nutrients in their diet, have a condition associated with altered nutrient metabolism, or have an increased nutrient requirement due to certain physiological states.

 

References

  1. Morris SF, Wylie-Rosett J. Medical nutrition therapy: a key to diabetes management and prevention. Clin Diabet 2010;28(1):12-18.
  2. Mechanick JI, Marchetti AE, et al. Diabetes-specific nutrition algorithm: a transcultural program to optimize diabetes and prediabetes care. Curr Diab Rep. 2012;12:180–94.
  3. American Dietetic Association. Initial Step: American Dietetic Association says medical nutrition therapy is “integral component” of disease treatment [Press Release]. 2010 [cited 2017 Oct 04]. Available from http://www.eatrightpro.org/resource/media/press-releases/positions-and-issues/medical-nutrition-therapy-is-integral-component-of-disease-treatment.
  4. Taber’s Medical Dictionary Online. 22nd ed. F.A. Davis Company; 2014. Available from http://www.tabers.com/tabersonline.
  5. National Cancer Institute. NCI Dictionary of Cancer Terms. 2016. Available from http://www.cancer.gov/dictionary.
  6. Kentucky Public Health. Community nutrition and medical nutrition therapy. 2015. Available from http://www.eatrightpro.org/resource/media/press-releases/positions-and-issues/medical-nutrition-therapy-is-integral-component-of-disease-treatmenthttp://chfs.ky.gov/NR/rdonlyres/46C003CD-D57F-4523-82A4-55E1CBE31E45/0/6CommunityNutritionandMNT.pdf.
  7. Gilbreath JL, Biesemeier C. Medical nutrition therapy: a powerful toll in disease management. Am J Manage Care. 1999;5(1):81-88.
  8. American Dietetic Association. Position of the American Dietetic Association: integration of medical nutrition therapy and pharmacotherapy. J Am Diet Assoc. 2010;110:950-56.
  9. Moreno-Castilla C, Mauricio D, Hernandez MN. Role of medical nutrition therapy in the management of gestational diabetes mellitus. Curr Diab Rep., 2016;16:22.
  10. Misra A, Chowbey P, Makkar BM, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the Metaboli Asian Indians and recommendations for physical activity, medical and surgical man. J Assoc Physicians India., 2009;57:163-70.
  11. Raj S. Introduction. In: Misra R, editor. Indian foods: AAPI’s guide to nutrition, health and diabetes. 2nd ed., Chapter 1. Anna Salai, Chennai: Allied Publishers Pvt. Ltd., p. 1-5.
  12. National Kidney Disease Education Program. Chronic kidney disease (CKD) and diet: assessment, management, and treatment. Treating CKD patients who are not on dialysis: an overview guide for dietitians. 2015. Available from https://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/a-z/Documents/ckd-diet-assess-manage-treat-508.pdf.
  13. Mayo Clinic. Healthy lifestyle: nutrition and healthy eating. 2014 [cited 2017 Oct 11]. Available from http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/supplements/art-20044894.
  14. Signutra. Growth and nutrition [Internet]. 2017 [cited 2017 Oct 11]. Available from http://signutra.com/nutrition.php?pageid=13.
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