Am J Clin Nutr. With this policy statement, we intend to support pediatricians and other health care providers in promoting healthy nutrition and advocating for the expansion of programs that affect early life nutrition as a means of providing scaffolding for later nutritional programs and preventing early developmental loss. Studies have shown that implementing DSME programs that directly connect with primary care and rely on technology is effective in improving clinical, psychosocial, and behavioral outcomes 16 , 71 — Twenty-first century behavioral medicine: In villages receiving the high-calorie, high-protein supplement, there were no differences in test scores between children of high and low socioeconomic status, but in villages receiving the low-calorie supplements, children in the higher socioeconomic group had higher test scores.
Benefits Associated with DSME/S
Moreover, knowing which nutrients are at risk in the breastfed infant after 6 months eg, zinc, iron, vitamin D will guide dietary recommendations in the clinic or practice. Guidance for pediatricians is provided in existing documents Tables 1 and 2 but over a spectrum of resources and chapters, and it is often without clear prescriptive recommendations;.
Leaders in childhood nutrition can advocate for incorporating into existing nutritional advice an actionable guide to healthy eating as a positive choice rather than an avoidance of unhealthy foods. This would give pediatricians and families more prescriptive advice as to optimal dietary choices.
Pediatricians and other child health care providers can focus the attention of existing programs on improving micro- and macronutrient offerings for infants and young children. For example, providing information to existing food pantries and soup kitchens to create food packages and meals that target the specific needs of pregnant women, breastfeeding women, and children in the first 2 years of life;.
Pediatricians and other child health care providers can encourage families to take advantage of programs providing early childhood nutrition and advocate for eliminating barriers that families face to enrolling and remaining enrolled in such programs.
Many families do not take advantage of WIC services after the first year of life. Encouraging the use of services and benefits for which the family is eligible and eliminating the requirement to recertify eligibility for young children at 1 year of age can improve early life nutrition for children;. Pediatricians and other child health care providers can oppose changes in eligibility or financing structures that would adversely affect key programs providing early childhood nutrition.
Such changes include changing funding to block grants or delinking nutrition and health assistance programs, such as the adjunctive eligibility between WIC and Medicaid. Federal nutrition programs such as SNAP are successful because of eligibility rules and a funding structure that makes benefits available to children in almost all families with little income and few resources;.
Pediatricians and other child health care providers can anticipate neurodevelopmental concerns in children with early nutrient deficiency. Pediatricians can educate themselves as to which nutrients are at risk for deficiency and at what age as well as about appropriate screening for children at high risk.
For example, the risk of iron deficiency is not equal throughout the pediatric life span. Pediatricians can be aware that the newborn, the toddler, and the adolescent are at highest risk and should be aware of factors that increase those risks;. As pediatricians consider their personal contribution to social action, involvement in 1 of these organizations is an excellent option see Table 3.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal AAP and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The 1, Days mark is used with permission from 1, Days. The authors have indicated they have no financial relationships relevant to this article to disclose.
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Sarah Jane Schwarzenberg , Michael K. Introduction Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence. View inline View popup. Obesity Although there is evidence that obesity in children and adolescents is associated with poorer educational success, studies are often complicated by small sample size, failure to control for confounding factors, and other aspects of study design.
Meeting the Nutritional Needs of Young Children for Neurodevelopment Opportunities to improve early child nutrition, and thus neurodevelopment, are currently focused in 2 areas: Food Pantries and Soup Kitchens Food pantries and soup kitchens are generally community-supported programs that serve as a safety net for children and families struggling with inadequate food.
Maternal, Infant, and Early Childhood Home Visiting Program Congress established the Maternal, Infant, and Early Childhood Home Visiting Program in to provide funds for states and tribes providing voluntary, evidence-based home visiting to at-risk families. American Academy of Pediatrics The American Academy of Pediatrics AAP provides substantial information on the nutritional needs and support of children from birth to age 2 years, including information and guidance on breastfeeding 45 and on feeding infants and toddlers.
Recommendations Pediatricians, family physicians, obstetricians, and other child health care providers need to be knowledgeable about breastfeeding to educate pregnant women about breastfeeding and be prepared to help breastfeeding mothers and their infants when problems occur.
Guidance for pediatricians is provided in existing documents Tables 1 and 2 but over a spectrum of resources and chapters, and it is often without clear prescriptive recommendations; Leaders in childhood nutrition can advocate for incorporating into existing nutritional advice an actionable guide to healthy eating as a positive choice rather than an avoidance of unhealthy foods. For example, providing information to existing food pantries and soup kitchens to create food packages and meals that target the specific needs of pregnant women, breastfeeding women, and children in the first 2 years of life; Pediatricians and other child health care providers can encourage families to take advantage of programs providing early childhood nutrition and advocate for eliminating barriers that families face to enrolling and remaining enrolled in such programs.
