When should you suggest a nutritionist?

Highlights:

• Patients dealing with obesity, type 2 diabetes, or cardiovascular diseases can improve their health and quality of life when working with a nutritionist
• Nutritionists can help at-risk patients address nutrient deficiencies before the onset of symptoms
• Working with a nutritionist can be cost-effective because of reduced medication and the use of hospital services

Introduction

Dietitians and nutritionists play an important role in a multi-disciplinary team necessary for the best long-term patient outcomes. Research shows that medical nutrition therapy is clinically effective, improves the patient experience, and reduces treatment costs. It might be an easy decision to suggest a nutritionist to those who are overweight or struggling with digestive issues. But there are many other scenarios where your patients could benefit. We want to help you identify these opportunities in your practice.

Medical nutrition therapy

There are many ways of working with a nutritionist. One of the most effective approaches to treating medical conditions with diet and lifestyle changes is called medical nutrition therapy. We will be referring to it throughout this article so it’s good to have a general understanding of what it entails. It is a structured nutrition-based treatment provided by a registered dietitian nutritionist and each therapy follows a pattern:

• Nutrition assessment - An in-depth individualized nutrition assessment is made using the best available current knowledge and evidence, client data, and medical record data.
• Nutrition diagnosis - Diagnosis is made after analyzing assessment data.
• Nutrition intervention - Goals, care plans, and interventions are defined. This includes a follow-up plan over multiple visits to assist with behavior and lifestyle changes.
• Nutrition monitoring and evaluation - Relevant biomarkers, weight, goals for food intake, and clinical and behavioral outcomes are monitored.
• Nutrition documentation - The initial assessment, nutrition diagnosis, and interventions are documented and shared with the physician.

Overweight and obese patients

Excess weight, especially obesity, is a major risk factor for cardiovascular disease, type 2 diabetes, some cancers, and a whole host of other illnesses. It is a notoriously hard task to reach and maintain a healthy weight. Fortunately, working with a registered dietitian nutritionist gives patients a much better chance. Research shows that dietitian-delivered interventions perform better at helping people accomplish weight loss than those performed by non-dietitians (1). The Academy of Nutrition and Dietetics claims that medical nutrition therapy results in clinically meaningful weight loss in overweight or obese adults. They specify that one visit per month for at least 1 year is necessary for weight maintenance (2).

Patients with type 2 diabetes

Type 2 diabetes is another metabolic disease that greatly benefits from lifestyle changes. According to research, dietitians are better at leading lifestyle interventions to reduce diabetes risk factors than non-dietitians (1). Medical nutrition therapy interventions significantly improve weight, glycemic outcomes, waist circumference, and blood pressure. These improvements have been observed in patients with prediabetes as well as type 2 diabetes. The data show that lifestyle interventions focused on healthy eating and physical activity improved clinical outcomes more than when compared with placebo or metformin therapy. These benefits are persistent even at the 15-year mark where interventions continue to reduce diabetes incidence (2).

Patients with cardiovascular disease risk factors

Using medical nutrition therapy also shows results in cardiovascular disease prevention. If your patients are at risk or already taking medication, you should suggest a nutritionist. Research shows that medical nutrition therapy interventions lowered low-density lipoprotein (LDL) cholesterol, total cholesterol, triglycerides, fasting blood glucose, hemoglobin A1c, and body mass index compared to a control group. It also says that 50% of drug-eligible patients no longer needed cholesterol-lowering medications after working with a registered dietitian nutritionist (3).

Patients at risk of nutrient deficiencies

Routine nutrient testing as a part of annual health check-ups allows for early detection of nutritional inadequacies and deficiencies. Suggesting a dietitian or nutritionist visit can then help with management before the onset of symptoms (4). Poor dietary quantity and quality are the most prominent drivers of nutrient deficiency, but several other scenarios increase the risk.

