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encounters reimbursable for the first 10 h\n(1 h of individual training and 9 h of grouptraining); if special needs that would inter-fere with effective group participation areidenti fied on the referral order, individual\nDSMES encounters are reimbursable forthe initial 10 h. For Medicaid, DSMES cov-erage varies by stat... | [
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Although DSMES is frequently reim-\nbursed when performed in person, DSMES\nc a na l s ob ep r o v i d e dv i at e l e h e a l t ha n d\nphone calls (13). These versions may notalways be reimbursed; however, changesin reimbursement policies that increase\nDSMES access and utilization will result in\na positive impact o... | [
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a positive impact on bene ficiaries ’clinical\noutcomes, quality of life, health care utili-zation, and costs (13,90 –92). During the\ntime of the coronavirus disease 2019\n(COVID-19) pandemic, reimbursement\npolicies were revised (professional.diabetes.org/content-page/dsmes-and-mnt-during-covid-19-national-pandemic), ... | [
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changes may provide a new reimburse-\nment paradigm for future provision ofDSMES through telehealth channels. Perupdated guidance from the Centers for\nMedicare & Medicaid Services, DSMES tel-\nehealth reimbursements remain the sameas they were during the public healthemergency for most practice settings. BothADA-recog... | [
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tes Care & Education Specialists –accredited\nprograms were added to the list of\napproved telehealth professionals via theConsolidated Appropriations Act, 2023.\nThe reimbursement of DSMES telehealth\nservices was extended through the end of2024. Importantly, DSMES is paid on thephysician fee schedule and not the outp... | [
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tient prospective payment system. Per the\nConsolidated Appropriations Act, 2023,distant-site health care professionals maydiabetesjournals.org/care Facilitating Positive Health Behaviors and Well-being S79\n©AmericanDiabetesAssociation | [
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be able to bill DSMES as a Medicare tele-\nhealth service through 31 December 2024.\nMEDICAL NUTRITION THERAPY\nWhen the first ADA Standards of Care\nguidelines were published in 1989, nutri-tion was mentioned in two sentences in\nthe entire 4-page document (93). Evennow, in 2024, the science of nutrition fordiabetes co... | [
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time, there has been change of emphasis\nfrom nutrients (macronutrients and micro-nutrients) to a focus on foods and, more\nbroadly, dietary patterns. This integrative\napproach aligns with the 2021 AmericanHeart Association dietary guidance to im-prove cardiovascular health (94), the Kid-\nney Disease: Improving Globa... | [
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ney Disease: Improving Global Outcomes\n(KDIGO) guidelines (95), the European As-sociation for the Study of Diabetes/ADA\ntype 1 consensus report (96) and type 2\nconsensus report (97), and the DietaryGuidelines for Americans, 2020 –2025 (98).\nSimply put, people eat food, not nutrients,\nand nutrient recommendations n... | [
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and nutrient recommendations need to be\napplied to what people eat. Additionally,macronutrients are not interchangeable\nentities and vary by nutrient type and qual-\nity. As an example, carbohydrates includelegumes, whole grains, and fruits and arei nt h es a m ec a t e g o r ya sr e fined grains, but\ntheir health ef... | [
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their health effects are very different (99).\nFor more detailed information on nu-\ntrition therapy, please refer to the ADAconsensus report on nutrition therapy\n(73). Contained in the report is an impor-\ntant and often repeated tenet, i.e., thereis not a one-size- fits-all eating pattern for\nindividuals with diabet... | [
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individuals with diabetes, and meal plan-\nning should be individualized. Nutrition\ntherapy plays an integral role in overall di-abetes management, and each person\nwith diabetes should be actively engaged\nin education, self-management, and treat-ment planning with the health care team,including the collaborative dev... | [
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of an individualized eating plan (73,100).\nAll health care professionals should referpeople with diabetes for individualized\nMNT provided by an RDN who is knowl-\nedgeable and skilled in providing diabetes-specific MNT (101 –103) at diagnosis and\nas needed throughout the life span, similar\nto DSMES. MNT delivered by... | [
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to DSMES. MNT delivered by an RDN is as-\nsociated with A1C absolute decreases of1.0–1.9% for people with type 1 diabetes\n(104) and 0.3 –2.0% for people with type 2\ndiabetes (104). See Table 5.1 for speci fic\nnutrition recommendations. Because ofthe progressive nature of type 2 diabetes,\nbehavior modi fication alone ... | [