Encouraging the use of services and benefits for which the family is eligible and eliminating the requirement to recertify eligibility for young children at 1 year of age can improve early life nutrition for children; Pediatricians and other child health care providers can oppose changes in eligibility or financing structures that would adversely affect key programs providing early childhood nutrition.
Federal nutrition programs such as SNAP are successful because of eligibility rules and a funding structure that makes benefits available to children in almost all families with little income and few resources; Pediatricians and other child health care providers can anticipate neurodevelopmental concerns in children with early nutrient deficiency.
Nutrition and brain development in early life. Issues in the timing of integrated early interventions: Ann N Y Acad Sci. How the timing and quality of early experiences influence the development of brain architecture. Developmental science and the media. Early life nutrition and neural plasticity.
Bick J , Nelson CA. Early adverse experiences and the developing brain. Childhood maltreatment predicts adult inflammation in a life-course study. Is the association between childhood socioeconomic circumstances and cause-specific mortality established? Update of a systematic review. J Epidemiol Community Health. Water, sanitation, and hygiene WASH , environmental enteropathy, nutrition, and early child development: Associations between obesity and cognition in the pre-school years.
Rao R , Georgieff MK. The nutritionally deprived fetus and newborn infant. Shevell M , Miller S , ed. International Reviews of Child Neurology Series: Mac Keith Press ; A review of studies of the effect of severe malnutrition on mental development. Nutrition in early life and the fulfillment of intellectual potential. Long-term brain and behavioral consequences of early iron deficiency. S43 — S48 pmid: J Child Psychol Psychiatry. Am J Clin Nutr. Long-term neurodevelopmental benefits of breastfeeding.
Breast milk feeding, brain development, and neurocognitive outcomes: Breastfeeding and the use of human milk. Fetal, neonatal, and infant microbiome: Semin Fetal Neonatal Med. The role of nutrition in brain development: Neurocognitive correlates of obesity and obesity-related behaviors in children and adolescents. Int J Obes Lond. Greater early gains in fat-free mass, but not fat mass, are associated with improved neurodevelopment at 1 year corrected age for prematurity in very low birth weight preterm infants.
Early breastfeeding problems mediate the negative association between maternal obesity and exclusive breastfeeding at 1 and 2 months postpartum. Maternal prepregnant body mass index and gestational weight gain are associated with initiation and duration of breastfeeding among Norwegian mothers.
Influence of infant feeding patterns over the first year of life on growth from birth to 5 years. Timing of solid food introduction and risk of obesity in preschool-aged children. Breastfeeding in the 21st century: A Review of Recent Research.
Accessed December 26, Maternal, infant, and early childhood visiting program. Accessed February 11 , pmid: Interventions to improve breastfeeding outcomes: Pregnancy and birth to 24 months project. Science-based regulatory and policy considerations in nutrition. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics ; Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children years of age.
Primary care interventions to support breastfeeding: The goals of the position statement are ultimately to improve the patient experience of care and education, to improve the health of individuals and populations, and to reduce diabetes-associated per capita health care costs 9.
Given that the cost of diabetes in the U. It has been projected that one in three individuals will develop type 2 diabetes by Besides this important reduction, DSME has a positive effect on other clinical, psychosocial, and behavioral aspects of diabetes.
These improvements clearly reaffirm the importance and value-added benefit of DSME. In addition, better outcomes have been shown to be associated with the amount of time spent with a diabetes educator 3 , 4 , 7 , This position statement arms health care teams with the information required to better understand the educational process and expectations for DSME and DSMS and their integration into routine care. The ultimate goal of the process is a more engaged and informed patient Regardless of the setting, communicating the information and supporting skills that are necessary to promote effective coping and self-management required for day-to-day living with diabetes necessitate a personalized and comprehensive approach.
Effective delivery involves experts in educational, clinical, psychosocial, and behavioral diabetes care 34 , Currently, CMS reimburses for 10 program hours of initial diabetes education and 2 hours in each subsequent year. Sample referral forms with information needed for reimbursement are available on the ADA Web site http: This person is considered the primary instructor.
Others can contribute to DSME and provide support with appropriate training and supervision. Trained community health workers, practice-based care managers, peers, and other support persons e.
Although this approach requires knowledge, time, and resources to effectively provide education, it offers a unique opportunity to reach patients at the point of care.
The algorithm defines four critical time points for delivery and key information on the self-management skills that are necessary at each of these critical periods. Associated with each principle are key elements that offer specific suggestions regarding interactions with the patient and topics to address at diabetes-related clinical and educational encounters Table 3.
