Development of a medical nutrition therapy protocol for female collegiate athletes

Nutrition intervention can improve athletic performance and reduce the risk of nutrition related problems in women athletes. The current healthcare environment demands that dietitians document the outcomes of the medical nutrition therapy (MNT) they provide. This requires the development and validation of MNT protocols so that outcomes can be documented and compared in similar populations across multiple settings. The purpose of this project was to develop a sports nutrition management MNT protocol for collegiate women athletes. A registered dietitian currently working with collegiate women athletes collaborated with four dietitians from the community to develop an MNT protocol. Further testing and validation using this MNT protocol will help dietitians document the outcomes of their interventions in this population.     

Effectiveness of Medical Nutrition Therapy Provided by Dietitians in the Management of Non–Insulin-Dependent Diabetes Mellitus: A Randomized, Controlled Clinical Trial

Objective To assess the the effect of medical nutrition therapy (MNT) provided by dietitians on medical and clinical outcomes for adults with non–insulin-dependent diabetes mellitus (NIDDM), and to compare MNT administered according to practice guidelines nutrition care (PGC) to MNT administered with basic nutrition care (BC).Design A prospective, randomized, controlled clinical trial of two levels of MNT on metabolic control in persons newly diagnosed with or currently under treatment for NIDDM was conducted at diabetes centers in three states (Minnesota, Florida, and Colorado). BC consisted of a single visit with a dietitian; PGC involved an initial visit with a dietitian followed by two visits during the first 6 weeks of the study period. Data were collected at entry to the study and at 3 and 6 months.Subjects Results are reported for 179 men and women aged 38 to 76 years: 85 assigned randomly to BC and 94 to PGC. This represents 72% of the 247 subjects enrolled. An additional 62 adults with NIDDM at one site who had no contact with a dietitian were identified as a nonrandom comparison group.Outcomes Medical outcome measures included fasting plasma glucose (FPG), glycated hemoglobin (HbA_1c), and serum lipid levels. Clinical outcomes included weight, body mass index, waist-to-hip ratio, and changes in medical therapy.Statistical analyses Initial analysis of the discrete variables was done using the χ² statistic with Yates' correction. Initial analysis of continuous variables was done by analysis of variance. The changes in variables between time periods were analyzed by paired t test, and comparisons between groups were analyzed using a t test for independent groups.Results At 6 months, PGC resulted in significant improvements in blood glucose control as indicated by FPG and HbA_1c levels and BC resulted in significant improvements in HbA_1c level. Participants assigned to the PGC group had a mean FPG level at 6 months that was 10.5% lower than the level at entry, and those in the BC group had a 5.3% lower value. Among subjects who had diabetes for longer than 6 months, those who received PGC had a significantly better HbA_1c level at 3 months compared with those receiving BC. The comparison group showed no improvement in glycemic control over a comparable 6 months. PGC subjects had significant improvements in cholesterol values at 6 months, and subjects in both the PGC and the BC groups had significant weight loss.Conclusions MNT provided by dietitians resulted in significant improvements in medical and clinical outcomes in both the BC and PGC groups and is beneficial to persons with NIDDM. Persons with a duration of diabetes longer than 6 months tended to do better with PGC than with BC. Because of the upward trend in glucose levels after 3 months, ongoing MNT by dietitians is important for long-term metabolic control. J Am Diet Assoc. 1995; 95:1009-1017.     

Dietetic practice in the management of gestational diabetes mellitus: A survey of Australian dietitians

Aim: To examine current Australian dietetic practice in the management of gestational diabetes, to identify models of dietetic care and to determine the need for national evidence‐based dietetic practice guidelines for gestational diabetes. Methods: A 55‐item cross‐sectional survey of Australian dietitians practicing in the area of gestational diabetes was undertaken. Participants were recruited via Dietitians Association of Australia interest group membership, public and private hospital maternity and diabetes services across Australia. The survey examined dietetic service provision, interventions, management recommendations, postnatal care, current guideline use and the perceived need for Australian evidence‐based dietetic management guidelines. Results: A total of 220 eligible dietitians participated in the survey. The majority (77%) reported that all women with gestational diabetes attending their service were referred to a dietitian. Group (33%) and individual consults (93%) were provided and 67% provided one to two dietetic consults per client. Fifty‐four per cent (54%) believed that their service currently offered adequate antenatal dietetic interventions and 8% adequate postnatal follow up for women with gestational diabetes. There were differences in the implementation of medical nutrition therapy by Australian dietitians in regards to nutrient recommendations. However, consistency was seen in key components of nutrition education. Dietitians perceived that there was a need for evidence‐based gestational diabetes dietetic practice guidelines (86%) and nutrition recommendations (87%). Conclusion: The survey results strongly indicate there is a need for evidence‐based gestational diabetes practice guidelines and nutritional recommendations and provide baseline data for future practice of Australian dietitians working in gestational diabetes.     

