TABLE 5.

Nutrition Therapy Recommendations

Topic	Recommendations	Evidence rating
Effectiveness of nutrition therapy	An individualized MNT program, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes.	A
	For people with type 1 diabetes or those with type 2 diabetes who are prescribed a flexible insulin therapy program, education on how to use carbohydrate counting or estimation to determine mealtime insulin dosing can improve glycemic control.	A
	For individuals whose daily insulin dosing is fixed, having a consistent pattern of carbohydrate intake with respect to time and amount can result in improved glycemic control and a reduced risk of hypoglycemia.	B
	A simple and effective approach to glycemia and weight management emphasizing healthy food choices and portion control may be more helpful for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, and who are elderly and prone to hypoglycemia.	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. E	B, A, E
Energy balance	Modest weight loss achievable by the combination of lifestyle modification and the reduction of energy intake benefits overweight or obese adults with type 2 diabetes and also those at risk for diabetes. Interventional programs to facilitate this process are recommended.	A
Eating patterns and macronutrient distribution	As there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind.	E
	Carbohydrate intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycemic load, should be advised over other sources, especially those containing sugars.	B
	People with diabetes and those at risk should avoid sugar-sweetened beverages in order to control weight and reduce their risk for CVD and fatty liver B and should minimize the consumption of sucrose-containing foods that have the capacity to displace healthier, more nutrient-dense food choices. A	B, A
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
Dietary fat	Whereas data on the ideal total dietary fat content for people with diabetes are inconclusive, an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates.	B
	Eating foods rich in long-chain omega-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat CVD B; however, evidence does not support a beneficial role for omega-3 dietary supplements. A	B, A
Micronutrients and herbal supplements	There is no clear evidence that dietary supplementation with vitamins, minerals, herbs, or spices can improve diabetes, and there may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene.	C
Alcohol	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
	Alcohol consumption may place people with diabetes at 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	As for the general population, people with diabetes should limit sodium consumption to ≤2,300 mg/day, although further restriction may be indicated for those with both diabetes and hypertension.	B