Final: Why Medical Nutrition Therapy is Important to Kidney Patients

 WHY MEDICAL NUTRITION THERAPY IS IMPORTANT TO KIDNEY PATIENTS

Introduction

On December 4, 2020, I did a live broadcast on the Urban Health Outreach Media Network (Steve Belcher's Network) with Dr. Melissa Prest, Foundation Dietitian for the National Kidney Foundation of Illinois and Marsha Schofield, the Senior Director of Governance and Nutrition Services Coverage for the Academy of Nutrition and Dietetics. https://www.facebook.com/UrbanHealthOutreachmedia/videos/400367248068313/

I did this at the request of Dr. Holly Kramer, Past President of the National Kidney Foundation. I wanted to share with you some of the things that I learned about Medical Nutrition Therapy.

What is Medical Nutrition Therapy?

Medical Nutrition Therapy, often abbreviated as MNT, is an evidence-based medical approach to treating certain chronic conditions through the use of an individually-tailored nutrition plan based on a comprehensive nutrition assessment conducted by a Registered Dietitian. A physician may refer an individual to a Registered Dietitian for this service.

What is the Goal of MNT?

The goal of Medical Nutrition Therapy is to prevent, delay or manage diseases or conditions like Chronic Kidney Disease.

Who Needs Medical Nutrition Therapy?

Diet is an important part of everything we do. Food gives our bodies and our minds the fuel to think clearly and execute daily tasks. Registered Dietitians believe that everyone should see a dietitian every year, in the same way that you see the dentist or general practitioner every year. Diet affects every facet of our lives, from how we look, to how we feel, to how we sleep, to how we move, and even to how we think. With diet affecting our lives in so many ways, it’s important to have regular check-ups and interventions with a dietitian to assure that your diet is in good condition in the same way that you have check-ups and interventions with a doctor to make sure your body is in good condition.

Medical Nutrition Therapy is Important for People who have Kidney Disease

MNT can play a life-changing role in reducing complications associated with certain chronic conditions, such as Type 2 Diabetes and Chronic Kidney Disease (CKD). Registered Dietitians from the Academy use the Academy of Nutrition and Dietetics’ Evidence-Based Nutrition Practice Guidelines to counsel patients on lifestyle changes and self- management skills.

"A person may prevent or delay some health problems from chronic kidney disease (CKD) by eating the right foods and avoiding foods high in sodium, potassium, and phosphorus. Learning about calories, fats, proteins, and fluids is important for a person with advanced CKD. Protein foods such as meat and dairy products break down into waste products that healthy kidneys remove from the blood.

As CKD progresses, nutritional needs change. A health care provider may recommend that a patient with reduced kidney function choose foods carefully."

https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/eating-nutrition/nutrition-advanced-chronic-kidney-disease-adults

Common considerations for Kidney Patients who work with a Registered Dietitian Nutritionist for MNT would include:

• Calorie intake;

• Protein intake;

• Meat Portion Size;

• Fat content in foods;

• Sodium Content;

• Potassium Content;

• Phosphorus Content;

• Fluid Intake for pre-dialysis, dialysis and kidney transplant patients;

• Keeping track of Lab Reports;

• Help with making healthy meals choices depending on your kidney disease situation;

• Keeping informed of Clinical Trials that could assist the Kidney Patient.

What is a Registered Dietitian Nutritionist?

This is not just a person who took a nutrition course her sophomore year in college. According to the Academy of Nutrition and Dietetics, a Registered Dietitian Nutritionist is, "Registered Dietitian Nutritionists (RDNs) are food and nutrition experts who have met the following criteria to earn the RDN credential:

• Completed a minimum of a bachelor’s degree at a US regionally accredited university or college and course work accredited or approved by the Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy of Nutrition and Dietetics.

• Completed an ACEND-accredited supervised practice program at a health-care facility, community agency, or a foodservice corporation or combined with undergraduate or graduate studies. Typically, a practice program will run six to 12 months in length.

