Optimizing Nutrition Strategies for Diabetes Management in India: An Expert Opinion

Abstract

A distinct “South Asian phenotype” and unhealthy dietary patterns contribute to the high burden of type 2 diabetes mellitus (T2DM) in India, highlighting the need for context-specific nutritional management. Five regional advisory board meetings were conducted to gather expert perspectives on the unique epidemiology of T2DM and key aspects of nutritional management, including optimal dietary practices and the role of high-protein, high-fiber (HPHF) supplements or meal replacements. A total of 60 experts attended the meetings. During each meeting, an optional multiple-choice poll was administered as part of the discussion. Expert perspectives were derived from optional poll responses and discussions informed by scientific evidence and participants’ clinical experience. High carbohydrate and low protein intake, insulin resistance, central obesity, suboptimal muscle mass, and genetic predisposition characterize Indian patients with diabetes. Recognizing this phenotype is essential for providing tailored nutritional interventions. Key assessments to facilitate nutritional interventions include anthropometry (weight, body mass index, and waist circumference), lipid profile, and 24-hour dietary recalls. Experts emphasized that customized nutrition plans should be developed based on individual nutritional status, clinical profile, and dietary preferences. Dietary strategies should emphasize increased consumption of complex carbohydrates, high-fiber foods, and protein. The high burden of “diabesity” underscores the need for nutritional interventions addressing both glycemic control and weight management, including the appropriate use of meal replacement strategies. Protein and fiber are key nutrients in diabetes management. While dietary sources should be prioritized, experts noted that low-glycemic index, HPHF supplements/replacements may be considered for patients with overweight/obesity, poor nutrition intake, weakness or fatigue, or uncontrolled hyperglycemia. However, their limited use in clinical practice highlights the need for further research to evaluate their indications for use, effectiveness, safety, implementation, cost considerations, and long-term outcomes. This expert opinion highlights the unique epidemiology of T2DM in India and provides context-specific, evidence-informed insights to support nutritional management strategies. These perspectives are derived from advisory board discussions and should be interpreted as expert opinion rather than systematic evidence synthesis or formal guideline recommendations.

Introduction

The increasing burden of diabetes poses a major public health concern. According to the 2024 International Diabetes Federation estimates, diabetes affected ~589 million adults aged 20–79 years globally, translating to a global prevalence of 11.1%. India had the second largest number of adults with diabetes (89.8 million), accounting for one in seven of all adults with diabetes globally, of whom a high proportion were undiagnosed (43%).¹ Results from the nationally representative Indian Council of Medical Research (ICMR)-India Diabetes (INDIAB) study revealed an overall weighted diabetes prevalence of 11.4%.²

Awareness, treatment, and control of diabetes are low in India.³ The IMPACT India program revealed that most patients with diabetes had glycated hemoglobin (HbA_1c) >7%, fasting plasma glucose (FPG) >130 mg/dL, and postprandial glucose (PPG) >160 mg/dL.⁴ The ICMR-INDIAB study showed that only 7.7% of adults with diabetes achieved combined HbA_1c, blood pressure, and low-density lipoprotein cholesterol (LDL-C) targets.⁵ Patients with diabetes have an increased susceptibility to both microvascular and macrovascular complications, including cardiovascular disease.^6–8

A unique “South Asian phenotype” predisposes Asian Indians to develop type 2 diabetes mellitus (T2DM) at a younger age and at a lower body mass index (BMI) compared with White Europeans.^8,9 Although genetic factors increase susceptibility, an unhealthy dietary pattern is a major contributor to the increasing burden of diabetes in India.^8–11 Current Indian dietary patterns are high in refined grains, processed foods, added sugars, and trans fats, and low in fiber-rich whole grains, protein, fruits, and vegetables.^8,10–12

Medical nutrition therapy (MNT) is an integral component of diabetes management that aims to optimize dietary practices to attain favorable glycemic and cardiometabolic outcomes in patients with diabetes.^13–17 It involves individualized nutrition planning, counseling and recommendations for food intake, and regular monitoring by a registered dietitian or nutrition specialist.¹⁴ MNT also requires active patient participation, self-management, and adherence.¹⁴ Evidence suggests that it may be associated with a 1–2% reduction in HbA_1c, which is comparable to the effects of some antidiabetic medications. MNT may also lower healthcare costs through improvements in overall metabolic health and quality of life.¹⁴ However, despite these established benefits, MNT implementation in India poses several challenges, including a dearth of nutrition specialists to offer patient-centric care, limited awareness of the importance of MNT in clinical practice, and the lack of a structured approach to its implementation.^14,15 While standardized MNT charts are available in clinical settings, the heterogeneity in dietary practices due to economic, regional, and cultural differences necessitates adopting a more nuanced approach to MNT.^14,15 Furthermore, adherence to MNT and dietary recommendations remains suboptimal among Indian patients with T2DM, with various behavioral, social, economic, and practical barriers affecting implementation.^18,19

Protein and fiber are important components of MNT for Indian patients with diabetes. A study in India revealed that while most patients with diabetes were aware of the importance of protein and fiber intake, only 14.8% and 21.2% of patients, respectively, were actually meeting their daily protein and fiber requirements.²⁰ Prior expert consensus highlighted unmet needs in dietary fiber and protein intake among Indian patients with T2DM, outlined the physiological role and benefits of these nutrients in T2DM management, and recognized the role of diabetes-specific supplements in bridging the protein and fiber gap.^12,21 The expert consensus (N=14) published by Mohan V et al provides practical guidance on improving dietary protein intake from foods, including strategies to incorporate protein in each meal, sample meal plans, and protein complementation to improve dietary protein quality.¹² Another expert opinion (N=14) by Saboo B et al details various approaches to increase dietary fiber intake from food while minimizing gastrointestinal side effects.²¹

