U.S. Department of Health and Human Services

Principle 4: Provide Individualized Nutrition Therapy

Nutrient intake and physical activity (discussed in Principle 5) are the key determinants of energy balance. Individualized nutrition therapy is an integral component of diabetes and prediabetes management. It helps people achieve blood glucose, blood pressure, blood lipid, and weight goals;1,3 prevent or delay the development of complications; address individual nutrition needs; and limit food choices when indicated by scientific evidence.

Reduced fat and caloric intake along with moderately intense physical activity was a key component of the lifestyle interventions in the Diabetes Prevention Program (DPP) and the Look AHEAD (Action for Health in Diabetes) study. DPP participants had prediabetes and achieved a mean 7 percent weight loss at 1 year. The lifestyle intervention reduced their risk of developing diabetes by 58 percent4 at the end of the study and by 34 percent at 10 years.5 Look AHEAD participants had type 2 diabetes and achieved a mean 8 percent weight loss at 1 year. Although the lifestyle intervention did not reduce cardiovascular events, benefits found in secondary analyses included reduced sleep apnea and need for diabetes medications, and improved mobility and quality of life.6

Nutrition therapy providers

​​

Ideally, people with diabetes are referred to a registered dietitian/registered dietitian nutritionist (RD/RDN) for medical nutrition therapy (MNT) at the time of diagnosis. 3 Studies have shown that MNT leads to decreases in A1C ranging from 0.5 percent to 2.6 percent (average of approximately 1 to 2 percent), similar to the effects of many glucose-lowering medications. 7

Nutrition therapy in a broader sense may be provided by other health care team members, such as diabetes educators.8 Health care team members providing nutrition therapy should have adequate training and work within the scope of their practice and state regulations. All nutrition therapy should involve a nutrition assessment, nutrition diagnosis, individualized nutrition interventions, and nutrition monitoring and evaluation with ongoing follow-up to support long-term lifestyle changes, evaluate outcomes, and modify interventions as needed.8

Macronutrient intake for people with or at risk for diabetes

​​

The following ranges for nutrients are provided for guidance, but specific therapy recommendations should be based on each person’s health status, comorbidities, food preferences, and nutritional needs. 1–3, 8 It is also recommended that individualized meal plans include optimization of food choices to meet recommended daily allowances and dietary reference intakes for all micronutrients.

Adjust the mix of carbohydrate, protein, and fat to meet diabetes management goals and patient preferences. Consider reduction of caloric intake and emphasize portion control for weight management goals.

Fat

Limit calories from fat to reduce caloric intake as needed to achieve weight loss, and limit trans and saturated fat to reduce the risk of cardiovascular disease.

  • Saturated fat should be less than 10 percent of total calories.
  • Minimize intake of trans fat.
  • Cholesterol intake should be less than 300 mg per day.
  • Choose monounsaturated and polyunsaturated fats (including omega-3 fatty acids), such as those found in seafood, nuts, seeds, avocado, and oils (e.g., olive, canola, corn, safflower, and sunflower oils).

Carbohydrate

Select foods high in fiber, and limit foods with added sugars and refined grains.

  • Eat a variety of fruits and vegetables each day.
  • Eat at least 14 g fiber/1,000 kcal per day.
  • At least half of all grains consumed should be whole grains.

Note: For people with diabetes on insulin, monitoring carbohydrate intake is a key strategy in achieving glycemic control, whether by carbohydrate counting, use of carbohydrate choices or exchanges, or experience-based estimation. For other people with diabetes, monitoring calories may be more important.

Protein

Recommended dietary intake of protein for individuals with diabetes is similar to that for the general public: 15 to 20 percent of calories.

  • Choose low-fat animal- and plant-based protein sources (e.g., lean meat, fish, poultry without skin, eggs, dried beans and peas, and soy products).

Sodium, alcohol, and fluid intake

  • Limit sodium intake to 2,300 mg per day for the general population. Intake as low as 1,500 mg per day may be appropriate for some people. 1, 9
  • Limit alcohol intake (≤ 2 drinks for men and ≤ 1 drink for women per day).
  • Drink water and other beverages with few or no calories. Sugar-sweetened beverages are a significant and often unrecognized source of calories.

Weight management for overweight and obese individuals

​​

Weight loss is an important goal in overweight or obese individuals with or at risk for diabetes. Although the goal is to achieve and maintain a healthy body weight (i.e., body mass index [BMI] of 18.5 kg/m 2 to 24.9 kg/m 2), even a 5 to 10 percent weight loss can improve health and lower the risk of type 2 diabetes for those at risk. In overweight and obese individuals with diabetes, calorie restriction and increased physical activity resulting in moderate weight loss (averaging 10 percent) led to improved glucose, blood pressure, and lipid control with less use of medication and also reduced mobility loss by half. 6,10

Weight loss requires a reduction in energy intake and is enhanced by regular physical activity. A moderate decrease in caloric balance (500–1,000 kcal/day) will result in a slow but progressive weight loss (1–2 lbs/week). However, maintaining a smaller deficit can have a meaningful influence on body weight over time. Weight loss meal plans should be individualized, and for most people, they should supply at least 1,200 to 1,500 kcal/day for women and 1,500 to 1,800 kcal/day for men. 11

