Table 4.1

Nutrition therapy recommendations

TopicRecommendationsEvidence rating
Effectiveness of nutrition therapy• Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan.A
• Individuals who have diabetes should receive individualized MNT to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT.A
• For individuals with type 1 diabetes, participation in an intensive, flexible insulin therapy education program using the carbohydrate-counting meal planning approach can result in improved glycemic control.A
• For individuals using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce hypoglycemia risk.B
• A simple diabetes meal planning approach, such as portion control or healthful food choices, may be better suited to individuals with type 2 diabetes with health and numeracy literacy concerns. This strategy also may be effective for older adults.C
• Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g., A1C reduction) A, MNT should be adequately reimbursed by insurance and other payers. EB, A, E
Energy balance• For overweight or obese adults with type 2 diabetes or at risk for diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss.A
• Modest weight loss may provide clinical benefits in some individuals with diabetes, especially those early in the disease process. To achieve modest weight loss, intensive lifestyle interventions with ongoing support are recommended.A
Eating patterns and macronutrient distribution• Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes B; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. EB, E
• Carbohydrate amount and available insulin may be the most important factors influencing glycemic response after eating and should be considered when developing the eating plan.A
• Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains critical in achieving glycemic control.B
• Carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium.B
• Substituting low glycemic−load foods for higher glycemic−load foods may modestly improve glycemic control.C
• Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture recommendation for dietary fiber (14 g fiber/1,000 kcal) and to consume foods containing whole grains (one-half of grain intake).B
• While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices.A
• People with diabetes and those at risk should limit or avoid intake of sugar-sweetened beverages to reduce risk for weight gain and worsening of cardiometabolic risk profile.B
Protein• In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia.B
• Evidence is inconclusive regarding an ideal amount of total fat for people with diabetes; therefore, goals should be individualized. C Fat quality appears to be far more important than quantity. BC, B
• A Mediterranean-style eating pattern, rich in monounsaturated fatty acids, may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern.B
Dietary fat• Increased consumption of foods containing long-chain omega-3 fatty acids (EPA and DHA), such as fatty fish, and omega-3 linolenic acid (ALA) is recommended.B
• The consumption of fish (particularly fatty fish) at least two times (two servings) per week is recommended.B
• The amount of dietary saturated fat, cholesterol, and trans fat recommended for people with diabetes is the same as that recommended for the general population.C
• Evidence does not support recommending omega-3 supplements for people with diabetes for the prevention or treatment of cardiovascular events.A
Micronutrients and herbal supplements• There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.C
• Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised due to insufficient evidence of efficacy and concerns related to long-term safety.C
• There is insufficient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes.C
• There is insufficient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes.E
• It is recommended that individualized meal planning include optimization of food choices to meet recommended dietary allowance/dietary reference intake for all micronutrients.E
Alcohol• If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men).C
• Alcohol consumption may place people with diabetes at an increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted.B
Sodium• The recommendation for the general population to reduce sodium to less than 2,300 mg/day is also appropriate for people with diabetes.B
• For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized.B