Dietary Considerations for Patients With Type 2 Diabetes

The references listed below are used in this DynaMed topic primarily to support background information and for guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text along with the evidence summaries.

1. American Diabetes Association (ADA). Standards of Care in Diabetes 2024. Diabetes Care. 2024 Jan 1;47(Supplement_1):S1-S321 PDF.
2. MacLeod J, Franz MJ, Handu D, et al. Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition Intervention Evidence Reviews and Recommendations. J Acad Nutr Diet. 2017 Oct;117(10):1637-58, executive summary can be found at AND 2015.
3. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019 May;42(5):731-54.

• American Diabetes Association (ADA) evidence grading system for clinical practice recommendations:
  • Grade A:
    • Clear evidence from well-conducted, generalizable, randomized controlled trials (RCTs) that are adequately powered, including evidence from well-conducted multicenter trial or meta-analysis that incorporated quality ratings in analysis
    • Supportive evidence from well-conducted RCTs that are adequately powered, including evidence from well-conducted trial at ≥ 1 institution or meta-analysis that incorporated quality ratings in analysis
  • Grade B:
    • Supportive evidence from well-conducted cohort studies, including evidence from well-conducted prospective cohort study, registry, or meta-analysis of cohort studies
    • Supportive evidence from well-conducted case-control study
  • Grade C:
    • Supportive evidence from poorly controlled or uncontrolled studies:
      • Evidence from RCTs with ≥ 1 major or ≥ 3 minor methodologic flaws that could invalidate results
      • Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
      • Evidence from case series or case reports
    • Conflicting evidence with weight of evidence supporting recommendation
  • Grade E - expert consensus or clinical experience
  • Reference - ADA 2024 standards of care in diabetes: introduction and methodology (Diabetes Care 2024 Jan 1;47(Supplement_1):S1)
• Academy of Nutrition and Dietetics (AND) grading system for recommendations:
  • Strength of recommendation:
    • Strong:
      • Benefits of recommended approach clearly exceed harms (or harms exceed benefits in case of strong negative recommendation)
      • Quality of supporting evidence is excellent/good, or may be made based on lesser evidence when high-quality evidence is impossible to obtain and anticipated benefits strongly outweigh harms
    • Fair:
      • Benefits exceed harms (or harms clearly exceed benefits in case of negative recommendation), but quality of supporting evidence is not as strong
      • May be made based on lesser evidence when high-quality evidence is impossible to obtain and anticipated benefits strongly outweigh harms
    • Weak - quality of evidence that exists is suspect, or well-done studies show little clear advantage to one approach versus another
    • Consensus - expert opinion supports guideline recommendation; available evidence did not present consistent results, or controlled trials were lacking
    • Insufficient evidence - lack of pertinent evidence and/or unclear balance between benefits and harms
  • Category of recommendation:
    • Imperative statement - broadly applicable to target population and do not impose restraints on pertinence
    • Conditional statement - clearly define specific situations or populations
  • Reference - AND practice guideline on diabetes type 1 and 2 nutrition for adults (J Acad Nutr Diet 2017 Oct;117(10):1637), executive summary can be found at AND 2015

• The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
• Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s) and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
• In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
• We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to classify synthesized recommendations as Strong or Conditional.
  • Strong recommendations may be used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
  • Conditional recommendations may be used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms).
  • Conditional recommendations may be used when clinicians disagree in judgments of the relative benefit and harm or have limited confidence in their judgments.
  • Conditional recommendations may also be used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
• DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology.
  • Recommendations are explicitly labeled as Strong recommendations or Conditional recommendations when a qualified organization has explicitly deliberated on making such a recommendation.
  • Recommendations are phrased to match the strength of recommendation.
    • Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients.
    • Conditional recommendations use "consider" or "suggested" phrasing.
  • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
  • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
  • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

• DynaMed topics are created and maintained by the DynaMed Editorial Team and adhere to evidence-based methodology and inclusive language standards.
• All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
• DynaMed content includes Practice-Changing Updates, with support from our partner, McMaster University.

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