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behavior modi fication alone may not be\nadequate to maintain euglycemia overtime. However, after medication is initi-\nated, nutrition therapy continues to be an\nimportant component, and RDNs provid-\ning MNT in diabetes care should assess\nand monitor medication changes in rela-\ntion to the nutrition care plan (73,1... | [
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tion to the nutrition care plan (73,100).\nGoals of Nutrition Therapy for All\nPeople With Diabetes\n1. To promote and support healthful eat-\ning patterns, emphasizing a variety of\nnutrient-dense foods in appropriate\nportion sizes, to improve overall health\nand:\n\x81achieve and maintain body weight\ngoals | [
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and:\n\x81achieve and maintain body weight\ngoals\n\x81attain individualized glycemic, bloodpressure, and lipid goals\n\x81delay or prevent the complications\nof diabetes\n2. To address individual nutrition needs\nbased on personal and cultural prefer-ences, health literacy and numeracy, ac- | [
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cess to healthful foods, willingness andability to make behavioral changes, and\nexisting barriers to change\n3. To maintain the pleasure of eating\nby providing nonjudgmental messagesabout food choices while limiting food\nchoices only when indicated by scien-\ntific evidence\n4. To provide an individual with diabetes | [
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tific evidence\n4. To provide an individual with diabetes\nthe practical tools for developing healthy\neating patterns rather than focusing\non individual macronutrients, micronu-\ntrients, or single foods\nWeight Management\nManagement and reduction of weight is\nimportant for people with type 1 diabe- | [
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important for people with type 1 diabe-\ntes, type 2 diabetes, or prediabetes withoverweight or obesity. To support weight\nloss and improve A1C, cardiovascular dis-\nease (CVD) risk factors, and well-being in\nadults with overweight/obesity and pre-\ndiabetes or diabetes, MNT and DSMES\nservices should include an indi... | [
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services should include an individualized\neating plan in a format that results in anenergy de ficit in combination with en-\nhanced physical activity (73). Lifestyle in-tervention programs should be intensive\nand have frequent follow-up to achieve\nsignificant reductions in excess body | [
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significant reductions in excess body\nweight and improve clinical indicators.Behavior modi fication targets includephysical activity, calorie restriction, weight\nmanagement strategies, and motivation.There is strong and consistent evidencethat modest, sustained weight loss can delaythe progression from prediabetes to t... | [
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diabetes (103,105,106) (see Section 3,\n“Prevention or Delay of Diabetes and\nAssociated Comorbidities ”) and is bene fi-\ncial for the management of type 2 diabe-\ntes (see Section 8, “Obesity and Weight\nManagement for the Prevention and\nTreatment of Type 2 Diabetes ”).\nIn prediabetes, the weight loss goal is\n5–7% ... | [
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5–7% or higher for reducing risk of pro-\ngression to type 2 diabetes (107). In con-junction with support for healthy lifestylebehaviors, medication-assisted weightloss can be considered for people at risk\nfor type 2 diabetes when needed to\nachieve and sustain 7 –10% weight loss\n(108,109) (see Section 8, “Obesity an... | [
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(108,109) (see Section 8, “Obesity and\nWeight Management for the Prevention\nand Treatment of Type 2 Diabetes ”). Peo-\nple with prediabetes at a healthy weight\nshould also be considered for behavioralinterventions to help establish routine aer-\nobic and resistance exercise (107,110,111) | [
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obic and resistance exercise (107,110,111)\nas well as to establish healthy eating pat-terns. Services delivered by health careprofessionals familiar with diabetes and itsmanagement, such as an RDN, have been\nfound to be effective (102).\nFor many individuals with overweight\nand obesity with type 2 diabetes, 5% | [
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and obesity with type 2 diabetes, 5%\nweight loss is needed to achieve bene fi-\ncial outcomes in glycemic control, lipids,\nand blood pressure (112,113). It should\nbe noted, however, that the clinical ben-efits of weight loss are progressive, and\nmore intensive weight loss goals (i.e.,\n15%) may be appropriate to maxi... | [
