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## Complete Summary

#### GUIDELINE TITLE

Joslin Diabetes Center & Joslin Clinic clinical nutrition guideline for
overweight and obese adults with type 2 diabetes, prediabetes or those
at high risk for developing type 2 diabetes.

#### BIBLIOGRAPHIC SOURCE(S)

Joslin Diabetes Center & Joslin Clinic clinical nutrition guideline for
overweight and obese adults with type 2 diabetes, prediabetes or those
at high risk for developing type 2 diabetes. Boston (MA): Joslin
Diabetes Center; 2005 Sep 30. 6 p. \[61 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Type 2 diabetes and prediabetes

-   Overweight and obesity

#### GUIDELINE CATEGORY

Management\
Prevention

#### CLINICAL SPECIALTY

Endocrinology\
Family Practice\
Internal Medicine\
Nutrition\
Preventive Medicine

#### INTENDED USERS

Dietitians\
Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To support clinical practice and to influence clinical behaviors in
    order to improve clinical outcomes and assure that patient
    expectations are reasonable and informed

-   To assist primary care physicians, specialists, and other healthcare
    providers in individualizing the care of and set goals for adult,
    non-pregnant patients with type 2 diabetes or individuals at high
    risk for developing type 2 diabetes

#### TARGET POPULATION

-   Non-pregnant, overweight or obese\* adults with type 2 diabetes or
    prediabetes

-   Individuals at high risk for developing type 2 diabetes

\*Body mass index (BMI) \>25 kg/m^2^ or waistline \>40\"/102 cm (men),
\>35\"/88 cm (women). For Asian populations (South Asian Indians, East
Asians and Malays) a BMI \>23 kg/m^2^ and a waistline \>35\"/90 cm in
men or \>31\"/80 cm in women is considered.

#### INTERVENTIONS AND PRACTICES CONSIDERED

Gradual weight reduction based on individualized balanced meal plan of
carbohydrate, protein, and fat; physical activity and behavioral
modification; and weight management medications (if indicated)

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

1.  Indicates strong scientific evidence to support this recommendation

2.  Indicates some scientific evidence to support this recommendation

3.  Indicates limited scientific evidence to support this recommendation

4.  Indicates no available evidence but clinical experience and expert
    consensus support this recommendation

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Guidelines are developed and approved through the Clinical Oversight
Committee that reports to the Chief Medical Officer of the Joslin
Diabetes Center, Joslin Clinic Inc. This guideline was approved by the
Joslin Clinical Oversight Committee on 9/30/05.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Strength of scientific evidence (1-4) definitions are provided at the
end of the \"Major Recommendations\" field.