• Passed a national examinationadministered by the Commission on Dietetic Registration (CDR). For more information regarding the examination, refer to CDR’s website at www.cdrnet.org.

• Completed continuing professional educational requirements to maintain registration."

https://www.eatrightpro.org/about-us/what-is-an-rdn-and-dtr/what-is-a-registered-dietitian-nutritionist.

As you can see for a Registered Dietitian Nutritionist, they go through an extensive training and educational program similar to what a Board Certified Physician may go through to become a specialist in a medical field, like a Board Certified Nephrologist.

Can a Registered Dietitian Nutritionist Obtain a Board Certification in a Specialized Field of Nutrition

A Registered Dietitian Nutritionist (RDN) can obtain a Board Certification in a specialized area of nutrition like Pediatrics, Oncology, or Sports Nutrition. This includes a specialization in Renal (Nephrology) as well. Dr. Melissa Prest is a Registered Dietitian Nutritionist and board certified specialist in renal nutrition, specializing in kidney diet issues. This educational and practical experience is what makes a RDN a credible source for nutrition and diet information. Roughly half of the RDs from the Academy have advanced academic degrees.

What Types of Things Does a Registered Dietitian Nutritionist Do for Their Patients?

As a Kidney Patient your best bet is to ask a registered dietitian to give you advice on your diet. They can tailor you diet plan to meet your goals and needs.

What is a visit with a RD like? The goal is to come up with a realistic plan to improve your health and lifestyle, tailored to your individualized needs.

Things they look at include:

• Family and Medical History, Do you eat alone, together as a family, or separately

• Where & what do you grocery shop for

• Do you Eat out frequently?

• What are your exercise habits?

There are some amazing things you and your Registered Dietitian Nutritionist may do together including:

• Plan meals:

• Tour the grocery store;

• Reading labels on products;

• Tracking your progress;

The key here is that a RD will help you understand how good nutrition helps benefit your health and lifestyle. Part of this is changing habits over the course of the long run. Meeting with the RD on a regular basis helps you meet challenges and find successful solutions. You will meet every 2 weeks for 2-3 month's and then monthly for another 3-4 months to track your progress.

Critical for Kidney Patients, a registered dietitian helps you manage chronic diseases, like HBP, diabetes, high cholesterol, kidney disease or cancer.

Other things a RDN helps you with include:

• Understanding your lab results and how that affects your diet plan;

• To create a personalized eating plan;

• To provide guidance on food allergies, sensitivities and intolerances;

• To teach you how to read food labels, teach you which ingredients to avoid;

• To help you find good healthy & tasty substitutes for the food you cannot eat.

Coverage for the RD are included in most insurance plans, including private insurance, Medicare, & State Medicaid within certain limits. Be sure to check with your carrier.

How Do I Find A Registered Dietitian Nutritionist Me?

It is very simple to find a RDN near you. Check out this link on the Academy's website: https://www.eatright.org/find-an-expert

Can I Just Schedule An Appointment With A RDN Or Do I Need A Referral From My Doctor?

Under Medicare Part B, a referral from a physician is required for a patient to utilize your MNT benefits and work with a RDN. Only doctors can make such a referral under current law. Others are barred from making referrals.

https://www.eatrightpro.org/payment/coding-and-billing/referral-requirements-for-coverage-for-nutrition-services

The Best Kept Secret in Kidney Advocacy: You Can Consult With An RDN At No Costs to You

If you are covered by Medicare, you can see an RDN for free since all cost-sharing (deductible, copays) are waived for MNT services. According to the Academy, "Medical nutrition therapy is covered by Medicare for diagnoses of diabetes, non-dialysis kidney disease, and 36 months post kidney transplant when a Medicare beneficiary has been referred by a physician, and when provided by an RDN who is enrolled as a Medicare Provider. Medicare covers 3 hours of MNT the initial year of referral and up to 2 hours of MNT for subsequent years. Hours are based on calendar year and cannot be carried over from year to year.

