By Wiam Ouahab, PharmD Candidate 2025 and Helen Berlie, BHS, PharmD, BCACP
Introduction
Medical nutrition therapy (MNT) is essential to the management of Type 2 Diabetes Mellitus (T2DM). Current American Diabetes Association (ADA) guidelines recommend referring patients to a registered dietitian nutritionist (RDN) for MNT upon diagnosis and subsequently as needed. To facilitate MNT, diabetes self-management education and support (DSMES) is also recommended.(1) Unfortunately, these referrals may not always be made, and when they are, successful follow-through may not always occur. Furthermore, nutrition counseling during primary care visits is often challenging. Patients may also turn to the internet, which can have misleading information.(2) Therefore, nutrition education provided by pharmacists can be critical. Effective nutrition counseling includes identifying barriers to proper nutrition. Food insecurity and affordability are common barriers that affect patients with diabetes (16%) more than those without diabetes (9%).(3) Food literacy level and health numeracy are other factors that may limit understanding of proper food and nutrition intake.(1) These barriers hinder informed decision-making and impede the use of numerical information such as macronutrient management and carbohydrate counting. Unique cultural and personal preferences of each patient can add another layer of complexity.(2) To maximize our efforts as pharmacists, we should be able to provide contemporary nutrition guidance and bridge the counseling provided by RDN and DSMES.
History of ADA Nutrition Guidance
In the 1989 ADA Standards of Medical Care for Patients with Diabetes Mellitus, the only stated nutrition guidance was to provide “Individual nutrition recommendations and instructions, preferably by a dietician.”(4) Over time, nutrition guidance expanded and became more detailed. For many years, the detailed guidance included counting macronutrients, which is a cumbersome approach. Over time, this approach was deemed to be inconclusive without evidence for optimal macronutrient intake. In turn, the ADA no longer supports specific proportions of carbohydrates, fats, and proteins. It is also important to note that the word “diet” is no longer used. Overall, there has been a shift away from complicated nutrition guidance, and current MNT goals are highlighted below.(1)
Summary of MNT Goals:
Improve overall health by incorporating a variety of eating patterns with nutrient dense foods and appropriate portion sizes.
Address patient barriers and individual needs (cultural, health literacy, access to food, etc.).
Provide nonjudgmental support regarding food choices and only discourage the avoidance of certain foods as indicated by scientific evidence.
Recommend practical tools for developing healthy eating patterns (avoid recommending individual macronutrients, micronutrients, or single foods).
Recent ADA MNT Guidelines
A key aspect of updated MNT guidelines is the emphasis on simplified nutrition guidance, such as eliminating specific macronutrient rules. Notably, this shift is observed from the 2013 to 2014 ADA nutrition recommendations.(5,6) More recently, technological advances like continuous glucose monitors enable instant feedback on how certain foods impact glucose levels, without the need for extensive nutrition knowledge or training. To facilitate patient-specific counseling, the ADA highlights differences between “eating/food patterns,” “dietary approaches,” and “eating/meal planning.” Although this language can appear confusing, there are clear differences between these three strategies. To simplify, they can be thought of as ‘food patterns’ (e.g. Mediterranean style), ‘dietary approaches’ (e.g. plate method), and ‘meal planning.’ Meal planning is the updated terminology for what was previously referred to as a “diet.” Furthermore, specific meal planning is suggested to be provided by an RDN. Pharmacists can effectively provide nutrition counseling using ‘food patterns’ and ‘dietary approaches.’ See Figure 1 for specific examples of each.(1) Due to the lack of head-to-head comparisons between the different eating strategies, it is important to note that no method is preferred over another. The ADA nutrition therapy Consensus Report recommends a flexible, patient-specific approach, focused on key nutrition guidance (listed below).(7)
Key Nutrition Guidance:
Reduce overall carbohydrate intake (most evidence for improving glycemia)
Emphasize consumption of non starchy vegetables and whole foods
Minimize consumption of added sugars, refined grains and processed foods
Figure 1: Menu of ADA Medical Nutrition Recommendations (1,2,7)
Conclusion
MNT is integral to diabetes management. When possible, patients should be referred to a RDN and enrolled in a DSMES program for more personalized nutrition counseling and/or meal planning. Notably, research suggests that there is no ideal macronutrient distribution for patients with T2DM. Recent ADA guidelines emphasize flexibility along with simplified nutrition goals and guidance. Pharmacists can use the menu of ‘food patterns’ and ‘dietary approaches’ to provide user-friendly, patient-centered, contemporary nutrition guidance.
1. ElSayed NA, Aleppo G, Bannuru RR, et al. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(Supplement_1):S77-S110. doi:10.2337/dc24-S005.
2. Reynolds A, Mitri J. Dietary Advice For Individuals with Diabetes. (Feingold KR, Anawalt B, Blackman MR, eds.). Endotext [Internet]; 2000.
3. Kirby JB, Bernard D, Liang L. The Prevalence of Food Insecurity Is Highest Among Americans for Whom Diet Is Most Critical to Health. Diabetes Care. 2021;44(6):e131-e132. doi:10.2337/dc20-3116.
4. American Diabetes Association. Standards of Medical Care for Patients With Diabetes Mellitus. Diabetes Care. 1989;12(5):365-368. doi:10.2337/diacare.12.5.365.
5. American Diabetes Association. Standards of Medical Care in Diabetes—2013. Diabetes Care. 2013;36(Supplement_1):S11-S66. doi:10.2337/dc13-S011.
6. American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014;37(Supplement_1):S14-S80. doi:10.2337/dc14-S014.
7. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019;42(5):731-754. doi:10.2337/dci19-0014.
Wiam Ouahab
PharmD Candidate 2025
Wayne State University
Eugene Applebaum College of Pharmacy and Health Sciences
Detroit, MI
Helen Berlie, BHS, PharmD, BCACP
Associate Professor, Clinical
Ambulatory Care - Diabetes Specialist
Wayne State University
Eugene Applebaum College of Pharmacy and Health Sciences
Health Centers Detroit Medical Group
Detroit, MI
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