The unique T2DM disease characteristics and suboptimal dietary patterns of patients with diabetes highlight the need for more structured, holistic, and patient-centric discussions around the nutritional management of diabetes in India. In this context, a series of regional advisory board meetings was conducted in India, engaging a large and geographically diverse group of experts. The objective of these meetings was to discuss current evidence and gain a broad perspective on various aspects of nutritional care throughout the patients’ journey, including unique risk factors and challenges, evaluation and assessments, and key components of nutritional management. At each meeting, an optional multiple-choice poll was administered as part of the discussion to gather expert insights on the (i) epidemiology of diabetes in India, including unique patient profiles and nutritional challenges; (ii) important assessments to facilitate nutritional interventions in patients with diabetes; (iii) nutritional strategies for patients with diabetes, including those who are overweight/obese; and (iv) the role of high-protein, high-fiber (HPHF) supplements/replacements in the nutritional management of diabetes.

While previous expert opinion and consensus publications have focused on specific aspects of nutritional management, such as dietary protein and fiber, the current manuscript aims to provide a broad, integrated overview of nutritional care across multiple domains in Indian patients with T2DM. It combines current evidence with geographically diverse expert perspectives derived from multiple regional advisory board meetings. In addition, optional polling across topics conducted during these meetings helped to supplement and contextualize the expert discussions.

This article provides an overview of the evidence and expert perspectives from the advisory board discussions, highlighting current challenges, providing actionable insights, and facilitating an evidence-informed approach to the nutritional management of Indian patients with diabetes.

Materials and Methods

Five regional advisory board meetings were held in the Indian cities of Kolkata, Chennai, Bengaluru, Mumbai, and Hyderabad from October 2023 to February 2024, ensuring geographic representation across all major regions of India. A total of 60 experts attended the meetings. Participating experts were identified and invited based on predefined criteria, including specialty (diabetologists and endocrinologists) and broad clinical experience ranging from 15 to 35 years. All meetings were facilitated by an independent chair who guided the discussion agenda and ensured scientific objectivity. During each meeting, an optional multiple-choice poll comprising 10 questions covering the meeting topics was administered. Participation in the poll was voluntary, and responses were collected from a subset of meeting attendees. The poll was intended as a facilitation tool to guide discussions and was not designed as a formal consensus-generating instrument. The poll data are exploratory and descriptive in nature; no inferential statistical analyses were performed. The discussions around each topic were informed by available scientific evidence and unique expert insights based on clinical experience. Expert perspectives were generated through a summary of key discussion points and a descriptive interpretation of the aggregated poll responses. In instances where expert opinions differed, the matter was discussed among participants until a resolution was reached. The advisory board meetings were not conducted as a systematic evidence synthesis or formal guideline development process. They were designed to capture expert perspectives from geographically diverse real-world clinical practice settings across India. Conflicts of interest were declared by all participating experts and are reported in the Disclosure section of this manuscript.

Results and Discussion

The Unique Epidemiology of Diabetes in India

The South Asian Phenotype

South Asians tend to develop T2DM at a younger age (almost a decade earlier) and at a lower BMI compared with their White counterparts.^9,22 Among Asians, peak diabetes prevalence may be attained ∼10 years earlier in Indians compared with that in Chinese and Japanese individuals.²³ The ICMR-INDIAB study noted a sharp rise in T2DM prevalence at the young age of 25–34 years and a substantial proportion of T2DM cases with a BMI of <25 kg/m².⁹

Compared with other ethnic groups, South Asians, including Asian Indians, have higher serum insulin levels and greater insulin resistance. They also have a higher susceptibility to abdominal obesity, with higher waist−hip ratios and trunk skinfold thickness, as noted in some studies.^24–30 South Asians have adverse body fat patterning and a higher body fat percentage despite low/normal BMI.^27,31 Higher levels of intermuscular, visceral, and hepatic fat, but lower lean mass, have been observed in South Asians compared with those in other ethnicities.³² South Asians may store more ectopic fat in the liver compared with White Europeans at similar BMI levels.³³ Compared with Caucasians, Asians tend to have 3–5% higher body fat percentage at a given BMI and a BMI that is 3–4 units lower at a given body fat percentage.³⁴ A high proportion of Indian patients with T2DM have body fat-defined obesity despite having a normal BMI.³⁵ The prevalence of abdominal obesity among Indian adults is high, and abdominal obesity is significantly associated with diabetes.³⁶

South Asians may be more likely to have dyslipidemia (high triglycerides and low high-density lipoprotein cholesterol [HDL-C]) within a healthy BMI range compared with other ethnic groups.^24,37 Inflammatory markers, such as C-reactive protein (CRP) concentrations, are higher in Asian Indians compared with those in White Europeans.³⁸

Studies have identified novel genetic variants associated with T2DM in South Asians and Indians.^39,40 South Asians have a greater genetic burden of beta-cell dysfunction, insulin deficiency, and lipodystrophy compared with White Europeans.^41,42

