Sanjay Kalra ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Bharti Kalra ( Department of Obstetrics, Bharti Hospital, Karnal, India. )
Rakesh Sahay ( Department of Endocrinology, Osmania Medical College, Hyderabad, India )
This article describes rational and pragmatic indications of signature or formula medical nutrition therapy (MNT) in diabetes care. Classifying MNT as meal/snack replacement and supplementation, it explores the biomedical, psychological and social indications of MNT usage. The need to ensure concordance of MNT with lifestyle and pharmacotherapy is reinforced. Highlighting the varied and flexible requirements of formula MNT, the authors reinforce the person-centred philosophy of diabetes care in general and MNT in particular.
Keywords: Biopsychosocial, Dietary therapy, Macronutrient, Micronutrient, Nutrition, Type 2 diabetes.
Medical nutrition therapy (MNT), an integral part of lifestyle modification, is the first line treatment for diabetes. Professional organizations of diabetes care providers and dieticians are in agreement regarding their understanding of the scope and relevance of MNT.1,2 MNT seeks to provide an individualized diet plan to every person with diabetes, based upon his or her biomedical, psychological, and socioeconomic needs, limitations and preferences. Thus, MNT follows a patient-centered philosophy which is similar to that suggested for pharmacotherapy in diabetes. One grey zone in current MNT praxis, however, is the role of commercial MNT products.
Heterogeneity of MNT
Just as diabetes is heterogeneous, so is MNT (Table-1).
MNT is defined not only as a prescription of a particular product (healthy nutrition), but also as the process of delivering that product. 345
as well as composition. Various preparations are available, which provide a mix of macronutrients, micro-nutrients, and other nutraceutical principles.
The Ideal MNT
Simple measuring devices (spoons and scoops) allow for easy calorie, carbohydrate or protein counting. Good diabetes-specific MNT formulae are sucrose-free, high in fibre, and replete with essential vitamins and minerals. They also contain nutraceuticals such as chromium and inositol, which help improve insulin sensitivity. Along with biomedical adequacy, a good diabetes-specific MNT must be acceptable in taste and flavour, easy to use, versatile enough to be used in a variety of cooking styles and methods, and lend itself to multiple recipes.
Indications of MNT
While there is comprehensive and detailed guidance for most aspects of MNT, specific indication for use of formula MNT have not been listed, 6,7
We also endeavor to correlate formula MNT use with lifestyle therapy and pharma-therapy, so that concordance can be achieved between these pillars of diabetes care.
Formula MNT for meal replacement may be used in persons who are unwilling to, or unable to, prepare or access tasty healthy food, at home or elsewhere. Examples include persons with a busy lifestyle, or those with limited access to home cooking. Limited culinary skills and limited nutritional literacy/numeracy are potential indications where formula MNT may be useful. Yet another psychosocial indication may be a need for variety in nutrition plans, or a desire for culinary experimentation. It must be noted that the natural history of diabetes is dynamic as well as flexible. Similarly the need for formula MNT may vary at different times of the day, and across weeks, months or years. An individual may report that he has access to healthy home cooked snacks in the evening, but not during morning office hours. Yet another may state that he brings home cooked lunch to office during summer, but needs an alternative for the cold winter months. MNT providers should take these person-centred specifics into consideration while discussing the role of formula therapy.
Formula MNT fulfils various types of biomedical needs.Signature MNT helps manage nutritional deficiency (e.g., protein deficiency), overcome limitations of digestion and absorption (e.g., in chewing-impaired persons, gluten enteropathy, diabetic gastroparesis) and provide requisite macro and micronutrients for health optimization in diabetes (e.g., during wound healing or recovery from acute illness) MNT formulae can be used according to the biomedical needs of the patient. Meal supplementation, and/or snack replacement is done in persons where adequate caloric intake is needed, at regular intervals, to prevent hypoglycaemia. This occurs in lean/underweight persons, those on intensive insulin therapy and modern sulfonylureas. Specifically timed signature MNT may be indicated in persons on high mix insulin, and those who are fasting. Low fibre, low protein containing formulae are indicated in diabetic gastroparesis, and persons on ultrarapid acting insulin analogues. Meal replacement is prescribed in persons who are targeting weight loss. Other persons with impaired appetite, or increased requirement for nutrient dense foods, e.g., during recovery from infection, injury, or invasive procedure), can use formula MNT supplements as well.
Lifestyle Modification-Related Indications
MNT must be personalized, or made concordant with physical activity as well. Formula feeds can be taken before or after physical activity, to prevent hypoglycaemia. Signature MNT, with high fibre and complex carbohydrate proportions, may be useful as meals replacement/supplement prior to fasting (e.g., Ramadan, Karva Chauth) as the slow release of nutrients prevents hunger, cravings and hypoglycaemia. High protein signature formulae are useful in persons following a ketogenic diet, or with protein wasting.
Short Term MNT
Changes in nutrient requirement and ingestion may occur due to variety of causes. Therefore, the need for signature MNT can vary as well. Commonly encountered indication for short term use of formula MNT includes debilitating illnesses such as diabetic foot, tuberculosis and hepatitis. Impaired appetite may respond to a short course of signature MNT in persons with renal impairment or gastrointestinal upset.
This communication shares rational indications for use of evidence backed signature MNT formula feeds in diabetes. Pragmatic usage of such preparations can help improve glycaemic control and weight modulation in diabetes and prediabetes.
1. Franz MJ, MacLeod J, Evert A, Brown C, Gradwell E, Handu D, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet. 2017; 117:1659-79.
2. Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American DiabetesAssociation, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2017; 43:40-53.
3. Marincic PZ, Hardin A, Salazar MV, Scott S, Fan SX, Gaillard PR. Diabetes self-management education and medical nutrition therapy improve patient outcomes: A pilot study documenting the efficacy of registered dietitian nutritionist interventions through retrospective chart review. J Acad Nutr Diet. 2017; 117:1254-64.
4. Raynor HA, Davidson PG, Burns H, Nadelson MD, Mesznik S, Uhley V, Moloney L. Medical nutrition therapy and weight loss questions for the evidence analysis library prevention of type 2 diabetes project: systematic reviews. J Acad Nutr Diet . 2017; 117:1578-611.
5. Look AHEAD Research Group. Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Controlled clinical trials. 2003; 24:610-28.6. American Diabetes Association. 4. Lifestyle management: Standards of medical care in diabetes-2018. Diabetes Care. 2018; 41(Supplement 1):S38-50.
7. American Diabetes Association. 7. Obesity management for the treatment of type 2 diabetes: standards of medical care in diabetes-2018. Diabetes care. 2018; 41(Supplement 1):S65-72.