medical nutrition therapy education

For New Providers

Refer a Patient

Who We Serve

Get started

Condition Management

What is Medical Nutrition Therapy? Beginner's Guide [2024]

Elizabeth Adrian, RDN, CDN

August 31, 2024

Medical review:

Michele D. Rager, MS, RDN-AP

Medical Nutrition Therapy (MNT): What it is, and How it Can Help You This Year

Are you confused by all of the nutrition information floating around the internet? It’s hard to know how to eat when you’re constantly bombarded with conflicting recommendations. Plus, nutrition guidelines seem to change too fast to even keep up with. 

Trying to chase nutrition fads can be a waste of time at best. But, at worst, some of these “helpful nutrition tips” from unqualified online influencers can actually be harmful to your health. Especially if you have a medical condition that requires an individualized food plan.

The best way to manage a condition using nutrition is to seek out medical nutrition therapy (MNT). Read on to learn if MNT is right for you and find out how it might help!

What is medical nutrition therapy? 

Medical nutrition therapy is a type of nutrition-based therapy that can help with the management and prevention of medical conditions.

MNT is provided by a registered dietitian (RD) in a variety of settings. These include hospitals, medical offices, private practices, nursing homes, behavioral health centers, telehealth, and other healthcare facilities. 

Medical Nutrition Therapy includes therapeutic recommendations like discussing what foods to prioritize over others to help prevent or manage a specific health condition. If you see an RD for MNT, they can also provide food plans that are tailored to meet your individual nutrient targets. 

Additionally, there is a counseling component to MNT where RDs provide guidance and support to help you make lasting changes.

You can receive medical nutrition therapy from a dietitian either in-person or through virtual visits via phone or online video communications. These virtual options expand access to MNT for those with mobility issues, lack of transportation, or those who simply prefer the convenience.

As mentioned, medical nutrition therapy can help with the management and prevention of medical conditions.

Here are just some of the conditions that can benefit from medical nutrition therapy:.

Overweight and obesity

Prediabetes and diabetes

Irritable bowel syndrome (IBS) and other digestive disorders

Polycystic ovary syndrome (PCOS)

Many insurance companies provide coverage for MNT services, but coverage varies based on the plan. 

Medicare covers MNT, but only under certain circumstances , such as a diagnosis of diabetes, kidney disease (without dialysis), or those within 36 months post kidney transplant. However, lawmakers are working to change these restrictions so that more conditions can be covered.

What is the medical nutrition therapy act? 

The Medical Nutrition Therapy Act of 2023 (MNT Act) would expand Medicare coverage of MNT services beyond diabetes and certain circumstances of kidney disease. If passed, coverage would extend to a variety of other conditions , such as obesity, prediabetes, hypertension (high blood pressure), eating disorders, and cancer.

As of this writing, the bill has not yet passed. Click here for the latest updates on the MNT Act from the Academy of Nutrition and Dietetics.

Are there medical nutritionists? 

The term “medical nutritionist” does not have an official definition. Practitioners who are able to provide medical nutrition therapy are called registered dietitians. Nutritionists cannot provide medical nutrition therapy.

What does a medical nutrition program look like? 

When you see a dietitian for MNT, they will typically practice using the Nutrition Care Process (NCP). NCP is a four-step process that provides evidence-based, personalized nutrition care and monitors progress in an action-oriented manner. 

Step 1: Nutrition Assessment

Your RD will collect information about your health history, including specific health conditions, family history, and medical tests or procedures you’ve had. 

The RD will also gather  your measurements, such as height and weight, to assess body size and composition.

Before making any changes to your food plan, your dietitian will want to know how you’re currently eating and your food preferences. The RD will also explore your food and nutrition history and find out if you have any food allergies or sensitivities.

Step 2: Nutrition Diagnosis

While you may have a medical diagnosis, your dietitian will determine your nutrition diagnosis. The nutrition diagnosis focuses on issues relating to food intake, clinical nutrition problems like elevated blood sugar, or behavioral and environmental factors that impact access to food or the ability to eat. 

Step 3: Nutrition Intervention

Your dietitian will work with you to put together a nutrition plan that addresses the nutrition diagnosis and, ultimately, to help manage your condition. These plans could include increasing certain nutrients in the diet like adding soluble fiber for gut health or decreasing others like eating less salt for blood pressure management.

Step 4: Nutrition Monitoring/Evaluation

This is where the magic happens! Receiving a plan from your dietitian is only the beginning of the journey. You then need to put the recommendations into practice to start moving towards your goals. You’ll continue to meet with your dietitian regularly so they can review your progress and help troubleshoot every step of the way.

Does MNT work for diabetes?

According to the Centers for Disease Control and Prevention , “MNT is a key component of diabetes education and management.” This is in part because of the impact of MNT on hemoglobin A1C levels.

Hemoglobin A1C (or A1C for short), is a test that measures your average blood sugar levels over the last few months. This lab value is used to help diagnose diabetes. Lowering A1C is one target in diabetes care and management.

Research has shown that when MNT is provided by a registered dietitian, A1C decreases. This decrease has been seen for those with both type 1 and type 2 diabetes.

Learn more about seeing a virtual diabetes dietitian here!

Does MNT work for weight loss? 

Medical nutrition therapy can be helpful for weight management . A dietitian can help determine a realistic weight goal and create a path forward. This includes reviewing your current eating habits, determining your calorie and nutrient needs, and creating an individualized plan that is personalized to your needs and goals.

Working with a weight management dietitian can help you achieve and maintain a healthy weight. Click here to schedule your first virtual session with a Season dietitian!

How Season can help with a MNT program  

If you’re looking for Medical Nutrition Therapy, we’ve got you covered! Our registered dietitians specialize in many areas, including weight management, diabetes, and digestive health. They can help you manage your health condition or work with you to optimize your health and support prevention! Click here to learn more about our virtual dietitian visits covered by your insurance.

In this article

Meet With an Online Registered Dietitian

95% of our patients meet with their dietitian for free.

Related Articles

Black Seed Oil: 6 Surprising Benefits

Healthy Living

12 Best Foods for Gut Health, According to Experts [2024]

Drinking Water While Fasting: A Simple How-To [2024]

Are Grapes Low FODMAP: Answers for IBS

Find a Dietitian

A .gov website belongs to an official government organization in the United States.

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• About the Diabetes Self-Management Education and Support (DSMES) Toolkit
• Participate
• DSMES Health Literacy Tool
• Patient Success With DSMES Through Telehealth
• DSMES Promotion Playbook Resources
• Terminology and Glossary
• How to Increase Referrals and Overcome Barriers to Participation Resources
• Who Provides DSMES Services: Staffing and Delivery Models
• DSMES Coverage Policies: Reimbursement and Sustainability
• Building the Business Case for DSMES

Related Topics:

• View All Home
• National Diabetes Prevention Program

Medical Nutrition Therapy

• Medical nutrition therapy (MNT) is defined as a "nutrition-based treatment provided by a registered dietitian."
• MNT includes a nutrition diagnosis as well as therapeutic and counseling services to manage diabetes.
• MNT is a key component of diabetes education and management.

About medical nutrition therapy

Studies have documented an association between MNT delivered by a registered dietitian and hemoglobin A1C decreases for people with type 1 diabetes (0.3%–1%) and type 2 diabetes (0.5%–2%).

Diabetes self-management training (DSMT) and MNT are separate but complementary services. Although relying on distinct techniques, studies report that DSMT and MNT together are more effective than either service would be if offered alone. Although DSMT and MNT practitioners can provide follow-up in the same year, the two types of services require separate referrals.

Note : Medicare will not reimburse DSMT and MNT if provided on the same day.

Differences between DSMT and MNT

Diabetes care and education specialists (DCESs) provide DSMT. DCESs

• Are licensed or nationally registered health care professionals.
• Provide overall guidance related to all aspects of diabetes.
• Increase knowledge and disease management skills.
• Promote effective self-care behaviors and glycemic control.

MNT providers

• Are registered dietitians or nutritional professionals.
• Plan for follow-up over multiple visits.
• Assist with behavioral and lifestyle changes.
• Manage individual nutrition problems and medical conditions.

American Diabetes Association Standards of Care in Diabetes – 2023 - Standards outlining recommendations for diagnosing and managing diabetes, including MNT.

Medicare Billing for DSMT and MNT Services - A presentation from the American Diabetes Association.

Diabetes Self-Management Education and Support (DSMES) Toolkit

The DSMES Toolkit is a comprehensive resource for achieving success in diabetes self-management education and support (DSMES) services.

Nutrition in Medicine

Evidence-based clinical nutrition education for medical students, residents, fellows, and other physicians..

• Online Nutrition
• Nutrition Tools

Newsletters

Youtube vignettes, publications.

• 2016/17 Survey
• Donate to NIM

Online Nutrition Modules

• evidence-based clinical nutrition education for advanced healthcare professionals, including physicians, residents, and fellows
• a core nutrition curriculum for medical students that includes both the preventive and therapeutic aspects of medical nutrition care for both pre-clinical and clinical education.
• interactivity, self-assessment, animations, video, and audio make for an engaging learning experience
• Only available for desktop/laptop computers

Continue to Courses »

Continuing Medical Education/Continuing Education

Users who support the Nutrition in Medicine Project with a donation receive access to a wide range of instructional materials, including continuing education certification for physicians, nurses, and nurse practitioners at no charge.

CURRENTLY UNAVAILABLE

Continue to CME/CE »

Tools for Mobile Devices

We are also developing nutrition applications and tools for mobile devices for use by current and future healthcare professionals.

Continue to Tools »

Tools for Desktops

We are also developing nutrition applications and tools for the desktop for use by current and future healthcare professionals.

Newsletters providing recent points of interest for current and future healthcare professionals.

Continue to Newsletters »

YouTube videos providing course overviews of a sampling of the online modules for practicing physicians.

Continue to Videos »

Laur C, Ball L, Ahankari AS, Avdagovska M, Crowley J, Deen D, Douglas P, Hark L, Kohlmeier M, Luzi L, McCotter L, Martyn K, Nowson C, Wall C, Ray S. Proceedings of the inaugural International Summit for Medical Nutrition Education and Research. Public Health 2016;140:59-67

Kohlmeier M, Nowson C, DiMaria-Ghalili RA, Ray S. Nutrition education for the healthcare professions. J Biomed Ed 2015

Adams KM, Butsch WS, Kohlmeier M. The state of nutrition education at US medical schools. J Biomed Ed 2015

Briggs Early K, Adams KM, Kohlmeier M. Analysis of nutrition education in osteopathic medical schools. J Biomed Ed 2015

Kris-Etherton PM, Akabas SR, Douglas P, Kohlmeier M, Laur C, Lenders CM, Levy MD, Nowson C, Ray S, Pratt CA, Seidner DL, Saltzman E. Nutrition Competencies in Health Professionals’ Education and Training: A New Paradigm. Adv Nutr 2015;6:83–87

Lenders CM, Deen DD, Bistrian B, Edwards MS, Seidner DL, McMahon MM, Kohlmeier M, Krebs N. Residency and specialties training in nutrition: a call for action. Am J Clin Nutr 2014;99:1167S-73S

Kushner RF, Horn L, Rock CL, Edwards MS, Bales CW, Kohlmeier M, Akabas SR. Nutrition education in medical school: a time of opportunity. Am J Clin Nutr 2014;99:1174S-83S

DiMaria-Ghalili RA, Edwards M, Friedman G, Jaferi A, Kohlmeier M, Kris-Etherton P, Lenders C, Palmer C, Wylie-Rosett J. Capacity building in nutrition science: revisiting the curricula for medical professionals. Ann NY Acad Sci 2013;1306:21–40

Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: latest update of a national survey. Acad Med 2010;85:1537-42

Adams KM, Kohlmeier M, Powell, M, Zeisel SH. Nutrition in Medicine: Nutrition Education for Medical Students and Residents. Nutr Clin Pract 2010;25:471-480

Lindell KC, Adams KM, Kohlmeier M, Zeisel SH. Evolution of a computer-assisted nutrition curriculum. Am J Clin Nutr 2006;83:956S-962

Adams KM, Lindell KC, Kohlmeier M, Zeisel SH. Status of nutrition education in medical schools. Am J Clin Nutr 2006;83:941S-944S

Kohlmeier M, Althouse L, Stritter F, Zeisel SH. Introducing cancer nutrition to medical students: effectiveness of computer-based instruction. Am J Clin Nutr 2000;71:873-877

2016/2017 Educators Survey

We are asking medical nutrition educators to help us with tracking nutrition instruction at medical schools. We have completed this survey every four years since 2000.

Because of the generous help of nutrition educators, these data are available to researchers, administrators, legislators and many other stakeholders. Findings from our previous surveys can be accessed from our publications list.

Continue to Survey »

Contact NIM

For technical problems, contact NIM Tech Support .

For other questions, contact NIM Professor .

Donate to Nutrition in Medicine

Make a tax-deductible donation, administered through the University of North Carolina's Nutrition Research Institute.

A full 100% of your donation will directly benefit the Nutrition in Medicine Project and the Nutrition Education for Practicing Physicians Initiative, bringing needed nutrition education to medical students, residents, and other healthcare providers.

Donate Now!

• Diet & Weight Management

What Is Medical Nutrition Therapy?

Medical Nutrition Therapy (MNT) is a way to manage chronic health conditions, especially through weight loss or weight maintenance. This therapeutic approach to health can help you reduce symptoms of certain conditions and prevent further health complications by following a personalized diet and meal plan. To get started with MNT, you need the help of a Registered Dietitian Nutritionist (RDN).

Who Should Seek Medical Nutrition Therapy?

Medical Nutrition Therapy aims to manage certain chronic conditions through an individualized nutrition plan. MNT is also called nutritional counseling. Your RDN will work with you to create a nutrition plan that meets your dietary needs while giving you feedback. While many people may feel nervous or reluctant about starting a new diet or meal plan, your  dietitian will give you the tools you need to manage your chronic condition through dietary changes.

Your doctor may suggest nutritional therapy if you have one of these conditions:

• Heart disease
• Renal disease
• Gastrointestinal disorders
• Osteoporosis
• History of heart attack

Nutrition and diabetes.  MNT is helpful for people with diabetes. Medical nutritional therapy often complements diabetes treatment, as your diet has a large impact on this condition. A personalized plan for nutrition and diabetes can help you maintain your blood glucose levels within a normal range. MNT can help reduce symptoms of diabetes, such as weight gain and frequent urination.

Weight loss. Nutrition therapy is a useful tool for people who want to lose weight. Weight management and  nutrition go hand in hand, so MNT can help you take a look at the foods you’re eating and your eating habits. Your doctor may recommend MNT if you are obese, because losing weight can help prevent further health complications, such as:

• High blood pressure
• Liver disease
• Infertility
• Certain cancers
• Mental health problems

How Does Medical Nutrition Therapy Work?

To start Medical Nutrition Therapy, you need a referral from your primary care doctor. Many MNT services are covered by insurance, including Medicare. Your insurance coverage will probably determine the number of sessions available to you.

You will begin by working with your RDN, who will help you create realistic goals to improve your health through nutrition. They will:

• Look at your current  eating habits and lifestyle
• Give you an in-depth assessment of your nutritional status
• Work with you to develop a personalized nutrition treatment plan

Your initial appointment with an RDN will take about an hour. During this time, the RDN will ask you about your current diet and lifestyle. Using this information and your medical history, they will ask you what your goals are for MNT. Together, you decide what outcomes you’re looking for while creating a personalized plan.

Your RDN will most likely ask you to start a  food journal so you can reflect on your diet and habits. This can help your dietitian decide where you need to change or improve your plan. Your RDN will keep in mind your cultural preferences and the latest research and science while working on your plan.

During follow-up visits, your dietitian will provide you with tools to help you through Medical Nutritional Therapy. They will teach you how to make better food choices and track your progress. Your RDN will use your updated lab results and monitor any health changes to make sure your nutritional needs are being met.

What Are the Benefits of Medical Nutrition Therapy?

There are lots of benefits of nutrition therapy. In addition to helping you manage your chronic condition, MNT can help prevent future health issues. Since you’re getting the help of a RDN, they can customize a diet plan for you that can help lower the risk of diseases like heart disease, obesity, and diabetic neuropathy.

While weight loss is often the goal, the benefits of weight loss include increased levels of energy and healthier habits. You’ll notice that when you work with a RDN, you will most likely start to:

• Increase your  physical activity
• Make healthier choices
• Read food labels
• Reduce the amount of fried or processed foods you eat
• Drink more water instead of sugary drinks

The habits you pick up while practicing Medical Nutritional Therapy can improve your overall health now and into the future.

Top doctors in ,

Find more top doctors on, related links.

• Diet & Weight Management Home
• Diet Medical Reference
• Diet Plans A-Z
• Popular Diet Plans
• Healthy Weight Guide
• Health Tools & Calculators
• Healthy Eating & Nutrition
• Best & Worst Health Choices
• All Health Guide Topics
• Weight Loss & Obesity
• Fitness & Exercise
• Food & Recipes
• Food Calculator
• BMI Calculator
• Cholesterol Management
• More Related Topics

What Is Medical Nutrition Therapy?

This form of nutritional counseling aims to help you better manage your chronic condition through a personalized diet.

A healthy diet is important for everyone. But for people with many chronic or serious medical conditions, it can be especially crucial, helping you manage your disease and prevent or minimize symptoms and complications. But what does eating healthfully really mean? And how do the foods you choose to eat or avoid impact your body in particular?

Medical nutrition therapy can help answer these questions and support you in your personal health journey. Simply put, medical nutrition therapy uses evidence-based nutrition strategies and counseling provided by a registered dietitian in order to help manage your health condition, says Levi Teigen, R.D., Ph.D. , an assistant professor of clinical nutrition in the Department of Food Science and Nutrition at the University of Minnesota in St. Paul.

Learn more about the conditions medical nutrition therapy can help with, what you can expect at your first and subsequent appointments, and how to find a provider (and possibly get it covered by your insurance).

How Does Medical Nutrition Therapy Work?

Medical nutrition therapy is diagnosis-specific, says Teigen, so someone with celiac disease should expect to get different guidance than someone with type 2 diabetes would. It’s also personalized. Many people have more than one health issue, not to mention an array of personal food preferences and lifestyle habits (such as how often they cook versus eat out). All of these factors need to be considered by the dietitian who is advising you.

Medical nutrition therapy doesn’t typically include a set meal plan to follow, though some providers may offer one, says Jessica Sylvester, R.D. , the lead dietitian and founder of the Florida Nutrition Group in Boca Raton and a spokesperson for the Academy of Nutrition and Dietetics. Instead, most medical nutrition therapy centers on patient education. Part of that education entails debunking common misconceptions, such as “all carbs are bad.” Food impacts everyone differently, so focusing on how various food groups and even specific ingredients affect you and your condition is the key.

“You should walk away with a much better understanding of how diet affects your health and your medical condition in particular,” she says.

What to Expect During Medical Nutrition Therapy

When you first meet with a dietitian, you’ll likely answer a bunch of questions for what’s known as an intake assessment, says Sylvester. “It’s not as simple as, ‘You have diabetes ; you should be on a consistent carb diet,’” she says. Instead, your dietitian will want to learn more about you and your particular needs and circumstances. That begins with a thorough review of your medical history, current/usual weight, recent lab test results, past and current dietary habits, and overall lifestyle. “Then you come up with an intervention with specific goals and things to monitor,” Sylvester explains.

Sign up for our bi-weekly Healthy Self Newsletter.

At the end of that first meeting, you should walk away with some knowledge about how to improve your dietary habits. You might get a list of foods to eat or avoid, a meal plan, or information about meal and snack times.

Ideally, someone in need of dietary guidance will have several meetings with a dietitian, says Sylvester, but cost is often a factor. (Whether or not it’s covered by your insurance will depend on your plan as well as the particulars of your condition.) Most people who seek nutrition counseling should have at least one follow up after their initial session.

Who Can Benefit From Medical Nutrition Therapy?

Ideally, medical nutrition therapy would be part of an interdisciplinary treatment plan for nearly every medical condition, says Teigen. Some conditions that are especially good fits for this therapy include:

Chronic kidney disease

Diabetes and prediabetes

Digestive disorders

Food allergies

Heart disease

Here’s a bit more about how it’s helpful with each one.

Chronic Kidney Disease

People with kidney (renal) disease often need to lower their intake of sodium and high-protein foods. They also may need to limit phosphorus and get enough—but not too much—potassium, according to the NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). A dietitian will walk patients with kidney problems through the steps needed to safely make these and other dietary changes.

Diabetes and Prediabetes

Research summarized in the Journal of the Academy of Nutrition and Dietetics shows that medical nutrition therapy can help people with prediabetes alter their eating habits in a way that makes them less likely to develop full-blown diabetes. For people who already have diabetes, this therapy is a cost-effective way to improve treatment outcomes; learning how to balance meals and choose more nutrient-dense foods helps to manage blood sugar levels and reduces the chances that patients develop serious diabetes complications.

Digestive Disorders

Someone with a digestive issue such as irritable bowel syndrome (IBS), an inflammatory bowel disease (IBD), celiac disease , or gastroesophageal reflux disease (GERD) would likely benefit from medical nutrition therapy, says Teigen. In the case of celiac disease, the focus would be on avoiding gluten, a protein that’s found in wheat and many other grains. For people with IBS, IBD, or GERD, the therapy might focus more on avoiding personal triggers foods and perhaps test-driving specific dietary plans that have helped some other people with similar digestive issues.

Food Allergies

People with food allergies should definitely consider medical nutrition therapy, says Teigan. As explained in a 2022 paper on nutritional management of food allergies published in Frontiers in Allergies, teaching patients how to avoid accidentally consuming a trigger that could be dangerous or life-threatening for them is only part of it. Learning how to obtain a balanced diet that isn’t deficient in key nutrients is also important, as is minimizing any impact that food restriction could have on one’s quality of life.

Heart Disease

High blood pressure, diabetes, and obesity are all leading risk factors for heart disease . Fortunately, many of these can be modified with lifestyle interventions including nutrition. In fact, a study in the American Journal of Lifestyle Medicine found that interventions that increased activity, improved nutrition, and helped with weight management and smoking cessation could help reduce cardiovascular disease risk by 80%. So if you’re at risk for heart disease , working with a dietitian to modify your diet to a more heart-healthy style of eating (and making other necessary habit changes, too) is critical to prevent complications or a cardiac event like a heart attack .

Other Conditions in Which Medical Nutrition Therapy May Help

Medical nutrition therapy may also be useful for people with many other health conditions, says Teigen, including:

Chronic obstructive pulmonary disease (COPD)

Eating disorders

Liver disease

Thyroid disorders

“The more we learn about the impact of food on health, the more it seems that medical nutrition can benefit most people,” says Sylvester.

Specialized Types of Medical Nutrition Therapy

Most medical nutrition therapy is synonymous with nutrition counseling provided by a registered dietitian. However, the broad umbrella of medical nutrition therapy also includes enteral and parenteral nutrition as alternate ways of getting nutrition to people with serious medical conditions, says Teigen.

