What Is Medical Nutrition Therapy?

June 14, 2000

Caryl B. Fairfull, RD, MBA
Co-Editor of NutritionNotes
MDvista

Medical Nutrition Therapy Defined

Medical nutrition therapy is the assessment of a patient's nutrition status followed by therapy ranging from diet modification and nutrition counseling to the administration of tube or intravenous feedings.¹ Dietary modification and counseling are the traditional interventions to achieve medical goals as ordered by the physician. This results in a personalized diet plan to reduce blood glucose, protein intake, caloric intake, or other objective prescribed by a physician. Medical nutrition therapy (MNT) is effective in reducing hospital stays, reducing the requirements for expensive drug and medical therapies, making treatments more effective, and generally helping patients recover faster. MNT plays a major role in successful disease management and improved patient outcomes. Registered dietitians cost effectively deliver MNT services.

Impact of Medical Nutrition Therapy on Specific Medical Conditions

AIDS
Nutrition therapy helps AIDS patients to maintain body weight, combat opportunistic infections, prevent complications and maintain a comfortable quality of life longer. Estimated cost savings per case attributable to MNT is $20,000. ²

CANCER
MNT increases patient responsiveness to chemotherapy and radiation treatments , enhances tolerance of the treatments, and helps to prevent weight loss associated with treatments. Nutrition therapy also gives the patient an opportunity for positive control, whereas most cancer treatments require passive compliance. Since one third of the annual deaths from cancer may be attributed to undesirable dietary practices, nutrition counseling is an important preventive measure.³

KIDNEY DISEASE
Renal disease requires complex dietary management of liquid, protein, and calorie intake to delay and reduce the need for dialysis. With MNT, under the direction of a Registered Dietitian or qualified nutrition professional, dialysis can be delayed from one to four years. This results in an improved quality of life and saves billions of Medicare dollars. In 1998, Medicare costs for kidney dialysis were over $9.6 billion.⁴

HEART DISEASE
Patients with heart disease who participate in a MNT program based on a low saturated fat and low cholesterol diet and exercise, can reverse damage to the cardiovascular system, and delay or eliminate the need for cardiac surgery, and prevent strokes. Registered Dietitians cost effectively counsel and monitor nutritional goals set for cardiac patients.

DIABETES
Aggressive nutrition counseling (MNT), along with frequent monitoring of blood sugar levels, prevents the need for insulin in many cases and reduces the occurrence of diabetic complications such as retinopathy, heart attacks, and amputations. In 1993, $92 billion was spent on diabetes care.⁵ MNT and patient education are effective in improving diabetes patient outcomes.⁶ Average cost savings per case is $9,000 for Type I, and $2,000 per case for Type II diabetes.⁷

GERIATRIC
Elderly patients in home health care systems, nursing homes, and CARE hospitals have many chronic diseases related to the aging process, as well as many economic and social factors that lead to poor nutrition. Of patients admitted to long term care facilities, 39% are malnourished. ⁸ Elderly patients admitted to the hospital are similarly malnourished, and without MNT will have longer stays and poorer outcomes. Over 150 studies, inspired by the article "The Skeleton in the Hospital Closet," reveal an incidence of malnutrition between 30% to 50% in hospitalized patients.⁹ Decubitus ulcers are a direct result of inadequate nutrition and reduce quality of life for many elderly patients.

OBESITY
Obesity is highly correlated with many chronic diseases: diabetes mellitus, hypertension, cardiovascular disease, stroke, gout, sleep apnea, and osteoarthritis.¹⁰ Healthcare costs related to obesity are over $40 billion annually.¹¹ This does not include an equal amount spent on "quick fix" weight loss solutions that are not as effective as MNT under the guidance of a physician and a qualified nutrition professional. Eight of the ten leading causes of death, including coronary heart disease, stroke, some types of cancer, and diabetes mellitus, are related to diet and alcohol.¹² Physicians and Registered Dietitians deliver MNT therapy to treat patients with these chronic conditions. Physicians often delegate nutritional care to Registered Dietitians, and then work closely with the dietitian as the treatment plan is established and revised, a cost effective model of care.

The process of medical nutrition therapy (MNT) parallels the medical treatment model. The therapeutic prescription is ordered by the physician and/or a treatment protocol is put into effect. A nutrition history is obtained and analyzed by the RD; laboratory, anthropometric measurements or other clinical data is obtained, and a therapeutic plan is developed according to the dietary prescription. This therapeutic plan must be discussed fully and negotiated with the patient. Dietary changes must be interpreted from the patient's viewpoint, considering ethnic and cultural issues, reviewing personal schedules and food habits, and tailoring the dietary prescription into foods and portions that the patient will accept. Appropriate medical nutrition therapy enhances medical treatment for the most efficacious patient care.