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

It is the position of the Academy of Nutrition and Dietetics that for adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective. MNT provided by RDNs is also successful and essential to preventing progression of prediabetes and obesity to type 2 diabetes. It is essential that MNT provided by RDNs be integrated into health care systems and public health programs and be adequately reimbursed. The Academy’s evidence-based nutrition practice guidelines for the prevention of diabetes and the management of diabetes document strong evidence supporting the clinical effectiveness of MNT provided by RDNs. Cost-effectiveness has also been documented. The nutrition practice guidelines recommend that as part of evidence-based health care, providers caring for individuals with prediabetes or type 2 diabetes should be referred to an RDN for individualized MNT upon diagnosis and at regular intervals throughout the lifespan as part of their treatment regimen. Standards of care for three levels of diabetes practice have been published by the Diabetes Care and Education Practice Group. RDNs are also qualified to provide additional services beyond MNT in diabetes care and management. Unfortunately, barriers to accessing RDN services exist. Reimbursement for services is essential. Major medical and health organizations have provided support for the essential role of MNT and RDNs for the prevention and treatment of type 2 diabetes.     

Medical nutrition therapy for the prevention and treatment of unintentional weight loss in residential healthcare facilities

OBJECTIVES: To identify the rate of unintentional weight loss (UWL) in adults following their admission into residential healthcare facilities, assess the effectiveness of a new medical nutrition therapy (MNT) protocol for the prevention and treatment of UWL, and describe nutrition assessment and intervention activities of dietitians. DESIGN: Prospective intervention study in which volunteer dietitians were randomly assigned to usual nutrition care (UC) or MNT protocol care (MNT-PC) groups. Dietitians recruited newly admitted residents and tracked their weights for up to 6 months using standardized weighing procedures. Data on weight outcomes and nutrition care activities were abstracted from medical records and compared between study groups. Subjects/settings Thirty-one dietitians from 29 facilities completed the field test (16 MNT-PC, 13 UC). Medical record data were available for 394 residents (223 MNT-PC, 171 UC), and complete weight trend data were available for 364 residents (200 MNT-PC, 164 UC). INTERVENTION: The new MNT protocol for UWL in residential facilities emphasized assessment; intervention (including weighing frequency); communication with staff, medical doctor, family, and resident; and reassessment. Main outcome measures Rate of UWL and weight status 90 days after admission and weight status 90 days after identification of UWL. Statistical analyses Chi;(2), Independent t test, analysis of variance, and multiple regression using the general linear model. RESULTS: Fourteen of 364 residents (4%) were admitted with significant preexisting weight loss, which was successfully treated in eight residents during the first 90 days. Substantial unintentional weight loss (>or=5% in any 30 days) developed in 78 residents (21%). MNT-PC dietitians were more likely to identify UWL. When UWL was identified, and, after providing nutrition care to these residents for an additional 90 days, 32 of 61 residents (52%) maintained or gained weight. Dietitians in UC and MNT-PC groups were equally successful in treating preexisting or postadmission unintentional weight loss when it was identified. Differences were found in nutrition care activities. MNT-PC dietitians reported more nutrition assessment activities, whereas UC dietitians reported more intervention activities. Conclusions/applications Nutrition care protocols with standardized weighing procedures can increase the identification of UWL in the residential healthcare environment. Improved identification supports the additional assessment activities used by MNT-PC dietitians. Similar outcomes for UC and MNT-PC groups when UWL was identified indicate that usual nutrition care was already a high standard of care for intervention.     