With enteral nutrition, instead of eating regular food, people receive part or all of their nourishment via a liquid diet of supplements (such as Ensure and similar products) or a solution that’s given through a feeding tube (such as a nasogastric tube). It takes the place of some or all regular food. Rather than oral or feeding tube administration, parenteral nutrition bypasses the digestive system entirely and is given intravenously (into a vein), according to the Cleveland Clinic .

Some people who might need enteral or parenteral nutrition include those with:

Crohn’s disease (a form of IBD)

Parkinson’s disease, multiple sclerosis, or another neuromuscular disease that impacts swallowing

Severe weight loss due to chemotherapy, HIV, or sepsis

Ulcerative colitis (another form of IBD)

Upper GI obstruction

Someone who requires enteral or parental nutrition may require care from multiple health care providers that might include a dietitian and doctor as well as a nurse specialist and pharmacist, according to the American College of Gastroenterology .

How to Get Medical Nutrition Therapy

Medical nutrition therapy can only be provided by a dietitian , also known as a registered dietitian (R.D.) or registered dietitian nutritionist (R.D.N.). Anyone can call themselves a “nutritionist,” but only dietitians have a standardized degree from an accredited dietetics program, says Sylvester. They are licensed by the state in which they practice and must meet continuing education requirements.

You can contact a dietitian directly and ask about making an appointment, says Teigen, but if you want your health insurance to cover it there may be various rules to consider. At the moment, Medicare Part B only covers outpatient medical nutrition therapy for people with diabetes, renal disease, and those who have had a kidney transplant, according to the American Society on Aging . (This organization, along with many others, is advocating in favor of legislation that would expand this coverage to include people with many other health conditions).

If you have private health insurance, Teigen recommends contacting your provider to find out whether any sessions with a dietitian will be covered. Even if your plan doesn’t cover medical nutrition therapy, you might decide that paying out of pocket for a few sessions is worthwhile, he adds.

Medical Nutrition Therapy for Diabetes: Journal of the Academy of Nutrition and Dietetics . (2018.) “Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes.” https://www.jandonline.org/article/S2212-2672(17)31849-X/fulltext

Food Allergy Counseling: Frontiers in Allergies . (2023.) “Nutritional Management of Food Allergies: Prevention and Treatment.”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9853442/

Kidney Disease and Diet: NIH National Institute of Diabetes and Digestive and Kidney Diseases. (2016.) “Eating Right for Chronic Kidney Disease.” https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/eating-nutrition

Dieticians Vs. Nutritionists: Academy of Nutrition and Dietetics. (n.d.) “About RDNs and NDTRs.” https://www.eatright.org/about-rdns-and-ndtrs

Medicare Coverage and Proposed Legislation: American Society on Aging. (n.d.) “New Medical Nutrition Therapy Act Would Benefit Those with Medicare.” https://generations.asaging.org/medical-nutrition-therapy-act-aids-medicare

Parental Nutrition: Cleveland Clinic. (2022.) “Parenteral Nutrition.” https://my.clevelandclinic.org/health/treatments/22802-parenteral-nutrition

Enteral Nutrition: StatPearls. (2023.) “Enteric Feedings.” https://www.ncbi.nlm.nih.gov/books/NBK532876/

Conditions Associated with Enteral and Parental Nutrition: American College of Gastroenterology. (2021.) “Enteral and Parental Nutrition.” https://gi.org/topics/enteral-and-parenteral-nutrition/

• Share via facebook
• Share via pinterest
• Share via twitter
• Share via mail

More Like This

How much biotin do you really need.

What to Eat (and Avoid) on GLP-1s

Is There a Best Diet for Psoriatic Arthritis?

Why Women Need Magnesium

Note: Since your browser does not support JavaScript, you must press the Continue button once to proceed.

• Update Profile
• Update Password
• ANFPConnect
• ANFP Marketplace

Top 10 Medical Conditions that benefit from Medical Nutrition Therapy

List compiled by: julie zikmund, rd, lrd, mph.

The nutrition services team plays an integral role in providing food and nutrition that assists to manage diseases in the healthcare setting. Medical Nutrition Therapy (MNT) is the nutrition assessment and treatment of a condition, illness, or injury that places an individual at risk, involving the assessment of nutrition status and treatment/intervention.

This list includes ten medical conditions that benefit from MNT.

1. Diabetes: Meal planning, carbohydrate (CHO) counting, and blood glucose monitoring are the cornerstones in diabetes management. Balancing CHO with medications and exercise assists in blood glucose control and a reduction of complications due to hyperglycemia. Learn more: www.diabetes.org .

2. Heart Disease: As the leading cause of death in the United States, heart disease is most commonly linked to hyperlipidemia – or high blood cholesterol. MNT for heart disease prevention includes the management of blood cholesterol, including limiting saturated and trans-fats in the diet to improve LDL cholesterol, HDL cholesterol, triglycerides, and total cholesterol levels. Learn more: www.heart.org .

3. Stroke: Strokes are most commonly linked to hyperlipidemia (see above) and hypertension (HTN)–high blood pressure (see below). When a person has a stroke, dysphagia (difficulty swallowing) may be a side effect. MNT for dysphagia may include altered consistency diets and thickened liquids as outlined by the International Dysphagia Diet Standardisation Initiative (IDDSI). Learn more: www.stroke.org  and www.iddsi.org .

4. Hypertension (HTN): High blood pressure increases the risk for stroke, heart disease, and kidney disease. MNT to improve HTN includes limiting salt/sodium intake and increasing potassium rich foods. This can be accomplished with the DASH (Dietary Approaches to Stop Hypertension) diet. Learn more: www.heart.org/en/healthtopics/high-blood-pressure  and www.nhlbi.nih.gov/health-topics/dash-eating-plan .

5. Cancer: Excess body weight (obesity), poor nutrition, lack of exercise, and alcohol consumption are contributing factors for cancer. Excess weight and obesity alone increase risks of developing 13 types of cancer. MNT for cancer prevention includes maintaining a healthy weight and a diet rich in fruits, vegetables, fiber rich beans and peas, and whole grains. Learn more: www.cancer.org .

6. Osteoporosis: Osteoporosis means “porous bone” or bones that have lost density and increase risk of fracture. Bones are constantly renewing, so risk prevention includes adequate calcium and vitamin D intake (especially in youth), prevention of eating disorders, and weight bearing exercise. MNT focuses on the consumption of calcium rich foods and adequate vitamin D. Learn more: www.bones.nih.gov .

7. Obesity: Obesity is a major health problem affecting all ages in the United States. Hallmarks of MNT for obesity treatment include caloric intake, portion control, balancing the diet, food journaling, energy expenditure & exercise, behavior modification, social support, and at times, weight loss surgery. Learn more: www.cdc.gov/obesity .

8. Kidney Disease: Of all the diseases, kidney disease is one of the most complex. The intake of protein, sodium, potassium, phosphorus, and fluids are carefully regulated from day-today. Actual nutrient restrictions are based on age, degree of kidney disease, treatment, and other nutrition factors. Learn more: www.niddk.nih.gov .

9. Celiac Disease: Celiac disease is an autoimmune disease, which requires a strict gluten-free (GF) diet. Following a GF diet allows for healing of the villi in the small intestine, allowing for proper absorption of nutrients. The MNT for Celiac Disease focuses on removing gluten from the diet and replacing it with GF items, preventing cross contact, label reading, and other nutrient deficiencies common with Celiac Disease. Learn more: www.celiac.org  and www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease .

10. Food Allergies: With a food allergy reaction, the body’s immune system overreacts, triggering a histamine response with symptoms ranging from mild to severe - with some instances leading to anaphylaxis. The most common food allergies include eggs, milk, peanuts, tree nuts, fish, shellfish, wheat and soy. MNT food allergies include strict avoidance of the food, preventing cross contact, and label reading. Learn more: www.acaai.org  and www.foodallergy.org .

Download a printable flyer below with the information on this page.

Printable PDF Flyer

• Previous Article
• Next Article

Evidence for the clinical effectiveness of MNT in diabetes

Randomized controlled trials of mnt, randomized controlled trials of mnt combined with dsmt, observational studies, meta-analyses of trials, summary of clinical effectiveness studies, evidence for prevention of diabetes, economic support for mnt, outcome studies lead to development of nutrition practice guidelines, outcome studies lead to expanded coverage for mnt, article information, the evidence for the effectiveness of medical nutrition therapy in diabetes management.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Open the PDF for in another window
• Cite Icon Cite
• Get Permissions

Joyce Green Pastors , Hope Warshaw , Anne Daly , Marion Franz , Karmeen Kulkarni; The Evidence for the Effectiveness of Medical Nutrition Therapy in Diabetes Management. Diabetes Care 1 March 2002; 25 (3): 608–613. https://doi.org/10.2337/diacare.25.3.608

Download citation file:

• Ris (Zotero)
• Reference Manager

Numerous advances in diabetes management and medical nutrition therapy (MNT) for individuals with diabetes make this an exciting time. Historically, a challenge to proving the benefit of MNT has been the lack of clinical and behavioral research. In recent years, however, evidence-based outcomes research that documents the clinical effectiveness of MNT in diabetes has been reported.

The term “medical nutrition therapy” was introduced in 1994 by the American Dietetic Association to better articulate the nutrition therapy process. It is defined as the use of specific nutrition services to treat an illness, injury, or condition and involves two phases: 1 ) assessment of the nutritional status of the client and 2 ) treatment, which includes nutrition therapy, counseling, and the use of specialized nutrition supplements ( 1 ). MNT for diabetes incorporates a process that, when implemented correctly, includes: 1 ) an assessment of the patient’s nutrition and diabetes self-management knowledge and skills; 2 ) identification and negotiation of individually designed nutrition goals ; 3 ) nutrition intervention involving a careful match of both a meal-planning approach and educational materials to the patient’s needs, with flexibility in mind to have the plan be implemented by the patient; and 4) evaluation of outcomes and ongoing monitoring. These four steps are necessary to assist patients in acquiring and maintaining the knowledge, skills, attitudes, behaviors, and commitment to successfully meet the challenges of daily diabetes self-management ( 2 ).

The primary purpose of this article is to review the evidence for the effectiveness of MNT in diabetes, both as an independent variable and in combination with other components of diabetes self-management training (DSMT). In addition, the recent studies that have demonstrated the effectiveness of lifestyle intervention, which included MNT, in preventing type 2 diabetes will be highlighted. Evidence from several studies that supports the cost-effectiveness of MNT in diabetes will also be presented.

To determine the clinical- and cost-effectiveness of MNT as a potential preventative benefit in the Medicare program, the 105th U.S. Congress, in the Balanced Budget Act of 1997, requested that a study be conducted by the Institute of Medicine (IOM) of the National Academy of Sciences. To complete their study, the IOM held a number of meetings with public testimony and presented and conducted a comprehensive literature review.

In December 1999, IOM released their report ( 3 ). In reference to diabetes, the report concluded that evidence exists demonstrating that MNT can improve clinical outcomes while possibly decreasing the cost of managing diabetes to Medicare. In conclusion, the IOM recommended to Congress that individualized MNT, provided by a registered dietitian with a physician referral, be a covered Medicare benefit as part of the multidisciplinary approach to diabetes care, which includes nutrition, exercise, blood glucose monitoring, and medications.

The IOM recommendation is consistent with the 2002 American Diabetes Association Position Statement “Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications,” which states that, “because of the complexity of nutrition issues, it is recommended that a registered dietitian, knowledgeable and skilled in implementing nutrition therapy into diabetes management and education, be the team member providing medical nutrition therapy. However, it is essential that all team members be knowledgeable about nutrition therapy and is supportive of the person with diabetes who needs to make lifestyle changes” ( 4 ).

The evidence from randomized controlled trials, observational studies, and meta-analyses that nutrition intervention improves metabolic outcomes, such as blood glucose and HbA 1c levels in individuals with diabetes, is summarized in Table 1 . Metabolic outcomes were improved in nutrition intervention studies, both as independent MNT and as part of overall DSMT. This evidence also suggests that MNT is most beneficial at initial diagnosis, but is effective at any time during the disease process, and that ongoing evaluation and intervention are essential.

The U.K. Prospective Diabetes Study (UKPDS) ( 5 ) was a randomized controlled trial that involved 30,444 newly diagnosed patients with type 2 diabetes at 15 centers. All treatment and control groups received nutrition counseling from a dietitian upon study entry until 3 months, at which time they were randomized into intensive or conventional therapy. During the initial period of the study when nutrition counseling was the primary intervention, the mean HbA 1c decreased by 1.9% (from ∼9 to ∼7%), fasting plasma glucose was reduced by 46 mg/dl, and there were average weight losses of ∼5 kg after 3 months.

Franz et al. ( 6 ) completed a randomized, controlled trial in 179 individuals with type 2 diabetes, comparing the usual nutrition care consisting of only one visit with a more intensive nutrition intervention, which included at least three visits with a dietitian. The results concluded that with more intensive nutrition intervention, changes in lifestyle can lead to significant improvements in glucose control. The fasting plasma glucose level decreased by 50–100 mg/dl and the HbA 1c dropped by 1–2%. The average duration of diabetes for all subjects was 4 years and the decrease in HbA 1c was 0.9% (from 8.3 to 7.4%). In the subgroup of subjects with a duration of diabetes <1 year, the decrease in HbA 1c was 1.9% (from 8.8 to 6.9%). By 6 weeks to 3 months, it was known if nutrition intervention had achieved target blood glucose goals; if it had not, the dietitian made recommendations for changes in medications.

In a prospective randomized trial, Kulkarni et al. ( 7 ) examined the effect of using nutrition practice guidelines in patients with type 1 diabetes, as compared with the use of standard nutrition intervention in a control group. The patients who received intervention incorporating the nutrition practice guidelines achieved a greater reduction in HbA 1c (1.0 vs. 0.33%) than those patients who received standard nutrition intervention. Dietitians who incorporated the nutrition practice guidelines with patients were more likely to conduct a nutrition assessment and paid more attention to glycemic control goals, which contributed to the positive outcomes.

Using a cross-over design, Glasgow et al. ( 8 ) studied 162 type 2 diabetic patients over the age of 60 years using a multidisciplinary team that included a dietitian. There was a significant reduction in caloric intake and percentage of calories from fat in the intervention group compared with the control group. When control patients crossed over to the intervention group, their HbA 1c levels decreased from 7.4 to 6.4% while the intervention group had a rebound effect, with their HbA 1c results returning to prestudy levels.

Sadur et al. ( 9 ) published the results of a randomized controlled trial with 185 patients participating in a health maintenance organization. A total of 97 patients received care from a multidisciplinary team (dietitian, nurse, psychologist, pharmacist) in cluster-visit settings (10–18 patients per month for 6 months) compared with 88 patients who received usual care provided by primary care physicians. HbA 1c decreased by 1.3% in the intervention group compared with 0.2% in the control subjects. Self-care practices and self-efficacy improved significantly and hospital admissions and outpatient use were significantly lower for the intervention group.

In the Diabetes Control and Complications Trial (DCCT) study, Delahanty and Halford ( 10 ) reported the results of a cross-sectional survey intended to examine the role of nutrition behaviors in achieving improved glycemic control in 623 intensively treated patients with type 1 diabetes. The control and intervention groups both received counseling by a dietitian; however, the control group received nutrition counseling every 6 months and the intensive management group received nutrition counseling every month. The four nutrition behaviors associated with clinically significant reductions in HbA 1c (0.9%) were:

adherence to prescribed meal and snack plan

adjustment of insulin dose in response to meal size

prompt treatment of hyperglycemia

avoidance of overtreatment of hypoglycemia

In addition, the DCCT Trial Research Group ( 11 ) published an expert opinion statement recognizing the importance of the dietitian as a team member in educating patients on nutrition and adherence to achieve HbA 1c goals. Franz et al. ( 12 ) also published an expert opinion highlighting the changing roles of the RN, RD, and MD and emphasizing the importance of dietitians and nurses as members of the diabetes care team in comanaging and educating patients.

Johnson and Valera ( 13 ) completed a 6-month retrospective chart audit of outcomes in 21 patients with type 2 diabetes who had completed three individual visits with an RD. At 6 months, blood glucose levels decreased 33.5% in patients receiving nutrition therapy by an RD. The mean total weight reduction was ∼2.05 kg. Of the 85% of patients who were on oral medication or insulin at the initiation of the study, approximately half (44%) had less or no need for medication at the 6-month end point of the chart audit.

In 2001, Johnson and Thomas ( 14 ) reported the results of a 12-month retrospective chart audit with 162 adults patients with diabetes, 81 of whom received MNT intervention with at least two visits from an RD. The remaining subjects served as a nonintervention group and were chosen by random selection from a registry of diabetic patients who had never seen an RD. In the patients who received MNT intervention, HbA 1c levels decreased 20% (−2.14 units), bringing mean levels to <8%. In comparison, subjects without MNT intervention had a 2% decrease in HbA 1c levels (−0.2 units), with mean levels remaining >8%.

A retrospective chart review was conducted by Christensen et al. ( 15 ) on 102 patients (15 with type 1 diabetes and 87 with type 2 diabetes) to determine the contribution of diabetes MNT and DSMT conducted by dietitians in lowering HbA 1c values. Patients had a minimum of two visits with a dietitian, which were typically scheduled 2 weeks apart. There was a significant difference (1.6%) between mean pre-education HbA 1c level (9.32%) and mean post-education HbA 1c level (7.74%) measured at 3 months.

Brown and colleagues ( 16 , 17 ) completed a meta-analysis of 89 studies of educational interventions and outcomes specific to weight loss in diabetes care. An important highlight of the results from these findings is that nutrition therapy alone had the largest statistically significant impact on weight loss and metabolic control. The combination strategy of nutrition and behavioral therapy plus exercise had a small effect on body weight, but a very significant impact on HbA 1c . These findings lend support to the effectiveness of diabetes patient education in improving patient outcomes.

In a review of the effects of educational and psychosocial interventions in the management of diabetes (including education and skill training in diabetes, nutrition, self-monitoring, exercise, and relaxation) in 7,451 patients, Padgett et al. ( 18 ) found that nutrition education showed the strongest effect and relaxation training showed the weakest effect.

In March 2001, Norris et al. ( 19 ) published a systematic review of the effectiveness of DSMT in type 2 diabetes. The results of 72 randomized controlled trials were identified. There were positive effects of DSMT on knowledge, frequency, and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control in studies with short-term follow-up of <6 months. With longer follow-up, interventions that used regular reinforcement throughout follow-up were sometimes effective in improving glycemic control. Educational interventions that involved patient collaboration were thought to be more effective than didactic interventions in improving glycemic control, weight, and lipid profiles. The authors concluded that there is evidence to support the short-term effectiveness of DSMT in type 2 diabetes, but further research is needed to assess the effectiveness of self-management intervention on sustained glycemic control and cardiovascular disease risk factors.

While there are few randomized controlled trials in which nutrition is the only variable ( 6 , 7 ,), there are many studies that demonstrate the effectiveness of multidisciplinary diabetes education on improved glycemic control that include nutrition as a component. While these studies demonstrated improved outcomes, it is difficult to discern benefits that can specifically be attributed to MNT alone. However, meta-analyses studies looking at diabetes education and a variety of weight loss methods have shown that nutrition intervention has the largest statistically significant effect on metabolic control and weight loss ( 16 – 18 ). In addition, these meta-analyses studies have shown that diabetes education in general is effective in improving knowledge, skills, psychosocial adjustment, and metabolic control ( 16 – 19 ). Overall, the evidence in many types of studies involving nutrition therapy in the management of diabetes is supportive of nutrition intervention.

Two recent studies ( 20 , 21 ) have shown that type 2 diabetes can be prevented by lifestyle interventions in subjects who are at high risk for diabetes. In the Finland Diabetes Prevention Study, published in May 2001 ( 20 ), 522 overweight subjects with impaired glucose tolerance were randomly assigned to an intervention or control group. The intervention group received individualized counseling to reduce weight (seven sessions the first year and every 3 months for the remainder of study), to decrease intake of total and saturated fat, and to increase intake of fiber and physical activity. Subjects were followed for 3.2 years and received an oral glucose tolerance test (OGTT) annually. Results at the end of 1 year showed a weight loss of 4.2 and 0.8 kg for the intervention and control groups, respectively. The incidence of diabetes after 4 years was 11% in the intervention group and 23% in the control group. During the study, the risk of diabetes was reduced by 58% in the intervention group.

The initial results of a similar study, the Diabetes Prevention Program (DPP), a multicenter National Institutes of Health study, suggest that type 2 diabetes can be prevented and delayed ( 21 ). The DPP was a randomized trial involving more than 3,200 adults who were >25 years of age and who were at increased risk of developing type 2 diabetes (i.e., having impaired glucose tolerance, being overweight, and having a family history of type 2 diabetes). The study involved a control group (standard care plus a placebo pill) and two intervention groups: one that received a intensive lifestyle modification (healthy diet, moderate physical activity of 30 min/day for 5 days/week) and one that received standard care plus an oral diabetes agent (Metformin). The major study findings indicate that participants in the intensive lifestyle modification group reduced their risk of developing diabetes by 58% compared with the medication intervention group who reduced their risk by 31%. Even more dramatic was the finding that individuals over 60 years of age in the intensive lifestyle modification group decrease their incidence of developing type 2 diabetes by 71%.

In a econometric study of 12,308 patients with diabetes, Sheils et al. ( 22 ) measured the potential savings from MNT and estimated the net cost to Medicare of covering these services for Medicare enrollees. Differences in health care utilization levels of individuals with diabetes, cardiovascular disease, and renal disease were estimated for hospital discharges, physician visits, and outpatient visits for those who did and did not receive MNT. MNT was associated with a reduction in utilization of hospital services of 9.5% for patients with diabetes. Also, utilization of physician services declined by 23.5% for individuals with diabetes who received MNT. The authors concluded that after an initial period of implementation, coverage for MNT can result in a net reduction in health services utilization and costs. In individuals aged 55 years and older, the savings will actually exceed the cost of providing the MNT benefit.

Franz et al. ( 23 ) evaluated the cost-effectiveness of implementing MNT in type 2 diabetes. The cost of unit of change in fasting plasma glucose (1 mg/dl) from entry to 6 months was determined. The intensive nutrition intervention had a cost-effectiveness ratio of $4.20 compared with usual nutrition care with a cost-effectiveness ratio of $5.32. These findings suggest that individualized nutrition interventions can be delivered by dietitians with a reasonable investment of resources and that the cost-effectiveness is enhanced when dietitians are engaged in active decision-making regarding intervention based on patient needs.

