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Introduction: This study of adults with type 2 diabetes employed a non-inferiority hypothesis to investigate whether an innovative lifestyle focused on minimizing postnutrient blood glucose (BG) excursions (glycemic excursion minimization (GEM)) would be equivalent or superior to conventional weight loss (WL) therapy in regard to reducing HbA1c, and superior to WL when investigating physical, behavioral and psychological secondary outcomes. The impact of BG feedback on GEM efficacy was also investigated., Research Design and Methods: 178 adults with type 2 diabetes for ≤10 years, HbA1c ≥6.8%, and not using insulin were randomized to WL (n=40) or one of three versions of GEM. Didactic (GEM-D, n=39) taught participants to choose low-glycemic load foods, reduce sedentary time and increase moderate routine physical activity. GEM-S (n=51) received GEM-D and systematically measured BG before and after meals and physical activity to educate and motivate food and activity choices. GEM-C (n=48) received GEM-D with continuous glucose monitoring feedback. All participants received 6 hours of group training and BG and activity monitors. Before and 3 months after treatment, participants were assessed for HbA1c, lipids, weight, routine physical activity, nutrition, depression, diabetes empowerment and distress., Results: GEM versions did not differ in primary or secondary outcomes, so they were combined for analyses. While WL reduced body mass index (BMI) (p=0.005), GEM demonstrated a greater reduction in HbA1c (p=0.005), BMI (p=0.013), carbohydrate intake (p=0.001), BG response to a glucose challenge (p=0.02), and cardiovascular risk (p=0.003). Only GEM participants significantly improved diabetes empowerment, diabetes distress, depressive symptoms, steps/day, and active hours and reduced calories/day. Neither intervention had negative side effects., Conclusions: GEM is an effective alternative to WL with respect to physical, behavioral and psychosocial outcomes., Trial Registration Number: NCT03196895., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In the 1990s, the American Dietetic Association (ADA) began developing nutrition practice guidelines for registered dietitians (RDs) and evaluating how their use affected clinical outcomes. Clinical trials and outcomes research report that diabetes medical nutrition therapy, delivered using a variety of nutrition interventions and multiple encounters, is effective in improving glycemic and other metabolic outcomes. The process of developing nutrition practice guidelines has evolved into evidence-based nutrition practice guidelines, which are disease/condition-specific recommendations and toolkits. An expert work group identified important clinical questions related to diabetes nutrition therapy. Research studies were analyzed and evidence summaries and conclusion statements written and graded for strength of research design. Based on the research conclusions, evidence-based nutrition recommendations and guidelines for adults with type 1 and type 2 diabetes were formulated. The ADA evidence-based nutrition practice guidelines for diabetes are published in the Web-based evidence analysis library. The recommendations are similar to those of the American Diabetes Association, although developed using a different method. To define the RD's professional practice, the ADA has published the Scope of Dietetics Practice Framework, the Standards of Practice and Standards of Professional Performance, and specialized standards for the RD in diabetes nutrition care. The latter defines the knowledge, skills, and competencies required by RDs to provide diabetes care at the generalist, specialist, and advanced practice level.

Research supports the importance of medical nutrition therapy in achieving diabetes treatment goals. For persons requiring insulin therapy, the first priority is to integrate an insulin regimen into the patient's lifestyle. For type 2 diabetes, the priority is to focus on lifestyle strategies (that is, nutrition and exercise) that will improve metabolic outcomes at diagnosis and as the disease progresses. Patients with diabetes need nutrition recommendations that are supported by scientific evidence and that can be easily understood and translated into everyday life. To achieve positive outcomes, a coordinated team effort that provides continued education and support is essential.