• Patients with multiple medications - B vitamin deficiencies have been frequently observed in older individuals taking three or more prescription drugs (5).
• Overweight and obese patients - Vitamin D has been shown to correlate with obesity. Fixing vitamin D deficiency may assist with weight loss (6).
• Patients with impaired gastrointestinal digestion or absorption - Patients suffering from gastric disorders such as inflammatory bowel disease or celiac disease are at high risk.
• Older adults - The ability to absorb nutrients decreases with age, and the risk of becoming underweight and malnourished increases (7). Vitamin B12 deficiency is especially common in the elderly.
• Genetic polymorphisms - People with certain gene polymorphisms can be predisposed to nutrient deficiencies. Nutrigenomics can highlight those at risk.
• Disordered eating - People with anorexia, bulimia, or other restrictive eating disorders are at an increased risk of various nutrient deficiencies.
• Pregnancy - Iron deficiency anemia, folic acid, and vitamin B12 deficiency are common problems for pregnant women that should be addressed with the help of a nutritionist.
• Children and adolescents - These age groups have increased requirements due to rapid growth.

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Working with a nutritionist can be cost-effective

Working with a registered dietitian nutritionist is an extra expense. Your patients are getting an individualized, evidence-based approach focused on long-term results. Registered dietitian nutritionists have demonstrated efficacy for improvements in outcomes for patients with a wide variety of medical conditions (8). Proven results are what allow this extra expense to be cost-effective.

Medical nutrition therapy for dyslipidemia showed reduced medication use for a cost savings of $638 to $1456 per patient per year in the United States (3). Among people aged 65 years and older, prediabetes lifestyle interventions were shown to be cost-saving to a health care insurance payer such as Medicare. Medical nutrition therapy was associated with a 9,5% reduction in the use of hospital services and a 23,5% reduction in the use of physician services for individuals with diabetes (2).

Conclusion

Medical nutrition therapy is effective for a wide variety of conditions, including obesity, type 2 diabetes, and cardiovascular disease. It improves biomarkers, enhances the patient experience, and reduces costs. Working with a nutritionist allows for more successful disease prevention and helps your patients address nutrient deficiencies before they become threatening. Knowing when to refer your patient to a registered dietitian nutritionist can make a big difference in their quality of life and health outcomes.

References:

(1)    Yu Sun, Wen You, Fabio Almeida, Paul Estabrooks, Brenda Davy. The effectiveness and cost of lifestyle intervention including nutrition education for diabetes prevention: A systematic review and meta-analysis. J Acad Nutr Diet. 2017 Mar; 117(3): 404–421.e36. doi: 10.1016/j.jand.2016.11.016.

(2)    Kathaleen Briggs Early, Kathleen Stanley. Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes. J Acad Nutr Diet. 2018 Feb;118(2):343-353. doi: 10.1016/j.jand.2017.11.021.

(3)    Geeta Sikand, Renee E Cole, Deepa Handu, Desiree deWaal, Joanne Christaldi, Elvira Q Johnson et al. Clinical and cost benefits of medical nutrition therapy by registered dietitian nutritionists for management of dyslipidemia: A systematic review and meta-analysis. J Clin Lipidol. Sep-Oct 2018;12(5):1113-1122. doi: 10.1016/j.jacl.2018.06.016. Epub 2018 Jul 3.

(4)    Maaike J. Bruins, Julia K. Bird, Claude P. Aebischer, and Manfred Eggersdorfer. Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries. Nutrients. 2018 Jan; 10(1): 47. Published online 2018 Jan 5. doi: 10.3390/nu10010047

(5)    Wendimere Reilly, Jasminka Ilich. Prescription Drugs and Nutrient Depletion: How Much Is Known? Advances in Nutrition, Volume 8, Issue 1, January 2017, Page 23, doi.org/10.1093/advances/8.1.23.

(6)    Silvia Savastano, Luigi Barrea, Maria Cristina Savanelli, Francesca Nappi, Carolina Di Somma, Francesco Orio, et al. Low vitamin D status and obesity: Role of nutritionist. Rev Endocr Metab Disord. 2017 Jun;18(2):215-225. doi: 10.1007/s11154-017-9410-7.

(7) Cristina, N.M.; Lucia, d. Nutrition and Healthy Aging: Prevention and Treatment of

Gastrointestinal Diseases. Nutrients 2021,13, 4337. https://doi.org/10.3390/nu13124337

(8)    Bonnie T Jortberg, Michael O Fleming. Registered dietitian nutritionists bring value to emerging health care delivery models. J Acad Nutr Diet. 2014 Dec;114(12):2017-22. doi: 10.1016/j.jand.2014.08.025. Epub 2014 Nov 24.

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