Nutrition practice guidelines (NPGs) define the “best” nutrition care for individuals with diabetes. NPGs are evidence-based and are descriptions of diabetes nutrition care that results in positive health outcomes. NPGs for type 1, type 2, and gestational diabetes have been developed, field tested, and published by the American Dietetic Association and are available online through their website at http:www.eatright.org . These NPGs compare “best” nutrition care for patients with diabetes with “usual” or basic nutrition care. As shown in the NPGs, the role of the dietitian involves more than tailoring a meal plan; rather, it involves integrating nutrition with the medical and behavioral care of the individual. Thus, the role of the dietitian is expanded by communicating closely with other health care professionals, focusing on blood glucose patterns as well as overall diabetes management, and serving as a case manager with diabetes patients. When NPGs were implemented, HbA 1c was reduced by an average of 1–2% in these outcome studies ( 6 , 7 ).

While it is well accepted and promoted that MNT is a critical element in the successful self-management of diabetes, the lack of reimbursement/coverage has made it difficult for individuals with diabetes to obtain MNT on an outpatient basis. Though hurdles still exist, the situation has improved over the last few years due to the passage of both federal and state laws and the recognition by some insurance companies that the coverage of this service is clinically and cost-effective.

At the federal level, Medicare beneficiaries with diabetes, who are eligible according to the Medicare guidelines ( www.cms.gov ), can be covered for a minimal amount (10 h initially and 2 h annually) of outpatient DSMT, which includes MNT. To be eligible for reimbursement, the provider of DSMT must be an American Diabetes Association Recognized Education Program ( www.diabetes.org ). DMST services must be prescribed by the referring physician or another nonphysician qualified health care provider.

In addition, a new Medicare benefit for MNT for diabetes (including gestational diabetes) and renal disease was signed into law in 2000 and went into effect in January 2002. The detailed regulations regarding eligibility, hours of service, etc., were published in the 2002 Physician Fee Schedule (PFS) in the 1 November 2001 Federal Register . Detailed information is available on the American Dietetic Association website at www.eatright.org

Forty-six states now have laws that mandate that private insurance plans and managed care organizations cover DSMT, inclusive of MNT, for people with type 1, type 2, and gestational diabetes. These laws generally affect ∼30% of the population. Detailed information about each of the laws is available in The Diabetes State Law Manual, American Diabetes Association and/or on the American Diabetes Association website ( www.diabetes.org ) in the Advocacy section. These laws do not cover the Medicaid or Medicare populations. They also do not cover people who have their health care coverage through a self-funded employer health plan.

As the role of nutrition in disease management has increased, large employer health plans and other types of health plans are recognizing the importance of providing MNT. Therefore, the number of patients who do have some coverage for MNT for diabetes has expanded. Individuals with diabetes should be encouraged to contact their health plan to determine their benefits for this service. A referral and/or letter from a physician, documenting the need for and importance of MNT, can also assist in improving reimbursement for this service.

Evidence-based research strongly suggests that MNT provided by a registered dietitian who is experienced in the management of diabetes is clinically effective. Randomized controlled nutrition therapy outcome studies have documented decreases in HbA 1c of ∼1% in newly diagnosed type 1 diabetes, 2% in newly diagnosed type 2 diabetes, and 1% in type 2 diabetes with an average duration of 4 years. MNT should be considered as monotherapy, along with physical activity, in the initial treatment of type 2 diabetes, provided the person has a fasting plasma glucose <200 mg/dl. Individuals with type 2 diabetes who cannot achieve optimal control with MNT and whose disease may be progressing due to β-cell failure should be prescribed blood glucose-lowering medication, along with additional encouragement to achieve goals of MNT and physical activity. As R. Holman (Oxford, U.K.) stated in a discussion of the UKPDS findings, “if the real problem is the progressive decrease in β-cell function, it is our duty to explain this and not castigate these individuals because they have failed to diet” (24). Despite the fact that the effective promotion of healthy eating and physical activity is challenging in our society, it is now well documented that MNT does make a difference.

Summary of evidence for nutrition therapy in diabetes

The authors are members of a task force supported by the Diabetes Care and Education Dietetic Practice Group of the American Dietetic Association.

Address correspondence and reprint requests to Joyce Green Pastors, Virginia Center for Diabetes Professional Education, Box 800770, UVA Health System, 1400 University Ave., Room 2019, Charlottesville, VA 22908. E-mail: [email protected] .

Received for publication 6 August 2001 and accepted 6 December 2001.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

Email alerts

• Online ISSN 1935-5548
• Print ISSN 0149-5992
• Diabetes Care
• Clinical Diabetes
• Diabetes Spectrum
• Standards of Medical Care in Diabetes
• Scientific Sessions Abstracts
• BMJ Open Diabetes Research & Care
• ShopDiabetes.org
• ADA Professional Books

Clinical Compendia

• Clinical Compendia Home
• Latest News
• DiabetesPro SmartBrief
• Special Collections
• DiabetesPro®
• Diabetes Food Hub™
• Insulin Affordability
• Know Diabetes By Heart™
• About the ADA
• Journal Policies
• For Reviewers
• Advertising in ADA Journals
• Reprints and Permission for Reuse
• Copyright Notice/Public Access Policy
• ADA Professional Membership
• ADA Member Directory
• Diabetes.org
• X (Twitter)
• Cookie Policy
• Accessibility
• Terms & Conditions
• Get Adobe Acrobat Reader
• © Copyright American Diabetes Association

This Feature Is Available To Subscribers Only

Sign In or Create an Account

• Find a Doctor
• Conditions & Services
• Patients & Visitors

Medical Nutrition Therapy or Nutrition Education?

Posted January 22, 2018 by Rose Ann Chiurazzi, MA, RDN, LD, CDE

Obesity currently affects 34% of all Americans. It contributes to many other conditions, including Type 2 Diabetes, GERD, Sleep Apnea, Hypertension, Hyperlipidemia, Joint Disorders, and a variety of cancers. Improving or eliminating obesity often can improve or cure these conditions, including Type 2 Diabetes.

A registered dietitian can approach obesity through either medical nutrition therapy or nutrition education.

Medical nutrition therapy (MNT) involves registered dietitians treating medical conditions such as obesity through the use of nutrition assessment and intervention techniques which will include patient education. The dietitian uses the patient’s medical history, a physical examination, and a dietary history to develop an appropriate plan. The plan is reviewed with the patient, and the patient is monitored at regular intervals to determine progress made and the need for modifications to the plan. MNT requires a physician referral.

Nutrition Education is a less intensive approach to treating obesity, but is also provided by a registered dietitian. The focus is on educating the patient regarding topics such as meal planning, nutrient content, portion sizes, and label reading. A physician referral is not needed for nutrition education.

Who Qualifies for Medical Nutrition Therapy?

You may want to consider Medical Nutrition Therapy if you have obesity and Type 2 diabetes, and/or if you have obesity with or without other comorbid conditions.

If you have Type 2 Diabetes and are also struggling with overweight or obesity and you feel that Medical Nutrition Therapy with a registered dietitian would be helpful, consider asking your doctor to refer you to the Summa Health Weight Management Institute. The goal is to address the obesity as the root cause of the Type 2 Diabetes, while simultaneously assisting you with learning how to manage the nutritional aspects of their diabetes.

If you are struggling with obesity without comorbid Diabetes, you may also benefit tremendously from MNT, with a focus on improving or eliminating the obesity, which will in turn improve the length and quality of your life.

Referrals for MNT are managed by the Summa Health Weight Management team, and each patient is scheduled with a registered dietitian with expertise in the treatment of obesity. The dietitians work closely with our board certified Obesity Medicine Specialist, to make sure all MNT treatment plans are based upon the most current research in obesity. Plans are individualized for each patient as needed.

Some patients with Type 2 Diabetes do not need to lose weight, and some patients with Type 2 Diabetes need to lose weight but are not ready to do so. We can still provide the MNT that you may need for your diabetes care if you do not want/need to lose weight.

Who Qualifies for Nutrition Education

If you are struggling with overweight or obesity, but do not have insurance coverage for medical nutrition therapy, consider seeing a dietitian for Nutrition Education.

The education you receive will be tailored to your needs, and will be provided by the same team of registered dietitians that provides the MNT. Current research in obesity medicine will still serve as the underlying foundation for the education you receive.

Nutrition education can include topics such as healthy eating, label reading, understanding carbohydrates, getting enough protein, and any other topic that you feel would help you with your goal of a healthy weight.

Fees for Nutrition Education are lower than those for Medical Nutrition Therapy, and are comparable to most copayments charged by insurance companies

If you are interested in scheduling an appointment, call us at 330.375.6201. Appointments can take place on Summa Health System’s Akron or Barberton Campuses or at our Hudson, Green, Medina and Wadsworth-Rittman Medical Centers.

About the Author

Rose Ann Chiurazzi, MA, RDN, LD, CDE

Vitality eNews Sign Up

Receive the Summa Health eNewsletter for the latest health tips, advice and updates.

Thank you for subscribing to the Vitality  eNewsletter.

We're sorry, there was an error while processing your request. Please try again.

Related Blogs

View all Flourish Blogs

Eat Your Way to Better Health: Why Leafy Greens Are Your Magic Weapon

Leafy greens sometimes get stereotyped as the soggy and wilted salad sidekick taking up space in our refrigerator’s crisper drawer. But the fact is they’re so much more! These nutritional powerhouses are loaded with vitamins, minerals, fiber and antioxidants that fuel our bodies and minds in countless ways.  Think of Popeye eating his spinach, but instead of only bulging biceps, he’s got strong bones, a sharp mind, radiant skin and a healthy immune…

Should I Declutter Before Winter? [Podcast]

3 tips to achieve your wellness goals.

Are you walking into the gym with a whirlwind of thoughts in your head? Whether it's dinner plans or making it home in time to watch the game, we understand that life can get hectic. But, let's make sure your fitness goals don't get lost in the shuffle. At Summa Health Wellness Center , we're here to help you work out with a purpose and guide you on your journey to becoming a healthier and fitter version of yourself.

1. Discover the Benefits of Our Free Assessments

For new…

Nutrition for Endurance Events: Fueling Your Performance

‘Tis the season for outdoor endurance sports! While gearing up with the best apparel, shoes and playlist is essential, don't overlook the power of nutrition. Learn how to properly fuel your body with carbohydrates, fluid and electrolytes during endurance activities that last longer than an hour.

Muscle Glycogen: Your Energy Source

Understanding muscle glycogen and energy utilization.

During exercise, your muscles rely on muscle glycogen as a primary energy source. As your…

7 Common Myths on Healthy Hydration Debunked

When it comes to hydration, it’s a simple rule: Drink eight glasses of water each day, right? Wrong. There is a lot of misinformation surrounding hydration, including this common myth, which can make it difficult to distinguish fact from fiction.

Water is essential for healthy bodies, as we are made up mostly of water. Getting enough water enables our bodies to regulate body temperature, keep joints lubricated, prevent infection, deliver nutrients to cells and keep organ…

12 Tips For Cooking Up A Delicious, Yet Nutritious Holiday Meal

Holidays are a time for family fun, celebration and good food! But if you’re not careful, unwanted pounds can quickly sneak up on you.

Sticking to a healthy diet during the holidays is easier said than done, but it’s not impossible. Holiday weight gain is not inevitable.

Summa Health offers 12 ways to make your holidays healthier — without sacrificing the tastes of the season you look forward to year after year. Instead of cutting out your favorite treats…

Let's Talk About Fiber!

Fiber is found in fruits, vegetables, whole grains, legumes, and nuts. Fiber has many health benefits, including:

• Playing a role in lowering blood cholesterol
• Helping to control blood sugars
• Aiding in preventing constipation
• Contributing to weight management

According to the Institute of Medicine and USDA, women should aim for about 25 grams of fiber per day, and men should aim for about 38 grams per day, or it is recommended to have about 14 grams for every 1000 calories. …

Myth vs. Fact: What you need to know to feel confident in your healthy food choices

We’ve been told time and again all fats are unhealthy, multigrain is healthier than white bread and fruit juice is a good replacement for the whole fruit. But, are these facts or myths that have been ingrained in us? 

With so much conflicting information, it can be difficult to make the healthiest choices and the unfortunate truth is we often fall victim to food myths.

We might reach for a food commonly believed to be healthy, but in actuality, it could be harmful to…

Feeling the pressure? 8 ways to live a heart-healthy lifestyle

Are you feeling the pressure to live a heart-healthy lifestyle? You’re not alone.

Heart disease is the leading cause of death for men and women in the United States, according to the American Heart Association (AHA). What’s more, nearly half of all adults in this country are living with some type of cardiovascular disease.

The good news is you don’t have to be a statistic. While genetics do play a role in heart disease, there are several risk factors that can…

Our Commitment to Creating a Healthier Community [Podcast]

Iriel Hopkins and Marlo Schmidt discuss ways in which Summa Health System contributes to a healthier community.

10 Early Signs of Diabetes That Shouldn't Be Ignored

FsoHigh blood sugar can cause gradual, unassuming symptoms that can sneak up on you. Frequent urination and excessive thirst — the telltale signs of type 2 diabetes — are often mild and can easily be attributed to other factors.

In fact, most people don’t even know they have high blood sugar until they’re diagnosed with type 2 diabetes.

Diabetes is a chronic condition that causes glucose (or sugar) levels in the body to rise. The problem is ignoring or writing off the symptoms…

How to introduce moderate exercise into your routine

Study after study has shown the positive effects of light-to-moderate physical activity and the negative effects of little or no exercise. Regular exercise is one of the most beneficial (and cost-effective) activities you can do to better your health.

Some benefits include:

• Reduced risk of cardiovascular disease:   Stroke and heart disease are two of the leading causes of death in the U.S. According to the CDC, just 150 minutes a week of moderate-intensity activity can put…

Sunscreen 101 - 5 reasons you should make it part of your daily routine

Did you know skin cancer is the most common form of cancer in the United States? According to the American Academy of Dermatology, one in five Americans will develop skin cancer in their lifetime, and men 65 or older are twice as likely to develop melanoma — the deadliest form of skin cancer — than women.

As we head into the summer months, most of us know the importance of wearing sunscreen in the hot, blazing sun. But what you may not realize is the importance of…

Best and worst foods for your next sizzling cookout

Nothing says summer like the classic American barbeque: hamburgers, hot dogs and macaroni salad with berry pie for dessert. Cookouts with family and friends are a favorite summer pastime to enjoy good food, the great outdoors and warmer temperatures.

But considering on average a person consumes upwards of 2,000 calories on typical barbeque fare, it’s not a bad idea to switch up this year’s cookouts to include healthier options. Who said cookouts had to be unhealthy…

Food allergy vs. food intolerance: How to tell the difference

Chances are good at one time or another you have experienced unpleasant symptoms — an upset stomach, diarrhea, nausea or bloating — after eating a delicious meal. Reactions from food are common, but it can be challenging to understand the cause.

Food intolerance can trigger some of the same physical symptoms as a food allergy. But, understanding the difference is vital to your health. Eating a food that your body is intolerant to can leave you feeling uncomfortable, but eating…

Weight Loss Options Built for Your Needs

Obesity and the need to lose weight is a deeply personal journey. With many new medical options available, it can be difficult to select the best individual approach to be successful with long-term weight loss.

Obesity is the second-highest cause of preventable deaths in the United States. The rate at which obesity has worsened over the past 20 years, especially in the state of Ohio is alarming, and there is now a growing amount of national attention focused on the problem. In…

7 ways to reduce sodium without sacrificing flavor this holiday season

With so many celebrations centered on food, it’s easy to lose track of how much we’re consuming — including our sodium intake. In fact, it’s not unusual for a typical holiday meal to meet or exceed our recommended daily value for sodium.

But, what’s all the fuss about? Sodium, or salt, is a mineral that’s essential for life. It’s regulated by your kidneys and is required for nerve and muscle function and maintaining your body’s…

Are veggie burgers really a healthier choice?

It’s no secret that meatless meals are becoming more popular. While this is certainly not anything new for our vegan or vegetarian consumers, terms like “plant based” and “meat alternatives” are quickly becoming more mainstream. Wildly popular, meatless burgers are even entering the fast food market with Burger King’s addition of the “Impossible Whopper” to their regular menu. But, are veggie burgers actually healthier than a…

Good vs. Bad: Understanding your cholesterol levels

Can obesity be considered a disease [podcast].

Dr. Adrian Dan discusses obesity as a metabolic disease.

Tips on Maintaining Fitness and Physical Health During the Pandemic [Podcast]

Dr. Cipriani discusses tips on maintaining physician health during the pandemic.

4 Impactful Lifestyle Changes That Help Improve Your Cholesterol

Your options for weight loss.

The desire to lose weight and the process chosen to go about it is a deeply personal journey. With many new options on the market, it can be tough to understand the best approach to reaching long-term weight loss.

Obesity is now ranked as the second-highest cause of preventable deaths in the United States. The rate at which obesity has worsened over the past 20 years is alarming, and there is now a growing amount of national attention focused on the problem. It is also important to note that Obesity has been proven to increase the risk for cancer including Colon and Breast cancers. Weight loss is an important cancer risk reduction effort for many patients at higher risk for cancer and a component of cancer survivorship plans as well.

Breaking Down Protein Powders

In the last decade or two, protein powders have become increasingly popular among physically active and health-conscious individuals.

Protein powders are concentrated sources of protein — the essential building block for muscle, tissue, bones and blood — made from either animal or plant sources. While whole foods come complete with the essential vitamins, minerals and fiber you require, protein powders are an easy, convenient way to bolster your protein intake when…

First Unified World Obesity Day

Obesity has been deemed a disease of worldwide epidemic proportions. In the United States, obesity directly affects 40% of the adult population and an additional 30% are considered overweight. Obesity is now ranked as the second-highest cause of preventable deaths in the United States. The rate at which obesity has worsened over the past 20 years is alarming, and there is now a growing amount of national attention focused on the problem.

When talking about obesity, it is very…

5 Ways to Make Healthy Eating a Piece of Cake

Eat healthy. Exercise. Lose the extra holiday L-Bs. These are some of the most common goals many of us try to accomplish each year. But, it’s just about the time of year when these all-too familiar New Year’s Resolutions start to fall by the wayside.

Life can get in the way, temptations arise and we can default to old habits. So this year, let’s try something different. Instead of listing the same goals year after year, let’s put to practice lifestyle…

Are short workouts effective?

As a general goal, it is recommended that we get at least 30 minutes of physical activity every day, more if you’re looking to lose weight. However, some people find it hard to carve out those 30 minutes every day. Some may only have time for a short 10-minute workout. So, is it still worth exercising even if it’s only for a few minutes at a time?

Studies have shown that short workouts throughout the day are just as beneficial as long continuous ones.

In this…

How to Successfully Manage Your Diabetes During the Holidays

The holidays can be tough for anyone on a diet with all the celebrating, snacking and treats. Those with diabetes have to be especially careful around the holidays because gaining weight or rising blood sugar could be dangerous to your health.

If you slip into bad eating habits and they extend well into the New Year, you can do long-term damage to your body. Just a little preparation can go a long way towards keeping your weight and blood sugar down – check out these…

Here's the scoop on intermittent fasting

This recent weight loss trend places more of an emphasis on WHEN you eat than WHAT you eat (but keep in mind that both are important for success). Intermittent fasting (IF) is an eating pattern that cycles between periods of fasting and eating.

Depending on the type of intermittent fasting pattern you choose, your fasting time may be a few hours or a whole day a few times per week. During the fasting periods, you eat either very little or nothing at all.

Here are some of the…

What Does A Fast Food Meal Do To Your Body?

It’s quick, fast, and cheap; it also tastes really good! Americans spend roughly $50 billion on fast food each year. With the availability of food “on-demand” more and more people are opting for prepared foods, whether through a drive thru or delivered to your door.

But have you ever felt not-so-great after eating fast food--maybe a little tired or bloated? Did you notice you became hungry again pretty soon after eating? That’s because although most…

Battle it Out: Artificial Sweetener v. Sugar

The sweeter things in life are present at most celebrations...weddings, birthdays, work promotions, new baby, office parties...you get the idea. But if you are like many Americans trying to cut back on your refined sugar intake for health reasons and/or weight management, you may think opting for sugar replacements might be a healthier choice.

When it comes to real sugar (sucrose) versus artificial sweeteners, like the ones found in diet sodas and ‘zero-calorie”…

Myths vs. Facts: Binge Eating

According to the American Psychiatric Association , eating disorders affect millions of Americans, mostly women between 12 and 35 years old. There are three main types of eating disorders: anorexia, bulimia and binge eating disorder (BED). The focus of this blog post will be on BED.

BED is the most common eating disorder in the US. It can be characterized by recurring episodes in which large quantities of food are consumed (more food than most people would consume over the same…

Sugar: It may be an Addiction

Most of us know that too much sugar is not good for our overall health. But what you may not know is that growing research is showing what’s bad for the body may also be bad for the brain.

A recent study published in  Scientific Reports  found that a group of men between 35 and 55 who consumed more than 67 grams of sugar daily from sweetened foods and beverages were more likely to develop  anxiety ,  depression , and other common mental disorders after 5 years, compared with men with a lower daily sugar intake. In no way does this imply that excess sugar causes mental disorders in the general population; rather this was a select study which also found no similar correlation for the women who participated in the research.

What are macros?

Paleo, keto, macros, carbs, complex carbs, clean eating, plant-based...we could keep going but I think you get the idea. With so many buzzwords out there, it can be difficult to analyze which ones would be a good addition to your weight loss journey or can help maintain a healthy lifestyle. Let’s explore one of these nutrition buzzwords: Macros.

Macros are short for macronutrients. These nutrients include protein, carbohydrates and fats and make up the caloric content of food.

Controversial Use of E-cigarettes and Vaping- A "Heated" Debate

Carbs: the good, the bad and the yummy.

Atkins, paleo, low-carb, no carb, how do you choose? If weight loss is a priority for you, or if you are just looking to eat healthier, there is an abundance of diets, meal plans and fads out there.

But what exactly are carbohydrates (carbs) and why are some of them so “bad” for us? Below is a breakdown of the types of carbohydrates, what they do to our bodies, which ones we can eat and those to avoid.

The Gift of Heart Health

When you think of February, you may think of Valentine's Day, chocolate and flowers. February also marks American Heart Month, a great time to commit to a healthy lifestyle and make small changes that can lead to a lifetime of heart health. Heart disease is the leading cause of death for men and women in the United States. But the good news is it's also one of the most preventable.

Making heart-healthy choices, knowing your family health history and the risk factors for heart…

Eating-Mindfully

We eat for many reasons beyond hunger, which is why learning to eat mindfully helps you maintain or even lose weight if desired. As we celebrate Healthy Weight week this week, here are ten tips that provide some food for thought.

1. Reject the Diet Mentality. Throw out the diet books and magazine articles that offer you false hope of losing weight quickly, easily and permanently. Get angry at the lies that have led you to feel as if you were a failure every time a new diet…

Options to Request an Appointment

If your situation is an emergency, call 911..

This site uses cookies.

We use cookies to give you the best experience on our website. For more information on what this means and how we use your data, please see our Privacy Policy .