Nutrition Management in Women with Gestational Diabetes Mellitus: A Review by ADA's Diabetes Care and Education Dietetic Practice Group

Gestational diabetes mellitus (GDM) is the most common medical disorder complicating pregnancy that requires the services of a registered dietitian. Despite three international workshops on GDM, many questions remain regarding its epidemiology, pathophysiology, screening, diagnosis, and management. Registered dietitians encounter these controversial issues when working with women referred for GDM education and counseling. Nutrition intervention remains the cornerstone of therapy. The purpose of this article is not to provide practice guidelines but to review the literature and current practices in research centers across the United States. Registered dietitians are in a position to individualize nutrition care to each woman's needs and to participate in the decision-making process of nutrition management. J Am Diet Assoc. 1995; 95:460–467.     

A review of guidelines for nutrition care of renal patients.

The third edition of the Guidelines for Nutrition Care of Renal Patients has been developed to follow the American Dietetic Association's Medical Nutrition Therapy (MNT) Protocol format and to further assist dietitians in providing optimal and consistent care to renal patients. The guidelines define the level, content, and frequency of nutrition care that is appropriate based on the best available scientific information and expert opinion. Seven separate guidelines, primarily written for care provided in the outpatient setting, are defined in the publication. Each guideline focuses on a different patient population and/or treatment modality for renal disease: Pre-End-Stage Renal Disease, Hemodialysis and Peritoneal Dialysis, Hospitalized Dialysis, Transplantation, Acute Renal Failure, Enteral/Parenteral Nutrition Support, and Pregnancy in Renal Disease. The Guidelines for Nutrition Care of Renal Patients, Third Edition is meant to support and assist dietitians as providers of MNT in kidney disease, to provide uniform treatment care guidelines and nutritional status identification criteria for all aspects of kidney disease and its complications, and to help secure the dietitian as the provider of these services for optimum cost-effective care. The guidelines should help to increase effectiveness of care by promoting consistency among practitioners and should facilitate the measurement of the quality and effectiveness of care.     

Ⅱ型糖尿病的营养治疗与肠内营养支持

营养治疗是Ⅱ型糖尿病综合治疗的基本组成部分。本介绍了美国糠尿病协会（ADA）2000年提出的营养治疗的目标，以及基于现有的临床经验和普遍认识而提出的热量及营养素推荐存量标准。对于难以累口摄取自然膳食的糖尿病患，应首选肠内营养。密切监测血糖、糖化血红蛋白、血脂、血压、体重及肾功能的代谢指标以及生活方式等，是保证治疗成功的关键。     

Guidelines for Medical Nutrition Therapy in Gestational Diabetes Mellitus: Systematic Review and Critical Appraisal

BackgroundMedical nutrition therapy is the cornerstone of gestational diabetes mellitus treatment. However, guidelines often present contradictory guidance to health care practitioners.ObjectiveTo systematically review and critically appraise medical nutrition therapy guidelines for treating patients with gestational diabetes mellitus.DesignWe searched Medline, the Cochrane Library, Guidelines International Network, and Google Scholar to retrieve clinical practice guidelines (CPGs) for medical nutrition therapy in gestational diabetes mellitus from professional or governmental organizations, published in English, between January 1, 2007, and November 24, 2018. CPGs were reviewed and appraised using the Appraisal of Guidelines, Research, and Evaluation II instrument.ResultsOf 1,286 retrieved articles, 21 CPGs fulfilled the inclusion criteria. CPGs of the Academy of Nutrition and Dietetics, Diabetes Canada, and Malaysia Health Technology Assessment Section received the greatest overall scores and the highest scores concerning rigor of recommendations development. Many CPGs failed to involve multidisciplinary teams in their development, including patients, and often, dietitians. Applicability of the recommendations was low, lacking facilitators and tools to enhance implementation. Many CPGs demonstrated low editorial independence by failing to disclose funding and competing interests. More medical nutrition therapy recommendations were incorporated in the Academy of Nutrition and Dietetics and Malaysia Health Technology Assessment Section CPGs. The Malaysia Health Technology Assessment Section, Diabetes Canada, Academy of Nutrition and Dietetics, and Endocrine Society guidelines were recommended by the review panel herein without modifications. Overall, the CPGs suggested the consumption of adequate protein and the selection of foods with low glycemic index, divided into three main meals and two to four snacks. Weight gain recommendations were mostly based on the Institute of Medicine body mass index thresholds.ConclusionsWith few exceptions, the main developmental limitations of the appraised CPGs involved low rigor of recommendations development, lack of multidisciplinary stakeholder involvement, low applicability, and inadequate editorial independence. This indicates a need for developing more clear, unbiased, practical, and evidence-based CPGs.     

