Jackie L. Boucher

Nutrition Therapy Recommendations for the Management of Adults With Diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

Mail and phone interventions for weight loss in a managed-care setting: Weigh-To-Be one-year outcomes

OBJECTIVE: To describe methods, recruitment success, and 1-y results of a study evaluating the effectiveness of phone- and mail-based weight-loss interventions in a managed care setting.DESIGN: Randomized clinical trial with three groups, that is, usual care, mail intervention, and phone intervention.SUBJECTS: In total, 1801 overweight members of a managed-care organization (MCO).MEASUREMENTS: Height, weight, medical status, and weight-loss history were measured at baseline. Participation in intervention activities was monitored for 12 months in the two active treatment groups. Self-reported weight was obtained at 6 and 12 months.RESULTS: More individuals assigned to mail treatment started it (88%) than did those assigned to phone treatment (69%). However, program completion rates were higher in the phone (36%) than mail (7%) intervention. The mean weight losses were 1.93, 2.38, and 1.47 kg at 6 months in the mail, phone, and usual care groups, respectively. The differences between the phone and usual care groups were statistically significant. The mean weight losses at 12 months did not differ by treatment group (2.28 kg mail, 2.29 kg phone, and 1.92 kg usual care). Greater weight loss was seen in men, older participants, and those with no prior experience in a weight-loss program. Heavier participants and those who reported current treatment for depression lost less weight.CONCLUSION: Although mail- and phone-based weight-loss programs can be delivered to large numbers of people in an MCO setting, additional work is needed to enhance their clinical efficacy as well as to assess their costs.

Motivational Interviewing and Diet Modification: A Review of the Evidence

Researchers and clinicians have long alluded to the complexities involved in diet modification.7,8 Humans must eat because food consumption is a necessary behavior for survival. Diet modification typically involves “tweaking” a series of existing behaviors versus adopting a new one (eg, exercise) or eliminating an old one (eg, smoking). Due to these and other factors, dietary behavior change is commonly approached with some form of ambivalence or resistance.7 Education is often recognized as a necessary, but insufficient sole strategy for addressing the complex factors that influence eating (eg, environment, economics, and culture), especially among individuals who are not ready to change.

Evidence-Based Nutrition Practice Guidelines for Diabetes and Scope and Standards of Practice

In the 1990s, the American Dietetic Association (ADA) began developing nutrition practice guidelines for registered dietitians (RDs) and evaluating how their use affected clinical outcomes. Clinical trials and outcomes research report that diabetes medical nutrition therapy, delivered using a variety of nutrition interventions and multiple encounters, is effective in improving glycemic and other metabolic outcomes. The process of developing nutrition practice guidelines has evolved into evidence-based nutrition practice guidelines, which are disease/condition-specific recommendations and toolkits. An expert work group identified important clinical questions related to diabetes nutrition therapy. Research studies were analyzed and evidence summaries and conclusion statements written and graded for strength of research design. Based on the research conclusions, evidence-based nutrition recommendations and guidelines for adults with type 1 and type 2 diabetes were formulated. The ADA evidence-based nutrition practice guidelines for diabetes are published in the Web-based evidence analysis library. The recommendations are similar to those of the American Diabetes Association, although developed using a different method. To define the RDs professional practice, the ADA has published the Scope of Dietetics Practice Framework, the Standards of Practice and Standards of Professional Performance, and specialized standards for the RD in diabetes nutrition care. The latter defines the knowledge, skills, and competencies required by RDs to provide diabetes care at the generalist, specialist, and advanced practice level.

The Impact of Cooking Classes on Food-Related Preferences, Attitudes, and Behaviors of School-Aged Children: A Systematic Review of the Evidence, 2003–2014

Introduction Cooking programs have been used to promote healthful eating among people of all ages. This review assesses the evidence on childhood cooking programs and their association with changes in food-related preferences, attitudes, and behaviors of school-aged children. Methods We systematically searched PubMed, Ovid-Medline, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. We included primary research articles that involved cooking education programs for children and searched reference lists for eligible articles. Studies considered for review contained a hands-on cooking intervention; had participants aged 5 to 12 years; were published in a peer-reviewed journal on or after January 1, 2003; and were written in English. We used the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to rate the strength of each article and assess bias. The following information was extracted from each study: study design, sample size, location, duration, intervention components, data collection methods, and outcomes. Results Eight studies met the inclusion criteria and used cooking education to influence children’s food-related preferences, attitudes, and behaviors. Programs varied in duration, evaluation methods, and outcomes of interest. Self-reported food preparation skills, dietary intake, cooking confidence, fruit and vegetable preferences, attitudes toward food and cooking, and food-related knowledge were among the outcomes measured. Program exposure ranged from 2 sessions to regular instruction over 2 years, and the effect of cooking programs on children’s food-related preferences, attitudes, and behaviors varied among the reviewed studies. Conclusions Findings suggest that cooking programs may positively influence children’s food-related preferences, attitudes, and behaviors. However, because study measurements varied widely, determining best practices was difficult. Further research is needed to fill knowledge gaps on ideal program length, long-term effects, and usefulness of parent engagement, tasting lessons, and other intervention components.

Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization.

