|Year : 2014 | Volume
| Issue : 2 | Page : 53-54
Quaternary prevention in medical nutrition therapy
Manash P Baruah1, Bharti Kalra2, Sanjay Kalra3
1 Department of Endocrinology, Excelcare Hospitals, Guwahati, Assam, India
2 Department of Obstetrics and Gynecology, Bharti Hospital and BRIDE, Karnal, Haryana, India
3 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
|Date of Web Publication||6-May-2014|
Manash P Baruah
Department of Endocrinology, Excelcare Hospitals, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Baruah MP, Kalra B, Kalra S. Quaternary prevention in medical nutrition therapy. J Med Nutr Nutraceut 2014;3:53-4
Medical nutrition therapy (MNT) is the cornerstone of diabetes management, and is indicated at all stages in the natural history of the disease. It is also an integral part of diabetes self-management skills, and helps minimize the potential adverse effects (hypoglycemia, weight gain, and gastrointestinal intolerance) of various anti diabetic and antiobesity medications.
| MNT in primary to tertiary prevention|| |
MNT is utilized in the primary, secondary, and tertiary prevention of diabetes. As a primary preventative measure, it is the intervention of choice for prevention of diabetes. Its benefits over pharmacopreventive therapy have been demonstrated in large trials conducted in various ethnic groups concerning the management of pre-diabetes or impaired glucose tolerance, so also its role as a primary preventative measure in public health strategies to reduce the prevalence of obesity. , MNT's contribution to secondary prevention of diabetes is also undoubted. Once diabetes has developed, lifestyle modification (including MNT) forms the first line of therapy, along with metformin. 
MNT continues to be prescribed irrespective of whichever pharmacological agent is used for initiation or intensification of antihyperglycemia management. In such cases, MNT must be individualized and tailored according to the drug regime, so as to prevent potentially life-threatening hypoglycemic episodes. Skillful use of MNT may help avoid weight gain and gastrointestinal intolerance seen with certain antidiabetic medications (weight gain with pioglitazone and insulin; gastrointestinal symptoms with metformin, alphaglucosidase inhibitors, and glucagon-like peptide-1 receptor agonists (GLP-1RA)). This is also true when MNT is co-prescribed with antiobesity drugs such as orlistat, as well. 
At tertiary level, MNT is used to retard, delay, or prevent the progression of complication of diabetes. Examples include restriction of protein intake in persons with chronic kidney disease, a low cholesterol diet in persons with coronary artery disease, and a low sodium diet in those with hypertension or symptomatic heart failure. Moderate weight loss, achievable by MNT, also helps reduce cardiovascular risk.
| Quaternary prevention|| |
All these levels of prevention are well-known, and are delineated in current recommendations and position statements.  There exists, however, further scope for utilizing MNT as a preventative measure. This is known as quaternary prevention. Quaternary prevention is defined as "action taken to identify patient at risk of over-medicalization, to protect him or her from new medical invasions, and to suggest interventions that are ethically acceptable
".  Using this definition as a framework, one can assess whether various MNT protocols fulfill the aim of health promotion, without the risk of over-medicalization.
That MNT is an essential part of diabetes management cannot be understated. Yet, as any other therapeutic modality, MNT can be wrongly prescribed, It may be under- or overutilized, leading to avoidable adverse effects. It is prevention of such misuse that forms the context of quaternary prevention MNT in diabetes. Here are some examples:
- Lack of skilled professionals "knowledgeable and skilled in MNT" may create a situation where MNT has to be offered by relatively less qualified team members
- One-sided interpretation of MNT may lead to extreme calorie restriction akin to the draconian pre-insulin era. This is especially important for children, adolescents, antenatal, and breast-feeding mothers, where adequate calories are necessary for growth and nourishment
- Lack of understanding of the pharmacology of commonly used drugs may lead to a clinical situation where their gastrointestinal effects are perpetuated. This can easily be averted by judicious use of MNT (e.g. low carbohydrate diet with alpha glucosidase inhibitors; small frequent meals with GLP1RA; and low-fat diet with orlistat)
- Inappropriate and injudicious use of meal replacement and supplement, which may be the outcome of lack of scientific knowledge or therapeutic inertia, can worsen glycemic control
- Adoption of MNT protocols which are economically and sociogeographically unviable, may lead to erosion of confidence of patients on MNT as a whole. This may be due to insensitiveness to the economic background of the patient and also lack of information regarding availability of a particular food item in that region (e.g. seasonal fruits).
Just as diabetes therapy is expected to be person-centric, so is MNT. While general recommendations may encourage protein restriction for persons with chronic kidney disease, this will not be appropriate for an already malnourished patient following a vegetarian diet. Similarly, low cholesterol diets may not necessarily be useful for thin persons, while weight loss diets are contraindicated in pregnancy.
MNT has evolved as an important part in the armamentarium of management of diabetes and other lifestyle disorders. The modern approach to providing MNT is by and large in the line of evidence-based medicine. Just as other arms in this armamentarium, MNT can also be misused. Understanding of the concept of quaternary prevention, and its applicability to MNT on the part of all healthcare professionals will help curb misuse of MNT, and also encourage appropriate utilization of this treatment modality.
| References|| |
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al
. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V. Indian Diabetes Prevention Programme (IDPP). Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49:289-97.
American Diabetes Association. Standards of medical care in diabetes 2014. Diabetes Care 2014;37:S14-80.
Jamoulle M, Roland M. Quaternary prevention. Paper presented at the Hong-Kong Meeting of the Wonca Classification Commitee, June 1995.