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15%) may be appropriate to maximize\nbene fit depending on need, feasibility,\nand safety (114,115). Long-term durabil-ity of weight loss remains a challenge;\nhowever, newer medications (beyond\nmetabolic surgery) may have potentialfor sustainability, impact on cardiovas-cular outcomes, and weight reduction\nbeyond 10 ... | [
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beyond 10 –15% (116– 120).\nIn select individuals with type 2 diabe-\ntes, an overall healthy eating plan that re-\nsults in energy defi cit in conjunction with\nweight loss medications and/or metabolic\nsurgery should be considered to help | [
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surgery should be considered to help\nachieve weight loss and maintenancegoals, lower A1C, and reduce CVD risk(108,121,122). Overweight and obesityare also increasingly prevalent in people\nwith type 1 diabetes and present clinical | [
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with type 1 diabetes and present clinical\nchallenges regarding diabetes treatmentS80 Facilitating Positive Health Behaviors and Well-being Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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Table 5.1 —Medical nutrition therapy recommendations\nRecommendations\nEffectiveness of nutrition therapy 5.9An individualized medical nutrition therapy program as needed to achieve treatment | [
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goals, provided by a registered dietitian nutritionist, preferably one who has compre-hensive knowledge and experience in diabetes care, is recommended for all peoplewith type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus. A\n5.10 Because diabetes medical nutrition therapy can result in cost savi... | [
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cardiometabolic outcomes, Amedical nutrition therapy should be adequately reim-\nbursed by insurance and other payers. E\nEnergy balance 5.11 For all people with overweight or obesity, behavioral modi fication to achieve and\nmaintain a minimum weight loss of 5% is recommended. A | [
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maintain a minimum weight loss of 5% is recommended. A\nEating patterns and macronutrient distribution 5.12 For diabetes prevention and management of people with prediabetes or diabetes,\nrecommend individualized meal plans that keep nutrient quality, total calories, and | [
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metabolic goals in mind, Bas data do not support a speci fic macronutrient pattern.\n5.13 Food-based dietary patterns should emphasize key nutrition principles (inclusion ofnonstarchy vegetables, whole fruits, legumes, whole grains, nuts/seeds, and low-fatdairy products and minimizing consumption of meat, sugar-sweetene... | [
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sweets, re fined grains, and ultraprocessed foods) in people with prediabetes and dia-\nbetes. B\n5.14 Consider reducing overall carbohydrate intake for adults with diabetes to improve\nglycemia, as this approach may be applied to a variety of eating patterns that meet\nindividual needs and preferences. B | [
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individual needs and preferences. B\nCarbohydrates 5.15 Emphasize minimally processed, nutrient-dense, high- fiber sources of carbohydrate\n(at least 14 g fiber per 1,000 kcal). B\n5.16 People with diabetes and those at risk are advised to replace sugar-sweetened bev- | [
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erages (including fruit juices) with water or low-calorie or no-calorie beverages asmuch as possible to manage glycemia and reduce risk for cardiometabolic disease B\nand minimize consumption of foods with added sugar that have the capacity to dis-\nplace healthier, more nutrient-dense food choices. A | [
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place healthier, more nutrient-dense food choices. A\n5.17 Provide education on the glycemic impact of carbohydrate, Afat, and protein B\ntailored to an individual ’s needs, insulin plan, and preferences to optimize mealtime\ninsulin dosing.\n5.18 When using fixed insulin doses, individuals should be provided with educa... | [
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consistent patterns of carbohydrate intake with respect to time and amount while\nconsidering the insulin action time, as it can result in improved glycemia and reduce\nthe risk for hypoglycemia. B | [
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the risk for hypoglycemia. B\nProtein 5.19 For people with type 2 diabetes, consider avoiding carbohydrate sources high in pro-tein when treating or preventing hypoglycemia, as ingested protein appears to in-\ncrease insulin response without increasing plasma glucose concentrations. B | [
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Dietary fat 5.20 Counsel people with diabetes to consider an eating plan emphasizing elements of a\nMediterranean eating pattern, which is rich in monounsaturated and polyunsatu-\nrated fats and long-chain fatty acids such as fatty fish, nuts, and seeds, to reduce\ncardiovascular disease risk Aand improve glucose metabo... | [