Tip Sheet: Medical Nutrition Therapy (MNT)

Medical Nutrition Therapy (MNT) Services are used to deliver nutritional assessment, one-on-one counseling, and group counseling services, provided by a registered dietitian or qualified nutrition professional, to eligible Medicare beneficiaries. MNT is a Part B benefit of Original Medicare. As a covered Part B service, MNT is also a covered Medicare Advantage (Part C) benefit because all Medicare Advantage plans are mandated to cover all Medicare Part A and Part B services.

Medicare beneficiaries are eligible for MNT services if they have one or more of the following conditions:

• Chronic Kidney Disease
• Have had a kidney transplant within the last 36 months

MNT, for beneficiaries with a diagnosis of diabetes, is intended to deliver nutritional counseling related to the impact of nutritional intake on the overall self-management of diabetes. MNT and diabetes self-management training (DSMT) can occur as part of a combined individual/group training class. However, providers cannot bill for MNT and DSMT given to the same beneficiary on the same day. For example, a group education program that focuses on carbohydrate counseling on Day 2 may fit the requirement of MNT group education. If the day 2 session, in this example, is billed for MNT, then the same provider cannot bill for DSMT on the same day. Subsequently, the program could begin billing for group DSMT on Day 3, in this example.

The DSMT benefit is ten (10) hours and the MNT benefit is three (3) hours, for a total of thirteen (13) covered hours of training for the initial training calendar year. However, unlike DSMT that allows for a qualified provider, including a physician, nurse practitioner (NP), or physician assistant (PA) to write an order for DSMT services, MNT can only be provided based on a physician referral. As a result, an NP or PA cannot refer a Medicare beneficiary to an MNT program but they can write a referral for DSMT.

• DSMT/MNT Service Order Form
• Background Information on DSMT/MNT Services Order Form

Effective October, 1, 2002, MNT became a covered Medicare Part B benefit for any beneficiary with a diagnosis of diabetes or chronic kidney disease, or who have had a kidney transplant within the last 36 months, pursuant to Section 1861 (s)(2)(V) of the Social Security Act. Centers for Medicare and Medicaid Services (CMS) regulations for MNT were established in the Code of Federal Regulations at 42 CFR §§410.130 – 410.134.

The benefit covers an initial three (3) hours of individual and group counseling services, that are given directly by, or under the direct supervision of, a qualified nutrition professional.

Generally, the qualified practitioner for MNT is a registered dietitian or qualified nutrition professional. Most states recognize “registered dietitian” as the entry-level credential to deliver MNT services. The notation of “qualified nutrition professional” is used because some states do not recognize the credential of registered dietitian. The licensing of professionals is a state mandated requirement. CMS defers to the state requirements for licensure. As a result, when a state defines the scope of practice for MNT as within the professional realm of a nutrition professional, then MNT coverage adheres to that same standard. The benefit also allows for additional MNT training to be given to an eligible beneficiary, for up to two (2) hours, in each subsequent calendar year, as long as the consumer continues to have a diagnosis of diabetes or chronic kidney disease. The twelve month time period for refresher training begins at the completion of the last training session that the beneficiary received during the prior year.

The benefit does not cover MNT services given to a beneficiary with End Stage Renal Disease (ESRD), because MNT is covered as part of the bundled rate for dialysis treatment.

All Medicare Advantage plans must cover MNT services, because MNT is a Part B benefit. Any organization that wishes to deliver MNT services to a particular Medicare Advantage plan must first obtain a direct contract with the specific Medicare Advantage plan to be a MNT provider in the Medicare Advantage plan network.

Scope of Practice

Professional scope of practice is defined by the professional practice acts of each particular state. The services outlined as part of MNT are within the scope of practice of a registered dietitian or qualified nutrition professional. However, the state professional licensing division is the responsible party to define the applicable guidance on the application of scope of practice in each particular state. If you have questions about the limits of scope of practice of nutrition professionals in your state, please refer to the state professional licensing division for guidance.

Eligibility Criteria

The Medicare beneficiary must have one of the following conditions:

• Chronic Kidney Disease (CKD)*

*Chronic Kidney Disease is a condition where the kidneys have impaired function as a result of damage that has occurred over time. The two (2) primary conditions that cause CKD are diabetes and hypertension. Many beneficiaries who have congestive heart failure also have CKD as they often present as co-morbid conditions.

Intervention Procedure

• First , each Medicare beneficiary who is being considered for an MNT service must have an initial assessment to determine their nutritional intake needs and current state of daily nutritional consumption.

NOTE : The initial face-to-face assessment must be conducted by a registered dietitian or qualified nutrition professional, with current licensure in the State or territory within which the service is being rendered.

As noted above, if the Medicare beneficiary is enrolled in Medicare Advantage (MA), the community-based organization wishing to become a contracted provider of MNT must first have a contract with the MA plan. The type of professional eligible to deliver MNT adheres to the same state-level licensure standards that apply to Medicare coverage. Medicare Advantage plans adhere to the same professional requirements for MNT to be provided by a registered dietitian or qualified nutrition professional, depending on the state licensure requirements.*

*A trained lay leader can assist the registered dietitian or qualified nutrition professional in obtaining the necessary information to complete the individual assessment, but that lay leader cannot be the sole provider of MNT.

• Second , the registered dietitian or qualified nutrition professional must develop an individualized MNT education plan, based on the assessment results.

Billing Requirements

MNT is a Medicare Part B benefit. Under Medicare Part B, MNT CPT® billing codes are only authorized for use by a registered dietitian or qualified nutrition professional. CPT® is the registered trademark of the American Medical Association (AMA). CPT stands for Common Procedural Therapy. The services associated with each professional code are defined by the AMA. Medicare and Medicare Advantage plans contract for professional services that are defined by the CPT code restrictions, defined by the AMA. The following MNT CPT® codes apply to Medicare and Medicare Advantage coverage.

MNT CPT® Codes are listed below:

• 97802 : Medical nutrition therapy; initial assessment and intervention, individual, faceto-face with the patient, each 15 minutes
• 97803 : Re-assessment and intervention, individual, face-to- face with the patient, each 15 minutes
• 97804 : Group (2 or more individual(s)), each 30 minutes

This project was supported in part by grant number 90CR2001-01-00 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

Stay informed

We'll send you resources to support independence, health, and economic security.

Related Articles

How health care is prioritizing diversity, equity, and inclusion, and why cbos should, too, community care hubs: the essentials of data-sharing, updated medicare reimbursement rule addresses health-related social needs and care coordination, community care hubs: quality, fidelity, and compliance expectations for service delivery partners.

Community Care Hubs: What Evidence-Based Program Providers Need to Know

How Evidence-Based Program Providers and Accountable Care Organizations Can Work Together on Quality and Performance Improvement

Get NCOA in Your Inbox

Choose where we'll send you resources to support your health and financial well-being. Select an option(s) below that best describes you to get communication that matches your interests.

• Pay Your Bill
• Thank Your Provider
• 509-332-2541
• Find a Provider
• Price Estimation
• Nearby Lodging
• Send an eCard
• Health Podcast
• Media Center
• Social Media
• Patient Stories
• Women's Leadership Guild
• Center for Learning & Innovation
• Support Groups
• Health Resources
• Community Partners
• Hospital Board
• Privacy Notice
• Transparency

NUTRITION THERAPY

(509) 336-7543

Nutrition and physical fitness are the foundations of a healthy lifestyle. Food is integral to our lives. We eat not only to nourish our bodies for growth, work and play, but also for pleasure. We realize the importance of healthy eating habits, but obtaining the most accurate information isn’t easy.

How our Dietitian Nutritionists can help:

They use their expertise to help individuals make unique, positive lifestyle changes by offering personalized nutrition counseling in a wide variety of areas. These include:

• Healthy food choices for all age groups
• Cardiovascular disease
• Hypertension
• Eating Disorders
• Gastrointestinal disease (e.g. gluten intolerance, irritable bowel, diverticulosis)
• Food intolerance/allergies
• Weight management
• Sports Nutrition
• Chronic obstructive pulmonary disease
• Health Coaching

Frequently Asked Questions

Registered dietitian nutritionists (RDNs) and nutrition and dietetics technicians, registered (NDTRs) are credentialed practitioners. A credential is a professional qualification — like MD for doctors or physicians — that lets the public know that the practitioner is a trained expert. In nutrition and dietetics, the credentials for trained experts is RDN and NDTR. Usually when someone says “dietitian,” they mean an RDN. “Registered dietitian nutritionist” and “nutrition and dietetics technicians, registered” are legally protected titles. Only practitioners who have completed specific educational requirements, passed a national exam and continue learning through ongoing education can use these titles and credentials. However, there is no specific, standardized meaning for “nutritionist.” Anyone can call themselves a nutritionist, and unfortunately, unqualified health care recommendations can cause people harm. So whether someone calls themselves “dietitian” or “nutritionist,” check for credentials to ensure they are qualified nutrition experts. You may see the credentials RD or RDN (Registered Dietitian or Registered Dietitian Nutritionist).  These credentials have the same meaning and are interchangeable.

Marian's Story

When Marian Sciachitano was diagnosed with Type 2 diabetes and hypertension, she knew it was time to seek out nutrition assistance. 

Looking for flavorful, healthy recipes?

Download our free digital cookbook to experience flavors from around the world.

How to Eat Healthy on a Budget

Sticking to a budget can be tricky in many cases; but when it comes to eating healthy, it doesn't mean you have to give up fresh, healthy foods. 

Why Fad Diets Don't Work

The internet is full of conflicting nutrition information and fad diets claiming quick results. Learn why it's best to avoid these types of meal plans.

Nutrition Team

Jana earned a master's degree in nutrition from Texas Tech University and has been a Certified Nutrition Support Clinician for 15 years. Her primary experience is in large academic medical centers, and she has extensive experience in critical care nutrition. She is passionate about advocating for patients and advancing the role of the clinical dietitian in healthcare. She enjoys working with dietetic students and medical students, as well as resident physicians, and helping them grow in their knowledge of the role of nutrition as a part of treatment and healing.

Melissa completed a combined dietetic internship and master’s degree in human nutrition through the VA Medical Center in Houston and Texas Woman’s University. As a Board Certified Health and Wellness Coach, Melissa is passionate about helping people improve their health and quality of life in authentic, personally meaningful ways. She is currently growing in knowledge and experience in the treatment of eating disorders. She enjoys working with people of all ages in English and Spanish, using nutrition to promote health and wellness in our community.

Shae completed her Bachelor’s Degree at Portland State University and Masters of Nutritional Sciences degree in Sports and Wellness at the University of Kentucky. She also completed an additional Bachelor's Degree in Dietetics at the University of Idaho. Shae is also a Board-Certified Specialist in Sports Dietetics. Her primary experiences in Division 1 athletic departments, including the University of Kentucky, the University of Wyoming, and Washington State University, allowed her the opportunity to work with elite-level athletes on performance nutrition. Shae is passionate about creating a safe space where people feel comfortable talking about their food preferences and eating habits, while also working towards their goals.

Lisa earned her undergraduate and graduate degrees in Human Nutrition from Washington State University, and completed her dietetic internship at Fairview University Medical Center in Minneapolis, MN. Over 20+ years, Lisa has worked as a home infusion dietitian specializing in pediatric tube feeding and weaning. She is a member of the interdisciplinary team that provides community-based feeding and nutrition services to infants and children at Summit Therapy. Lisa has been an active member of the Pediatric Nutrition Practice Group and has served in many leadership roles within this national organization.

I have been visiting with Melissa Francik for weight management and wellness coaching since 2016. It has been life changing. From learning how to cook healthy meals to changing my relationship with food and my perspective on wellbeing, Melissa is always encouraging and supportive in my ongoing wellness journey. Susan

Meeting with Melissa Francik has been life changing for me. She has helped me navigate health issues that have popped up in effective ways with the latest research and tools. She is kind, extremely knowledgeable and easy to work with. I would recommend her highly to anyone who wants to improve their overall health and quality of life.  Tammy

I have received phenomenal nutrition assistance from Melissa Francik. Melissa combines current scientific knowledge with practical help. I credit her with my continued success on my road to better health. Gail Miller

Get Connected. Sign up for e-newsletters for your health

• Awards & Accreditations
• Find A Provider
• Price Transparency

Clinical Nutrition

Nutrition is essential to healing and living better..

Good nutrition is essential for your health. Gritman offers programs to help you manage weight loss and chronic disease and create healthy eating habits. We provide education to patients and consultations with physicians and nurses to address nutrition concerns. We care about your recovery, and we will teach you how to manage your diet once you leave the hospital. Our team of registered dietitians, nutritionists are ready to help.

Individual Counseling Services

• Chronic kidney disease
• Eating disorders
• Food allergies
• Gastroesophageal reflux disease
• Gestational diabetes
• Hypertension
• Heart disease/health
• Hypoglycemia
• Intuitive eating
• Inflammatory bowel disease
• Irritable bowel syndrome
• Prediabetes
• Meal planning for special diets
• MedGem® Metabolic Testing (Measure the calories your body burns at a resting state and use results for setting and tracking nutrition and weight-loss goals)
• Overall nutrition for all life stages
• Additional options available

Please check with your insurance company to find out if your plan covers medical nutrition therapy.

Location and hours

Location 803 S Main St., Suite 220 Moscow, ID 83843

Contact 208-883-6341

Hours Monday – Friday, 8 a.m. – 5:00 p.m. Closed on major holidays. --->

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Diabetes Care
• v.42(5); 2019 May

Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report

Alison b. evert.

1 UW Neighborhood Clinics, UW Medicine, University of Washington, Seattle, WA

Michelle Dennison

2 Oklahoma City Indian Clinic, Oklahoma City, OK

Christopher D. Gardner

3 Stanford Diabetes Research Center and Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA

W. Timothy Garvey

4 Diabetes Research Center, Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL

5 Birmingham Veterans Affairs Medical Center, Birmingham, AL

Ka Hei Karen Lau

6 Joslin Diabetes Center, Boston, MA

Janice MacLeod

7 Companion Medical, Inc., Columbia, MD

Joanna Mitri

8 Section on Clinical, Behavioral and Outcomes Research Lipid Clinic, Adult Diabetes Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA

Raquel F. Pereira

9 Simple Concepts Consulting, Bellevue, WA

Kelly Rawlings

10 Vida Health, San Francisco, CA

Shamera Robinson

11 American Diabetes Association, Arlington, VA

Laura Saslow

12 Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI

Sacha Uelmen

Patricia b. urbanski.

13 St. Luke’s Health Care System, Duluth, MN

William S. Yancy, Jr.

14 Duke Diet and Fitness Center, Department of Medicine, Duke University Health System, Durham, NC

15 Durham Veterans Affairs Medical Center, Durham, NC

Associated Data

This Consensus Report is intended to provide clinical professionals with evidence-based guidance about individualizing nutrition therapy for adults with diabetes or prediabetes. Strong evidence supports the efficacy and cost-effectiveness of nutrition therapy as a component of quality diabetes care, including its integration into the medical management of diabetes; therefore, it is important that all members of the health care team know and champion the benefits of nutrition therapy and key nutrition messages. Nutrition counseling that works toward improving or maintaining glycemic targets, achieving weight management goals, and improving cardiovascular risk factors (e.g., blood pressure, lipids, etc.) within individualized treatment goals is recommended for all adults with diabetes and prediabetes.

Though it might simplify messaging, a “one-size-fits-all” eating plan is not evident for the prevention or management of diabetes, and it is an unrealistic expectation given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences, co-occurring conditions (often referred to as comorbidities), and socioeconomic settings in which they live. Research provides clarity on many food choices and eating patterns that can help people achieve health goals and quality of life. The American Diabetes Association (ADA) emphasizes that medical nutrition therapy (MNT) is fundamental in the overall diabetes management plan, and the need for MNT should be reassessed frequently by health care providers in collaboration with people with diabetes across the life span, with special attention during times of changing health status and life stages ( 1 – 3 ).

This Consensus Report now includes information on prediabetes, and previous ADA nutrition position statements, the last of which was published in 2014 ( 4 ), did not. Unless otherwise noted, the research reviewed was limited to those studies conducted in adults diagnosed with prediabetes, type 1 diabetes, and/or type 2 diabetes. Nutrition therapy for children with diabetes or women with gestational diabetes mellitus is not addressed in this review but is covered in other ADA publications, specifically Standards of Medical Care in Diabetes ( 5 , 6 ).

Data Sources, Searches, and Study Selection

The authors of this report were chosen following a national call for experts to ensure diversity of the members both in professional interest and cultural background, including a person living with diabetes who served as a patient advocate. An outside market research company was used to conduct the literature search and was paid using ADA funds. The authors convened in person for one group meeting and actively participated in monthly teleconference calls between February and November 2018. Focused teleconference calls, email, and web-based collaboration were also used to reach consensus on final recommendations between November 2018 and January 2019. The 2014 position statement ( 4 ) was used as a starting point, and a search was conducted on PubMed for studies published in English between 1 January 2014 and 28 February 2018 to provide the updated evidence of nutrition therapy interventions in nonhospitalized adults with prediabetes and type 1 and type 2 diabetes. Details on the keywords and the search strategy are reported in the Supplementary Data , emphasizing randomized controlled trials (RCTs), systematic reviews, and meta-analyses of RCTs. An exception was made to the inclusion criteria for the use of meal studies for the insulin dosing section. In addition to the search results, in select cases the authors identified relevant research to include in reaching consensus. The consensus report was peer reviewed (see acknowledgments ) and suggestions incorporated as deemed appropriate by the authors. Though evidence-based, the recommendations presented are the informed, expert opinions of the authors after consensus was reached through presentation and discussion of the evidence.

EFFECTIVENESS OF DIABETES NUTRITION THERAPY

Consensus recommendations.

• Refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT at diagnosis and as needed throughout the life span and during times of changing health status to achieve treatment goals. Coordinate and align the MNT plan with the overall management strategy, including use of medications, physical activity, etc., on an ongoing basis.
• Refer adults with diabetes to comprehensive diabetes self-management education and support (DSMES) services according to national standards.
• Diabetes-focused MNT is provided by a registered dietitian nutritionist/registered dietitian (RDN), preferably one who has comprehensive knowledge and experience in diabetes care.
• Refer people with prediabetes and overweight/obesity to an intensive lifestyle intervention program that includes individualized goal-setting components, such as the Diabetes Prevention Program (DPP) and/or to individualized MNT.
• Diabetes MNT is a covered Medicare benefit and should be adequately reimbursed by insurance and other payers or bundled in evolving value-based care and payment models.
• DPP-modeled intensive lifestyle interventions and individualized MNT for prediabetes should be covered by third-party payers or bundled in evolving value-based care and payment models.

How is diabetes nutrition therapy defined and provided?

The National Academy of Medicine (formerly the Institute of Medicine) broadly defines nutrition therapy as the treatment of a disease or condition through the modification of nutrient or whole-food intake ( 7 ). To complement diabetes nutrition therapy, members of the health care team can and should provide evidence-based guidance that allows people with diabetes to make healthy food choices that meet their individual needs and optimize their overall health. The Dietary Guidelines for Americans (DGA) 2015–2020 provide a basis for healthy eating for all Americans and recommend that people consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level ( 8 ). For people with diabetes, recommendations that differ from the DGA are highlighted in this report.

MNT is an evidence-based application of the nutrition care process provided by an RDN and is the legal definition of nutrition counseling by an RDN in the U.S. ( 9 – 12 ). Essential components of MNT are assessment, nutrition diagnosis, interventions (e.g., education and counseling), and monitoring with ongoing follow-up to support long-term lifestyle changes, evaluate outcomes, and modify interventions as needed ( 9 , 10 ). The goals of nutrition therapy are described in Table 1 .

Goals of nutrition therapy

The unique academic preparation, training, skills, and expertise make the RDN the preferred member of the health care team to provide diabetes MNT and leadership in interprofessional team-based nutrition and diabetes care ( 1 , 9 , 13 – 18 ). Although certification (such as Certified Diabetes Educator, Board Certified-Advanced Diabetes Management) is not required, ideally the RDN will have comprehensive knowledge and experience in diabetes care and prevention ( 9 , 17 ). Detailed guidance for the RDN to obtain the expert knowledge and experience can be found in the Academy of Nutrition and Dietetics Standards of Practice and Standards of Professional Performance ( 12 ). Health care professionals can use the education algorithm suggested by ADA, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics ( 1 ) that defines and describes the four critical times to assess, provide, and adjust care. The algorithm is intended for use by the RDN and the interprofessional team for determining how and when to deliver diabetes education and nutrition services. The number of encounters the person with diabetes might have with the RDN is described in Table 2 ( 9 ).

Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines–recommended structure for the implementation of MNT for adults with diabetes ( 9 )

In addition to diabetes MNT, DSMES is important for people with diabetes to improve cardiometabolic and microvascular outcomes in a disease that is largely self-managed ( 1 , 19 – 23 ). DSMES includes the ongoing process that facilitates the knowledge, skills, and abilities necessary for diabetes self-care throughout the life span, with nutrition as one of the core curriculum topics taught in comprehensive programs ( 21 ).

Is MNT effective in improving outcomes?

Reported hemoglobin A 1c (A1C) reductions from MNT can be similar to or greater than what would be expected with treatment using currently available medication for type 2 diabetes ( 9 ). Strong evidence supports the effectiveness of MNT interventions provided by RDNs for improving A1C, with absolute decreases up to 2.0% (in type 2 diabetes) and up to 1.9% (in type 1 diabetes) at 3–6 months. Ongoing MNT support is helpful in maintaining glycemic improvements ( 9 ).

Cost-effectiveness of lifestyle interventions and MNT for the prevention and management of diabetes has been documented in multiple studies ( 12 , 17 , 24 , 25 ). The National Academy of Medicine recommends individualized MNT, provided by an RDN upon physician referral, as part of the multidisciplinary approach to diabetes care ( 7 ). Diabetes MNT is a covered Medicare benefit and should also be adequately reimbursed by insurance and other payers, or bundled in evolving value-based care and payment models, because it can result in improved outcomes such as reduced A1C and cost savings ( 12 , 17 , 25 ).

What nutrition therapy interventions best help people with prediabetes prevent or delay the development of type 2 diabetes?

The strongest evidence for type 2 diabetes prevention comes from several studies, including the DPP ( 26 – 28 ). The DPP demonstrated that an intensive lifestyle intervention resulting in weight loss could reduce the incidence of type 2 diabetes for adults with overweight/obesity and impaired glucose tolerance by 58% over 3 years ( 26 ). Follow-up of three large studies of lifestyle intervention for diabetes prevention has shown sustained reduction in the rate of conversion to type 2 diabetes: 43% reduction at 20 years in the Da Qing Diabetes Prevention Study ( 29 ); 43% reduction at 7 years in the Finnish Diabetes Prevention Study (DPS) ( 30 ); and 34% reduction at 10 years ( 28 ) and 27% reduction at 15 years extended follow-up of the DPP ( 31 ) in the U.S. Diabetes Prevention Program Outcomes Study (DPPOS). The follow-up of the Da Qing study also demonstrated a reduction in cardiovascular and all-cause mortality ( 32 ).