+------------+--------------+--------+---+------------+--------------+
| **Target   |              |        |   |            |              |
| I          |              |        |   |            |              |
| ndividuals |              |        |   |            |              |
| and        |              |        |   |            |              |
| General    |              |        |   |            |              |
| Goals of   |              |        |   |            |              |
| Clinical   |              |        |   |            |              |
| Nutrition  |              |        |   |            |              |
| G          |              |        |   |            |              |
| uideline** |              |        |   |            |              |
+============+==============+========+===+============+==============+
| ***Target  | **Body Mass  | \> 25  |   | **Type 2   |              |
| Pop        | Index        | k      |   | Diabetes\  |              |
| ulation*** | (BMI)**      | g/m^2^ |   | \          |              |
|            |              |        |   | *or***     |              |
+------------+--------------+--------+---+------------+--------------+
|            |              |        | * |            |              |
|            |              |        | * |            |              |
|            |              |        | * |            |              |
|            |              |        | a |            |              |
|            |              |        | n |            |              |
|            |              |        | d |            |              |
|            |              |        | * |            |              |
|            |              |        | * |            |              |
|            |              |        | * |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***or*       | \>     |   | **Pre      | Impaired     |
|            | Waistline**  | 40     |   | diabetes** | glucose      |
|            |              | \"/102 |   |            | tolerance    |
|            |              | cm     |   |            | (IGT)\       |
|            |              | (men)\ |   |            | Impaired     |
|            |              | \>     |   |            | fasting      |
|            |              | 3      |   |            | glucose      |
|            |              | 5\"/88 |   |            | (IFG)        |
|            |              | cm     |   |            |              |
|            |              | (      |   |            |              |
|            |              | women) |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            |              |        |   | ***or***   |              |
+------------+--------------+--------+---+------------+--------------+
|            |              |        |   | **High     | The          |
|            |              |        |   | Risk for   | Metabolic    |
|            |              |        |   | Type 2     | Syndrome     |
|            |              |        |   | diabetes** | (ATP III     |
|            |              |        |   |            | Criteria)\   |
|            |              |        |   |            | Family       |
|            |              |        |   |            | history of   |
|            |              |        |   |            | type 2       |
|            |              |        |   |            | diabetes     |
|            |              |        |   |            | mellitus     |
|            |              |        |   |            | (DM) (first  |
|            |              |        |   |            | degree       |
|            |              |        |   |            | relative)\   |
|            |              |        |   |            | Confirmed    |
|            |              |        |   |            | diagnosis of |
|            |              |        |   |            | insulin      |
|            |              |        |   |            | resistance   |
|            |              |        |   |            | (e.g., high  |
|            |              |        |   |            | basal        |
|            |              |        |   |            | insulin)     |
+------------+--------------+--------+---+------------+--------------+
|            | For Asian    |        |   |            |              |
|            | populations  |        |   |            |              |
|            | (South Asian |        |   |            |              |
|            | Indians,     |        |   |            |              |
|            | East Asians  |        |   |            |              |
|            | and Malays)  |        |   |            |              |
|            | a BMI \>23   |        |   |            |              |
|            | kg/m^2^ and  |        |   |            |              |
|            | a waistline  |        |   |            |              |
|            | \>35\"/90 cm |        |   |            |              |
|            | in men or    |        |   |            |              |
|            | \>31\"/80 cm |        |   |            |              |
|            | in women is  |        |   |            |              |
|            | considered.  |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| *          | 1.  To       |        |   |            |              |
| **Goals*** |     improve  |        |   |            |              |
|            |     overall  |        |   |            |              |
|            |              |        |   |            |              |
|            |    metabolic |        |   |            |              |
|            |     control  |        |   |            |              |
|            |     while    |        |   |            |              |
|            |              |        |   |            |              |
|            |    achieving |        |   |            |              |
|            |     gradual  |        |   |            |              |
|            |     weight   |        |   |            |              |
|            |              |        |   |            |              |
|            |    reduction |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            |  maintaining |        |   |            |              |
|            |     achieved |        |   |            |              |
|            |     weight   |        |   |            |              |
|            |     loss     |        |   |            |              |
|            |              |        |   |            |              |
|            | 2.  To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     fasting  |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            | postprandial |        |   |            |              |
|            |     h        |        |   |            |              |
|            | yperglycemia |        |   |            |              |
|            |     in order |        |   |            |              |
|            |     to       |        |   |            |              |
|            |     prevent  |        |   |            |              |
|            |     or       |        |   |            |              |
|            |     reduce   |        |   |            |              |
|            |     diabetes |        |   |            |              |
|            |     co       |        |   |            |              |
|            | mplications. |        |   |            |              |
|            |              |        |   |            |              |
|            | 3.  To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     fasting  |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            | postprandial |        |   |            |              |
|            |     hypertri |        |   |            |              |
|            | glyceridemia |        |   |            |              |
|            |     as a     |        |   |            |              |
|            |     major    |        |   |            |              |
|            |     lipid    |        |   |            |              |
|            |              |        |   |            |              |
|            |  abnormality |        |   |            |              |
|            |     in the   |        |   |            |              |
|            |     target   |        |   |            |              |
|            |              |        |   |            |              |
|            |   population |        |   |            |              |
|            |              |        |   |            |              |
|            | 4.  To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     lipid    |        |   |            |              |
|            |     profile  |        |   |            |              |
|            |              |        |   |            |              |
|            |    including |        |   |            |              |
|            |     increase |        |   |            |              |
|            |     of       |        |   |            |              |