Dietary Patterns in Indian Adults

Findings from the nationally representative ICMR-INDIAB survey among Indian adults (N=18,090) showed that carbohydrates comprised the main source of energy (62.3% of total daily energy intake), predominantly high intakes of low-quality carbohydrates, such as added sugars, milled whole grains, and refined cereals.⁴³ This dietary pattern was associated with an increased risk of newly diagnosed prediabetes and T2DM, as well as a higher likelihood of developing general and abdominal obesity.⁴³ These findings align with prior reports linking total dietary carbohydrates, glycemic index (GI), glycemic load, or refined grain intake to an increased risk of diabetes.^44,45

The ICMR-INDIAB survey also showed that protein consumption fell short of recommended levels, contributing to only 12% of total daily energy intake.⁴³ The ICMR-National Institute of Nutrition study assessing dietary consumption among Indian adults reported that only 5% of the rural population and 18% of the urban population consumed recommended levels of good quality protein, defined as >66% of protein from pulses, legumes, nuts, milk, and flesh foods.⁴⁶

Notably, modeling estimates from the ICMR-INDIAB study showed that substituting 5% of total daily energy intake from carbohydrates with an equivalent energy contribution from protein, specifically from plant sources (pulses and legumes) or from dairy, fish, or eggs, but not from other animal-protein sources, was associated with a reduced risk of developing prediabetes and T2DM.⁴³

Expert Opinion on the Unique Characteristics of Diabetes in India

Most experts (98%) either strongly agreed or agreed that diabetes in India is unique, indicating acknowledgement of its distinct clinical and metabolic profile. Furthermore, 86% of experts regarded it as very/extremely important to recognize the uniqueness of T2DM in Indians as a separate entity, reinforcing the need for context-specific diagnostic and management approaches Table 1. When examining the factors contributing to this uniqueness, several India-specific patterns emerged. Most experts identified high carbohydrate intake (82%), central obesity (78%), and insulin resistance (76%) as key distinguishing features. Additionally, poor protein intake (75%) and low lean muscle mass (69%) were also frequently cited, suggesting that dietary imbalances and unfavorable body composition play crucial roles in the pathophysiology of diabetes in Indians. The influence of genetic predisposition (67%) was also recognized, underscoring the interplay between inherent susceptibility and environmental factors Table 1.

Table 1.

Expert Opinion on the Unique Characteristics of Diabetes in India

Question	Choices	Responses, n (%)
Do you agree that the characteristics of diabetes in India are unique? (N=58)	Strongly agree	33 (57)
	Agree	24 (41)
	Neutral	1 (2)
	Disagree	0 (0)
	Strongly disagree	0 (0)
How important is it to recognize the uniqueness of T2DM in the Indian population as a separate entity from that in the Western world? (N=50)	Not important at all	0 (0)
	Slightly important	2 (4)
	Moderately important	5 (10)
	Very important	31 (62)
	Extremely important	12 (24)
In your opinion, what distinguishes patients with diabetes in India from those in Western countries in terms of unique characteristics and experiences with the condition? (Check all that apply). (N=55)	Genetic factors	37 (67)
	Insulin resistance	42 (76)
	Central obesity	43 (78)
	Poor lean muscle mass	38 (69)
	High carbohydrate intake	45 (82)
	Poor protein intake	41 (75)

Abbreviation: T2DM, Type 2 diabetes mellitus.

Assessments for Patients with Diabetes

Recommendations for Anthropometric and/or Biochemical Assessments

The American Diabetes Association (ADA) recommends annual screening for overweight and obesity using BMI. Additional assessments of body fat using either anthropometric assessments, such as waist-to-hip ratio, or direct measurements, such as dual-energy X-ray absorptiometry (DEXA) and bioelectrical impedance analysis, could be considered to confirm excess adiposity.⁴⁷ Obesity-related anthropometric measurements should be monitored at least annually or at least every 3 months during active weight management treatment.⁴⁷

A consensus on MNT for South Asian adults recommends measuring BMI, waist circumference (WC), and waist-to-hip ratio for screening and diagnosing diabetes and obesity, while body fat percentage is a useful optional investigation.¹⁵ DEXA scans and bioelectric impedance tests can be considered for body composition assessments. The group also recommends monitoring HbA_1c, FPG, and PPG levels, fasting lipid profiles, and the albumin/creatinine ratio. Other lab tests can be considered based on individual evaluation.¹⁵ The Research Society for the Study of Diabetes in India (RSSDI) recommends that patients with T2DM should undergo body weight screening using BMI and WC at the first visit and on each subsequent visit. WC is preferred over the waist-to-hip ratio as a marker of abdominal obesity.¹³ South Asian-specific cutoff values should be used for reference Figure 1.^13,15 Other than glycemic monitoring, the group recommends blood pressure measurements at every visit and lipid measurements at diagnosis or age 40 years and thereafter at 6-monthly intervals.¹³ The ICMR-recommended ideal targets for cardiometabolic control in patients with diabetes are presented in Table 2.⁴⁸

Figure 1.

South Asian-specific cutoff values for defining overweight/obesity in patients with diabetes.^13,15 Adapted from: Kapoor et al.¹⁵

Abbreviation: BMI, Body mass index.

Table 2.

