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Recommendations Summary

PDM: Nutrition Counseling 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    PDM: Nutrition Counseling

    The registered dietitian nutritionist (RDN) should counsel individuals who are at high risk for type 2 diabetes based on established, well-defined behavior change strategies, such as (but not limited to) the following:

    • Goal setting
    • Motivational interviewing
    • Practice of new behavior
    • Relapse prevention
    • Self-monitoring
    • Self-talk
    • Social support
    • Time management.

    These strategies are associated with initiation and maintenance of behavior change.

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      • The RDN should incorporate behavior change techniques that are appropriate to age, culture, setting and so forth
      • The RDN may maximize their effectiveness by gaining additional training and experience in counseling strategies to impact behavior change.

    • Potential Costs Associated with Application

      The costs of medical nutrition therapy (MNT).

    • Recommendation Narrative

      From Project IMAGE European Evidence-Based Guideline for the Prevention of Type 2 Diabetes, 2010 (page S23)

      • Individual level interventions for people at risk of T2DM should:
        • Aim to promote changes in both diet and physical activity (Grade A)
        • Use established, well-defined behavior change techniques (e.g., specific goal setting, relapse prevention, self-monitoring, motivational interviewing, prompting self-talk, prompting practice, individual tailoring, time management) (Grade A)
        • Work with participants to engage social support for the planned behavior change (i.e., engage important others such as family, friends and colleagues) (Grade A)
        • Maximize the frequency or number of contacts with participants (within the resources available) (Grade B)
        • Include a strong focus on maintenance. It is not clear how best to achieve this, but behavior change techniques designed to address maintenance include establishing self-monitoring of progress, providing feedback (e.g., on changes achieved in blood glucose and other risk factors), reviewing of goals, engaging social support, use of relapse prevention, relapse management techniques and providing follow-up prompts (Grade A).
        • Building on a coherent set of self-regulatory intervention techniques (specific goal setting; prompting self-monitoring; providing feedback on performance; review of behavioral goals) may provide a good starting point for intervention design. However, this is by no means the only approach available and it is worth noting that self-regulation techniques are not normally used in isolation (e.g., techniques designed to explore and enhance initial motivation would normally be applied prior to goal setting) (Grade C).
      • From the Academy of Nutrition and Dietetics Evidence Analysis Library on Nutrition Counseling, 2007:
        • Three RCTs, two positive-quality and one neutral-quality, provide evidence that self-monitoring of food intake improves nutrition-related outcomes related to weight loss (Boutelle et al, 1999; Tate et al, 2003) and compliance with renal diets (Milas et al, 2002). Three observational studies of neutral quality revealed that clients enrolled in cognitive behavioral weight-loss programs that were successful in losing weight were significantly more consistent with self-monitoring (Baker et al, 1998; Mattfeldt-Beman et al, 1999; Streit et al, 1991) (Grade I).
        • Four RCTs, three positive-quality and one neutral-quality, assessed the efficacy of various types of meal replacement or structured meal plan strategies, as compared to self-selected diets in middle-aged adults and found the use of various types of meal replacements or structured meal plans helpful in achieving health and food behavior change in middle-aged adults (Wing et al, 1996; Metz et al, 1997; Ditschuneit et al, 1999; Flechter-Mors et al, 2000; Ashley et al, 2001; Ditschuneit and Flechter-Mors, 2001). Additional research is needed to determine if benefits derived from temporary use of these behavioral strategies can be sustained over time (Grade I).
        • Two positive-quality (one RCT and one meta-analysis) and one neutral-quality RCT found monetary rewards or reinforcement had no treatment effect (Jeffery and Wing, 1995; Fuller et al, 1998; Paul-Ebhohimhen and Avenell, 2007) (Grade I)
        • Two positive-quality RCTs, one in overweight and obese women and the other in post-menopausal women with diabetes, utilized interventions that incorporated problem-solving strategies (Perri et al, 2001, Glasgow et al, 2004). In both studies, use of problem-solving strategies resulted in improvements in key outcome measures, including maintenance of weight loss and in subjects with diabetes, was linked to improvements in fat consumption, self-efficacy and physical activity (Grade II).
        • One highly intense lifestyle change study found social support was helpful and four traditional lifestyle change programs did not find it helpful (Wing et al, 1991; Wing et al, 1999; Barrera et al, 2002; Barrera et al, 2006; Toobert et al, 2007). The definition of social support has evolved to include multiple dimensions of social support measured pre- and post-treatment. Two RCTs conducted in the 1990s manipulated social support and found no significant treatment effect. In an RCT published in 2006, multiple dimensions of social support were measured pre- and post-treatment and use of social resources was shown to mediate intervention effects on physical activity, fat consumption and HgA1C change. Additional studies are needed to measure impact of social support interventions on outcomes (Grade II).
        • One positive-quality RCT found a 30-minute motivational interviewing session, based on self-selected diabetic self-management goals, followed by three 10-minute phone calls at one, three and seven weeks, was significantly more effective than usual care in reducing dietary fat intake and increasing physical activity at one year in 100 adults with type 2 diabetes (Clark et al, 2004). A positive-quality RCT showed similar results regarding the value of clients' self-selected behavior change goals and demonstrated the effectiveness of goal-attainment training in realizing dietary improvements (Berry et al, 1989). One neutral-quality observational study found 422 clients with diabetes who used computer technology to self-select a behavior-change goal in an area of diet or exercise and received brief (eight to 10 minutes) counseling related to the goal, were successful in reducing fat intake two months later (Estabrook et al, 2005). Clients' active participation in selecting and setting goals led to the selection of a goal from the area that could use the most improvement and the goal that was most personally appropriate (Grade II).
        • One neutral-quality RCT assessed the additive effect of a cognitive restructuring component to a 10-week strictly behavioral weight-loss program in 63 middle-aged overweight subjects and found no significant difference between the treatment group and control group in any physiological, behavioral or cognitive measures at baseline, post-treatment and at three-month follow-up (DeLucia and Kalodner, 1990). Additional research is needed on the isolated effect of cognitive restructuring as part of a behavioral intervention on nutrition-related outcomes (Grade III).
        • Two studies (one positive- and one neutral-quality) employed motivational interviewing as the sole style of intervention with little added effect, compared to standard therapy. Further research is warranted with larger sample sizes, longer follow-up periods and measurement of readiness to change diet behaviors (Grade III).
        • Four RCTs of positive quality assessed the effect of motivational interviewing as an added component to cognitive-behavioral programs (three studies, Smith et al, 1997; Bowen et al, 2002; West et al, 2007) or a self-help intervention (one study, Resnicow et al, 2001) and found motivational interviewing significantly enhanced adherence to program recommendations and improved targeted diet-related outcomes including glycemic control, percentage of energy intake from fat, fruit and vegetable intake and weight-loss (Grade I).

    • Recommendation Strength Rationale

      • From Project IMAGE European Evidence-Based Guideline for the Prevention of Type 2 Diabetes, 2010:
        • The Academy of Nutrition and Dietetics Prevention of Type 2 Diabetes Work Group concurs with the references cited
        • Evidence in support of the recommendation was grades A, B and C.
      • From the Academy of Nutrition and Dietetics Evidence Analysis Library on Nutrition Counseling, 2007:
        • The Academy of Nutrition and Dietetics Prevention of Type 2 Diabetes Work Group concurs with the references cited
        • Conclusion Statements in support of these recommendations received Grades I, II and III.

    • Minority Opinions

      Consensus reached.