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Micronutrients and herbal supplements 5.21 Dietary supplementation with vitamins, minerals (such as chromium and vitamin D),herbs, or spices (such as cinnamon or aloe vera) are not recommended for glycemicbene fits. Health care professionals should inquire about intake of supplements and\ncounsel as needed. C | [
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counsel as needed. C\n5.22 Counsel against b-carotene supplementation, as there is evidence of harm for certain\nindividuals and it confers no bene fit.B\nAlcohol 5.23 Advise adults with diabetes who consume alcohol to not exceed the recommended daily\nlimits (one drink per day for adult women and two drinks per day for... | [
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Advise abstainers to not start to drink, even in moderation, solely for the purpose of im-\nproving health outcomes. C | [
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proving health outcomes. C\n5.24 Educating people with diabetes about the signs, symptoms, and self-management ofdelayed hypoglycemia after drinking alcohol, especially when using insulin or insulinsecretagogues, is recommended. The importance of monitoring glucose after drinking | [
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alcoholic beverages to reduce hypoglycemia risk should be emphasized. B\nSodium 5.25 Counsel people with diabetes to limit sodium consumption to <2,300 mg/day. B\nNonnutritive sweeteners 5.26 Counsel people with prediabetes and diabetes that water is recommended over nu-\ntritive and nonnutritive sweetened beverages. H... | [
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sweeteners as a replacement for sugar-sweetened products in moderation is accept-\nable if it reduces overall calorie and carbohydrate intake. Bdiabetesjournals.org/care Facilitating Positive Health Behaviors and Well-being S81\n©AmericanDiabetesAssociation | [
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and CVD risk factors (123,124). Sustaining\nweight loss can be challenging (112,125)\nbut has long-term bene fits; maintaining\nweight loss for 5 years is associated withsustained improvements in A1C and lipid\nlevels (126). MNT guidance from an RDN\nwith expertise in diabetes and weightmanagement throughout the course ... | [
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structured weight loss plan is strongly\nrecommended.\nAlong with routine medical management\nvisits, people with diabetes and prediabetesshould be screened during DSMES andMNT encounters for a history of dieting and\npast or current disordered eating behaviors.\nNutrition therapy should be individualized\nto help addr... | [
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to help address maladaptive eating behav-\nior (e.g., purging) or compensatory changesin medical treatment plan (e.g., overtreat-\nment of hypoglycemic episodes and re-\nd u c t i o ni nm e d i c a t i o nd o s i n gt or e d u c e\nhunger) (73) (see\nDISORDERED EATING BEHAVIOR , | [
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hunger) (73) (see\nDISORDERED EATING BEHAVIOR ,\nbelow). Disordered eating, eating disor-ders, and/or disrupted eating can in-\ncrease challenges for weight and diabetesmanagement. For example, caloric restric-\ntion may be essential for glycemic man-\nagement and weight maintenance, but\nrigid meal plans may be contra... | [
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rigid meal plans may be contraindicated\nfor individuals who are at increased riskof clinically signi ficant maladaptive eating\nbehaviors (127). If eating disorders areidenti fied during screening with diabetes-\nspecifi c questionnaires, individuals should\nbe referred to a quali fied behavioral\nhealth professional (1). | [
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be referred to a quali fied behavioral\nhealth professional (1).\nStudies have demonstrated that a vari-\nety of eating plans, varying in macronutri-ent composition, can be used effectively\nand safely in the short term (1 –2y e a r s )t o\nachieve weight loss in people with diabe-\ntes. These plans include structured l... | [
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tes. These plans include structured low-\ncalorie meal plans with meal replacements\n(114,126,128), a Mediterranean eating\npattern (129), and low-carbohydrate meal\nplans with additional support (130,131).\nHowever, no single approach has been\nproven to be consistently superior (73,132–134), and more data are needed ... | [
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identify and validate those meal plansthat are optimal with respect to long-\nterm outcomes and acceptability. Any\napproach to meal planning should be in-dividualized, considering the health sta-\ntus, personal and cultural preferences,\nhealth goals, ability to sustain the recom-\nmendations, and ultimately food acce... | [