Indian Council of Medical Research Targets for Cardiometabolic Control in Patients with Diabetes⁴⁸

Parameter	Ideal Target
FPG (mg/dL)	80–110
2-hour PPG (mg/dL)	120–140
HbA1c (%)	<7
Blood pressure (mmHg)	<130/80
BMI (kg/m2)	20–23
WC (cm)	Men <90; women <80
Lipid profile, mg/dL
Total cholesterol	<200
HDL-C	>40 for men; >50 for women
LDL-C	<100 (<70 for those at high-risk)*
Non-HDL-C	<130
Triglycerides	<150

Notes: *Established cardiovascular disease, smoking, obesity, hypertension, family history of premature cardiovascular disease, or evidence of other vascular disease. Adapted from: The Indian Council of Medical Research guidelines.⁴⁸

Abbreviations: BMI, Body mass index; FPG, Fasting plasma glucose; HbA_1c, Glycated hemoglobin; HDL-C, High-density lipoprotein cholesterol; LDL-C, Low-density lipoprotein cholesterol; PPG, Postprandial glucose; WC, Waist circumference.

Expert Opinion on Assessments for Patients with Diabetes

Assessing an individual’s medical and family history is critical, as those who are genetically predisposed to obesity may find it challenging to achieve weight loss through conventional means. Weight, BMI, and WC are conventional anthropometric assessments for patients with diabetes. Most experts stated that they measure weight (75%) and BMI (81%), 49% measure WC, while only 34% assess fat or muscle mass in patients with diabetes. Most experts assess lipid profiles (81%) and conduct 24-hour diet recalls (62%) Table 3. A 24-hour dietary recall should be obtained for at least two or three follow-ups. Experts also opined that the patient’s functional status should be evaluated. DEXA scans and bioimpedance analysis can be considered for body composition assessment. Screening for sarcopenia can be performed using handgrip strength tests, along with adjunctive anthropometric measurements such as skinfold thickness.

Table 3.

Expert Opinion on Assessments for Patients with Diabetes

Question	Choices	Responses, n (%)
What parameters (from the following) do you assess among your patients with diabetes? (Check all that apply). (N=53)	Weight	40 (75)
	BMI	43 (81)
	WC	26 (49)
	Fat mass/muscle mass	18 (34)
	Lipid profile	43 (81)
	24-hour diet recall	33 (62)

Abbreviations: BMI, Body mass index; WC, Waist circumference.

Nutritional Recommendations for Patients with Diabetes

Overview of MNT

The ADA recommends individualized MNT programs provided by experienced registered dietitian nutritionists for all patients with diabetes at diagnosis and as needed thereafter to achieve treatment goals.¹⁷ MNT should focus on healthy eating patterns and the consumption of nutrient-dense foods to attain cardiometabolic goals and delay diabetes-related complications.¹⁷ The RSSDI recommends that MNT should be individualized, dietitian-guided, and based on the type, amount, and frequency of foods.¹³ The ICMR endorses providing flexible and individualized MNT.⁴⁸

General Dietary Recommendations

The ADA does not provide recommendations for a specific percentage of calories from individual macronutrients. Rather, the focus should be on total calories, nutrient quality, and overall metabolic goals, while considering current eating patterns and preferences. The overall carbohydrate intake may be reduced to improve glycemia.¹⁷ The RSSDI recommends fiber-rich, low-GI complex carbohydrates and high protein intake. Overall, the guidelines recommend dietary patterns rich in fiber and whole grains, pulses, legumes, lean proteins, vegetables and whole fruits, nuts and seeds, unsaturated fats, and low-fat dairy or nondairy alternatives. Consumption of refined grains, red meat, added sugars, fried foods, and processed foods should be limited or avoided.^13,17,48

Suggested Revisions to Macronutrient Levels for Indian Patients with Diabetes

The STARCH study in Indian patients with T2DM revealed that carbohydrates constituted 64.1% of the total energy intake, which is higher than guideline-recommended levels. The percentage of total energy from protein and fat was 14.3% and 21.5%, respectively.⁴⁹ Macronutrient recommendations for T2DM remission based on the ICMR-INDIAB study suggest a reduction in carbohydrates to 49–54% of the total energy and an increase in protein to 19%–20%, while keeping fat intake at 21–26% and dietary fiber at 5–6% of the total energy.⁵⁰

Role of Diabetes-Specific Nutrition Formulas in MNT

Diabetes-specific nutrition formulas (DSNFs) are constituted to provide essential nutrients in line with MNT recommendations.⁵¹ They contain nutrients in calorie-controlled portions that facilitate glycemic control, such as low-GI carbohydrates, fiber, unsaturated fatty acids, protein, and micronutrients. DSNFs can be used for calorie replacement, calorie supplementation, enteral nutrition support, or as part of very low-calorie diets.^16,51 Guidance on the use of DSNFs for patients with prediabetes or diabetes is summarized in Figure 2.^16,51 Meta-analyses have shown that DSNFs administered as enteral nutrition supplements are associated with improvements in glucose control and higher HDL-C levels than standard formulas in patients with diabetes.^52,53 In Indian patients with T2DM, DSNFs may be associated with reductions in HbA_1c, FPG, PPG, serum insulin, and mean cholesterol levels.^54–56

Figure 2.

Guidance on the use of diabetes-specific nutrition formulas for prediabetes and diabetes.^16,51 Adapted from: Mechanick et al.¹⁶

Notes: *Can be considered for patients with loss of muscle mass and/or muscle function, micronutrient deficiencies, or for those who require weight maintenance support and/or a healthy meal plan.

Abbreviations: DSNF, Diabetes-specific nutrition formula; HbA_1c, Glycated hemoglobin.