Substantial evidence indicates that individuals with prediabetes should be referred to an intensive behavioral lifestyle intervention program modeled on the DPP and/or to individualized MNT typically provided by an RDN with the goals of improving eating habits, increasing moderate-intensity physical activity to at least 150 min per week, and achieving and maintaining 7–10% loss of initial body weight if needed ( 14 , 17 , 33 , 34 ). More intensive intervention programs are the most effective in decreasing diabetes incidence and improving cardiovascular disease (CVD) risk factors ( 35 ).

Both DPP-modeled intensive lifestyle interventions and individualized MNT for prediabetes have demonstrated cost-effectiveness ( 17 , 36 ) and therefore should be covered by third-party payers or bundled in evolving value-based care and payment models ( 25 ).

To make diabetes prevention programs more accessible, digital health tools are an area of increasing interest in the public and private sectors. Preliminary research studies support that the delivery of diabetes prevention lifestyle interventions through technology-enabled platforms and digital health tools can result in weight loss, improved glycemia, and reduced risk for diabetes and CVD, although more rigorous studies are needed ( 37 – 44 ).

MACRONUTRIENTS

• Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.
• When counseling people with diabetes, a key strategy to achieve glycemic targets should include an assessment of current dietary intake followed by individualized guidance on self-monitoring carbohydrate intake to optimize meal timing and food choices and to guide medication and physical activity recommendations.
• People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general public; increasing fiber intake, preferably through food (vegetables, pulses [beans, peas, and lentils], fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering A1C.

Do macronutrient needs differ for people with diabetes compared with the general population?

Although numerous studies have attempted to identify the optimal mix of macronutrients for the eating plans of people with diabetes, a systematic review ( 45 ) found that there is no ideal mix that applies broadly and that macronutrient proportions should be individualized. It has been observed that people with diabetes, on average, eat about the same proportions of macronutrients as the general public: ∼45% of their calories from carbohydrate (see Table 3 ), ∼36–40% of calories from fat, and the remainder (∼16–18%) from protein ( 46 – 48 ). Regardless of the macronutrient mix, total energy intake should be appropriate to attain weight management goals. Further, individualization of the macronutrient composition will depend on the status of the individual, including metabolic goals (glycemia, lipid profile, etc.), physical activity, food preferences, and availability.

Eating patterns reviewed for this report

*Source: RCTs, meta-analyses, observational studies, nonrandomized single-arm studies, cohort studies. USDA, U.S. Department of Agriculture.

Do carbohydrate needs differ for people with diabetes compared with the general population?

Carbohydrate is a readily used source of energy and the primary dietary influence on postprandial blood glucose ( 8 , 49 ). Foods containing carbohydrate—with various proportions of sugars, starches, and fiber—have a wide range of effects on the glycemic response. Some result in an extended rise and slow fall of blood glucose concentrations, while others result in a rapid rise followed by a rapid fall ( 50 ). The quality of carbohydrate foods selected—ideally rich in dietary fiber, vitamins, and minerals and low in added sugars, fats, and sodium— should be addressed as part of an individualized eating plan that includes all components necessary for optimal nutrition ( 4 , 9 ).

The amount of carbohydrate intake required for optimal health in humans is unknown. Although the recommended dietary allowance for carbohydrate for adults without diabetes (19 years and older) is 130 g/day and is determined in part by the brain’s requirement for glucose, this energy requirement can be fulfilled by the body’s metabolic processes, which include glycogenolysis, gluconeogenesis (via metabolism of the glycerol component of fat or gluconeogenic amino acids in protein), and/or ketogenesis in the setting of very low dietary carbohydrate intake ( 49 ).

What are the dietary fiber needs of people with diabetes?

The regular intake of sufficient dietary fiber is associated with lower all-cause mortality in people with diabetes ( 51 , 52 ). Therefore, people with diabetes should consume at least the amount of fiber recommended by the DGA 2015–2020 (minimum of 14 g of fiber per 1,000 kcal) with at least half of grain consumption being whole intact grains ( 8 ). Other sources of dietary fiber include nonstarchy vegetables, avocados, fruits, and berries, as well as pulses such as beans, peas, and lentils.

A few studies have shown modest A1C reduction (−0.2% to −0.3%) ( 53 , 54 ) with intake in excess of 50 g of fiber per day. However, such very high intake of fiber may cause flatulence, bloating, and diarrhea. Meeting the recommended fiber intake through foods that are naturally high in dietary fiber, as compared with supplementation, is encouraged for the additional benefits of coexisting micronutrients and phytochemicals ( 55 ).

Does the use of glycemic index and glycemic load impact glycemia?

The use of the glycemic index (GI) and glycemic load (GL) to rank carbohydrate foods according to their effects on glycemia continues to be of interest for people with diabetes and those at risk for diabetes. As defined by Brand-Miller et al. ( 56 ), “the GI provides a good summary of postprandial glycemia. It predicts the peak (or near peak) response, the maximum glucose fluctuation, and other attributes of the response curve.” Two systematic reviews of the literature regarding GI and GL in individuals with diabetes and at risk for diabetes reported no significant impact on A1C and mixed results on fasting glucose ( 9 , 50 ). Further, studies have used varying definitions of low and high GI foods, leading to uncertainty in the utility of GI and GL in clinical care ( 45 ).

What are the total protein needs of people with diabetes?

There is limited research in people with diabetes or prediabetes without kidney disease on the impact of various amounts of protein consumed. Some comparisons of protein amounts have not demonstrated differences in diabetes-related outcomes ( 57 – 60 ). A 12-week study comparing 30% vs. 15% energy from protein noted improvements in weight, fasting glucose, and insulin requirements in the group that consumed 30% energy from protein ( 61 ). A meta-analysis from 2013 of studies ranging from 4–24 weeks in duration reported that high-protein eating plans (25–32% of total energy vs. 15–20%) resulted in 2 kg greater weight loss and 0.5% greater improvement in A1C but no statistically significant improvements in fasting serum glucose, serum lipid profiles, or blood pressure ( 62 ).

What are the dietary fat and cholesterol goals for people with diabetes?

The National Academy of Medicine has defined an acceptable macronutrient distribution for total fat for all adults to be 20–35% of total calorie intake ( 49 ). Eating patterns that replace certain carbohydrate foods with those higher in total fat, however, have demonstrated greater improvements in glycemia and certain CVD risk factors (serum HDL cholesterol [HDL-C] and triglycerides) compared with lower fat diets. The types or quality of fats in the eating plans may influence CVD outcomes beyond the total amount of fat ( 63 ). Foods containing synthetic sources of trans fats should be minimized to the greatest extent possible ( 8 ). Ruminant trans fats, occurring naturally in meat and dairy products, do not need to be eliminated because they are present in such small quantities ( 64 ).

The body makes enough cholesterol for physiological and structural functions such that people do not need to obtain cholesterol through foods. Although the DGA concluded that available evidence does not support the recommendation to limit dietary cholesterol for the general population, exact recommendations for dietary cholesterol for other populations, such as people with diabetes, are not as clear ( 8 ). Whereas cholesterol intake has correlated with serum cholesterol levels, it has not correlated well with CVD events ( 65 , 66 ). More research is needed regarding the relationship among dietary cholesterol, blood cholesterol, and CVD events in people with diabetes.

What is the role of fat in the prevention of type 2 diabetes?

Large epidemiologic studies have found that consumption of polyunsaturated fat or biomarkers of polyunsaturated fatty acids are associated with lower risk of type 2 diabetes ( 67 ). Supplementation with omega-3 fatty acids in prediabetes has demonstrated some efficacy in surrogate outcomes beyond serum triglyceride levels. In a single-blinded RCT design in Asia, 107 subjects with newly diagnosed impaired glucose metabolism and coronary heart disease (CHD) supplemented with 1,800 mg/day of eicosapentaenoic acid (EPA) experienced improved postprandial triglycerides, glycemia, insulin secretion ability, and endothelial function over a 6-month period ( 68 ). Further, in a recent multisite RCT that included 57% of participants with diabetes, age 50 years or older, and with at least one additional CVD risk factor, plus elevated fasting triglycerides and low HDL-C, benefits were seen from adding 2 g of icosapent ethyl twice daily to statin therapy in terms of lower rates of a composite CVD outcome and CVD mortality, but there were also slightly higher rates of hospitalization for atrial fibrillation and serious bleeding ( 68a ).

The intervention in the PREvención con DIeta MEDiterránea (PREDIMED) study, comparing a Mediterranean-style eating pattern supplemented either with extra-virgin olive oil or with nuts versus a control diet, reduced incidence of type 2 diabetes among people without diabetes at high cardiovascular risk at baseline ( 69 ). The Malmö Diet and Cancer cohort study examined specific food sources of saturated fat and found that intake of saturated fat from dairy products, coconut oil, and palm kernel oil were associated with lower diabetes risk ( 70 ), whereas saturated fat intake was associated with higher risk of diabetes in the PREDIMED study ( 71 ). Other meta-analyses of observational studies have not shown an inverse relationship with full-fat dairy intake and diabetes risk ( 72 , 73 ). The inconsistent results in the above studies may be due to variations in food sources of fat ( 70 ) or the fact that some analyses have relied on self-reported dietary information, which can be limited by inaccuracy.

For more information on fat intake and CVD risk, see the section role of nutrition therapy in the prevention and management of diabetes complications (cvd, diabetic kidney disease, and gastroparesis).

EATING PATTERNS

• A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes.
• ○ Emphasize nonstarchy vegetables.
• ○ Minimize added sugars and refined grains.
• ○ Choose whole foods over highly processed foods to the extent possible.
• 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.
• For select adults with type 2 diabetes not meeting glycemic targets or where reducing antiglycemic medications is a priority, reducing overall carbohydrate intake with low- or very low-carbohydrate eating plans is a viable approach.

An eating pattern represents the totality of all foods and beverages consumed ( 8 ) ( Table 3 ). An eating plan is a guide to help individuals plan when, what, and how much to eat on a daily basis and applies to the foods emphasized in the individual’s selected eating pattern.

This section emphasizes evidence from randomized trials of eating patterns in people with type 1 diabetes, type 2 diabetes, and prediabetes and was limited to those trials with at least 10 people in each dietary group and a retention rate of >50%. Overall, few long-term (2 years or longer) randomized trials have been conducted of any of the dietary patterns in any of the conditions examined.

What is the evidence for specific eating patterns to manage prediabetes and prevent type 2 diabetes?

The most robust research available related to eating patterns for prediabetes or type 2 diabetes prevention are Mediterranean-style, low-fat, or low-carbohydrate eating plans ( 26 , 69 , 74 , 75 ). The PREDIMED trial, a large RCT, compared a Mediterranean-style to a low-fat eating pattern for prevention of type 2 diabetes onset, with the Mediterranean-style eating pattern resulting in a 30% lower relative risk ( 69 ). Epidemiologic studies correlate Mediterranean-style ( 76 ), vegetarian ( 77 – 80 ), and Dietary Approaches to Stop Hypertension (DASH) ( 76 , 81 ) eating patterns with a lower risk of developing type 2 diabetes, with no effect for low-carbohydrate eating patterns ( 82 ).

Several large type 2 diabetes prevention RCTs ( 26 , 74 , 83 , 84 ) used low-fat eating plans to achieve weight loss and improve glucose tolerance, and some demonstrated decreased incidence of diabetes ( 26 , 74 , 83 ). Given the limited evidence, it is unclear which of the eating patterns are optimal.

What is the evidence for specific eating patterns to manage type 2 diabetes?

Mediterranean-style eating pattern.

The Mediterranean-style pattern has demonstrated a mixed effect on A1C, weight, and lipids in a number of RCTs ( 85 – 90 ). In the Dietary Intervention Randomized Controlled Trial (DIRECT), obese adults with type 2 diabetes were randomized to a calorie-restricted Mediterranean-style, a calorie-restricted lower-fat, or a low-carbohydrate eating pattern (28% of calories from carbohydrate) without emphasis on calorie restriction. A1C was lowest in the low-carbohydrate group after 2 years, whereas fasting plasma glucose was lower in the Mediterranean-style group than in the lower-fat group ( 90 ).

One of the largest and longest RCTs, the PREDIMED trial, compared a Mediterranean-style eating pattern with a low-fat eating pattern. After 4 years, glycemic management improved and the need for glucose-lowering medications was lower in the Mediterranean eating pattern group ( 89 ). In addition, the PREDIMED trial showed that a Mediterranean-style eating pattern intervention enriched with olive oil or nuts significantly reduced CVD incidence in both people with and without diabetes ( 91 ).

Vegetarian or Vegan Eating Patterns

Studies of vegetarian or vegan eating plans ranged in duration from 12 to 74 weeks and showed mixed results on glycemia and CVD risk factors. These eating plans often resulted in weight loss ( 92 – 97 ). Two meta-analyses of controlled trials ( 98 , 99 ) concluded that vegetarian and vegan eating plans can reduce A1C by an average of 0.3–0.4% in people with type 2 diabetes, and the larger meta-analysis ( 99 ) also reported that plant-based eating patterns reduced weight (weight reduction of 2 kg), waist circumference, LDL cholesterol (LDL-C), and non–HDL-C with no significant effect on fasting insulin, HDL-C, triglycerides, and blood pressure.

Low-Fat Eating Pattern

In the Look AHEAD (Action for Health in Diabetes) trial ( 100 ), individuals following a calorie-restricted low-fat eating pattern, in the context of a structured weight loss program using meal replacements, achieved moderate success compared with the control condition eating plan ( 101 ). However, lowering total fat intake did not consistently improve glycemia or CVD risk factors in people with type 2 diabetes based on a systematic review ( 45 ), several studies ( 102 – 105 ), and a meta-analysis ( 106 ). Benefit from a low-fat eating pattern appears to be mostly related to weight loss as opposed to the eating pattern itself ( 100 , 101 ). Additionally, low-fat eating patterns have commonly been used as the “control” intervention compared with other eating patterns.

Very Low-Fat: Ornish or Pritikin Eating Patterns

The Ornish and Pritikin lifestyle programs are two of the best known multicomponent very low-fat eating patterns. The Ornish program emphasizes a very low-fat, whole-foods, plant-based eating plan (about 70% of calories from carbohydrate, 10% from fat, 20% from protein, and 60 g of fiber), predominantly from vegetables, beans, fruits, grains, nonfat dairy, and egg whites. The Pritikin intervention advises that people consume 77% of calories from carbohydrate, about 10% from fat, 13% from protein, and 30–40 g of fiber per 1,000 calories, with no calorie restriction during a 26-day stay in an in-patient treatment center. Three nonrandomized single-arm studies with 69 to 652 participants lasting between 3 weeks and 2–3 years show that these multicomponent lifestyle intervention programs may improve glucose levels, weight, blood pressure, and HDL-C, with a mixed effect on triglycerides ( 107 – 109 ).

Low-Carbohydrate or Very Low-Carbohydrate Eating Patterns

Low-carbohydrate eating patterns, especially very low-carbohydrate (VLC) eating patterns, have been shown to reduce A1C and the need for antihyperglycemic medications. These eating patterns are among the most studied eating patterns for type 2 diabetes. One meta-analysis of RCTs that compared low-carbohydrate eating patterns (defined as ≤45% of calories from carbohydrate) to high-carbohydrate eating patterns (defined as >45% of calories from carbohydrate) found that A1C benefits were more pronounced in the VLC interventions (where <26% of calories came from carbohydrate) at 3 and 6 months but not at 12 and 24 months ( 110 ).

Another meta-analysis of RCTs compared a low-carbohydrate eating pattern (defined as <40% of calories from carbohydrate) to a low-fat eating pattern (defined as <30% of calories from fat). In trials up to 6 months long, the low-carbohydrate eating pattern improved A1C more, and in trials of varying lengths, lowered triglycerides, raised HDL-C, lowered blood pressure, and resulted in greater reductions in diabetes medication ( 111 ). Finally, in another meta-analysis comparing low-carbohydrate to high-carbohydrate eating patterns, the larger the carbohydrate restriction, the greater the reduction in A1C, though A1C was similar at durations of 1 year and longer for both eating patterns ( 112 ). Table 4 provides a quick reference conversion of percentage of calories from carbohydrate to grams of carbohydrate based on number of calories consumed per day.

Quick reference conversion of percent calories from carbohydrate shown in grams per day as reported in the research reviewed for this report

Because of theoretical concerns regarding use of VLC eating plans in people with chronic kidney disease, disordered eating patterns, and women who are pregnant, further research is needed before recommendations can be made for these subgroups. Adopting a VLC eating plan can cause diuresis and swiftly reduce blood glucose; therefore, consultation with a knowledgeable practitioner at the onset is necessary to prevent dehydration and reduce insulin and hypoglycemic medications to prevent hypoglycemia.

No randomized trials were found in people with type 2 diabetes that varied the saturated fat content of the low- or very low-carbohydrate eating patterns to examine effects on glycemia, CVD risk factors, or clinical events. Most of the trials using a carbohydrate-restricted eating pattern did not restrict saturated fat; from the current evidence, this eating pattern does not appear to increase overall cardiovascular risk, but long-term studies with clinical event outcomes are needed ( 113 – 117 ).

DASH Eating Pattern

One small, 8-week study comparing the DASH eating pattern with a control group in people with type 2 diabetes indicated improved A1C, blood pressure, and cholesterol levels and weight loss with the DASH eating pattern, with no difference in triglycerides ( 118 ). Another RCT compared the DASH eating pattern incorporating increased physical activity with a standard eating pattern without increased physical activity and found blood pressure was lower in the DASH and physical activity group, but A1C, weight, and lipids did not differ ( 119 ).

Paleo Eating Pattern

Research studies focused on a paleo eating pattern in adults with type 2 diabetes are small and few, ranging from 13–29 participants, lasting no longer than 3 months, and finding mixed effects on A1C, weight, and lipids ( 120 – 122 ).

Intermittent Fasting

While intermittent fasting is not an eating pattern by definition, it has been included in this discussion because of increased interest from the diabetes community. Fasting means to go without food, drink, or both for a period of time. People fast for reasons ranging from weight management to upcoming medical visits to religious and spiritual practice. Intermittent fasting is a way of eating that focuses more on when you eat (i.e., consuming all daily calories in set hours during the day) than what you eat. While it usually involves set times for eating and set times for fasting, people can approach intermittent fasting in many different ways.

Published intermittent fasting studies involving diabetes and diabetes prevention demonstrate a variety of approaches, including restricting food intake for 18 to 20 h per day, alternate-day fasting, and severe calorie restriction for up to 8 consecutive days or longer ( 123 ). Four fasting studies of participants with type 2 diabetes were small (≤63 participants) and of short duration (≤20 weeks). Three of the studies ( 124 – 126 ) demonstrated that intermittent fasting, either in consecutive days of restriction or by fasting 16 h per day or more, may result in weight loss; however, there was no improvement in A1C compared with a nonfasting eating plan. One of the studies ( 127 ) showed similar reductions in A1C, weight, and medication doses when 2 days of severe energy restriction were compared with chronic energy restriction. Another study looked at men with prediabetes and timing of food intake over a 24-h period, with the intervention group restricted to a 6-h schedule of eating (with final meal before 3 p.m. ) compared with a control schedule where eating occurred over a 12-h period; improved insulin sensitivity, β-cell responsiveness, blood pressure, oxidative stress, and appetite were shown in the intervention group ( 128 ). The safety of intermittent fasting in people with special health situations, including pregnancy and disordered eating, has not been studied.

What is the evidence to support specific eating patterns in the management of type 1 diabetes?

For adults with type 1 diabetes, no trials met the inclusion criteria for this Consensus Report related to Mediterranean-style, vegetarian or vegan, low-fat, low-carbohydrate, DASH, paleo, Ornish, or Pritikin eating patterns. We found limited evidence about the safety and/or effects of fasting on type 1 diabetes ( 129 ).

A few studies have examined the impact of a VLC eating pattern for adults with type 1 diabetes. One randomized crossover trial with 10 participants examined a VLC eating pattern aiming for 47 g carbohydrate per day without a focus on calorie restriction compared with a higher carbohydrate eating pattern aiming for 225 g carbohydrate per day for 1 week each. Participants following the VLC eating pattern had less glycemic variability, spent more time in euglycemia and less time in hypoglycemia, and required less insulin ( 130 ). A single-arm 48-person trial of a VLC eating pattern aimed at a goal of 75 g of carbohydrate or less per day found that weight, A1C, and triglycerides were reduced and HDL-C increased after 3 months, and after 4 years A1C was still lower and HDL-C was still higher than at baseline ( 131 ). This evidence suggests that a VLC eating pattern may have potential benefits for adults with type 1 diabetes, but clinical trials of sufficient size and duration are needed to confirm prior findings.

Does the current evidence support specific eating patterns for the management of diabetes?

Until the evidence surrounding comparative benefits of different eating patterns in specific individuals strengthens, health care providers should focus on the key factors that are common among the patterns: 1 ) emphasize nonstarchy vegetables, 2 ) minimize added sugars and refined grains, and 3 ) choose whole foods over highly processed foods to the extent possible ( 132 ).

Multiple trials and meta-analyses have been published addressing the comparative effects of specific eating patterns for diabetes. Whereas no single eating pattern has emerged as being clearly superior to all others for all diabetes-related outcomes, evidence suggests certain eating patterns are better for specific outcomes. All eating patterns include a range of more-healthy versus less-healthy options: lentils and sugar-sweetened beverages are both considered part of a vegan eating pattern; fish and processed red meats are both considered part of a low-carbohydrate eating pattern; and removing the bun from a fast food burger might make it part of a paleo eating pattern but does not necessarily make it healthier. Further, studies comparing the same two or more eating patterns could easily differ in the investigators’ definition of the patterns, the effectiveness of the research team in fostering pattern adherence among study participants, the accuracy of assessing pattern adherence, study duration, and participant population characteristics.

ENERGY BALANCE AND WEIGHT MANAGEMENT

• To support weight loss and improve A1C, CVD risk factors, and quality of life in adults with overweight/obesity and prediabetes or diabetes, MNT and DSMES services should include an individualized eating plan in a format that results in an energy deficit in combination with enhanced physical activity.
• For adults with type 2 diabetes who are not taking insulin and who have limited health literacy or numeracy, or who are older and prone to hypoglycemia, a simple and effective approach to glycemia and weight management emphasizing appropriate portion sizes and healthy eating may be considered.
• In type 2 diabetes, 5% weight loss is recommended to achieve clinical benefit, and the benefits are progressive. The goal for optimal outcomes is 15% or more when needed and can be feasibly and safely accomplished. In prediabetes, the goal is 7–10% for preventing progression to type 2 diabetes.
• In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunction with weight loss medications and/or metabolic surgery should be considered to help achieve weight loss and maintenance goals, lower A1C, and reduce CVD risk.
• In conjunction with lifestyle therapy, medication-assisted weight loss can be considered for people at risk for type 2 diabetes when needed to achieve and sustain 7–10% weight loss.
• People with prediabetes at a healthy weight should be considered for lifestyle intervention involving both aerobic and resistance exercise and a healthy eating plan such as a Mediterranean-style eating plan.
• People with diabetes and prediabetes should be screened and evaluated during DSMES and MNT encounters for disordered eating, and nutrition therapy should accommodate these disorders.