Helping people with diabetes to learn and apply knowledge, skills, and behavioral, problem-solving, and coping strategies requires a delicate balance of many factors.
There is an interplay between the individual and the context in which he or she lives, such as clinical status, culture, values, family, and social and community environment. In a patient-centered approach, collaboration and effective communication are considered the route to patient engagement 43 — This approach includes eliciting emotions, perceptions, and knowledge through active and reflective listening; asking open-ended questions; exploring the desire to learn or change; and supporting self-efficacy Through this approach, patients are better able to explore options, choose their own course of action, and feel empowered to make informed self-management decisions 45 , Table 4 provides a list of patient-centered assessment questions that can be used at diagnosis and at other encounters to guide the education and ongoing support process.
Sample questions to guide a patient-centered assessment Although four distinct time-related opportunities are listed, it is important to recognize that type 2 diabetes is a chronic condition and situations can arise at any time that require additional attention to self-management needs. The educational content listed in each box in Fig. However, these topics can guide the educational assessment and plan.
Mastery of skills and behaviors takes practice and experience. Often a series of ongoing education and support visits are necessary to provide the time for a patient to practice new skills and behaviors and to form habits that support self-management goals. The diagnosis of diabetes is often overwhelming The emotional response to the diagnosis can be a significant barrier for education and self-management.
At diagnosis, important messages should be communicated that include acknowledgment that all types of diabetes need to be taken seriously, complications are not inevitable, and a range of emotional responses is common.
The patient should understand that treatment will change over time as type 2 diabetes progresses and that changes in therapy do not mean that the patient has failed. The task of self-management is not easy, yet worth the effort Other diabetes education topics that are typically covered during the visits at the time of diagnosis are treatment targets, psychosocial concerns, behavior change strategies e.
At diagnosis of type 2 diabetes, education needs to be tailored to the individual and his or her treatment plan.
At a minimum, plans for nutrition therapy and physical activity need to be addressed. Patients are supported when personalized education and self-management plans are developed in collaboration with the patients and their primary care provider.
Depending on the qualifications of the diabetes educator or staff member facilitating these steps, additional referrals to a registered dietitian nutritionist for MNT, mental health provider, or other specialist may be needed. Patients presenting at the time of diagnosis with diabetes-related complications or other health issues may need additional or reprioritized education to meet specific needs.
The health care team and others can help to promote the adoption and maintenance of new diabetes management tasks 52 , yet sustaining these behaviors is frequently difficult. Thus, annual assessments of knowledge, skills, and behaviors are necessary for those who do meet the goals as well as for those who do not.
Annual visits for diabetes education are recommended to assess all areas of self-management, to review behavior change and coping strategies and problem-solving skills, to identify strengths and challenges of living with diabetes, and to make adjustments in therapy 35 , Importantly, the educator is charged with communicating the revised plan to the referring provider.
Family members are an underutilized resource for ongoing support and often struggle with how to best provide this help 53 , Since the patient has now experienced living with diabetes, it is important to begin each maintenance visit by asking the patient about successes he or she has had and any concerns, struggles, and questions.
The focus of each session should be on patient decisions and issues—what choices has the patient made, why has the patient made those choices, and if those decisions are helping the patient to attain his or her goals— not on perceived adherence to recommendations.
Through shared decision making, the plan is adjusted as needed in collaboration with the patient. The identification of diabetes complications or other patient factors that may influence self-management should be considered a critical indicator for diabetes education that requires immediate attention and adequate resources. During routine medical care, the provider may identify factors that influence treatment and the associated self-management plan.
These factors may be identified at the initial diabetes encounter or may arise at any time. Such patient factors influence the clinical, psychosocial, and behavioral aspects of diabetes care. The diagnosis of additional health conditions and the potential need for additional medications can complicate self-management for the patient. Diabetes education can address the integration of multiple medical conditions into overall care with a focus on maintaining or appropriately adjusting medication, eating plan, and physical activity levels to maximize outcomes and quality of life.
Diabetes-related health conditions can cause physical limitations, such as visual impairment, dexterity issues, and physical activity restrictions. Diabetes educators can help patients to manage limitations through education and various support resources. Psychosocial and emotional factors have many contributors and include diabetes-related distress, life stresses, anxiety, and depression.
In fact, these factors are often considered complications of diabetes and result in poorer diabetes outcomes 59 , It has a greater impact on behavioral and metabolic outcomes than does depression Social factors, including difficulty paying for food, medications, monitoring and other supplies, medical care, housing, or utilities, negatively affect metabolic control and increase resource use When basic living needs are not met, diabetes self-management becomes increasingly difficult.
