Guidelines vs practice in the delivery of diabetes nutrition care

The American Dietetic Association and the American Diabetes Association have published recommendations for the nutrition care of people with diabetes. However, the frequency of this care is rarely documented. As part of a study of diabetes care and education practices, the Michigan Diabetes Research and Training Center collected extensive data from 440 randomly selected adults who receive diabetes care from community physicians. These data provided a basis for comparison between diabetes nutrition care as recommended and as delivered in typical American communities. In this population (mean age = 61 years; 54% women), 89% (393) had non-insulin-dependent diabetes mellitus (NIDDM). Of these, 152 were managed with insulin (NIDDM/I) and 241 were not managed with insulin (NIDDM/NI). Most of the NIDDM/NI group was overweight (71%) and had elevated levels of glycated hemoglobin (62%) and serum cholesterol (53%). Yet they were significantly less likely than those with NIDDM/I to see a dietitian. The most frequently reported reason for not seeing a dietitian was that a physician had not referred them (53%). More than 90% of those with NIDDM/I or NIDDM/NI who were referred to a dietitian saw one. Because this population was from randomly selected communities, physicians, and patients, the results are probably generalizable to other regions of the United States. This study shows that in community practice, insulin use is the primary marker of the need for nutrition intervention, and the lack of physician referral to a dietitian is an important barrier to people receiving recommended diabetes nutrition care.