Table 5.1

Medical nutrition therapy recommendations

TopicRecommendationsEvidence rating
Effectiveness of nutrition therapy5.6 An individualized medical nutrition therapy program as needed to achieve treatment goals, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus.A
5.7 A simple and effective approach to glycemia and weight management emphasizing portion control and healthy food choices may be considered for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, or who are older and prone to hypoglycemia.B
5.8 Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g., A1C reduction) A, medical nutrition therapy should be adequately reimbursed by insurance and other payers. EB, A, E
Energy balance5.9 Weight loss (>5%) achievable by the combination of reduction of calorie intake and lifestyle modification benefits overweight or obese adults with type 2 diabetes and also those with prediabetes. Intervention programs to facilitate weight loss are recommended.A
Eating patterns and macronutrient distribution5.10 There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes; therefore, meal plans should be individualized while keeping total calorie and metabolic goals in mind.E
5.11 A variety of eating patterns are acceptable for the management of type 2 diabetes and prediabetes.B
Carbohydrates5.12 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber, including vegetables, fruits, legumes, whole grains, as well as dairy products.B
5.13 For people with type 1 diabetes and those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate counting A and in some cases how to consider fat and protein content B to determine mealtime insulin dosing is recommended to improve glycemic control.A, B
5.14 For individuals whose daily insulin dosing is fixed, a consistent pattern of carbohydrate intake with respect to time and amount may be recommended to improve glycemic control and reduce the risk of hypoglycemia.B
5.15 People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (including fruit juices) in order to control glycemia and weight and reduce their risk for cardiovascular disease and fatty liver B and should minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices. AB, A
Protein5.16 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 be avoided when trying to treat or prevent hypoglycemia.B
Dietary fat5.17 Data on the ideal total dietary fat content for people with diabetes are inconclusive, so an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates.B
5.18 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat cardiovascular disease B; however, evidence does not support a beneficial role for the routine use of n-3 dietary supplements. AB, A
Micronutrients and herbal supplements5.19 There is no clear evidence that dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve outcomes in people with diabetes who do not have underlying deficiencies and they are not generally recommended for glycemic control.C
Alcohol5.20 Adults with diabetes who drink alcohol should 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
5.21 Alcohol consumption may place people with diabetes at increased risk for hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted.B
Sodium5.22 As for the general population, people with diabetes should limit sodium consumption to <2,300 mg/day.B
Nonnutritive sweeteners5.23 The use of nonnutritive sweeteners may have the potential to reduce overall calorie and carbohydrate intake if substituted for caloric (sugar) sweeteners and without compensation by intake of additional calories from other food sources. For those who consume sugar-sweetened beverages regularly, a low-calorie or nonnutritive-sweetened beverage may serve as a short-term replacement strategy, but overall, people are encouraged to decrease both sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake.B