Current nutrition therapy recommendations for the prevention and treatment of diabetes are based on a systematic review of evidence and answer important nutrition care questions. First, is diabetes nutrition therapy effective? Clinical trials as well as systematic and Cochrane reviews report a ~1%–2% lowering of hemoglobin A1c values as well as other beneficial outcomes from nutrition therapy interventions, depending on the type and duration of diabetes and level of glycemic control. Clinical trials also provide evidence for the effectiveness of nutrition therapy in the prevention of diabetes. Second, are weight loss interventions important and when are they beneficial? Modest weight loss is important for the prevention of type 2 diabetes and early in the disease process. However, as diabetes progresses, weight loss may or may not result in beneficial glycemic and cardiovascular outcomes. Third, are there ideal percentages of macronutrients and eating patterns that apply to all persons with diabetes? There is no ideal percentage of macronutrients and a variety of eating patterns has been shown to be effective for persons with diabetes. Treatment goals, personal preferences (eg, tradition, culture, religion, health beliefs, economics), and the individual’s ability and willingness to make lifestyle changes must all be considered by clinicians and/or educators when counseling and educating individuals with diabetes. A healthy eating pattern emphasizing nutrient-dense foods in appropriate portion sizes, regular physical activity, and support are priorities for all individuals with diabetes. Reduced energy intake for persons with prediabetes or type 2 diabetes as well as matching insulin to planned carbohydrate intake are intervention to be considered. Fourth, is the question of how to implement nutrition therapy interventions in clinical practice. This requires nutrition care strategies.

Prevalence of the American Heart Association's "ideal cardiovascular health" metrics in a rural, cross-sectional, community-based study: the Heart of New Ulm Project.

Background The American Heart Association (AHA) recently created the construct of “ideal cardiovascular health” based on 7 cardiovascular health metrics to measure progress toward their 2020 Impact Goal. The present study applied this construct to assess the baseline cardiovascular health of a rural population targeted with a community‐based cardiovascular disease prevention program. Methods and Results The sample consists of 4754 New Ulm, Minn, adult residents who participated in either the 2009 or 2011 community heart health screenings offered by the Hearts Beat Back: The Heart of New Ulm (HONU) Project (mean age 52.1 years, 58.3% women). Data collected at the screenings were analyzed to replicate the AHAs ideal cardiovascular health measure and the 7 metrics that comprise the construct. Screening participants met, on average (±SD), 3.4 (±1.4) ideal cardiovascular health metrics. Only 1.0% of participants met the AHAs definition of ideal health in all metrics and 7.1% met ≤1 ideal health metric. Higher proportions of women met the ideal category in all metrics except physical activity. Women over the age of 60 were less likely to meet the ideal category for cholesterol and hypertension than were men in the same age range. Conclusion Prevalence of ideal cardiovascular health is extremely low in this rural population. To make progress toward the 2020 Impact Goal, targeted community‐based interventions must be implemented based on the most prevalent cardiovascular risk factors.

Systems approach to childhood and adolescent obesity prevention and treatment in a managed care organization.

OBJECTIVE: To outline an intervention approach to childhood and adolescent obesity prevention and treatment, that will systematically facilitate effective communication, provide long-term social support and access to resources, that may be accessed proactively or on demand. Furthermore, this approach operates in an environment that involves all critical parties: child/adolescent, family-unit, physician and allied health professionals.SYSTEMS THINKING APPROACH: The objective is to bring together all key stakeholders and consider the inter-relationships among them as a common process. In a managed care setting, this may be accomplished by optimizing the contributions of care delivery, health promotion and information systems.SETTING: A not-for-profit, community governed Managed Care Organization (MCO) in the Midwestern United States. Telephone-based, centralized services facilitate a process of access, communication, documentation and intervention implementation.CASE STUDIES:Two case studies are presented as examples of how access is obtained, the intervention is tailored to individual needs, communication is established, documentation is organized and long-term support is facilitated.CONCLUSIONS: A systems thinking approach to obesity prevention and treatment in youth has great potential. In a MCO setting, such an approach may be implemented, since integrated health care delivery systems may allow a common process to be established that can bring together all key stakeholders.

The new credential: advanced diabetes management.

A new multidisciplinary credential, the advanced diabetes manager, has been developed by the American Association of Diabetes Educators (AADE) and the American Nurses Credentialing Center (ANCC), in collaboration with the American Dietetic Association, the American Diabetes Association, and the American Pharmaceutical Association (APhA). The credential, designated as BC-ADM, is conferred upon successful completion of an exam to registered dietitians, registered nurses and registered pharmacists who hold advanced degrees and meet experience requirements. The exam is based on the scope and standards of practice approved by the governing agencies of the sponsoring organizations and defines advanced diabetes management knowledge and skills associated with improved outcomes. Information related to the test content outline, application process, suggested exam preparation, test sites, etc., is available from www.aadenet.org or www.nursingworld.org/ancc.

The heart of new ulm: a vision for the future.

Coronary artery disease (CAD) continues to be a leading cause of death in the USA and throughout the world. Allina Health System, with the Minneapolis Heart Institute at Abbott Northwestern, recently announced a long-term study in the city of New Ulm, MN, to reduce risk factors for myocardial infarction and, ultimately, reduce myocardial infarction incidence. To achieve this goal, the focus will be on health promotion interventions and primary and secondary prevention strategies for CAD that are innovative, community-wide, and able to impact individuals at home, at work, in their community, and in their health care settings. Factors considered in selecting this city included the identification of health as a priority by the community, readiness and willingness of the community to change, the ability to provide and deliver systematic care, and partnerships established across multiple disciplines and sectors centered on improved health. The following stakeholders will be engaged: the community, employers, public health, health care, and health plans. Unique aspects of the intervention include centralized healthcare, including an automated medical record; genetic testing; integrated behavioral interventions; social environmental change and social circumstances; health promotion, primary prevention and secondary prevention interventions; advanced diagnostics and imaging; and state-of-the-art therapy.