Expert Opinion on Nutrition Recommendations for Patients with Diabetes

Each patient should be assessed for their dietary patterns; calorie, micronutrient, and macronutrient intake; physical activity; meal timing; and meal type. Customized diet charts and personalized nutritional plans should be an integral part of the patient’s healthcare journey. However, current regional diet charts lack this specificity. MNT should be individualized based on patient profiles, while also considering food habits, religious choices, cultural differences, and socioeconomic constraints. A balanced dietary pattern with the appropriate macronutrient distribution, consuming complex carbohydrates and high-fiber foods, increasing protein intake, and incorporating vegetables and fruits is crucial for diabetes management. Nutritional supplementation should be incorporated gradually based on patient profiles and individualized goals. Lifestyle interventions should be integrated into nutritional plans, and patients should be informed about accessible lifestyle management tools.

Patients should be encouraged to consult healthcare practitioners (HCPs) for personalized nutritional guidance rather than relying on online recommendations. Clinicians should collaborate with dietitians to develop dietary strategies that align with the patient’s diabetes management goals. Involving family members can promote supportive environments that enhance dietary adherence and foster healthy lifestyle choices.

Special nutritional interventions and dietary recommendations may be required for patients with prediabetes, gestational diabetes, nocturnal hypoglycemia, sarcopenia, metabolic syndrome, liver disease, and acute illnesses, and for those who are poor eaters or lack an appetite. Nutritional interventions should be individualized for patients with diabetic kidney disease, especially for those on dialysis, focusing on specific meal and snack replacements that align with their dietary restrictions.

Most experts stated that ≤25% of their patients adhered to dietary recommendations for at least 6 months Figure 3. To overcome this challenge, a team of dietitians should work closely with patients to provide tailor-made meal plans, offer dedicated nutrition and lifestyle counseling, and maintain routine follow-ups at regular intervals. Convenient nutritional options that can be consumed on the go may offer flexibility to patients who find it challenging to adhere to recommended eating patterns because of demanding work schedules. Culture-specific patient education programs should be prioritized to bring about a mindset change. Nutritional products should be made more affordable and accessible.

Figure 3.

Expert opinion on patient adherence to dietary recommendations.

Nutritional Interventions for Overweight or Obese Patients with Diabetes

Burden of Diabetes and Obesity in India

The 2016 Global Burden of Disease study revealed that in India, among every 100 overweight adults, 38 adults had diabetes, whereas the global average was 19 adults. Around 36% of the diabetes disability-adjusted life-years were attributed to being overweight.⁵⁷ Another nationally representative study showed that the probability of being a patient with diabetes was twice or more among individuals who were overweight or obese than among non-overweight individuals.⁵⁸ Patients with T2DM who are obese may have higher odds of uncontrolled glycemia than those with a normal BMI.⁶

Recommendations for Calorie Restriction, Weight Loss, and Use of Meal Replacements

The ADA recommends that weight management should be a primary treatment goal, along with glycemic control, in overweight/obese patients with T2DM.⁴⁷ The aim should be to create an energy deficit of 500–750 kcal/day through physical activity, behavioral therapy, and individualized MNT. While any magnitude of weight loss is recommended, a weight loss of 5–7% can improve glycemia, blood pressure, and lipid profile. Sustained weight loss of >10% may be associated with disease-modification or remission and long-term improvements in cardiovascular outcomes.⁴⁷ Partial or total meal replacements containing fixed amounts of macronutrients and micronutrients are a useful strategy for energy/calorie restriction that can improve nutrient quality and reduce portion size.^17,47 Structured, very low-calorie meals (800–1000 kcal/day) using high-protein foods and meal replacement products should be prescribed only by HCPs for carefully selected patients, with close monitoring and behavioral support, and used for a short duration.⁴⁷

The RSSDI recommends creating an overall negative energy balance through a combination of moderate calorie restriction and physical activity, with a 5–10% weight loss goal, for overweight/obese patients with T2DM.¹³ A low-calorie diet with high fiber and protein intake, low saturated and trans fats, an optimal ratio of essential fatty acids, and low salt and sugar intake is recommended. Modifying carbohydrate intake may be important, considering the high consumption in India. Meal plans with partial or complete meal replacements are beneficial and may be considered under supervision.¹³

Evidence for Meal Replacement Strategies in Diabesity Management

Meta-analyses have shown that compared with conventional diabetes diets or traditional low-calorie diets, meal replacements are associated with reductions in BMI; body fat; WC; waist-to-hip ratio; HbA_1c, FPG, and fasting insulin levels; and blood pressure in overweight/obese patients with T2DM.^59,60 In the Indian context, findings from a Phase IV, randomized controlled study showed that partial meal replacement with a low GI DSNF (once daily) administered along with standard of care was associated with greater reductions in HbA_1c levels, body weight, and WC compared with standard of care alone in overweight/obese patients with T2DM.⁶¹ Regarding quality-of-life outcomes, a significantly higher proportion of patients receiving partial meal replacement plus standard of care (vs standard of care alone) adhered to the treatment regimen and felt more energetic and better.⁶¹

Overall, the available evidence suggests that meal replacement strategies are effective for improving glycemic control and supporting weight management in patients with T2DM across diverse populations. However, a systematic scoping review highlighted that these interventions have been predominantly evaluated in high-income countries, with limited evidence from Southeast Asia, South Asia, and Africa.⁶² The review also identified several challenges to the real-world implementation of meal replacement strategies in these regions, including limited access to dietitians, the absence of a structured approach to diabetes care, limited accessibility and availability of these interventions, and insufficient evidence regarding their cost-effectiveness.⁶²