For weight loss, a low-carbohydrate, low-fat calorie-restricted, or Mediterranean diet may be effective in the short term (up to 2 years). 12 A low-fat, low-calorie diet along with moderate-intensity physical activity for 150 minutes per week markedly reduced development of type 2 diabetes in the DPP 4 and the Finnish Diabetes Prevention Study. 13 Strong evidence shows that eating patterns that are low in calorie density improve weight loss and weight maintenance and also may be associated with a lower risk of type 2 diabetes in adults. 1 A dietary pattern low in calorie density has a relatively high intake of vegetables, fruit, and dietary fiber and a relatively low intake of total fat, saturated fat, and added sugars. The U.S. Department of Agriculture (USDA) Food Patterns and the Dietary Approaches to Stop Hypertension (DASH) Eating Plan are examples of eating patterns that are low in calorie density. (See Resources.)

Helpful behaviors and practices for weight management

​​

Several behaviors and practices have been shown to help people manage their food and beverage intake and calorie expenditure and, ultimately, body weight. The behaviors with the strongest evidence related to body weight that people can be encouraged to follow include:

Behaviors related to food intake

  • Focus on the total number of calories consumed and portion sizes.
  • Monitor food intake. Recording intake of calories can help individuals become more aware of what and how much they eat and drink.
  • Choose smaller portions or lower-calorie options when eating out.
  • Prepare, serve, and consume smaller portions of foods and beverages, especially those high in calories and sugar.
  • Choose water to drink instead of sugar-sweetened beverages.
  • Eat a healthy breakfast. Choose whole grains, fruit, and protein foods low in fat. Consider getting about 20 percent of daily calories at breakfast.

Other behaviors

  • Record physical activity.
  • Limit screen time and avoid eating while watching television, which can result in overeating.
  • Improve nutrition literacy, gardening, and cooking skills to heighten enjoyment of preparing and consuming healthy foods.
  • Self-weigh consistently — at least once per week. 14

Amount and frequency of medical nutrition therapy for diabetes

​​

An initial series of three to four encounters with an RD/RDN, each lasting 45 to 90 minutes, is recommended. 7 This series, beginning at diagnosis of diabetes or at first referral for therapy, should be completed within 3 to 6 months. The RD/RDN should determine whether additional therapy is needed based on an assessment of the patient’s learning needs and progress toward desired outcomes. When delivered by an RD/RDN according to nutrition practice guidelines, medical nutrition therapy is covered by Medicare and other health insurance plans.

Coverage for obesity and nutrition therapy

The Centers for Medicare & Medicaid Services (CMS) cover intensive behavioral therapy and nutrition counseling for obesity (BMI ≥ 30 kg/m 2). Counseling may be covered for up to 12 months if it is provided by a qualified primary care physician or other primary care practitioner in a primary care setting and if the person achieves certain weight loss goals. In addition, some state Medicaid programs or commercial payers provide health insurance coverage for nutrition therapy for people with prediabetes.

Patient follow-up and community resource referral 1, 10

  • Follow-up and monitoring of a patient’s progress is essential. Review the meal plan and discuss any related issues at each visit.
  • A focus on improved glucose and cholesterol levels, blood pressure, and self-esteem can reinforce the importance of lifestyle changes that lead to improved well-being.
  • Referral to weight control or wellness clinics can help overweight patients maintain lifestyle changes and achieve modest weight loss.
  • For people at risk of diabetes, the National Diabetes Prevention Program (NDPP) offers structured lifestyle interventions.
  • Family and community support are important for helping people with or at risk for diabetes to obtain and maintain proper nutrition.

References

1. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office; 2010.

2. Wheeler ML, Dunbar SA, Jaacks LM, et al. Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010. Diabetes Care. 2012;35(2):434–45.

3. Franz MJ, Boucher JL, Green-Pastors J, Powers MA. Evidence-based nutrition practice guidelines for diabetes and scope and standards of practice. J Am Diet Assoc. 2008;108(4 Suppl 1):S52–8.

4. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403.

5. Knowler WC, Fowler SE, Hamman RF, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677–86.

6. Rejeski WJ, Ip EH, Bertoni AG, et al. Lifestyle change and mobility in obese adults with type 2 diabetes. N Engl J Med. 2012;366(13):1209–17.

7. Franz MJ, Powers MA, Leontos C, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc. 2010;110(12):1852–89.

8. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36(11):3821–42.

9. Appel LJ, Frohlich ED, Hall JE, et al. The importance of population-wide sodium reduction as a means to prevent cardiovascular disease and stroke: a call to action from the American Heart Association. Circulation. 2011;123(10):1138–43.

10. Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010;170(17):1566–75.

11. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129(25 Suppl2):S102–38.

12. American Diabetes Association: Standards of medical care in diabetes 2014. Diabetes Care. 2014;37(Suppl 1):S14–80.

13. Lindstrom J, Louheranta A, Mannelin M, et al. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care. 2003;6(12):3230–6.

14. Butryn ML, Phelan S, Hill JO, Wing RR. Consistent self-monitoring of weight: a key component of successful weight loss maintenance. Obesity. 2007;15(12):3091–6.