Additional coverage is available in the same calendar year with a second referral when more MNT is medically necessary. There could be many reasons why individuals may need more care, including but not limited to a change in diagnosis, medical condition or treatment regimen. Medicare Advantage (Medicare Part C) plans may also offer additional benefits, including coverage beyond these diagnoses covered by traditional Medicare. Registered dietitian nutritionists must become credentialed with each Medicare Advantage plan in order to provide and get paid for MNT to patients enrolled in Medicare Advantage."

https://www.eatrightpro.org/payment/medicare/mnt

How Do Registered Dietitian Nutritionists Help Kidney Doctors and Nurses?

Doctors and Nurses often speak to patients about what they should and should not eat. This is helpful, but not enough for patients with CKD.

"Dietitians work closely with Registered Nurses and Certified Nursing Assistants in a variety of settings. Whether it is the clinical setting, a long-term care facility, or even in a health clinic in a school district, RNs and RDs can greatly support one another in the work that they do. Because a RN is at the forefront of patient care, they are able to provide RDs with a wealth of information to help RDs asses a patient’s nutrition status. Whether it is enteral or parenteral nutrition tolerance, food and supplement intake, family concern for appetite or weight loss prior to admission, or other clinical information, RNs play a vital role in helping the RD come up with a clinical plan of care for the patient.

In many health care settings, there is a screening tool completed by the nurse when a patient is admitted that indicates whether the patient has lost weight or had a poor appetite prior to admission, if they have any difficulties with eating, or if they have any past medical history of need for nutrition support, among other indicators. While this screening tool is different based on the facility, the purpose of the tool is universal: to help facilitate a conversation among the RDs, RNs, physicians, auxiliary staff, and family to help create the best plan of care for the patient’s nutritional well-being.

RDs and RNs work together with open, honest communication to collaborate the best care for the patient. If nurses have questions regarding the appropriateness of a diet or supplement, enteral or parenteral tolerance, or diet consistencies, they should contact the RD available on staff. As the experts, RD’s will be able to help streamline any problems and create the best nutrition plan for patients. Nurses’ help is invaluable to the care registered dietitians provide. They could not do their jobs without nurses!"

https://www.elitecme.com/resource-center/nursing/the-registered-dietitians-role-in-health-promotion

According to Dr Holly Kramer, because of a CKD patient's unique individual needs, kidney patients should see a dietitian in addition to a doctor or a nurse. This would include before dialysis, during dialysis and after transplant.

Current Legislation Supported by the National Kidney Foundation and the Academy of Nutrition and Dietetics

There is current legislation that was first introduced to Congress in 2020, The Medical Nutrition Therapy Act (H.R. 6971/S. 4504).

What does the Bill Do?

The bill amends the Social Security Act to:

• Provide Medicare Part B coverage of outpatient MNT for prediabetes, obesity, high blood pressure, high cholesterol, malnutrition, eating disorders, cancer, celiac disease, HIV/AIDS and any other disease or condition causing unintentional weight loss;

• Authorize the Secretary of Health to include other diseases based on medical necessity; and

• Allow nurse practitioners, physician’s assistants, clinical nurse specialists and psychologists to refer their patients for MNT.

So the Bill does two things:

1. It increases the types of professionals who can make referrals to a RDNs under Medicare Part B, currently only physicians can make such a referral;

2. The current law only covers MNT for CKD and Diabetes. The proposed changes expand the Chronic Diseases covered beyond those two.

Key Points for Legislators

• Medical nutrition therapy is nutritional diagnostic, therapy, and counseling services furnished by a registered dietitian for the purpose of disease prevention, management, or treatment;

• MNT is an evidence-based, cost-effective component of treatment that can help combat many of the nation’s most prevalent and costly chronic conditions, including conditions that are contributing to poor COVID-19 outcomes;

• Access to MNT is especially critical for communities of color that suffer from chronic disease health disparities driven by reduced access to care, healthy foods and safe places to be active; and

• CMS does not have the authority to expand MNT in Medicare; passage of the MNT Act is a necessary step to providing adequate care to seniors.