Expert Opinion on Nutritional Recommendations for Overweight/Obese Patients with Diabetes

Most experts (61%) reported that more than half of their patients with diabetes are overweight or obese Table 4, indicating a high prevalence of overweight and obesity among Indian patients with diabetes in clinical practice. This highlights the growing overlap between diabetes and obesity, often termed “diabesity”, and reinforces the need for effective nutritional interventions that address both glycemic control and weight management. Despite the high burden of diabesity, the use of partial or complete meal replacements remains relatively limited in clinical practice. Most experts (64%) reported recommending meal replacements to ≤25% of patients with overweight or obesity, while only 14% of experts provide such recommendations to >50% of their patients Table 4.

Table 4.

Expert Opinion on the Prevalence of Overweight/Obesity and the Use of Meal Replacements for Overweight/Obese Patients with Diabetes

Question	Choices	Responses, n (%)
What percentage of your patients with diabetes are overweight/obese? (N=44)	0–25%	4 (9)
	26–50%	13 (30)
	51–75%	20 (45)
	>75%	7 (16)
In what percentage of your patients with overweight/obesity do you recommend a partial/complete meal replacement? (N=42)	0–25%	27 (64)
	26–50%	9 (21)
	51–75%	6 (14)
	>75%	0 (0)

Experts opined that a holistic approach that addresses both T2DM and weight concerns is essential. Lifestyle and behavioral counseling should be offered to patients. Nutritional plans and calorie intake should be individualized according to the patient’s BMI, metabolic profile, and glycemic targets. Consistent meal timing, portion size control and calorie awareness, and a balanced dietary pattern rich in essential nutrients should be prioritized. Carbohydrate intake can be reduced, focusing on low-GI, complex carbohydrates. Consumption of millets and fiber-rich foods should be encouraged. Fruits and nuts should be included as healthy snack options as they promote satiety and provide nutritional variety. Oily, fried, processed, or refined foods should be preferably eliminated. In general, nutrient-dense meal or snack replacements along with a low-calorie diet can be an effective intervention for managing calorie intake. Although the composition of such formulas may remain standard, the amount prescribed can vary based on the patient’s BMI.

Role of HPHF Supplements/Replacements in the Nutritional Management of Patients with Diabetes

High-Protein Diets for Diabetes Management

Dietary protein plays a significant role in diabetes management. Clinical evidence suggests that compared with standard diets, a high-protein diet may be associated with significant reductions in insulin requirement, FPG levels, BMI, fat mass, and fat-free mass in patients with T2DM.⁶³ In overweight/obese patients with T2DM, high-protein diets may be associated with lower BMI, WC, hip circumference, and fat mass, reduced insulin resistance, and improved glucose homeostasis.^64,65 Consumption of an enriched protein drink combined with lifestyle intervention showed beneficial effects on leg muscle mass, appendicular muscle mass, total lean mass, and insulin sensitivity in older adults with obesity and T2DM.⁶⁶

Plant Proteins vs Animal Proteins

Some evidence suggests that substituting animal proteins with plant proteins or a high intake of plant proteins may be associated with a reduced risk of T2DM.^67–69 The Chennai Urban Rural Epidemiology (CURE) study suggested that low dietary protein intake may contribute to the increased genetic susceptibility of Indians to diabetes.⁷⁰ Another population-based study revealed a possible inverse association between legume intake and diabetes prevalence among Indian adults.⁷¹

The ADA recommends incorporating more plant-based protein sources in the context of an overall diverse eating pattern to reduce cardiovascular risk, noting that plant proteins are low in saturated fat and high in fiber.¹⁷ In patients with T2DM, soy supplementation has been associated with reductions in total cholesterol, triacylglycerol, and LDL-C levels and an increase in HDL-C levels.⁷² Replacement of animal protein with plant protein may be associated with reductions in HbA_1c, fasting glucose, and fasting insulin levels in patients with diabetes.⁷³ High adherence to a healthy dietary protein pattern high in legumes, fruits, nuts, seeds, and fish and low in red meat may be associated with a reduced risk of mortality in patients with T2DM.⁷⁴

High-Fiber Diets for Diabetes Management

High-fiber diets are associated with reductions in HbA_1c, FPG, and serum insulin levels; insulin resistance; blood lipid levels; BMI; WC; CRP levels; and all-cause mortality in patients with prediabetes or diabetes.⁷⁵ The CURE study showed that low dietary fiber intake among Indian adults with T2DM was associated with a high risk of hypercholesterolemia and high LDL-C levels.⁷⁶ A low-GI diet compared with a usual diet was associated with significant reductions in BMI, triceps skinfold thickness, and truncal fat and improvements in HbA_1c levels among South Indians with T2DM.⁷⁷