Most large hospitals have nutritional standards of care for major diseases and conditions. These standards ensure that best practices are followed. Nutritional standards of care are also available through the American Dietetic Association.¹³ The increasing acuity of hospitalized patients, and the coexistence of malnutrition and chronic disease mandate MNT. MNT may be managed by a multidisciplinary nutrition support team in major hospitals. Adequate nutrition is essential to reduce morbidity and mortality from acute and chronic disease.

Outpatients may not receive optimal MNT, because it is not covered by many insurers. Further, many do not value MNT sufficiently to pay out of pocket. Physicians may not stress the value of MNT consultation with a Registered Dietitian, or try to do an adequate job in a few minutes. Most patients need extensive consultation and follow-up to achieve lasting dietary changes. Inadequate MNT may mean that the patient's recovery is delayed or compromised, or becomes more costly in terms of patient suffering and medical resources required.

MNT Through the Life Cycle

Nutrition education and screening is an accepted part of maternity care. Optimal nutrition for pregnant women promotes proper growth and development of the fetus, preventing low-birth-weight infants and the related complications. In the United States, the Special Supplemental Food Program for Women, Infants, and Children (WIC) yields over four dollars in reduced medical care for every dollar spent. ¹⁴

Gestational diabetes can result in a large baby, as well as delivery and neonatal complications. Careful control of blood sugar through MNT may prevent the need for insulin therapy, and be sufficient to achieve positive pregnancy outcome.

Many pediatric diseases such as juvenile diabetes, cystic fibrosis, phenylketonuria and other metabolic diseases, celiac sprue, allergies, require MNT support to provide improved growth and development.

From early adulthood to midlife, clients may need nutrition counseling to met their athletic needs or to prevent chronic conditions such as osteoporosis. The health and fitness industry promotes a wide range of nutritional products that confuse the general public. The prudent person will discuss these products with their physician and a qualified nutrition therapist. Patients may divulge more of their health practices and questions to a nutrition professional because of longer appointments, more attention to personal habits, and more opportunity for follow-up.

By the year 2010, one in seven Americans will be over 65 years of age.¹⁵ Some of the medical conditions requiring MNT in the elderly have already been discussed. However, MNT may be necessary to promote wound healing postoperatively or after a traumatic accident. Other diseases, such as chronic obstructive pulmonary disease, and infectious diseases such as tuberculosis or pneumonia, may require dietary support through MNT. Home health services should include MNT, for dietary consultation and treatment with medical supplements, as well as enteral and parenteral nutrition.

Summary

MNT is effective in treating disease and preventing disease complications, resulting in health benefits and cost savings. MNT services provided by Registered Dietitians are an essential component of comprehensive health care services. MNT can improve health status while controlling the costs of medical care. Research on the costs and benefits of MNT can be used to facilitate insurance coverage decisions by governments and other health care payors.¹⁶ Future articles in NutritionNotes will present MNT protocols for specific diseases and conditions as well as other interesting topics.

REFERENCES

1. Medical Nutrition Therapy: A Solution that Saves. Chicago, Ill: American Dietetic Association; 1997:5.

2. American Dietetic Association. : Tapping into the Politics of Medicare.

3. Work Study Group on Diet, Nutrition and Cancer. American Cancer Society Guidelines on Diet, Nutrition and Cancer. Atlanta, Ga: American Cancer Society;1992.

4. The Lewin Group. The Financial Impact of the Health Security Act. Washington, DC: The Lewin Group, 1993.

5. Diabetes: 1993 Vital Statistics. Alexandria, Va: American Diabetes Association; 1993.

6. Holler H, Pastors J. Diabetes Medical Nutrition Therapy: A Professional Guide to Management and Nutrition Education Resources. Chicago, Ill: American Dietetic Association; 1997.

7. Medical Nutrition Therapy: A Solution that Saves. Chicago, Ill: American Dietetic Association; 1997:10.

8. Sullivan DH, Sun S, Walls RC. Protein-energy undernutrition among elderly hospitalized patients. JAMA 1999;218:2013-2019.

9. Coats KG, Morgan SL, Bartolucci AA, et al. Hospital-associated malnutrition: a re-evaluation 12 years later. J Am Diet Assoc 1993;93:27-33.

10. Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med 1993;119:655-660.

11. Colditz GA. Economic costs of obesity. Am J Clin Nutr 1992;55(suppl):503S-507S.

12. Thompson D, Edelsberg J, Colditz G. Lifetime health and economic consequences of obesity. Arch Intern Med 1999; 159:2177-2183.

13. US Department of Health and Human Services. The Surgeon General's Report on Nutrition and Health. Washington, DC: US Department of Health and Human Services; 1988. Publication 88-50210.

14. Position of The American Dietetic Association: cost effectiveness of medical nutrition therapy. J Am Diet Assoc 1995;95:88.

15. US Bureau of the Census. 1990 Census of Population: General Population Characteristics for United States. Washington, DC: US Bureau of the Census; 1992.

16. Shiels JF, Rubin R, Stapleton DC. The estimated costs and savings of medical nutrition therapy: the Medicare population. J Am Diet Assoc 1999;99: 428-435.