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mendations, and ultimately food access\nand nutrition security (73).Food Insecurity and Access\nFood insecurity is de fined as a lack of con-\nsistent access to enough food for an active,\nhealthy life (135). Food insecurity affects\n16% of adults with diabetes compared\nwith 9% of adults without diabetes (136). | [
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with 9% of adults without diabetes (136).\nThere is a complex bidirectional associationbetween food insecurity and cooccurring\ndiabetes. Food security screening should\nhappen at all levels of the health care sys-\ntem. Any member of the health care team\ncan screen for food insecurity using The\nHunger Vital Sign. Ho... | [
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Hunger Vital Sign. Households are consid-\nered at risk if they answer either or both ofthe following statements as “often true ”or\n“sometimes true ”(compared with “never\ntrue”) (137):\n\x81“Within the past 12 months, we wor-\nried whether our food would run outbefore we got money to buy more. ”\n\x81“Within the past... | [
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\x81“Within the past 12 months, the\nfood we bought just didn’ t last, and\nwe didn’ t have money to get more. ”\nIf screening is positive for food insecurity,\nefforts should be made to make referrals to\nappropriate programs and resources. For\nmore information on efforts and policy rec-\nommendations, see “The Biden... | [
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ommendations, see “The Biden-Harris Ad-\nministration National Strategy on Hunger,Nutrition, and Health ”(138).\nEating Patterns and Meal Planning\nFor an understanding of nutrition and di-\nabetes, it is important to clarify the dif-\nferences between food patterns, eating\nplans, and approaches. These are termsthat a... | [
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they are different and relevant in individ-\nualizing nutrition care plans (139).\n\x81Eating pattern(s) or food pattern(s).\nThe totality of all foods and beverages\nconsumed over a given period of time.\nAn eating pattern can be ascribed to an\nindividual, but it is also the term usedin prospective cohort and observa... | [
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nutrition studies to classify and study\nnutrition patterns. Examples of eating\npatterns include Mediterranean style,\nDietary Approaches to Stop Hyperten-\nsion (DASH), low-carbohydrate vegetar-\nian, and plant based (139).\n\x81Eating/meal plan (historically referred\nto as a diet). An individualized guide to\nhelp ... | [
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help plan when, what, and how much\nto eat on a daily basis, completed by\nt h ep e r s o nw i t hd i a b e t e sa n dt h eR D N .The eating plan could incorporate an\neating pattern combined with a strat-egy or method to direct some of thechoices. Eating plans are based on the\nindividual ’s usual eating style.\n\x81D... | [
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\x81Dietary approach. Method or strategy\nto individualize a desired eating pattern\nand provide a practical tool(s) for devel-\noping healthy eating patterns. Examples\nof dietary approaches include the platemethod, carbohydrate choice, carbohy-drate counting, and highly individual-\nized behavioral approaches (140). | [
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ized behavioral approaches (140).\nEvidence suggests that there is not an\nideal percentage of calories from carbo-\nhydrate, protein, and fat for people withdiabetes. Therefore, macronutrient distri-\nbution should be based on an individual- | [
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bution should be based on an individual-\nized assessment of current eating patterns,preferences, and metabolic goals. Mem-bers of the health care team should com-\nplement MNT by providing evidence-based\nguidance that helps people with diabetesmake healthy food choices that meet their\nindividualized needs and improv... | [
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individualized needs and improve overall\nhealth.\nResearch con firms that a variety of eat-\ning patterns are acceptable for the man-agement of diabetes (73,104,141,142).\nUntil the evidence around bene fits of dif-\nferent eating patterns is strengthened,\nhealth care professionals should focus onthe core dimensions co... | [
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terns: inclusion of nonstarchy vegetables,\nwhole fruits, legumes, whole grains, nuts,seeds, and low-fat dairy products and\nminimizing consumption of meat, sugar-\nsweetened beverages, sweets, re fined\ngrains, and ultraprocessed foods (143,144).\nEvidence for eating patterns has been\ninformed by RCTs, prospective coh... | [
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informed by RCTs, prospective cohort\nstudies, systematic reviews, and network\nmeta-analysis. Those most frequentlyreferenced include Mediterranean, DASH,\nlow-fat, carbohydrate-restricted, vegetarian,\nand vegan eating patterns. As stated previ-ously, there is insuf ficient evidence to select\none over the other (137,... | [