Role of HPHF Supplements in Diabetes Management

The Indian dietary pattern is high in refined carbohydrates, inadequate in dietary fiber, and low in protein.^10,11 Such a pattern promotes weight gain and central obesity as well as loss of muscle mass and frailty.¹³ In scenarios where protein and fiber requirements cannot be met through dietary sources, HPHF supplements can aid in the nutritional management of patients with diabetes.^12,21 The RSSDI recommends that HPHF food supplements fortified with micronutrients may be used as part of MNT for elderly patients with diabetes.¹³ The ADA notes that it is important to monitor protein and fiber intake in individuals undergoing weight loss treatment. It further highlights the importance of optimizing protein intake alongside resistance training to preserve lean mass, and suggests that protein supplementation should be encouraged as needed.⁴⁷ HPHF supplements should be used under medical supervision, and prescriptions should be guided by individual patients’ dietary requirements and clinical profiles.¹²

In overweight/obese Indian adults, a plant-based HPHF supplement was associated with low GI and good satiety.⁷⁸ Overweight/obese Indian adults with T2DM consuming a HPHF supplement twice daily (25 g each) in addition to standard of care showed significant improvements in HDL-C, HbA_1c, and FPG levels compared with patients receiving only standard of care.^79,80

While the short-term benefits of HPHF supplements in improving glycemic control and HDL-C for up to 24 weeks in Indian patients with T2DM have been demonstrated in randomized studies with small sample sizes, there is a need for data from large-scale clinical trials in the Indian setting.^79,80 Specifically, future research should address the long-term effects of HPHF supplements/replacements on glycemic and metabolic outcomes, real-world adherence, and implementation feasibility.^62,79,80 This is particularly relevant given that non-adherence to MNT or dietary recommendations remains a challenge among Indian patients with T2DM.^18,19 In addition, commercially available oral nutritional supplements or meal replacements may differ in their macronutrient composition, GI, and functional ingredients, thus reflecting possible heterogeneity across products.^62,81 Lastly, limited studies have evaluated the cost-effectiveness of meal replacements in low- and middle-income settings. The high cost or limited availability of these formulations in such settings may present a barrier for some patients with limited financial resources.⁶²

Expert Opinion on the Role of HPHF Supplements/Replacements in Diabetes Management

Most experts (86%) stated that they would recommend HPHF replacements/supplements in ≤50% of patients with diabetes, suggesting that they are currently prescribed only in select scenarios Figure 4A. When evaluating patient profiles that might benefit from HPHF supplements/replacements, experts noted that they can be recommended for patients with diabetes who have poor nutrition intake (64%), are overweight/obese (54%), or report weakness or fatigue (42%) Figure 4B. These insights are consistent with prior reports noting that high-protein supplements may help promote or preserve lean body mass and bridge nutritional deficiencies in undernourished patients or in older adults with sarcopenia.¹² High-protein or high-fiber supplements can also support weight management and potentially improve metabolic health in patients with diabesity.^12,21 Some experts opined that they would also recommend HPHF replacements/supplements for patients with uncontrolled hyperglycemia despite medication (40%), indicating a potential role for such nutritional interventions in improving glycemic control and reducing glycemic excursions.^12,21 Figure 4B. During discussions on the ideal characteristics of HPHF supplements/replacements, a substantial proportion of experts agreed that such interventions should contain a high amount of the right proteins (66%), be high in fiber (66%), have a low GI (66%), and contain essential vitamins and minerals (54%), with clinically proven benefits for managing diabetes (62%) Figure 4C.

Figure 4.

Expert opinion on the use of high-protein high-fiber supplements/replacements for patients with diabetes. (A) Expert responses (%) regarding the proportion of patients with diabetes for whom HPHF supplements/replacements are recommended. (B) Expert responses (%) regarding indications for recommending HPHF supplements/replacements for patients with diabetes. (C) Expert responses (%) regarding the characteristics of an ideal HPHF supplement/replacement.

Abbreviations: GI, Glycemic index; HPHF, High-protein high-fiber.

Experts noted that HPHF supplements can be offered as a partial meal/snack replacement for mid-morning, mid-evening, or bedtime consumption or before major meals to reduce the portion size and calorie intake of the subsequent meal. The carbohydrate content of HPHF supplements/replacements should be considered and subtracted from the recommended dietary intake. HPHF supplements/replacements can be continued as part of a long-term dietary strategy, if required. Nutritional assessments should be performed before prescribing these interventions, and patients should be educated on their proper consumption. HPHF supplements/replacements should be prescribed with caution after individualized assessment in patients with renal disease. These interventions are generally not indicated for individuals with optimal glycemic control who can adhere to standard dietary recommendations. HPHF supplements/replacements should be avoided if they are not well tolerated, are less palatable, or are not effective.

Conclusions

This article has some limitations that should be acknowledged. The perspectives presented are based on expert opinion generated during advisory board discussions conducted across India. As such, the findings should be interpreted in the context of the inherent limitations associated with this methodology. They represent expert opinion rather than systematic evidence synthesis or formal guideline recommendations. Although a geographically diverse group of experienced clinicians from across India was included, the views expressed are not representative of all HCPs involved in diabetes management in the country. Furthermore, the optional multiple-choice poll was used to facilitate discussions and capture expert perspectives but was not designed or validated as a research instrument. Participation was voluntary, and responses were obtained from a subset of attendees, which introduces the possibility of response bias. The poll data are exploratory and descriptive in nature, and no inferential statistical analyses were performed. Given these limitations, the findings of this study should be viewed as expert perspectives aimed at complementing but not replacing evidence from clinical research.