Basic living needs include food security, adequate housing, safe environment, and access to medications and health care. Education staff can address such issues, provide information about available resources, and collaborate with the patient to create a self-management plan that reflects these challenges.
However, complicating factors may arise at any time; providers should be prepared to promptly refer patients who develop complications or other issues for diabetes education and ongoing support. Throughout the life span, changes in age, health status, living situation, or health insurance coverage may require a reevaluation of the diabetes care goals and self-management needs.
Critical transition periods include transitioning into adulthood, hospitalization, and moving into an assisted living facility, skilled nursing facility, correctional facility, or rehabilitation center. Providing input into the development of practical and realistic self-management and treatment plans can be an effective asset for successful navigation of changing situations. A written plan prepared in collaboration with diabetes educators, the patient, family members, and caregivers to identify deficits, concerns, resources, and strengths can help to promote a successful transition.
The plan should include personalized diabetes treatment targets; a medical, educational, and psychosocial history; hypo- and hyperglycemia risk factors; nutritional needs; resources for additional support; and emotional considerations 63 , The health care provider can make a referral to a diabetes educator to develop or provide input to the transition plan, provide education, and support successful transitions.
The goal is to minimize disruptions in therapy during the transition, while addressing clinical, psychosocial, and behavioral needs. The ADA publishes nutrition recommendations that detail nutrition therapy goals and nutrition and eating pattern recommendations For example, only 6. Barriers are associated with a number of factors including the health system, the individual health care professional, community resources, and the individual with diabetes.
Although people with diabetes report wanting to be actively engaged in their health care, most indicate that they are not actively engaged by their providers and that education and psychological services are not readily available Removing barriers to access and increasing quality care can be achieved by using data to coordinate care and build workforce capacity Studies have shown that implementing DSME programs that directly connect with primary care and rely on technology is effective in improving clinical, psychosocial, and behavioral outcomes 16 , 71 — Patients receiving care in these practice settings report more confidence in provider communication and satisfaction with direct access to an educator for information and ongoing support Despite the proven value and effectiveness of diabetes education and support services, one of the biggest looming threats to their success is low utilization, which has recently forced many such programs to close.
Attention to these challenges needs to be met to provide access particularly for areas such as rural and underserved communities. Diabetes is a complex and burdensome disease that requires the person with diabetes to make numerous daily decisions regarding food, physical activity, and medications. It also necessitates that the person be proficient in a number of self-management skills 35 , 75 , In order for people to learn the skills necessary to be effective self-managers, DSME is critical in laying the foundation with ongoing support to maintain gains made during education.
This position statement and algorithm provide the evidence and strategies for the provision of education and support services to all adults living with type 2 diabetes. The authors gratefully acknowledge the commitment and support of the collaborating organizations—the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics; their colleagues, including members of the Executive Committee of the National Diabetes Education Program, who participated in discussions and reviews about this inaugural position statement; and patients who teach and inspire them.
No potential conflicts of interest relevant to this article were reported. We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Diabetes Care Jul; 38 7: View inline View popup.
Table 1 Key definitions. Table 4 Sample questions to guide a patient-centered assessment New Diagnosis of Diabetes The diagnosis of diabetes is often overwhelming Annual Assessment of Education, Nutrition, and Emotional Needs The health care team and others can help to promote the adoption and maintenance of new diabetes management tasks 52 , yet sustaining these behaviors is frequently difficult.
Diabetes-Related Complications and Other Factors Influencing Self-management The identification of diabetes complications or other patient factors that may influence self-management should be considered a critical indicator for diabetes education that requires immediate attention and adequate resources.
Transitional Care and Changes in Health Status Throughout the life span, changes in age, health status, living situation, or health insurance coverage may require a reevaluation of the diabetes care goals and self-management needs.
Table 5 Overview of MNT. Conclusion Diabetes is a complex and burdensome disease that requires the person with diabetes to make numerous daily decisions regarding food, physical activity, and medications. Acknowledgments The authors gratefully acknowledge the commitment and support of the collaborating organizations—the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics; their colleagues, including members of the Executive Committee of the National Diabetes Education Program, who participated in discussions and reviews about this inaugural position statement; and patients who teach and inspire them.
Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure. J Multidiscip Healthc ; 7: Association between participation in a brief diabetes education programme and glycaemic control in adults with newly diagnosed diabetes. Diabet Med ; Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. Assessing the value of diabetes education.
Diabetes Educ ; Fan L , Sidani S. Effectiveness of diabetes self-management education intervention elements: Can J Diabetes ; Patient Educ Couns ; Self-management education for adults with type 2 diabetes: Diabetes Care ; Standards of medical care in diabetes— Diabetes Care ; 38 Suppl. Health Aff Millwood ; Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control.