What is the role of weight loss therapy in people with prediabetes or diabetes with overweight or obesity?

There is substantial evidence indicating that weight loss is highly effective in preventing progression from prediabetes to type 2 diabetes and in managing cardiometabolic health in type 2 diabetes. Overweight and obesity are also increasingly prevalent in people with type 1 diabetes and present clinical challenges regarding diabetes treatment and CVD risk factors ( 133 , 134 ). Therefore, MNT and DSMES that include an overall healthy eating plan in a format that results in an energy deficit, as well as a collaborative effort to achieve weight loss in people with type 1 diabetes, type 2 diabetes, or prediabetes and overweight/obesity, are recommended.

Eating plans that create an energy deficit and are customized to fit the person’s preferences and resources can help with long-term sustainment and are the cornerstone of weight loss therapy. Regular physical activity, which can contribute to both weight loss and prevention of weight regain, and behavioral strategies are also important components of lifestyle therapy for weight management ( 26 , 74 , 83 , 135 – 137 ). Structured weight loss programs with regular visits and use of meal replacements have been shown to enhance weight loss in people with diabetes ( 138 – 140 ).

The combined data do not point to a threshold of weight loss for maximal clinical benefits in people with diabetes; rather, the greater the weight loss, the greater the benefits. Previous recommendations of weight loss of 5% or ≥7% for people with overweight or obesity are based on the threshold needed for therapeutic advantages; however, weight loss targeted at ≥15%, when such can feasibly and safely be accomplished, is associated with even better outcomes in type 2 diabetes ( 138 , 141 ).

The UK Prospective Diabetes Study (UKPDS) demonstrated that decreases in fasting glucose were correlated with degree of weight loss ( 142 ). A meta-analysis conducted by Franz et al. ( 137 ) found that lifestyle interventions producing <5% weight loss had less effect on A1C, lipids, or blood pressure compared with studies achieving weight loss of ≥5%. Other meta-analyses focusing on nonmedicine or medicine-assisted weight loss interventions in type 2 diabetes support this finding ( 143 – 145 ). More recently, the Look AHEAD trial ( 139 , 141 ) compared standard DSMES to a more intensive lifestyle intervention and reduced-calorie eating plan. The intensive lifestyle intervention resulted in 8.6% weight loss at 1 year, and the downstream therapeutic benefits were far-ranging even though benefits were not seen for the primary cardiovascular outcomes ( 100 ).

A systematic review of the effectiveness of MNT revealed mixed weight loss outcomes in participants with type 1 and 2 diabetes ( 9 ). Similarly, while DSMES is a fundamental component of diabetes care ( 1 ), it does not consistently produce sufficient weight loss to achieve optimal therapeutic benefits in people with diabetes ( 136 , 146 , 147 ). For these reasons, diabetes MNT and DSMES should emphasize a targeted and concerted plan for weight management.

The addition of metabolic surgery ( 148 ), weight loss medications ( 149 ), and glucose-lowering agents that promote weight loss ( 150 ) can also be used as an adjunct to lifestyle interventions, resulting in greater weight loss that is maintained for a longer period of time. The data also support the position that weight loss therapy is effective at all phases of type 2 diabetes, both in individuals with recent-onset disease ( 1 , 149 ) and in people with longer durations of diabetes treated with multiple diabetes medications ( 136 , 149 ).

In the DPP, maximal prevention of diabetes over 4 years was observed at about 7–10% weight loss ( 151 ). This is consistent with the study using phentermine/topiramate ER, where weight loss of 10% reduced incident diabetes by 79% over 2 years and any further weight loss to ≥15% did not lead to additional prevention ( 152 ). For this reason, nutrition therapy to support a 7–10% weight loss is the appropriate goal in treating people with prediabetes, unless additional weight loss is desired for other purposes. Nutrition therapy can be a component of a lifestyle intervention program or used in conjunction with antiobesity medications and/or metabolic surgery ( 153 , 154 ) in people with prediabetes.

Regular physical activity by itself ( 155 , 156 ) or as part of a comprehensive lifestyle plan ( 26 , 74 , 83 , 151 ) can prevent progression to type 2 diabetes in high-risk individuals. Studies have demonstrated beneficial effects of both aerobic and resistance exercise and additive benefits when both forms of exercise are combined ( 157 – 159 ).

What is the best weight loss plan for individuals with diabetes?

For purposes of weight loss, the ability to sustain and maintain an eating plan that results in an energy deficit, irrespective of macronutrient composition or eating pattern, is critical for success ( 160 – 163 ). Studies investigating specific weight loss eating plans using a broad range of macronutrient composition in people with diabetes have shown mixed results regarding effects on weight, A1C, serum lipids, and blood pressure ( 102 , 103 , 106 , 164 – 171 ). As a result, the evidence does not identify one eating plan that is clearly superior to others and that can be generally recommended for weight loss for people with diabetes ( 172 ). Thus, an individualized plan for diabetes nutrition therapy is warranted, taking into account dietary preferences together with the individual’s health literacy, resources, food availability, meal preparation skills, and physical activity to maximize the ability to attain and maintain the eating plan ( 173 , 174 ). Individualized eating plans should support calorie reduction (e.g., employing use of appropriate portion sizes, meal replacements, and/or behavioral interventions) in the context of a lifestyle program, with appropriate modifications in the medication plan to minimize associated adverse effects such as weight gain, hypoglycemia, and hypotension.

Weight loss interventions can be implemented in usual care settings and alternately in telehealth programs ( 175 , 176 ). In general, the intervention intensity and degree of individual participation in the program are important factors for successful weight loss ( 161 – 163 , 175 ).

What is the role of weight loss on potential for type 2 diabetes remission?

The Look AHEAD trial ( 177 ) and the Diabetes Remission Clinical Trial (DiRECT) ( 138 ) highlight the potential for type 2 diabetes remission—defined as the maintenance of euglycemia (complete remission) or prediabetes level of glycemia (partial remission) with no diabetes medication for at least 1 year ( 177 , 178 )—in people undergoing weight loss treatment. In the Look AHEAD trial, when compared with the control group, the intensive lifestyle arm resulted in at least partial diabetes remission in 11.5% of participants as compared with 2% in the control group ( 177 ). The DiRECT trial showed that at 1 year, weight loss associated with the lifestyle intervention resulted in diabetes remission in 46% of participants ( 138 ). Remission rates were related to magnitude of weight loss, rising progressively from 7% to 86% as weight loss at 1 year increased from <5% to ≥15% ( 138 ). Diet composition may also play a role; in an RCT by Esposito et al. ( 179 ), despite only a 2-kg difference in weight loss, the group following a low-carbohydrate Mediterranean-style eating pattern (see Table 3 ) experienced greater rates of at least partial diabetes remission, with rates of 14.7% at year 1 and 5% at year 6 compared with 4.7% and 0%, respectively, in the group following a low-fat eating plan.

What is the role of eating plans that result in energy deficits and weight loss in type 1 diabetes?

Obesity prevalence among people with type 1 diabetes has been significantly increasing ( 180 – 182 ). Currently, over 50% of people with type 1 diabetes have overweight or obesity ( 180 – 182 ). A recent study suggested obesity may promote progression to overt type 1 diabetes in at-risk individuals ( 183 ), but further confirmatory studies are needed. In addition, in people with established type 1 diabetes, presence of obesity can worsen insulin resistance, glycemic variability, microvascular disease complications, and cardiovascular risk factors ( 184 – 188 ). Therefore, weight management has been recommended as an essential component of care for people with type 1 diabetes who have overweight or obesity ( 189 – 192 ).

There is a scarcity of evidence from RCTs evaluating weight loss interventions in type 1 diabetes. A retrospective nested-control study indicated that lifestyle-induced weight loss improved glycemia with a reduction in insulin doses compared with controls ( 193 ). Individuals with type 1 diabetes and obesity may benefit from eating plans that result in an energy deficit and that are lower in total carbohydrate and GI and higher in fiber and lean protein ( 194 ). Currently, adjunctive pharmacotherapy is not indicated for individuals with type 1 diabetes. However, there is preliminary evidence that in select individuals with type 1 diabetes and excess adiposity, newer pharmacotherapy (i.e., glucagon-like peptide 1 receptor agonists or sodium–glucose cotransporter 2 inhibitors) ( 195 , 196 ) can decrease body weight and improve glycemia, though they are currently not indicated. In addition, metabolic surgery in appropriate candidates can decrease body weight and improve glycemia ( 197 , 198 ).

How does disordered eating factor into weight management?

When counseling individuals with diabetes and prediabetes about weight management, special attention also must be given to prevent, diagnose, and treat disordered eating. Disordered eating can make following an eating plan challenging ( 199 ). The prevalence of disordered eating varies, affecting 18% to 40% of people with diabetes ( 199 – 205 ). Health care professionals should consider screening for disordered eating, refer to a mental health professional, and individualize nutrition therapy accordingly ( 206 ).

• Replace sugar-sweetened beverages (SSBs) with water as often as possible.
• When sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources.

Does the consumption of SSBs impact risk of diabetes?

SSB consumption in the general population contributes to a significantly increased risk of type 2 diabetes, weight gain, heart disease, kidney disease, nonalcoholic liver disease, and tooth decay ( 207 ). For example, a meta-analysis reported that consumption of at least one serving of SSB per day increased risk of type 2 diabetes in adults with prediabetes by 26% ( 208 ). In a separate meta-analysis, consumption of regular soda increased type 2 diabetes risk by 13%, while consumption of diet soda increased type 2 diabetes risk by 8% ( 209 ). Conversely, the replacement of SSBs with an equal amount of water reduced the risk of type 2 diabetes by 7–8% ( 210 ).

What is the impact of sugar substitutes?

The U.S. Food and Drug Administration (FDA) has reviewed several types of sugar substitutes for safety and approved them for consumption by the general public, including people with diabetes ( 211 ). In this report, the term sugar substitutes refers to high-intensity sweeteners, artificial sweeteners, nonnutritive sweeteners, and low-calorie sweeteners. These include saccharin, neotame, acesulfame-K, aspartame, sucralose, advantame, stevia, and luo han guo (or monk fruit). Replacing added sugars with sugar substitutes could decrease daily intake of carbohydrates and calories. These dietary changes could beneficially affect glycemic, weight, and cardiometabolic control. However, an American Heart Association science advisory on the consumption of beverages containing sugar substitutes that was supported by the ADA concluded there is not enough evidence to determine whether sugar substitute use definitively leads to long-term reduction in body weight or cardiometabolic risk factors, including glycemia ( 212 ). Using sugar substitutes does not make an unhealthy choice healthy; rather, it makes such a choice less unhealthy. If sugar substitutes are used to replace caloric sweeteners, without caloric compensation, they may be useful in reducing caloric and carbohydrate intake ( 213 ), although further research is needed to confirm these concepts ( 214 ). Multiple mechanisms have been proposed for potential adverse effects of sugar substitutes, e.g., adversely altering feelings of hunger and fullness, substituting for healthier foods, or reducing awareness of calorie intake ( 215 ). As people aim to reduce their intake of SSBs, the use of other alternatives, with a focus on water, is encouraged ( 212 ).

Sugar alcohols represent a separate category of sweeteners. Like sugar substitutes, sugar alcohols have been approved by the FDA for consumption by the general public and people with diabetes. Whereas sugar alcohols have fewer calories per gram than sugars, they are not as sweet. Therefore, a higher amount is required to match the degree of sweetness of sugars, generally bringing the calorie content to a level similar to that of sugars ( 216 ). Use of sugar alcohols needs to be balanced with their potential to cause gastrointestinal effects in sensitive individuals. Currently, there is little research on the potential benefits of sugar alcohols for people with diabetes ( 217 ).

ALCOHOL CONSUMPTION

• It is recommended that adults with diabetes or prediabetes who drink alcohol do so in moderation (one drink or less per day for adult women and two drinks or less per day for adult men).
• 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 alcohol beverages to reduce hypoglycemia risk should be emphasized.

What are the effects of alcohol consumption on diabetes-related outcomes?

It is important that health care providers counsel people with diabetes about alcohol consumption and encourage moderate and sensible use for people choosing to consume alcohol. Moderate alcohol consumption has minimal acute and/or long-term detrimental effects on glycemia in people with type 1 or type 2 diabetes ( 218 – 221 ), with some epidemiologic data showing improved glycemia and improved insulin sensitivity with moderate intake. One alcohol-containing beverage is defined as 12-oz beer, 5-oz wine, or 1.5-oz distilled spirits, each containing approximately 15 g of alcohol ( 8 ). Excessive amounts of alcohol (>3 drinks per day or 21 drinks per week for men and >2 drinks per day or 14 drinks per week for women) consumed on a consistent basis may contribute to hyperglycemia ( 222 ). Starting with one drink per day, risk for reduced adherence to self-care and healthy lifestyle behaviors has been reported with increasing alcohol consumption ( 223 ).

What are the effects of alcohol consumption on hypoglycemia risk in people with diabetes?

Despite the potential glycemic and cardiovascular benefits of moderate alcohol consumption, alcohol intake may place people with diabetes at increased risk for delayed hypoglycemia ( 221 , 224 – 226 ). This effect may be a result of inhibition of gluconeogenesis, reduced hypoglycemia awareness due to the cerebral effects of alcohol, and/or impaired counterregulatory responses to hypoglycemia ( 227 ). This is particularly relevant for those using insulin or insulin secretagogues who can experience delayed nocturnal or fasting hypoglycemia after evening alcohol consumption. Consuming alcohol with food can minimize the risk of nocturnal hypoglycemia ( 227 , 228 ). It is essential that people with diabetes receive education regarding the recognition and management of delayed hypoglycemia and the potential need for more frequent glucose monitoring after consuming alcohol ( 227 , 229 ).

How does alcohol consumption impact risk of developing type 2 diabetes?

Comprehensive reviews and meta-analyses suggest a protective effect of moderate alcohol intake on the risk of developing type 2 diabetes, with a higher rate of diabetes in alcohol abstainers and heavy consumers ( 222 , 230 – 232 ). Moderate alcohol intake ranging from 6–48 g/day (0.5–3.4 drinks) was associated with a 30–56% lower incidence of type 2 diabetes ( 9 , 222 , 230 – 232 ). Knott et al. ( 232 ) reported reduced risk of type 2 diabetes at all levels of alcohol intake <63 g per day with peak reduction at a daily alcohol intake of 10–14 g (approximately 1 drink) per day in women and non-Asian populations.

A meta-analysis and systematic review ( 233 ) that examined the effects of specific types of alcohol beverage consumption and the incidence of type 2 diabetes found that wine consumption was associated with significantly lower diabetes risk, as compared with a smaller reduction in risk with beer and spirits. A U-shaped relationship between alcohol dose and diabetes risk was found among all three types of alcohol, with lowest diabetes risk at 20–30 g of alcohol per day from wine and beer and 7–15 g of alcohol per day from spirits; the decrease in diabetes incidence was 20% for wine, 9% for beer, and 5% for spirits.

While epidemiologic evidence shows a correlation between alcohol consumption and risk of diabetes, the evidence does not suggest that providers should advise abstainers to start consuming alcohol. Ultimately, alcohol consumption is an individual’s choice, but additional factors such as history of alcohol use, religion, genetic factors, and mental health, as well as medication interactions, should be considered when counseling on alcohol use.

MICRONUTRIENTS, HERBAL SUPPLEMENTS, AND RISK OF MEDICATION-ASSOCIATED DEFICIENCY

• Without underlying deficiency, the benefits of multivitamins or mineral supplements on glycemia for people with diabetes or prediabetes have not been supported by evidence, and therefore routine use is not recommended.
• It is recommended that MNT for people taking metformin include an annual assessment of vitamin B12 status with guidance on supplementation options if deficiency is present.
• The routine use of chromium or vitamin D micronutrient supplements or any herbal supplements, including cinnamon, curcumin, or aloe vera, for improving glycemia in people with diabetes is not supported by evidence and is therefore not recommended.

What is the effectiveness of micronutrients on diabetes-related outcomes?

Scientific evidence does not support the use of dietary supplements in the form of vitamins or minerals to meet glycemic targets or improve CVD risk factors in people with diabetes or prediabetes, in the absence of an underlying deficiency ( 234 – 236 ). People with diabetes not achieving glucose targets may have an increased risk of micronutrient deficiencies ( 237 ), so maintaining a balanced intake of food sources that provide at least the recommended daily allowance for nutrients and micronutrients is essential ( 234 ). For special populations, including women planning pregnancy, people with celiac disease, older adults, vegetarians, and people following an eating plan that restricts overall calories or one or more macronutrients, a multivitamin supplement may be justified ( 238 ).

A systematic review on the effect of chromium supplementation on glucose and lipid metabolism concluded that evidence is limited by poor study quality and heterogeneity in methodology and results ( 239 , 240 ). Evidence from clinical studies that evaluated magnesium ( 241 , 242 ) and vitamin D ( 243 – 253 ) supplementation to improve glycemia in people with diabetes is likewise conflicting. However, evidence is emerging that suggests that magnesium status may be related to diabetes risk in people with prediabetes ( 254 ).

What is the role of herbal supplementation in the management of diabetes?

It is important to consider that nutritional supplements and herbal products are not standardized or regulated ( 255 , 256 ). Health care providers should ask about the use of supplements and herbal products, and providers and people with or at risk for diabetes should discuss the potential benefit of these products weighed against the cost and possible adverse effects and drug interactions. The variability of herbal and micronutrient supplements makes research in this area challenging and makes it difficult to conclude effectiveness. To date, there is limited evidence supporting the addition of herbal supplements to manage glycemia. Because of public interest and the lack of conclusive data, the National Center for Complementary and Integrative Health at the National Institutes of Health aims to answer important public health and scientific questions by funding and conducting research on complementary medicine.

Does the use of metformin affect vitamin B12 status?

Metformin is associated with vitamin B12 deficiency, with a recent systematic review recommending that annual blood testing of vitamin B12 levels be considered in metformin-treated people, especially in those with anemia or peripheral neuropathy ( 257 ). This study found that even in the absence of anemia, B12 deficiency was prevalent. The exact cause of B12 deficiency in people taking metformin is not known, but some research points to malabsorption caused by metformin, with other studies suggesting improvements in B12 status with calcium supplementation ( 258 – 261 ). The standard of treatment has been B12 injections, but new research suggest that high-dose oral supplementation may be as effective ( 258 , 259 ). More research is needed in this area.

MNT and Antihyperglycemic Medications (Including Insulin)

• All RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan.
• For individuals with type 1 diabetes, intensive insulin therapy using the carbohydrate counting approach can result in improved glycemia and is recommended.
• For adults using fixed daily insulin doses, consistent 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.
• When consuming a mixed meal that contains carbohydrate and is high in fat and/or protein, insulin dosing should not be based solely on carbohydrate counting. A cautious approach to increasing mealtime insulin doses is suggested; continuous glucose monitoring (CGM) or self-monitoring of blood glucose (SMBG) should guide decision-making for administration of additional insulin.

What is the role of the RDN in medication adjustment?

RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan. Along with other diabetes care providers, RDNs who possess advanced practice training and clinical expertise should take an active role in facilitating and maintaining organization-approved diabetes medication protocols. Use of organization-approved protocols for insulin and other glucose-lowering medications can help reduce therapeutic inertia and/or reduce the risk of hypoglycemia and hyperglycemia ( 12 , 16 – 18 , 262 , 263 ).

How should nutrition therapy vary based on type and intensity of insulin plan?

For people with type 1 diabetes using basal-bolus insulin therapy, a primary focus for MNT should include guidance on adjusting insulin based on anticipated dietary intake, particularly carbohydrate intake ( 9 , 264 – 270 ); recent or expected physical activity; and glucose data. Intensive insulin management education programs that include nutrition therapy have been shown to improve A1C ( 9 , 264 , 268 , 271 – 273 ) and quality of life ( 9 , 274 ). For people using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be consistent with respect to time and amount per meal ( 9 , 275 , 276 ).

Results from recent high-fat and/or high-protein mixed meal studies continue to support previous findings that glucose response to mixed meals high in protein and/or fat along with carbohydrate differ among individuals; therefore, a cautious approach to increasing insulin doses for high-fat and/or high-protein mixed meals is recommended to address delayed hyperglycemia that may occur 3 h or more after eating ( 277 – 290 ). If using an insulin pump, a split bolus feature (part of the bolus delivered immediately, the remainder over a programmed duration of time) may provide better insulin coverage for high-fat and/or high-protein mixed meals ( 278 , 281 ). Checking glucose 3 h after eating may help to determine if additional insulin adjustments (i.e., increasing or stopping bolus) are required ( 278 , 290 ). Because these insulin dosing algorithms require determination of anticipated nutrient intake to calculate the mealtime dose, health literacy and numeracy should be evaluated. The effectiveness of insulin dosing decisions should be confirmed with a structured approach to SMBG or CGM to evaluate individual responses and guide insulin dose adjustments.

ROLE OF NUTRITION THERAPY IN THE PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS (CVD, DIABETIC KIDNEY DISEASE, AND GASTROPARESIS)

• In general, replacing saturated fat with unsaturated fats reduces both total cholesterol and LDL-C and also benefits CVD risk.
• In type 2 diabetes, counseling people on eating patterns that replace foods high in carbohydrate with foods lower in carbohydrate and higher in fat may improve glycemia, triglycerides, and HDL-C; emphasizing foods higher in unsaturated fat instead of saturated fat may additionally improve LDL-C.
• People with diabetes and prediabetes are encouraged to consume less than 2,300 mg/day of sodium, the same amount that is recommended for the general population.
• The recommendation for the general public to eat a serving of fish (particularly fatty fish) at least two times per week is also appropriate for people with diabetes.

Does comprehensive diabetes nutrition therapy support cardiovascular risk factor reduction?

Nutrition therapy that includes the development of an eating plan designed to optimize blood glucose trends, blood pressure, and lipid profiles is important in the management of diabetes and can lower the risk of CVD, CHD, and stroke ( 9 ). Findings from clinical trials support the role of nutrition therapy for achieving glycemic targets and decreasing various markers of cardiovascular and hypertension risk ( 9 , 24 , 291 – 293 ).

What are considerations for fat intake for people who are at risk for or have CVD and diabetes?

There has been increasing research examining the effects of high-fat, low-carbohydrate eating patterns on cardiometabolic risk factors, with two systematic reviews showing benefits of low-carbohydrate eating plans compared with low-fat eating plans on glycemic and CVD risk parameters in the treatment of type 2 diabetes (see the section Low-Carbohydrate or Very Low-Carbohydrate Eating Patterns ) ( 106 , 111 ).

Saturated Fat

The 2015–2020 DGA recommend consuming less than 10% of calories from saturated fat by replacing it with monounsaturated and polyunsaturated fatty acids ( 8 ). The scientific rationale for decreasing saturated fat in the diet is based on the effect of saturated fat in raising LDL-C, a contributing factor in atherosclerosis ( 294 ).