Practice guidelines for nutrition care by dietetics practitioners for outpatients with non-insulin-dependent diabetes mellitus: consensus statement.

In summary, nutrition practice guidelines for dietitians who provide outpatient care for persons with NIDDM provide a roadmap for nutrition care that allows for consistency in individualized care. A field test that compares care according to practice guidelines with usual or basic care can provide evidence, based on medical, education/behavior, and cost outcomes, that practice guidelines are not only reasonable and realistic but also effective.     

The Effect of Medical Nutrition Therapy by a Registered Dietitian Nutritionist in Patients with Prediabetes Participating in a Randomized Controlled Clinical Research Trial

BackgroundPrior studies have provided evidence that lifestyle change prevents or delays the occurrence of type 2 diabetes mellitus. The challenge is to translate research evidence for type 2 diabetes mellitus prevention into health care settings.ObjectiveWe investigated the effect of medical nutrition therapy (MNT) compared with usual care on fasting plasma glucose values, glycated hemoglobin (HbA1c), serum lipid levels, and Diabetes Risk Score, from baseline to the end of a 12-week intervention in overweight or obese adults with prediabetes.DesignProspective, randomized, parallel group study of 76 adults with impaired fasting plasma glucose or an HbA1c of 5.7% to 6.4%, recruited between April 2010 and May 2011 who completed a 12-week intervention period.Main outcome measuresThe primary outcome measure was fasting plasma glucose. Secondary outcome measures were HbA1c, serum lipid levels, and Diabetes Risk Score.Statistical analysesA factorial repeated measures analysis of variance was used to make comparisons between the two groups (the MNT and usual care groups) and two measures of time (baseline and 12 weeks postintervention). Data analysis was performed using the Statistical Package for the Social Sciences (release 19.0, 2010, SPSS Inc).ResultsThere was a significant interaction for group assignment and HbA1c (P=0.01), with the MNT group experiencing significantly lower HbA1c levels than the usual care group (5.79% vs 6.01%) after the 12-week intervention. There was a significant interaction for group assignment and Diabetes Risk Score (P=0.001). Diabetes Risk Score for the MNT group decreased from 17.54±3.69 to 15.31±3.79 compared with the usual care group score, which went from 17.23±4.69 to 16.83±4.73. Regardless of group assignment, both groups experienced a reduction in total cholesterol (P=0.01) and low-density lipoprotein cholesterol (P=0.04) level.ConclusionsThe results demonstrate that individualized MNT is effective in decreasing HbA1c level in patients diagnosed with prediabetes.     

Guidelines vs practice in the delivery of diabetes nutrition care

The American Dietetic Association and the American Diabetes Association have published recommendations for the nutrition care of people with diabetes. However, the frequency of this care is rarely documented. As part of a study of diabetes care and education practices, the Michigan Diabetes Research and Training Center collected extensive data from 440 randomly selected adults who receive diabetes care from community physicians. These data provided a basis for comparison between diabetes nutrition care as recommended and as delivered in typical American communities. In this population (mean AGE = 61 years; 54% women), 89% (393) had non-insulin-dependent diabetes mellitus (NIDDM). Of these, 152 were managed with insulin (NIDDM/I) and 241 were not managed with insulin (NIDDM/NI). Most of the NIDDM/NI group was overweight (71%) and had elevated levels of glycated hemoglobin (62%) and serum cholesterol (53%). Yet they were significantly less likely than those with NIDDM/I to see a dietitian. The most frequently reported reason for not seeing a dietitian was that a physician had not referred them (53%). More than 90% of those with NIDDM/I or NIDDM/NI who were referred to a dietitian saw one. Because this population was from randomly selected communities, physicians, and patients, the results are probably generalizable to other regions of the United States. This study shows that in community practice, insulin use is the primary marker of the need for nutrition intervention, and the lack of physician referred to a dietitian is an important barrier to people receiving recommended diabetes nutrition care.     