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one over the other (137,141,142,145 –154).\nUltimately, ongoing diabetes and nutritioneducation paired with appropriate supportto implement and sustain health behaviorsis recommended (103).\nMeal Planning\nReferral to and ongoing support from anRDN is essential to assess the overall nu-trition status of, and to work co... | [
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tively with, the person with diabetes to\ncreate a personalized meal plan thatS82 Facilitating Positive Health Behaviors and Well-being Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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coordinates and aligns with the overall\nlifestyle treatment plan, including physical\nactivity and medication use. Using shared\ndecision-making to collaboratively selecta method for how to execute the planmay be part of the nutrition care process.\nDietary Approaches/Methods | [
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Dietary Approaches/Methods\nFew head-to-head studies have compareddifferent dietary approaches. In a system-atic review and meta-analysis of carbohy-drate counting versus other forms ofdietary advice (standard education, lowglycemic index, and fixed carbohydrate\nquantities), no signi ficant differences were | [
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quantities), no signi ficant differences were\nseen in A1C levels compared with stan-dard education (145). In another RCT,as i m p l i fied carbohydrate counting tool\nbased on individual glycemic response was\nnoninferior to conventional carbohydrate | [
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counting in 85 adults with type 1 diabetes(146). In a randomized crossover trial, car-bohydrate counting and qualitative mealsize (low, medium, and high carbohydrate)were compared. Time in range was 74%for carbohydrate counting and 70.5% forthe quantitative meal size estimates. Non-inferiority was not con firmed for the... | [
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tative method (147). Newer technologies(smart phone apps and CGM), includingautomated insulin delivery, may decreasethe need for precise carbohydrate count-ing and allow for personalized nutrition ap-proaches (148,149).\nAn RCT found that two meal-planning | [
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approaches (diabetes plate method andcarbohydrate counting) were effective inhelping achieve improved A1C (150). Thediabetes plate method is a commonlyused visual approach for providing basicmeal planning guidance in type 1 andtype 2 diabetes. This simple graphic (fea-turing a 9-inch plate) shows how to por-tion foods ... | [
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a 9-inch plate) shows how to por-tion foods (one-half of the plate fornonstarchy vegetables, one-quarter ofthe plate for protein, and one-quarter ofthe plate for carbohydrates). Carbohy-drate counting is a more advanced skillthat helps plan for and track how muchcarbohydrate is consumed at meals andsnacks. Meal plannin... | [
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is consumed at meals andsnacks. Meal planning approaches shouldbe customized to the individual, includingtheir numeracy (150) and food literacylevel. Health numeracy refers to under-standing and using numbers and numericalconcepts in relation to health and self-management (155). Food literacy generallydescribes pro fici... | [
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edge and skills that ultimately impact health,although specifi cd efinitions vary across ini-\ntiatives (151,152).\nIntermittent fasting or time-restricted\neating as strategies for weight and glu-\ncose management have been studied\nand have gained popularity. Intermittent | [
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and have gained popularity. Intermittent\nfasting is an umbrella term that includesthree main forms of restricted eating: al-ternate-day fasting (energy restriction of500–600 calories on alternate days), the\n5:2 diet (energy restriction of 500 – | [
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5:2 diet (energy restriction of 500 –\n600 calories on consecutive or noncon-secutive days with usual intake the otherfive), and time-restricted eating (daily\ncalorie restriction based on window of timeof 8–15 h). Each produces mild to moder-\nate weight loss (3 –8% loss from baseline)\nover short durations (8– 12 week... | [
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over short durations (8– 12 weeks) with no\nsignificant differences in weight loss when\ncompared with continuous calorie restric-tion (153,154,156,157). A few studies haveextended up to 52 weeks and show similarfindings (158 –162) with diverse popula- | [
