By Mary Ellen Posthauer, RDN, CD, LD, FAND

After reading Laurie Swezey's blog, "Diabetic Foot - Risk Factors and Prevention", I decided to weigh in on the issue of poor glycemic control. Teamwork is an essential ingredient since achieving glycemic control is a challenge for all clinicians including the registered dietitian (RD).

A key component in achieving glycemic control is referral of the client, who is a qualifying beneficiary under Medicare Part B, to the dietitian for Medical Nutrition Therapy (MNT) and/or to a Diabetes Self Management Training (DSMT) program. Medicare regulations defines the program requirements that qualified providers must follow for MNT and DSMT program compliance. Medicare MNT involves comprehensive clinical care provided by licensed/certified (as applicable) RDs and nutritional professionals. DSMT programs, which must be accredited as meeting quality standards by a Center for Medicare and Medicaid Services (CMS) approved national accreditation organization, include a nutrition education component based on the National Standards for Diabetes Self-Management Education.

CMS regulations allow for RDs to provide the nutrition education component of an accredited DSMT program, as well as MNT to qualifying Medicare Part B beneficiaries. CMS acknowledges that the provision of MNT and DSMT may be more medically effective for some beneficiaries than receiving just one of the benefits. RDs providing services to individuals with diabetes and/or services under the DSMT program typically have advanced practice for diabetes care or are certified diabetes educators.

Providing MNT services begins with a comprehensive assessment including data collection on the client's Food and Nutrition History:

• Food/Nutrient Intake: composition of the meals and snacks during the course of a day.
• Medication/Herbal Supplements: checking all medications, in particular those over-the-counter medications or herbal supplements that could be problematic.
• Knowledge/Beliefs: understanding the client's feelings/emotions on nutrition concepts related to diabetes and the readiness to adjust their nutrition related behaviors.
• Behaviors: includes client activities and actions that influence the ability to achieve nutrition goals.
• Factors Affecting Access to Food: includes understanding the factors that affect the individual's availability to secure a sufficient quantity of safe, nourishing food.
• Physical Activity/Function: includes their cognitive and physical ability to engage in specific tasks; shopping, meal preparation, physical activity, medication delivery.
• Nutrition-Related Client Centered Measures: consists of the client's perception of their nutrition intervention and its impact on life plus the understanding of their diet's contribution to their health.

Additional assessment data consists of anthropometric measurements (height, weight and weight history), biochemical data plus a nutrition-focused physical exam. A nutrition-focused physical exam is an evaluation of the body systems such as subcutaneous fat wasting, oral health, ability to chew/swallow, etc. Client history is an important piece of the assessment process that encompasses general information for the client such as age, role in the family, race/ethnicity, family or medical history that may have a nutritional impact, in addition to any social history, housing situation or support systems.

Once all of the above data has been evaluated the RD will write a nutrition diagnosis, not a medical diagnosis. The client and the RD will develop an individualized intervention plan and together they will monitor and evaluate this plan in an effort to achieve a successful outcome such as glycemic control, to be part of a comprehensive wound prevention strategy.

Next month we will follow a client thought this process and discuss methods for achieving glycemic control.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the Academy of Nutrition and Dietetics’s Unintentional Weight Loss work group.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.