Position of the American Dietetic Association: nutrition services in managed care

It is the position of the American Dietetic Association that medical nutrition therapy is an essential component of disease management and healthcare provided by managed care organizations, and that such care must be provided by qualified nutrition professionals. Compared with traditional fee-for-service reimbursement systems, managed care presents new opportunities for dietetics professionals. Until recently, the lack of billing infrastructure has handicapped nutrition providers who wish to bill for their services and has made it difficult to track the outcomes of nutrition care. With the publication of current procedure terminology codes for medical nutrition therapy (MNT) and the implementation of MNT benefits in Medicare part B for diabetes and nondialysis kidney disease, commercial payers, including managed care organizations (MCOs) are likely to implement or expand their coverage of MNT. A large body of evidence supports the efficacy and cost-effectiveness of MNT coverage within managed care plans. This evidence includes cost analyses of conditions treated by MNT, and clinical trial data confirming the efficacy of MNT in improving patient outcomes. MNT is also an important part of national standards of care for many chronic disease conditions. Based on evidence supporting the role of MNT in improving patient outcomes, the Institute of Medicine (IOM) recommended that MNT services be reimbursed by Medicare when patients are referred by a physician. Provision of appropriate MNT can also help MCOs meet accreditation and quality standards established by entities such as the National Committee for Quality Assurance and the Joint Commission for the Accreditation of Health Care Organizations. Much of the work required to secure a place for MNT in MCOs will be done at the practitioner level, by nutrition professionals themselves. Registered dietitians must market MNT to their customers in managed care by addressing the needs of each player. By emphasizing the importance of MNT and other cost-effective forms of preventive care and disease management, MCOs will be well positioned to improve population health at modest cost.     

Clinical and cost outcomes of medical nutrition therapy for hypercholesterolemia: a controlled trial

OBJECTIVE: To compare the results and cost-effectiveness of a cholesterol lowering protocol implemented by registered dietitians with cholesterol lowering advice by physicians. DESIGN: Six month randomized controlled trial, cost-effectiveness analysis. Subjects included 90 ambulatory care patients (60 men, 30 women), age range 21 to 65 years, with hypercholesterolemia and not taking hypolipidemic drugs. Patients were randomly assigned to receive medical nutrition therapy (MNT) from dietitians using a NCEP based lowering protocol or usual care (UC) from physicians. Outcome measures were plasma lipid profiles, dietary intake, weight, activity, patient satisfaction, and costs of MNT. Changes from baseline for each variable of interest were compared between treatment groups using analysis of covariance controlling for baseline value of the variable and gender. RESULTS: MNT achieved a 6% decrease in total and LDL cholesterol levels at 3 and 6 months compared with a 1% increase and a 2% decrease in both values at 3 and 6 months with UC (P<.001 and P<.05, respectively). Weight loss (1.9 vs 0 kg, P<.001) and dietary intake of saturated fat (7% of energy vs 10%, P<.001) were better in the MNT than the UC group. The additional costs of MNT were $217 per patient to achieve a 6% reduction in cholesterol and $98 per patient to sustain the reduction. The cost-effectiveness ratio for MNT was $36 per 1% decrease in cholesterol and LDL level. APPLICATIONS/CONCLUSIONS: MNT from registered dietitians is a reasonable investment of resources because it results in significantly better lipid, diet, activity, weight, and patient satisfaction outcomes than UC.     

Position of the American Dietetic Association: Integration of Medical Nutrition Therapy and Pharmacotherapy

It is the position of the American Dietetic Association that medical nutrition therapy (MNT), as a part of the Nutrition Care Process, should be the initial step and an integral component of medical treatment for management of specific disease states and conditions. If optimal control cannot be achieved with MNT alone and concurrent pharmacotherapy is required, the Association promotes a team approach and encourages active collaboration among registered dietitians (RDs) and other health care team members. RDs use MNT as a cost-effective means to achieve significant health benefits by preventing or altering the course of diabetes, obesity, hypertension, disorders of lipid metabolism, heart failure, osteoporosis, celiac disease, and chronic kidney disease, among other diseases. Should pharmacotherapy be needed to control these diseases, a team approach in which an RD brings expertise in food and nutrition and a pharmacist brings expertise in medications is essential. RDs and pharmacists share the goals of maintaining food and nutrient intake, nutritional status, and medication effectiveness while avoiding adverse food-medication interactions. RDs manipulate food and nutrient intake in medication regimens based on clinical significance of the interaction, medication dosage and duration, and recognition of potential adverse effects related to pharmacotherapy. RDs who provide MNT using enhanced patient education skills and pharmacotherapy knowledge are critical for successful outcomes and patient safety.     

