Table 5.1

Medical nutrition therapy recommendations

TopicRecommendationEvidence rating
Effectiveness of nutrition therapy5.6 An individualized medical nutrition therapy program as needed to achieve treatment goals, provided by a registered dietitian nutritionist (RD/RDN), preferably one who has comprehensive knowledge and experience in diabetes care, is recommended for all people with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus.A
5.7 Because diabetes medical nutrition therapy can result in cost savings B and improved outcomes (e.g., A1C reduction, reduced weight, decrease in cholesterol) A, medical nutrition therapy should be adequately reimbursed by insurance and other payers. EB, A, E
Energy balance5.8 For all patients with overweight or obesity, lifestyle modification to achieve and maintain a minimum weight loss of 5% is recommended for all patients with diabetes and prediabetes.A
Eating patterns and macronutrient distribution5.9 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
5.10 A variety of eating patterns are acceptable for the management of type 2 diabetes and prediabetes.B
Carbohydrates5.11 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber and minimally processed. Eating plans should emphasize nonstarchy vegetables, minimal added sugars, fruits, whole grains, as well as dairy products.B
5.12 Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.B
5.13 For people with diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate counting A and on dosing for fat and protein content B should be used to determine mealtime insulin dosing.A, B
5.14 For adults using fixed insulin doses, consistent pattern of carbohydrate intake with respect to time and amount, while considering the insulin action time, can result in improved glycemia and reduce the risk for hypoglycemia.B
5.15 People with diabetes and those at risk are advised to replace sugar-sweetened beverages (including fruit juices) with water as much as possible 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 An eating plan emphasizing elements of a Mediterranean-style eating pattern rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk.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 Educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended. The importance of glucose monitoring after drinking alcoholic beverages to reduce hypoglycemia risk should be emphasized.B
Sodium5.22 As for the general population, people with diabetes and prediabetes 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