The expert perspectives presented in this article underscore the importance of considering the unique metabolic and dietary characteristics of Indian patients with T2DM when developing nutritional management strategies. Nutritional assessments and dietary strategies should be tailored to the specific metabolic and nutritional needs of the Indian population, rather than directly extrapolating from Western guidelines. Individualized, dietitian-guided nutritional plans that account for clinical, nutritional, cultural, and socioeconomic factors are essential for effective diabetes care. Offering dedicated nutrition counseling and maintaining regular follow-up is important to ensure adherence to dietary recommendations. Nutritional interventions should address both glycemic control and weight management in patients with overweight or obesity. While dietary sources should be prioritized, the appropriate use of meal replacements or HPHF supplements/replacements may be considered in selected patients based on individualized clinical and nutritional assessments. They should be incorporated gradually, with appropriate patient education on proper use. However, the feasibility of implementing these expert perspectives may differ across healthcare settings in India, especially in primary care and rural settings, where access to dietitians, structured counseling, and specialized nutritional products may be limited.

Several areas require further attention and future research. Expert insights indicate that the use of meal replacements for patients with overweight/obesity and the use of HPHF supplements/replacements for patients with diabetes remain limited in clinical practice. These findings suggest that although clinicians recognize the importance of MNT, there may be hesitancy or underutilization of nutritional supplements, highlighting the need for research into barriers to their use. Future randomized controlled studies and real-world evidence in Indian populations are needed to evaluate indications for use, effectiveness, safety, implementation, cost considerations, and long-term outcomes of meal replacement strategies and HPHF supplements/replacements. Such evidence may help inform clinical practice, guide nutrition policy and implementation efforts, and support optimal nutritional management for Indian patients with T2DM.

Funding Statement

This research received no external funding.

Abbreviations

ICMR, Indian Council of Medical Research; INDIAB, India Diabetes; HbA_1c, Glycated hemoglobin; FPG, Fasting plasma glucose; PPG, Postprandial glucose; LDL-C, Low-density lipoprotein cholesterol; T2DM, Type 2 diabetes mellitus; BMI, Body mass index; MNT, Medical nutrition therapy; HPHF, High-protein, high-fiber; HDL-C, High-density lipoprotein cholesterol; CRP, C-reactive protein; GI, Glycemic index; ADA, American Diabetes Association; WC, Waist circumference; DEXA, Dual-energy X-ray absorptiometry; RSSDI, Research Society for the Study of Diabetes in India; DSNF, Diabetes-specific nutrition formula; HCP, Healthcare practitioner; CURE, Chennai Urban Rural Epidemiology.

Data Sharing Statement

All data generated or analyzed during this study are included in this published article.

Ethics Approval and Consent to Participate

Ethical approval from an institutional review board or ethics committee was not sought, as this work does not constitute research involving human participants as defined under the Indian Council of Medical Research (ICMR) National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017). The article presents an expert opinion derived from five regional advisory board meetings attended by 60 practicing clinicians with expertise in diabetes management in India. No patients were enrolled, no clinical interventions were administered, and no identifiable patient data were collected or analyzed. The optional, anonymous polls conducted during the meetings captured only the participating experts’ professional opinions and were used solely to inform the scientific discussion. All experts attended voluntarily, were informed that the aggregated content would be used to develop a publication, and consented to this use.

Author Contributions

Banshi Saboo: Investigation, Resources, Validation, Writing—review and editing.

Ameya Joshi: Investigation, Resources, Validation, Writing—review and editing.

Subir Chandra Swar: Investigation, Resources, Validation, Writing—review and editing.

Mahesh D M: Investigation, Resources, Validation, Writing—review and editing.

Anantharaman Ramakrishnan: Investigation, Resources, Validation, Writing—review and editing.

Apoorva Hajirnis: Investigation, Resources, Validation, Writing—review and editing.

Suhas Khaire: Investigation, Resources, Validation, Writing—review and editing.

Subrata Chakrabarti: Investigation, Resources, Validation, Writing—review and editing.

Sreedevi Patnala: Investigation, Resources, Validation, Writing—review and editing.

Sattik Siddhanta: Investigation, Resources, Validation, Writing—review and editing.

Virendra A Patil: Investigation, Resources, Validation, Writing—review and editing.

Parthasarathy Balasubramanian: Investigation, Resources, Validation, Writing—review and editing.

Uthra Subash Chandra Bose: Investigation, Resources, Validation, Writing—review and editing.

Sriram Kalangani Mohan: Investigation, Resources, Validation, Writing—review and editing.

Nandan Arun Joshi: Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Visualization, Writing—original draft, Writing—review and editing.

Sourabh Bharat Sonawale: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Supervision, Visualization, Writing—original draft, Writing—review and editing.

All authors have agreed to the submission of this paperto Diabetes, Metabolic Syndrome and Obesity. All authors have reviewed and approved the original submission and the revised version of the paperand agree to approve the final version prior to publication. All authors agree to take responsibility for and be accountable for the content of the article.

Disclosure

All authors participated as expert members in advisory board meetings and received honoraria for their expert opinions and insights. Nandan Arun Joshi and Sourabh Bharat Sonawale are employees of Dr. Reddy’s & Nestle Health Science Limited and report support for this paper from Dr. Reddy’s & Nestle Health Science, during the conduct of the study. To ensure scientific independence, all advisory board meetings were facilitated by an independent chair who guided the discussion agenda. Nandan Arun Joshi and Sourabh Bharat Sonawale did not participate in or influence clinical deliberations or the formulation of expert opinion; their involvement was limited to organizational coordination and review of the paper before submission. The other authors declare no other conflicts of interest.