In a Presidential Advisory on dietary fat and CVD, the American Heart Association concluded that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD ( 295 ). A meta-analysis of randomized trials not focused on people with diabetes showed a 17% reduction (hazard ratio 0.83 [95% CI 0.72–0.96]) in risk of CVD events in studies that reduced saturated fat intake from about 17% to about 9% of energy, but reductions in stroke, cardiovascular mortality, or overall mortality were not found. Subgrouping of the studies suggested that benefit occurred by replacing saturated fat with polyunsaturated fat but not with carbohydrate or protein ( 296 ). In a systematic review of observational studies, saturated fats were not associated with all-cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but limitations common to observational studies were noted ( 297 ). Further, in a more recent large, prospective study including 7% of participants with self-reported diabetes, higher intake of saturated fat was associated with lower risk of total mortality (hazard ratio 0.86 [0.76–0.99], P for trend = 0.0088) ( 298 ). In the PREDIMED study, which included close to 50% of people with diabetes, intakes of monounsaturated and polyunsaturated fats were associated with a lower risk of CVD and death, whereas intakes of saturated fat and trans fat were associated with a higher risk of CVD. The replacement of saturated fat with monounsaturated or polyunsaturated fat in food or replacement of trans fat with monounsaturated fat in food was inversely associated with CVD ( 299 ).

In general, replacing saturated fat with unsaturated fats, especially polyunsaturated fat, significantly reduces both total cholesterol and LDL-C, and replacement with monounsaturated fat from plant sources, such as olive oil and nuts, reduces CVD risk. Replacing saturated fat with carbohydrate also reduces total cholesterol and LDL-C, but significantly increases triglycerides and reduces HDL-C ( 299 , 300 ).

Monounsaturated Fats

A recent meta-analysis of nine RCTs showed that, compared with control, the Mediterranean-style eating pattern, which is high in monounsaturated fats from plant sources such as olive oil and nuts, improved outcomes of glycemia, body weight, and cardiovascular risk factors in participants with type 2 diabetes ( 301 ). A systematic review and meta-analysis of 24 studies and including 1,460 participants compared the effect of eating plans high in monounsaturated fat with that of eating plans high in carbohydrates. The eating plans high in monounsaturated fat showed significant reductions in fasting glucose, triglycerides, body weight, and systolic blood pressure along with significant increases in HDL-C. The systematic review and meta-analysis also reviewed four studies with a total of 44 participants comparing eating plans high in monounsaturated fat with those high in polyunsaturated fat. The eating plans high in monounsaturated fat led to a significant reduction in fasting plasma glucose ( 63 ).

Polyunsaturated Fats

As is recommended for the general public, an increase in foods containing the long-chain omega-3 fatty acids EPA and docosahexaenoic acid (DHA), such as are found in fatty fish, is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies ( 302 , 303 ). For people following a vegetarian or vegan eating pattern, omega-3 α-linoleic acid (ALA) found in plant foods such as flax, walnuts, and soy are reasonable replacements for foods high in saturated fat and may provide some CVD benefits, though the evidence is inconclusive.

Evidence does not conclusively support recommending omega-3 (EPA and DHA) supplements for all people with diabetes for the prevention or treatment of cardiovascular events. In the most recent ASCEND (A Study of Cardiovascular Events iN Diabetes) trial, when compared with placebo, supplementation of omega-3 fatty acids at the dose of 1 g/day did not lead to cardiovascular benefit in people with diabetes without evidence of CVD ( 68a , 304 – 305 ). Omega-3 fatty acid supplements have not reduced CVD events or mortality in randomized trials but may have utility in people who require triglyceride reduction ( 304 , 306 ). The Vitamin D and Omega-3 Trial (VITAL), in which 13% of the participants had type 2 diabetes, supplementation with 1 g of omega-3 fatty acids did not result in a lower incidence of major cardiovascular events ( 305 ). However, in the Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial (REDUCE-IT), in which 57% of 823 participants had diabetes, 2 g of prescription icosapent ethyl twice daily (total daily dose, 4 g) significantly reduced cardiovascular events by 25% when compared with placebo ( 68a ).

A meta-analysis of seven RCTs showed that increased trans fat intake did not result in changes in glucose, insulin, or triglyceride concentrations but led to an increase in total and LDL-C and a decrease in HDL-C concentrations ( 307 ). Trans fats also have been associated with all-cause mortality, total CHD, and CHD mortality ( 297 ).

Can lowering sodium intake reduce blood pressure and other cardiovascular risk factors in people with diabetes?

Many health groups acknowledge the current average intake of sodium, which is >3,500 mg daily ( 308 ), should be reduced ( 8 , 309 – 312 ) to prevent and manage hypertension. While reducing sodium to the general recommendation of <2,300 mg/day demonstrates beneficial effects on blood pressure ( 118 ), further reduction warrants caution. Some studies measuring urine sodium excretion in people with type 1 ( 313 ) and type 2 ( 314 ) diabetes have shown increased mortality associated with the lowest sodium intakes. A secondary analysis of data from the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) suggests sodium excretions <3 g/day and >7 g/day were both associated with increased mortality in people with type 2 diabetes ( 315 ), leading to continued controversy over the potential benefits versus harms of lowering sodium intake below the general recommendation. In the absence of clear scientific evidence for benefit in people with combined diabetes and hypertension ( 313 , 314 ), sodium intake goals that are significantly lower than 2,300 mg/day should be considered only on an individual basis. When individualizing sodium intake recommendations, careful consideration must be given to issues such as food preference, palatability, availability, and additional cost of fresh or specialty low-sodium products ( 316 ).

Diabetic Kidney Disease

Consensus recommendation.

• In individuals with diabetes and non–dialysis-dependent diabetic kidney disease (DKD), reducing the amount of dietary protein below the recommended daily allowance (0.8 g/kg body weight/day) does not meaningfully alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate decline and may increase risk for malnutrition.

Are protein needs different for people with diabetes and kidney disease?

Historically, low-protein eating plans were advised to reduce albuminuria and progression of chronic kidney disease in people with DKD, typically with improvements in albuminuria but no clear effect on estimated glomerular filtration rate. In addition, there is some indication that a low-protein eating plan may lead to malnutrition in individuals with DKD ( 317 – 321 ). The average daily level of protein intake for people with diabetes without kidney disease is typically 1–1.5 g/kg body weight/day or 15–20% of total calories ( 45 , 146 ). Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake.

For people with DKD and macroalbuminuria, changing to a more soy-based source of protein may improve CVD risk factors but does not appear to alter proteinuria ( 322 , 323 ).

Gastroparesis

• Selection of small-particle-size foods may improve symptoms of diabetes-related gastroparesis.
• Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying.
• Use of CGM and/or insulin pump therapy may aid the dosing and timing of insulin administration in people with type 1 or type 2 diabetes with gastroparesis.

How is diabetic gastroparesis best managed?

Consultation by an RDN knowledgeable in the management of gastroparesis is helpful in setting and maintaining treatment goals ( 324 ). Treatment goals include managing and reducing symptoms; correcting fluid, electrolyte, and nutritional deficiencies and glycemic imbalances; and addressing the precipitating cause(s) with appropriate drug therapy ( 227 ). Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying ( 325 , 326 ). Modification of food and beverage intake is the primary management strategy, especially among individuals with mild symptoms.

People with gastroparesis may find it helpful to eat small, frequent meals. Replacing solid food with a greater proportion of liquid calories to meet individualized nutrition requirements may be helpful because consuming solid food in large volumes is associated with longer gastric emptying times ( 327 , 328 ). Large meals can also decrease the lower esophageal sphincter pressure, which may cause gastric reflux, providing further aggravation ( 327 ).

Results from an RCT demonstrated eating plans that emphasize small-particle-size (<2 mm) foods may reduce severity of gastrointestinal symptoms ( 329 ). Small-particle-size food is defined as “food easy to mash with a fork into small particle size.” High-fiber foods, such as whole intact grains and foods with seeds, husks, stringy fibers, and membranes, should be excluded from the eating plan. Many of the foods typically recommended for people with diabetes, such as leafy green salads, raw vegetables, beans, and fresh fruits, and other food like fatty or tough meat, can be some of the most difficult foods for the gastroparetic stomach to grind and empty ( 324 , 329 ). Notably, the majority of nutrition therapy interventions for gastroparesis are based on the knowledge of the pathophysiology and clinical judgment rather than empirical research ( 227 ).

The use of an insulin pump is another option for individuals with type 1 diabetes and insulin-requiring type 2 diabetes with gastroparesis ( 330 ). A small but positive 12-month trial reported a 1.8% reduction in A1C and decreased hospitalizations with insulin pump use ( 331 ). An insulin pump can be used to provide consistent basal insulin infusion, as well as the ability to modify mealtime insulin delivery doses as needed. The variable bolus feature allows the user to administer a portion of the meal bolus in an extended fashion over a longer period of time ( 227 ). Use of this feature may help to decrease the risk of postprandial hyperglycemia as well as hypoglycemia.

How is the risk of malnutrition in diabetic gastroparesis managed?

When an individual with gastroparesis falls below target weight, nutrition support in the form of oral (for acute exacerbation of symptoms), enteral, or parenteral nutrition should be considered ( 327 ). A 5% unintentional loss of usual body weight over 3 months or 10% loss over 6 months is indicative of severe malnutrition. Other nutritional risk parameters include weight <80% of ideal weight, BMI <20 kg/m 2 , or a loss of 5 lb or 2.5% of baseline weight in 1 month.

PERSONALIZED NUTRITION

• Studies using personalized nutrition approaches to examine genetic, metabolomic, and microbiome variations have not yet identified specific factors that consistently improve outcomes in type 1 diabetes, type 2 diabetes, or prediabetes.

Do genetic, metabolomic, or microbiome variants, or other types of personalized nutrition prescriptions, influence glycemic or other diabetes-related outcomes?

Currently, use of nutrition counseling approaches aimed at personalizing guidance based on genetic, metabolomic, and microbiome information is an area of intense research. Testing has become available commercially, with direct-to-consumer advertising. Some intriguing research has shown, for example, the wide interpersonal variability in blood glucose response to standardized meals that could be predicted by clinical and microbiome profiles ( 332 ). At this point, however, no clear conclusions can be drawn regarding their utility owing to wide variations in the markers used for predicting outcomes, in the populations and nutrients studied, and in the associations found.

Further, overall findings tend to support evidence from existing clinical trials and observational studies showing that people with markers indicating higher risk for diabetes, prediabetes, or insulin resistance have lower risk when they reduce calorie, carbohydrate, or saturated fat intake and/or increase fiber or protein intake compared with their peers ( 333 – 337 ).

Conclusions

Ideally, an eating plan should be developed in collaboration with the person with prediabetes or diabetes and an RDN through participation in diabetes self-management education when the diagnosis of prediabetes or diabetes is made. Nutrition therapy recommendations need to be adjusted regularly based on changes in an individual’s life circumstances, preferences, and disease course ( 1 ). Regular follow-up with a diabetes health care provider is also critical to adjust other aspects of the treatment plan as indicated.

One of the most commonly asked questions upon receiving a diagnosis of diabetes is “What can I eat?” Despite widespread interest in evidence-based diabetes nutrition therapy interventions, large, well-conducted nutrition trials continue to lag far behind other areas of diabetes research. Unfortunately, national data indicate that most people with diabetes do not receive any nutrition therapy or formal diabetes education ( 4 , 9 , 16 , 20 ).

Strategies to improve access, clinical outcomes, and cost effectiveness include the following

• reducing barriers to referrals and allowing self-referrals to MNT and DSMES;
• providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management ( 9 , 12 , 13 , 15 , 16 , 19 , 22 , 291 – 293 , 338 – 342 );
• engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data ( 38 , 264 , 343 );
• increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES ( 15 , 19 , 23 , 38 , 343 , 344 ).

Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic management and CVD risk factors, and the influence of a combination of factors can be substantial. Based on a review of the evidence, it is clear that knowledge gaps continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 diabetes, type 2 diabetes, and prediabetes. Future studies should address

• the impact of different eating patterns compared with one another, controlling for supplementary advice (such as stress reduction, physical activity, or smoking cessation);
• the impact of weight loss on other outcomes (which eating plans are beneficial only with weight loss, which can show benefit regardless of weight loss);
• how cultural or personal preferences, psychological supports, co-occurring conditions, socioeconomic status, food insecurity, and other factors impact being consistent with an eating plan and its effectiveness;
• the need for increased length and size of studies, to better understand long-term impacts on clinically relevant outcomes;
• tailoring MNT and DSMES to different racial/ethnic groups and socioeconomic groups;
• comparisons of different delivery methods aided by technology (e.g., mobile technology, apps, social media, technology-enabled and internet-based tools); and
• ongoing cost-effectiveness studies that will further support coverage by third-party payers or bundling services into evolving value-based care and payment models.

Supplementary Material

Article information.

Acknowledgments. The authors acknowledge Mindy Saraco (Managing Director, Medical Affairs, ADA) for her help with the development of the Consensus Report. The authors thank Margaret Powers for providing her expertise in reviewing and/or consulting with the authors, Melinda Maryniuk for serving as a liaison to the ADA Professional Practice Committee (PPC), and the PPC for providing valuable review and feedback. The authors acknowledge the invited peer reviewers who provided comments on an earlier draft of this report: Kelli Begay (Indian Health Service, Rockville, MD), Guoxun Chen (University of Tennessee, Knoxville, TN), Frank Hu (Harvard T.H. Chan School of Public Health, Boston, MA), Melinda Maryniuk (Maryniuk & Associates Diabetes and Nutrition Consultants, Jamaica Plain, MA), Margaret Powers (HealthPartners Institute, Minneapolis, MN), Judith Wylie-Rosett (Albert Einstein College of Medicine, Bronx, NY), Alyce Thomas (St. Joseph’s Health, Paterson, NJ), Emily Weatherup (Michigan Medicine, University of Michigan, Ann Arbor, MI), and Gretchen Youssef (MedStar Health, Washington, DC).

Duality of Interest. The authors disclosed all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the consensus statement development process. The ADA uses general revenues to fund development of its consensus reports and does not rely on industry support for these purposes. A.B.E. reports honorarium from the Academy of Nutrition and Dietetics and the ADA outside of the submitted work. W.T.G. reports personal fees from Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, the American Medical Group Association, and Janssen and grants from Sanofi, Pfizer, Merck, and Novo Nordisk outside of the submitted work. K.H.K.L. reports personal fees from Sunstar Foundation outside of the submitted work. J.Mi. reports speaking fees from New England Dairy and Dairy Farmer, research support and consulting/speaking fees from the National Dairy Council, and research support from Kowa Company and the National Institutes of Health outside of the submitted work. K.R. was previously employed by the ADA. L.S. reports grants from the National Institutes of Health and internal University of Michigan grants. W.S.Y. reports a consulting relationship with dietdoctor.com, which began after the Consensus Report was submitted to Diabetes Care . No other potential conflicts of interest relevant to this article were reported.

Author Contributions. All authors were responsible for drafting the Consensus Report and revising it critically for important intellectual content. All authors approved the version to be published.

This article contains Supplementary Data online at http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dci19-0014/-/DC1 .

This article is part of a special article collection available at http://care.diabetesjournals.org/evolution-nutritional-therapy .

This article is featured in a podcast available at http://www.diabetesjournals.org/content/diabetes-core-update-podcasts .

PALOUSE NUTRITION

Marissa Rudley | Registered Dietitian Nutritionist

Consulting in all Things

 Food and Nutrition

I'm Marissa Rudley, a registered and licensed dietitian nutritionist practicing in Idaho and Washington. My passion for making nutrition enjoyable is what inspires me to connect with others and share this joy every single day. I adore cooking, eating, and sharing delicious meals with others. From individualized nutrition counseling, public speaking, and consulting services, Palouse Nutrition is my way to share my love for all things food and nutrition.

AVAILABLE SERVICES

NUTRITION COUNSELING

The Guidance You Need

A one-on-one appointment to discuss, collaborate and create an individualized plan that fits you. My approach embraces Health at Every Size and Intuitive Eating. I have experience providing Medical Nutrition Therapy to all ages and stages. I look forward to helping you reach your healthiest potential.

ETIQUETTE SPEAKER

Dining with Style

All your dining etiquette questions, and more are answered in this interactive, guided dining experience.  From University etiquette meals, conferences, and corporate lunch and learn events, this presentation will have your audience engaged, entertained, and educated on dining and business etiquette.

Inquire for pricing.

NUTRITION SPEAKING

Group Education

Let's talk about nutrition. You choose the topic and I'll provide the education. 

Topics of Interest:

Raising healthy eaters

Eating on a budget

Nutrition for kids

Nutrition basics

Intuitive Eating 

Sports Nutrition 

Geriatric Nutrition

SCHEDULE A SESSION

Get in touch today to schedule an initial consultation with Marissa

Moscow, Idaho

[email protected]

208-340-2023

Thanks for submitting!

• Open access
• Published: 03 September 2024

Integrating nutrition and culinary medicine into preclinical medical training

• Emily A. Johnston 1 ,
• Maria Torres 2 ,
• Sara Goldgraben 2 &
• Christopher M. Burns 3  

BMC Medical Education volume  24 , Article number:  959 ( 2024 ) Cite this article

Metrics details

Poor nutrition is a leading cause of preventable death, but is inconsistently taught in medical education and inadequately discussed in medical care. To overcome this problem, we developed a hybrid nutrition team-based learning/culinary medicine approach to integrate practical nutrition knowledge and basic cooking skills into the training of future health professionals.

Nutrition was integrated into the systems-based courses at a college of osteopathic medicine, complemented by culinary medicine sessions based on the Health meets Food curriculum (HmF; culinarymedicine.org). Students participated in the program for one year and two cohorts of students were included in this analysis. Outcomes were measured via online food frequency questionnaire (FFQ, Vioscreen, Viocare, Inc) and surveys administered via Qualtrics online survey software. Diet quality was measured using the Healthy Eating Index (HEI)-2015. Data were analyzed using SAS 9.4.

One hundred and ninety-five first year students completed a baseline FFQ (97.5% response rate). Mean age of students was 26 years, 47% were female ( n  = 92/195). The average BMI of participants was 24.8 kg/m 2 (range 17-45.4) and the majority of participants reported being active. Seventy-five students (38%) completed an end of year FFQ. Diet quality was poor among students at baseline ( n  = 195; 67.59 (SD 10.54)) and improved slightly but significantly at the end of year 1 ( n  = 75, 69.63 (SD: 12.42), p  = 0.04). The survey was administered to the second cohort only; 63 students responded (53% response rate). Talking to patients about nutrition was seen as more relevant to future practice among respondents than talking to patients about safe sex, weight, tobacco, alcohol, other substance abuse and domestic violence.

Conclusions

This study evaluated the nutrition and culinary medicine curriculum at a new college of osteopathic medicine. Students rated the program highly and attendance was excellent, even though not required. Student diet quality did not decline over the first year of medical school. Students rated talking to patients about nutrition as highly relevant, providing encouragement that they will do so in future practice. We believe our work shows that nutrition can be integrated into the training of future physicians and that it may pay dividends, particularly with the increasing awareness of the importance of preventive care.

Peer Review reports

Poor nutrition is a leading cause of preventable death globally [ 1 ] , but it is taught in less than 30% of US medical schools [ 2 ] and discussed in less than 10% of US medical office visits [ 3 ]. Doctors of Osteopathic Medicine are trained in holistic care, with a focus on self-regulation, self-healing and health maintenance [ 4 ] but few colleges of osteopathic medicine (22/ 26 responding DO schools surveyed) meet minimum hours recommended by the National Academy of Sciences for nutrition education [ 5 ] and most provide less than half of the recommended amount [ 6 ]. In a survey of 257 preclinical osteopathic medical students, 171 participants (67%) felt that nutrition counseling and meal planning were the responsibility of the physician, but only 30 participants (12%) were aware of the current nutrition guidelines and 130 participants (51%) scored below the school’s passing rate (73%) on a nutrition knowledge quiz [ 7 ]. A majority of osteopathic medical students go on to practice in primary care [ 8 ] and have the opportunity to treat patients over many years. They are thus well situated to implement preventive strategies with patients, particularly recommending healthy dietary choices.

The American Heart Association [ 9 ], the European Society for Parenteral and Enteral Nutrition [ 10 ] and others have called for increases in training in nutrition for future physicians. The Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM) have not released similar statements, although the AAMC did endorse a bill to improve nutrition education in medical schools in 2019 [ 11 ]. There are many barriers to increasing rates of nutrition in medical education broadly across the country. Few medical schools have nutrition professionals on the faculty, few curricular standards exist for teaching or assessing nutrition in medical education, there is little open time in the medical curriculum and a lack of questions on board exams. A 2019 Harvard Law Report suggested that the Liaison Committee on Medical Education (LCME) amend their accreditation standards to require nutrition education, which would lead to increased rates of nutrition in medical training [ 12 ]. However, there has been no change thus far.

Culinary medicine is an evidence-based educational intervention aimed at helping people to access, prepare and consume nutrient rich meals that taste good, are culturally appropriate and help prevent and manage disease [ 13 ]. This provides a strategy for integrating practical nutrition knowledge and basic cooking skills into the training of future health professionals to enable them to better advise their patients on eating well. In the Health meets Food (HmF) culinary medicine curriculum, started at Tulane University [ 14 ], students complete pre-work, participate in team-based case study activities, and then prepare healthful meals with their teams. The teams present the meals to the rest of the class and then the entire group eats the meal together and completes an informal debriefing session. The HmF coursework is based on the Mediterranean diet, which has been implicated in reductions in cardiovascular disease risk and other positive health outcomes [ 15 ].

While CM sessions are often taught in teams, CM is not technically taught in the team-based learning style. Team-based learning (TBL) is defined by the Team-based Learning Collaborative as “an evidence based collaborative learning teaching strategy designed around units of instruction, known as “modules,” that are taught in a three-step cycle: preparation, in-class readiness assurance testing, and application-focused exercise” [ 16 ]. We integrated core concepts of biochemical and physiological aspects of nutrition into the curriculum of an osteopathic medical school via team-based learning modules, self-study activities within the systems-based coursework, and through culinary medicine. Students participated in one culinary medicine workshop (CMW) per systems course (approximately once per month), aligning with the systems-based curriculum of the medical school.

We aimed to integrate nutrition content into the preclinical curriculum with related culinary medicine TBL sessions for medical students in their first year of osteopathic medical training. The purpose of this study was to evaluate perceptions and personal dietary habits of first year osteopathic medical students. We hypothesized that students would be more interested in incorporating nutrition and culinary medicine in their future practice and report improved personal diet quality following these sessions.