个体化医学营养治疗对妊娠期糖尿病患者营养代谢的影响

目的：研究个体化医学营养治疗（MNT）对妊娠期糖尿病患者（GDM）营养代谢的影响。方法将2010年1月至2012年7月在首都医科大学附属北京同仁医院产科确诊为妊娠糖尿病并接受营养科MNT的87例GDM患者作为研究组,同时期未接受营养科MNT的76例GDM患者作为对照组,研究组内又分为血糖达标组40例和血糖不达标组47例,首次营养科就诊时记录孕12周建档、孕24周糖尿病筛查和分娩前各项指标,比较治疗前后空腹血糖、餐后2小时血糖、血清总蛋白、血清白蛋白、血红蛋白、甘油三酯及胆固醇等指标变化。结果①分娩前研究组空腹血糖和餐后2小时血糖均低于对照组,血红蛋白和高密度脂蛋白胆固醇均高于对照组,有显著性差异（ t值分别为0．006、0．039、0．000、0．008,均P＜0．05）;血清总蛋白、血清白蛋白、甘油三酯、总胆固醇、低密度脂蛋白胆固醇也高于对照组,但无无显著性差异（P＞0．05）;②研究组内血糖达标者与不达标者分娩前的血红蛋白、血清总蛋白、血清白蛋白、甘油三酯、总胆固醇、低密度脂蛋白胆固醇和高密度脂蛋白胆固醇7项指标均无显著性差异（P＞0．05）;③分娩前1周与建档时相比,研究组空腹血糖、餐后2h血糖、总蛋白和白蛋白明显下降,血红蛋白、甘油三酯、总胆固醇、低密度脂蛋白明显升高,有显著性差异（t值分别为2．185、1．152、－1．244、2．185、1．976、－1．865、－1．532、－0．567,均P＜0．05）。高密度脂蛋白胆固醇升高,但无显著性差异（P＞0．05）。结论 MNT可使GDM糖代谢有效改善,预防和纠正孕期贫血,但是对脂代谢影响有限。孕期生理变化是导致脂代谢变化的主要原因,以往将脂代谢用于妊娠期医学营养治疗效果的评价可能不妥。     

营养治疗对妊娠期糖尿病孕妇的影响初探

目的：探讨营养治疗对妊娠期糖尿病孕妇的影响。方法：48例妊娠期糖尿病孕妇,随机分为观察组（营养治疗＋胰岛素治疗）24例和对照组（胰岛素治疗）24例,对两组疗效进行对比分析。结果：观察组孕妇在血糖的改善与对照组比较无显统计学意义（P〉0.05）;观察组并发症发生率为12.5％,对照组并发症发生率为16.7％,两组并发症发生率差异有统计学意义（P〈0.05）。结论：对采用胰岛素治疗加营养治疗的妊娠期糖尿病,与常规单纯胰岛素治疗对比,临床疗效显著,且并发症少,安全可靠,为妊娠期糖尿病治疗的首选方法之一。     

The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults

This article reviews the evidence and nutrition practice recommendations from the American Dietetic Association's nutrition practice guidelines for type 1 and type 2 diabetes in adults. The research literature was reviewed to answer nutrition practice questions and resulted in 29 recommendations. Here, we present the recommendations and provide a comprehensive and systematic review of the evidence associated with their development. Major nutrition therapy factors reviewed are carbohydrate (intake, sucrose, non-nutritive sweeteners, glycemic index, and fiber), protein intake, cardiovascular disease, and weight management. Contributing factors to nutrition therapy reviewed are physical activity and glucose monitoring. Based on individualized nutrition therapy client/patient goals and lifestyle changes the client/patient is willing and able to make, registered dietitians can select appropriate interventions based on key recommendations that include consistency in day-to-day carbohydrate intake, adjusting insulin doses to match carbohydrate intake, substitution of sucrose-containing foods, usual protein intake, cardioprotective nutrition interventions, weight management strategies, regular physical activity, and use of self-monitored blood glucose data. The evidence is strong that medical nutrition therapy provided by registered dietitians is an effective and essential therapy in the management of diabetes.