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tions. Generally, time-restricted eating orshortening the eating window can beadapted to any eating pattern and hasbeen shown to be safe for adults with\ntype 1 or type 2 diabetes (161). People\nwith diabetes who are on insulin and/orsecretagogues should be medically moni-tored during the fasting period (163). Be- | [
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cause of the simplicity of intermittent\nfasting and time-restricted eating, thesemay be useful strategies for people withdiabetes who are looking for practical eat-ing management tools.\nUse of partial meal replacements or to- | [
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Use of partial meal replacements or to-\ntal meal replacements is an additionaltool or strategy for energy restriction.Meal replacements are prepackaged foods(bars, shakes, and soups) that contain a\nfixed amount of macroutrients and mi-\ncronutrients. They have been shown to\nimprove nutrient quality and glycemicmanage... | [
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and consequent energy intake. In a meta-\nanalysis involving 17 studies incorporatingboth partial and total meal replacements,greater weight loss and improvement in\nA1C and fasting blood glucose were dem- | [
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A1C and fasting blood glucose were dem-\no n s t r a t e dc o m p a r e dw i t hc o n v e n t i o n a ld i -ets (164). Meal replacements have beenused in several landmark clinical trials, in-cluding Look AHEAD (Action for Health in\nDiabetes) (165), DiRECT (Diabetes Remis- | [
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Diabetes) (165), DiRECT (Diabetes Remis-\nsion Clinical Trial) (166), and PREVIEW (Pre-vention of Diabetes Through LifestyleIntervention and Population Studies in\nEurope and Around the World) (167),\nshowing partial or total meal replacementscan be a potential short-term strategy forweight loss.\nRegardless of the eat... | [
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Regardless of the eating pattern, meal\nplan, and/or dietary approach selected,long-term follow-up and support from\nmembers of the diabetes care team are\nneeded to optimize self-ef ficacy and main-\ntain behavioral changes (140).\nChrononutrition is a growing and\nemerging specialty in the field of nutri- | [
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emerging specialty in the field of nutri-\ntion and biology that tries to understandhow the timing of food ingestion affectsmetabolic health (168). Glucose metabo-lism follows a circadian rhythm through\ndiurnal variation of glucose tolerance, | [
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diurnal variation of glucose tolerance,\npeaking during daylight hours when food isconsumed. Some preliminary studies showcardiometabolic bene fits when food is con-\nsumed earlier (169). Similarly, circadian dis-ruptions found in shift workers increaserisk of type 2 diabetes (170). Althoughmore research needs to be don... | [
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evolving area of research may show prom-\nise to improve glucose regulation.\nReligious Fasting\nAlthough intermittent fasting and time-restricted eating are speci ficd i e t a r ys t r a t - | [
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egies for energy restriction, religious fast-ing has been practiced for thousands ofyears and is part of many faith-based tra-ditions. Duration, frequency, and type offast vary among different religions (171).\nFor example, Jewish people abstain from\nany intake for /C2424 h during Yom Kippur | [
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any intake for /C2424 h during Yom Kippur\n(172,173). For Muslims, Ramadan fastinglasts for a full month, when abstinence\nfrom any food or drink is required from\ndawn to dusk (174). Individuals with dia-betes who fast have an increased risk forhypoglycemia, dehydration, hyperglyce-\nmia, and ketoacidosis. Risk can va... | [
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mia, and ketoacidosis. Risk can vary de-\npending on the type of diabetes, type oftherapy, and presence and severity of dia-betes-related complications (175). Health\ncare professionals, including RDNs, certi-\nfied DCES, and others, should inquire\nabout any religious fasting for peoplewith diabetes and provide educati... | [
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support to accommodate their choice.\nEducation regarding glucose checking,medication/fl uid adjustment, timing and\nintensity of physical activity, and meal\nchoices pre- and post-fast should be pro-\nvided (176). Treatment pre- and post-fastshould be culturally sensitive and individ-ualized (177). Speci fic recommendat... | [
0.0043058497831225395,
0.07431916892528534,
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for diabetes management during Rama-\ndan (175) and Yom Kippur (172) are\navailable.diabetesjournals.org/care Facilitating Positive Health Behaviors and Well-being S83\n©AmericanDiabetesAssociation | [
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0.04902426525950432,
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