Table 1. Summary of Recommendations in EBNPGs for Persons With Type 1 and 2 Diabetes Mellitus^a.

Step of Nutrition Care Process	Recommendationb	Strength of Recommendationc and Categoryd	Guideline	Comparison to Usual Care in Indiae
	Number and length of initial series of MNT encounters	Strong, imperative	3-4 encounters (45-90 min) within 3-6 mo after referral	Different
	MNT long-term follow-up encounters	Strong, imperative	Dietitian determined, regular sessions sustained positive outcomes	Different
Nutrition assessment	Nutrition assessment	Strong, imperative	Assess food intake, medication, metabolic control, anthropometric measurement, and physical activity	Usually same
	Assessment of glycemic control	Strong, imperative	Assess glycemic control and focus on achieving target blood glucose levels	Usually same
	Assess relative importance of weight management	Strong, conditional (for those who are overweight or obese)	Modest weight loss may improve insulin resistance; however, long-term impact inconsistent	Usually same
Nutrition intervention	Intervention options	Strong, imperative	Implement MNT selecting from a variety of interventions, education, and counseling sensitive to personal needs and based on willingness to change and ability to make changes	Varied, usually relied on nutrition education vs nutrition counseling
	Macronutrient percentages	Strong, imperative	Macronutrients based on national dietary guidelines	Usually same
	Carbohydrate intake consistency	Strong, conditional (persons with medication)	Keep meal and snack carbohydrate intake consistent on a day-to-day basis	Usually same
	Sucrose intake	Strong, conditional (persons who choose to eat foods with sucrose)	Not more than 10%-35% of total energy substituted for other carbohydrate containing foods	Usually same
	Nonnutritive sweeteners	Fair, conditional (persons who choose to consume nonnutritive sweeteners)	Advise to stay less than average daily intakes; no impact on glycemic control	Different; not usually addressed
	GI	Fair, conditional (when GI is proposed as a method of meal planning)	Advise that GI research reports mixed results on HbA1C	Different
	Fiber intake and glycemia	Strong, imperative	44- to 50-g fiber is reported to improve glycemia; however, unsure if this level is feasible	Same
	Fiber intake and cholesterol	Strong, imperative	25- to 30-g fiber (emphasizing soluble) can reduce cholesterol	Same
	Protein intake and normal renal function	Fair, conditional (persons with normal renal function)	Maintain usual intake of 20%-25% of energy from protein	Same
	Blood glucose monitoring	Fair, conditional (persons on nutrition therapy alone or in combination with glucose-lowering medication)	Frequency and timing of blood glucose monitoring dependent on DM goals and therapies and incorporated into diabetes education programs	Different; not usually addressed in T2DM
	CVD and cardioprotective nutrition interventions	Strong, imperative	Reduction in saturated and trans fat and dietary cholesterol and interventions to reduce blood pressure	Different
	Diabetes and weight management	Fair, conditional	Unclear that weight loss along will improve glycemic control	Same
	T2DM and physical activity	Strong, conditional	50-90 min of accumulated moderate-intensity aerobic physical activity per week as well as resistance/strength training 3 times per week	Different
	Coordination of care	Imperative, consensus	Coordinate care with interdisciplinary team approach	Different
Monitoring and evaluation	Monitoring and evaluation	Strong, imperative	Monitor and evaluate food intake, medication, metabolic control, anthropometric measures, and physical activity	Different; many times not able to have follow-up visits to monitor
	Evaluation of glycemic control	Consensus, imperative	Use blood glucose monitoring results to evaluate effectiveness of MNT	Different; many times not able to have follow-up visits to monitor

Abbreviations: CVD, cardiovascular disease; DINGS, Diabetes in India Nutrition Guidelines Study; EBNPG, evidence-based nutrition practice guideline; GI, glycemic index; HbA_1C, hemoglobin A_1C; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MNT, medical nutrition therapy; SMBG, self-monitoring blood glucose; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; UC, usual care.

^aAdapted with permission from American Dietetic Association31 and Academy of Nutrition and Dietetics.40

^bSelected recommendations that apply to the DINGS population. Other recommendations not applicable to this population are carbohydrate intake and insulin dose adjustment, protein intake and nephropathy, protein intake and late-stage nephropathy, frequency of blood glucose monitoring, possible need for continuous glucose monitoring or more frequent SMBG, T1DM and physical activity, physical activity and insulin/insulin secretagogue use).

^cRecommendations are rated as Strong, Fair, Weak, Consensus, or Insufficient Evidence. Strong: Good/strong evidence identified that benefits of following the recommendation exceed the harms; practitioners should generally follow the recommendation unless a clear and compelling rationale for alternative approach is present. Fair: Good/fair evidence identified that benefits of following the recommendation exceed the harms; practitioners should generally follow the recommendation but remain alert to new information and sensitive to patient preferences. Consensus: No studies are available, conclusion based on expert opinion; practitioners should be flexible in deciding whether to follow, and patient preferences should be a substantial influencing role.

^dRecommendations fall into 2 categories: Imperative or conditional. Imperative recommendations are broadly applicable to the target population, whereas conditional recommendations apply only to a specific situation or population.

^eComparison to Usual Care in India: Same indicates that all dietitians agreed that this was the same as their usual practice, usually same indicates that few dietitians did not indicate it was the same of their usual practice, and different indicates that all dietitians agreed that this was different from their usual care. Dietitians attempted to implement all applicable guidelines.