The nutrition curriculum was created and taught by a nutrition faculty member and Registered Dietitian Nutritionist (RDN). Nutrition was integrated into the systems-based courses as shown in Fig.  1 , complemented by culinary medicine sessions on related topics when possible. For example, during the Biochemistry pre-clinical course, the culinary medicine course was Introduction to Nutrition lab, which focuses on safety in the kitchen, basic knife skills, and giving an overview of the program, not on biochemistry. Curricula aligned when possible, such as during the Immune System course when the CM module was Food Allergies. We used the Health meets Food curriculum (HmF; culinarymedicine.org) and selected nine of the available modules to teach the students. Most CMW sessions took place in a teaching kitchen on campus; some sessions were taught virtually due to health and safety requirements resulting from the global pandemic.

Cohort 1 engaged in culinary medicine in the method established by HmF. Cohort 2 engaged in culinary medicine via TBL sessions utilizing the readiness assurance process. Both cohorts were from the same university and were first year medical students. TBL sessions were delivered online via InteDashboard software (CognaLearn Pte. Ltd. Singapore). Two items were dedicated to nutrition coursework on mid-course exams and 2 items were dedicated to culinary medicine on all final exams.

Outcomes were measured via online food frequency questionnaire (FFQ; Vioscreen, Viocare, Inc) and surveys administered via Qualtrics online survey software. Vioscreen provides in-depth reports, including the Healthy Eating Index (HEI-2015) [ 17 ], a measure of adherence to the Dietary Guidelines for Americans. Detailed reports from Vioscreen were integrated into future coursework to allow students to apply what they learn in the coursework to their personal diet reports. The Vioscreen FFQ was selected for several reasons, including that it is online and includes pictures to enhance accuracy of portion size estimation. The FFQ includes two questions on multivitamin use: 1. Yes/No; If Yes, how frequently do you take the multivitamin? There is also one question on physical activity where respondents rate their perceived level of activity from sedentary to extremely active. Selected survey questions were adapted from previously published surveys [ 18 ].

Data were collected between August 2020 and June 2022. This study was approved by the California Health Sciences University (CHSU) Institutional Review Board. All participants provided written informed consent.

Curriculum outline of nutrition and culinary medicine integration in year 1 of preclinical osteopathic medical training

Data collection and analysis

Students received an email invitation to complete an online FFQ via Vioscreen.com prior to the start of nutrition-related coursework. Dedicated time to complete the questionnaire was allotted as part of the curricular session. Students received several reminders during class sessions to complete the FFQ. Data collection was closed after 1 month. No incentives were offered for participation.

A survey was administered via Qualtrics to Cohort 2 only. The survey asked questions about prior nutrition training, attitudes about relevance of nutrition to medical school coursework, and whether and how medical students access nutrition information.

The survey and FFQ were pilot tested with a group of faculty and staff to identify errors in advance of dissemination to students. No power calculation was performed, all students were invited to complete FFQ’s and surveys. Data were analyzed using SAS 9.4 software. Wilcoxon signed rank test and paired t-tests were used to compare scores from baseline to end of year 1 in those with 2 completed FFQ’s and p  < 0.05 was used to determine statistical significance.

One hundred and ninety-five first year medical students completed a baseline food frequency questionnaire (195/200, 98% response rate) and 75 (38%) completed an end of year FFQ. The average age of students was 26 years, 47% of respondents were female ( n  = 92/195). The average BMI of participants was 24.8 kg/m 2 (range 17-45.4) and the majority of participants reported being active (Table  1 ).

Diet quality

When comparing only participants with 2 complete FFQ’s ( n  = 75) Healthy Eating Index (HEI)-2015 score improved significantly from baseline (2.13, P  = 0.04). The HEI-2015 Fatty Acid component score was also significantly higher at end of year 1 (Table  2 ). No other component scores were significantly different between timepoints.

Nutrient intake

Mean energy intake was 1926 kcals per day (SD: 839 kcals) at baseline and 1512 kcals (SD: 764 kcals) at the end of year 1. Participants reported intake of an average of 23 g/day of fiber per day at baseline and 20 g/day at the end of year 1 ( p  = 0.001). Mean sodium intake was over 3770 mg/day at baseline and 2981 mg/day at the end of year 1 (< 0.001). Mean potassium intake was 2957 mg/day at baseline and 2466 mg/day at the end of year 1 ( p  = 0.0003). Intake in grams and calories of added sugar decreased from baseline to the end of year 1 (both p  = 0.01). Other individual nutrient scores are listed in Table  3 .

Survey responses

The Qualtrics survey was administered to the second cohort only; 63 students responded (53% response rate; 52% female ( n  = 33)). Respondents reported that they intended to enter primary care fields (19%, n  = 12), internal medicine (14%, n  = 9), emergency medicine (13%, n  = 8), surgery (8%, n  = 5), psychiatry (6%, n  = 4), 3% each ( n  = 2 each) selected obstetrics/gynecology and cardiology, 1 student (1.5% each) selected neurology, sports medicine, integrative medicine and pain management; 27% ( n  = 17) were unsure. When asked to rate their current health ( n  = 62 for this item), 15% ( n  = 9) responded that their health is excellent, 40% ( n  = 25) responded very good, 39% ( n  = 24) responded average, and 6% ( n  = 4) responded that their health is poor.

27% of respondents (17/63) reported taking a nutrition class prior to entering medical school and 13% ( n  = 8) reported that they would feel confident assessing a patient’s diet. More than half ( n  = 38) of respondents have done their own reading or research related to nutrition; of those, 58% ( n  = 22) reported getting their information only from diet books or the popular media, 13% ( n  = 5) have read peer-reviewed nutrition journals or nutrition articles geared toward physicians and 26% ( n  = 10) reported getting their nutrition information from both media and peer-reviewed sources (respondents could select more than 1 answer).

60% of respondents ( n  = 38) correctly identified the daily fruit and vegetable recommendations from the Dietary Guidelines for Americans, 51% ( n  = 32) correctly identified the daily fiber intake recommendations, 84% ( n  = 53) correctly identified the added sugar and 43% ( n  = 27) correctly identified the saturated fat recommendations on the knowledge questions based on the Dietary Guidelines for Americans [ 19 ].

84% of respondents ( n  = 53) reported that talking to patients about nutrition is highly relevant to their intended practice, 14% ( n  = 9) rated it somewhat important. Talking to patients about nutrition was more relevant to future practice among respondents than talking to patients about safe sex, weight, tobacco, alcohol, other substance abuse and domestic violence (Fig.  2 ). Responses to perception questions are displayed in Figs.  2 , 3 and 4 .

Perceived relevance of prevention topics to intended practice ( n  = 63)

Perceived credibility as a healthcare provider based on personal health habits ( n  = 63)

Opinions on prevention topics of medical students ( n  = 63)

Students favorably reviewed the culinary medicine curriculum, including comments such as: “I love having these classes. It’s such a breather and plus I get to cook!” and

“It [the recipe] was awesome! I will definitely make it again.” Students specifically highlighted eating more legumes and vegetables after participating in culinary medicine (Table  4 ).

Students also shared stories about how they felt better equipped to include nutrition education in patient care. For instance, after learning about weight management techniques, students shared how they would like to include a discussion of weight management during their future patient interactions.

This study evaluated the nutrition and culinary medicine curriculum at a new college of osteopathic medicine. The culinary medicine curriculum was licensed from an established program (HmF), however the integration with nutrition coursework and the assessment strategies were novel. There was a small but significant change in overall diet quality between baseline and the end of the year among participants who completed food frequency questionnaires at two time points. While students learned about nutrition, they were also adjusting to a new routine, new budget, new environment and new stressors, all of which may have contributed to their dietary choices. Students did not report a decline in diet quality and there was also no increase in intake of alcohol or caffeine reported over the first year of medical school in our sample.

Our results show that overall diet quality among 195 participating medical students was above the national average of 58 [ 20 ], but still below desirable levels. Participant reported average intake of fiber of is below the recommended 25–38 g/day [ 21 ]. Fiber is a shortfall nutrient in the US [ 19 ], and medical students are also not getting the recommended minimal daily amount. Average sodium intake was well above recommendations [ 19 ], while potassium intake was below recommended levels [ 19 ]. These findings are important for two main reasons: first, diet quality is less than desirable among medical students, coupled with the high stress and limited sleep typical of medical school puts students at risk for preventable chronic disease. Healthy habits tend to decline in the first year of medical school due to the pressures and time limitations of engaging in a rigorous curriculum [ 22 ]. Our finding that diet did not significantly decline during the first year of medical school suggests that a culinary medicine and nutrition curriculum could help prevent these declines. Secondly, evidence from studies among medical students [ 18 , 23 ] and physicians [ 24 , 25 ] suggest that personal lifestyle habits of health professionals influence provider counseling for patients on a healthy lifestyle [ 26 ]. Therefore, educating future physicians not just on nutritional biochemistry and evidence-based lifestyle interventions, but also providing education on food purchasing, preparation and practical information for improving personal diets are integral to training physicians likely to counsel on these topics.

Attendance at all culinary medicine sessions was approximately 92% for the first cohort and 88% for the second cohort. Attendance was excellent for most of the year and declined in April and May as students began studying for their COMLEX and STEP exams. Students were aware most of the topics would not be tested on board exams and the content from CMW held a low weight on their course examinations. There was no penalty for missing CMW sessions, yet students rarely missed sessions until the late spring. Students were able to eat together at the end of each session and shared that the class reduced their stress levels. They received feedback and reinforcement of their knowledge through the TBL readiness assurance process and applied what they learned in the teaching kitchen.

Nutrition and culinary medicine sessions were facilitated by a nutrition faculty member and a Registered Dietitian Nutritionist. This gave students the opportunity to learn from healthcare providers who would be part of a future interdisciplinary healthcare team. Dietetic interns training at a local university attended sessions and functioned as Teaching Assistants. They also shared cases from their own clinical training and answered questions for the medical students on nutrition topics important to them personally and of professional interest. Other faculty members often stopped by the sessions to sample recipes, talk to students, or just observe the culinary medicine sessions. One faculty member reported that she learned more about a student in observing one session than she did in the whole course she taught that the student attended. This attests to the way students are able to be themselves and interact with faculty in a lower stress environment in the CMW. These types of close interactions between faculty and students may help to promote professional identity formation.

Just 26% of respondents took a nutrition class prior to entering medical school and while more than half of survey respondents ( n  = 38) reporting doing their own reading or research related to nutrition, less than half of those have read peer-reviewed nutrition journals or nutrition articles geared toward physicians; instead most respondents reported reading nutrition information in the popular media and in diet books. This suggests that the nutrition information being consumed by future physicians could be fraught with misinformation, without guidance from a nutrition course and nutrition professionals.

Nutrition and culinary medicine curricula are well-suited to team-based learning models and some programs have been redesigned to utilize TBL approaches in the undergraduate setting [ 27 , 28 ] and in selected medical schools [ 29 , 30 ]. Hands-on cooking classes are increasingly being taught in medical schools across the country [ 13 , 31 , 32 ], but it does not appear that these programs have implemented team-based learning approaches. A college of pharmacy created a lifestyle modification elective course using TBL and taught it with two different cohorts of second year pharmacy students [ 33 ] . Investigators evaluated the impact using pre and post-course surveys and a voluntary course evaluation. Examinations showed improved knowledge of nutrition and lifestyle topics and surveys showed high levels of satisfaction (85%); this was done in a curriculum that was primarily lecture-based.

Colleges of medicine provide inadequate nutrition education to allow future providers to be proficient in having discussions of nutrition and lifestyle with patients. A lack of evidence-based guidance to prepare future doctors has limited progress thus far, but we have agreed upon goals. Future physicians should be prepared to assess nutrition-related problems at the individual and community level, provide basic dietary recommendations to patients, identify patients with or at risk for malnutrition and recognize when to refer to a specialist [ 10 ]. Medical schools with lasting/sustainable nutrition programs “thread” it throughout the curriculum from pre-clinical to clinical years aiming for a total of at least 30 h [ 10 ] . The medical school curriculum is overloaded, but this program did not take away meaningfully from other coursework and integrated skills and topics that students would see in classes and on national board exams. A review of USMLE step exam questions from 1989 to 1993 found a reasonable amount (11%) of questions dedicated to testing nutrition knowledge, but a dearth of questions related to prevention, nutrition support and malnutrition, with an overemphasis on vitamin deficiencies [ 34 ]. A review published in 2015 found that the STEP exam preparatory materials contained many references to vitamin and minerals deficiencies, with few references to prevention or diet-related disease management [ 35 ]. An analysis of board examinations in Germany found that < 1% of questions were devoted solely to testing nutrition knowledge and 2% included some nutrition-related topic [ 36 ]. This is clearly an area of needed improvement to move nutrition in medical education forward.

A recent report from three institutions utilizing culinary medicine training (at the undergraduate and graduate medical education levels) [ 37 ] called for additional research into class format and outcome measures in order to create best practices for implementation of culinary medicine. We contribute this work to the evidence-base, however, this study had several limitations. We did not utilize incentives for completion of surveys as they were administered during class time and there was a low response rate on optional and follow up surveys. Poor responses are common among surveys of medical students, and this study was complicated by rapidly changing restrictions due to a global pandemic. Comparisons between baseline and end of year 1 data should be interpreted with caution due to the smaller sample size that completed both diet assessments and surveys. Diet assessment tools are prone to bias due to poor recall or social desirability and limited ability of respondents to estimate portion sizes. The FFQ used in this study uses images to assist with portion size estimation, which helps to mitigate some error [ 38 ]. Students received a study ID and were made aware that their data would be anonymized. The strengths of this study were use of a tested curriculum (HmF), use of a validated tool for data collection (FFQ), and data collection at two time points.

In conclusion, nutrition and diet are important components of preventive care and should be integrated into medical education. Including dietetic interns in training is free of cost and of benefit to all learners. Teaching nutrition in a student friendly, interactive way, was effective, beneficial, and this strategy could be used for teaching other topics, particularly those important for the training of future healthcare providers that may not be tested extensively on board examinations.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Afshin A, Sur PJ, Fay KA, et al. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the global burden of Disease Study 2017. Lancet. 2019;393(10184):1958–72. https://doi.org/10.1016/S0140-6736(19)30041-8 .

Article   Google Scholar  

Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: latest update of a national survey. Acad Med. Sep 2010;85(9):1537–42. https://doi.org/10.1097/ACM.0b013e3181eab71b .

Office of Disease Prevention and Health Promotion. Nutrition and weight status objectives. Healthy People 2020 topics and objectives. 2019. https://www.healthypeople.gov/2020/topics-objectives/topic/nutrition-and-weight-status/objectives .

AACOM. What is Osteopathic Medicine? American Association of Colleges of Osteopathic Medicine. 9/5/2022. 2022. aacom.org/become-a-doctor/about-osteopathic-medicine .

National Research Council. Nutrition Education in U.S. Medical Schools. 1985. https://doi.org/10.17226/597 .

Briggs Early K, Adams KM, Kohlmeier M. Analysis of Nutrition Education in Osteopathic Medical Schools. J Biomedical Educ. 2015;376041. https://doi.org/10.1155/2015/376041 . /08/05 2015;2015.

Hargrove EJ, Berryman DE, Yoder JM, Beverly EA. Assessment of Nutrition Knowledge and attitudes in Preclinical Osteopathic Medical Students. J Am Osteopath Assoc. Oct 2017;1(10):622–33. https://doi.org/10.7556/jaoa.2017.119 .

American Osteopathic Association. Osteopathic medical profession report. 2022. osteopathic.org/about/aoa-statistics/ .

Aspry KE, Van Horn L, Carson JAS et al. Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association. Circulation . Jun 5. 2018;137(23):e821-e841. https://doi.org/10.1161/cir.0000000000000563 .

Cuerda C, Muscaritoli M, Donini LM, et al. Nutrition education in medical schools (NEMS). An ESPEN position paper. Clin Nutr Jun. 2019;38(3):969–74. https://doi.org/10.1016/j.clnu.2019.02.001 .

Association of American Medical Colleges. AAMC Endorses Bill to Enhance Medical School Curricula in Nutrition. 2019. Accessed 6/5/2023. aamc.org/advocacy-policy/washington-highlights/aamc-endorses-bill-enhance-medical-school-curricula-nutrition .

Food Law and Policy Clinic. Harvard Law School. Policy Tools to Include Nutrition in U.S. Medical Training. 2019. https://chlpi.org/wp-content/uploads/2013/12/Doctoring-Our-Diet_-September-2019-V2.pdf .

La Puma J. What is Culinary Medicine and what does it do? Popul Health Manag Feb. 2016;19(1):1–3. https://doi.org/10.1089/pop.2015.0003 .

Health meets Food. Culinary Medicine. 2022. https://culinarymedicine.org/health-meets-food-the-culinary-medicine-curriculum/about-health-meets-food/ . Accessed 9 May 2022.

Estruch R, Ros E, Salas-Salvadó J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet supplemented with Extra-virgin Olive oil or nuts. N Engl J Med. Jun 2018;21(25):e34. https://doi.org/10.1056/NEJMoa1800389 .

Team-Based Learning Collaborative. What is TBL? 2022. http://www.teambasedlearning.org/definition/ . Accessed 9 May 2022.

Krebs-Smith SM, Pannucci TE, Subar AF, et al. Update of the healthy eating index: HEI-2015. J Acad Nutr Diet. Sep 2018;118(9):1591–602. https://doi.org/10.1016/j.jand.2018.05.021 .

Frank E, Carrera JS, Elon L, Hertzberg VS. Predictors of US medical students’ prevention counseling practices. Prev Med. 2007;44(1):76–81.

U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. Vol. 9th edition. 2020–2025.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. Average healthy eating index-2015 scores for adults by age groups. What We Eat in America, NHANES 2017–2018; 2021.

King DE, Mainous AG, Lambourne CA. Trends in Dietary Fiber Intake in the United States, 1999–2008. Journal of the Academy of Nutrition and Dietetics. 2012/05/01/ 2012;112(5):642–648. https://doi.org/10.1016/j.jand.2012.01.019 .

Brehm B, Summer S, Khoury J, Filak A, Lieberman M, Heubi J. Health status and lifestyle habits of US medical students: a longitudinal study. Annals Med Health Sci Res. 2016;6(6):341–7.

Frank E, Elon L, Hertzberg V. A quantitative assessment of a 4-year intervention that improved patient counseling through improving medical student health. MedGenMed Jun. 2007;14(2):58.

Google Scholar  

Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89–92.

Frank E, Wright EH, Serdula MK, Elon LK, Baldwin G. Personal and professional nutrition-related practices of US female physicians. Am J Clin Nutr. 2002;75(2):326–32.

Bergeron N, Al-Saiegh S, Ip EJ. An analysis of California pharmacy and medical students’ dietary and lifestyle practices. Am J Pharm Educ. 2017;81(8):5956.

Bailey RL, Kiesel VA, Lobene AJ, Zou P. Redesigning an Undergraduate Nutrition Course through active learning and team-based projects enhances Student Performance. Curr Developments Nutr. 2020;4(4). https://doi.org/10.1093/cdn/nzaa039 .

Jaime PC, Tramontt CR, Gabe KT, Dos Reis LC, de Mattos Maia T. Students’ perceptions of team-based learning in an undergraduate Nutrition School. MedEdPublish; 2018.

Warrier KMK, Schiller J, Mcbee-Orzulak F, Frei N. Pediatric Nutrition Team-based Learning Module. MedEdPORTAL. 2010;6(8358). https://doi.org/10.15766/mep_2374-8265.8358 .

Elder JPJ, Branski L, Brown K. Nutrition in critical care: a modified team-based Learning Exercise. MedEdPORTAL. 2016;12(10386). https://doi.org/10.15766/mep_2374-8265.10386 .

Hauser ME. A Novel Culinary Medicine Course for Undergraduate Medical Education. Am J Lifestyle Med May-Jun. 2019;13(3):262–4. https://doi.org/10.1177/1559827619825553 .

Razavi AC, Monlezun DJ, Sapin A, et al. Multisite Culinary Medicine Curriculum is Associated with cardioprotective dietary patterns and Lifestyle Medicine competencies among Medical trainees. Am J Lifestyle Med Mar-Apr. 2020;14(2):225–33. https://doi.org/10.1177/1559827619901104 .

Pogge E. A team-based learning course on nutrition and lifestyle modification. Am J Pharm Educ Jun. 2013;12(5):103. https://doi.org/10.5688/ajpe775103 .

Hark LA, Iwamoto C, Melnick D, et al. Nutrition coverage on medical licensing examinations in the United States. Am J Clin Nutr. 1997;65(2):568–71.

Patel S, Taylor KH, Berlin KL, Geib RW, Danek R, Waite GN. Nutrition Education in US Medical schools: an Assessment of Nutrition Content in USMLE STEP Preparation materials. J Curriculum Teach. 2015;4(1):108–13.

Storz MA, Oksche A, Schlasius-Ratter U, Schillings V, Beckschulte K, Huber R. Nutrition Coverage in Medical Licensing examinations in Germany: an analysis of six Nationwide exams. Nutrients. 2022;14(24):5333.

Sicker K, Habash D, Hamilton L, Nelson NG, Robertson-Boyd L, Shaikhkhalil AK. Implementing Culinary Medicine Training: collaboratively learning the Way Forward. J Nutr Educ Behav Jul. 2020;52(7):742–6. https://doi.org/10.1016/j.jneb.2019.12.009 .

Kristal AR, Kolar AS, Fisher JL, et al. Evaluation of web-based, self-administered, graphical food frequency questionnaire. J Acad Nutr Diet Apr. 2014;114(4):613–21. https://doi.org/10.1016/j.jand.2013.11.017 .

Download references

Acknowledgements

We would like to acknowledge the students for their time and participation.

This work was partially funded through a 2021 TBL Research Grant from the Team-Based Learning Collaborative (TBLC).

Author information

Authors and affiliations.

Department of Medicine, NYU Grossman School of Medicine, New York, NY, 10016, USA

Emily A. Johnston

California Health Sciences University College of Osteopathic Medicine, Clovis, CA, 93611, USA

Maria Torres & Sara Goldgraben

The University of Arizona College of Medicine – Phoenix, Phoenix, AZ, 85004, USA

Christopher M. Burns

You can also search for this author in PubMed   Google Scholar

Contributions

EAJ conceptualized the project, secured project and wrote the main manuscript. CMB co-authored grant and provided oversight of programming and editorial oversight of manuscript. EAJ, MT and SG taught the courses and facilitated data collection. All authors reviewed the manuscript.

Corresponding author

Correspondence to Emily A. Johnston .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the California Health Sciences University (CHSU) Institutional Review Board. All participants provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Johnston, E.A., Torres, M., Goldgraben, S. et al. Integrating nutrition and culinary medicine into preclinical medical training. BMC Med Educ 24 , 959 (2024). https://doi.org/10.1186/s12909-024-05795-3

Download citation

Received : 28 January 2024

Accepted : 17 July 2024

Published : 03 September 2024

DOI : https://doi.org/10.1186/s12909-024-05795-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Culinary medicine
• Team-based learning
• Undergraduate medical education
• Registered dietitian nutritionist

BMC Medical Education

ISSN: 1472-6920

• General enquiries: [email protected]