|            |              |        |   |            |              |
|            | high-density |        |   |            |              |
|            |              |        |   |            |              |
|            |  lipoprotein |        |   |            |              |
|            |     (HDL)    |        |   |            |              |
|            | -cholesterol |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     decrease |        |   |            |              |
|            |     of       |        |   |            |              |
|            |              |        |   |            |              |
|            |  low-density |        |   |            |              |
|            |              |        |   |            |              |
|            |  lipoprotein |        |   |            |              |
|            |     (LDL)    |        |   |            |              |
|            | -cholesterol |        |   |            |              |
|            |              |        |   |            |              |
|            | 5.  To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     insulin  |        |   |            |              |
|            |              |        |   |            |              |
|            |  sensitivity |        |   |            |              |
|            |     as a     |        |   |            |              |
|            |     major    |        |   |            |              |
|            |              |        |   |            |              |
|            |    precursor |        |   |            |              |
|            |     of type  |        |   |            |              |
|            |     2        |        |   |            |              |
|            |     diabetes |        |   |            |              |
|            |              |        |   |            |              |
|            | 6.  To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     body fat |        |   |            |              |
|            |              |        |   |            |              |
|            | distribution |        |   |            |              |
|            |     and to   |        |   |            |              |
|            |     reduce   |        |   |            |              |
|            |     visceral |        |   |            |              |
|            |     fat      |        |   |            |              |
|            |     burden   |        |   |            |              |
|            |              |        |   |            |              |
|            | 7.  To       |        |   |            |              |
|            |     reduce   |        |   |            |              |
|            |     ca       |        |   |            |              |
|            | rdiovascular |        |   |            |              |
|            |     risk as  |        |   |            |              |
|            |              |        |   |            |              |
|            |    evidenced |        |   |            |              |
|            |     by       |        |   |            |              |
|            |              |        |   |            |              |
|            |  improvement |        |   |            |              |
|            |     of       |        |   |            |              |
|            |              |        |   |            |              |
|            |  endothelial |        |   |            |              |
|            |     function |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            |  endothelial |        |   |            |              |
|            |     markers  |        |   |            |              |
|            |              |        |   |            |              |
|            | 8.  To       |        |   |            |              |
|            |     reduce   |        |   |            |              |
|            |              |        |   |            |              |
|            | inflammatory |        |   |            |              |
|            |              |        |   |            |              |
|            |   cytokines, |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     markers  |        |   |            |              |
|            |     of       |        |   |            |              |
|            |              |        |   |            |              |
|            | inflammation |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            |    increased |        |   |            |              |
|            |              |        |   |            |              |
|            |  coagulation |        |   |            |              |
|            |              |        |   |            |              |
|            | 9.  To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     blood    |        |   |            |              |
|            |     pressure |        |   |            |              |
|            |     as a     |        |   |            |              |
|            |              |        |   |            |              |
|            | contributing |        |   |            |              |
|            |     risk     |        |   |            |              |
|            |     factor   |        |   |            |              |
|            |     for      |        |   |            |              |
|            |     ca       |        |   |            |              |
|            | rdiovascular |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     renal    |        |   |            |              |
|            |     c        |        |   |            |              |
|            | omplications |        |   |            |              |
|            |              |        |   |            |              |
|            | 10. To       |        |   |            |              |
|            |     enhance  |        |   |            |              |
|            |     t        |        |   |            |              |
|            | hermogenesis |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     maintain |        |   |            |              |
|            |     lean     |        |   |            |              |
|            |     body     |        |   |            |              |
|            |     mass     |        |   |            |              |
|            |              |        |   |            |              |
|            | 11. To       |        |   |            |              |
|            |     provide  |        |   |            |              |
|            |     a        |        |   |            |              |
|            |     balanced |        |   |            |              |
|            |     meal     |        |   |            |              |
|            |     plan of  |        |   |            |              |
|            |     c        |        |   |            |              |
|            | arbohydrate, |        |   |            |              |
|            |     protein, |        |   |            |              |
|            |     and fat  |        |   |            |              |
|            |              |        |   |            |              |
|            | 12. To       |        |   |            |              |
|            |     improve  |        |   |            |              |
|            |     overall  |        |   |            |              |
|            |     health   |        |   |            |              |
|            |     through  |        |   |            |              |
|            |              |        |   |            |              |
|            |    increased |        |   |            |              |
|            |     physical |        |   |            |              |
|            |     activity |        |   |            |              |
|            |              |        |   |            |              |
|            | 13. To       |        |   |            |              |
|            |     prevent  |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     treat    |        |   |            |              |
|            |     the      |        |   |            |              |
|            |     chronic  |        |   |            |              |
|            |     c        |        |   |            |              |
|            | omplications |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     diabetes |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| **General  |              |        |   |            |              |
| Gu         |              |        |   |            |              |
| idelines** |              |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| 1.  Con    |              |        |   |            |              |
| sideration |              |        |   |            |              |
|     of     |              |        |   |            |              |
|     recent |              |        |   |            |              |
|            |              |        |   |            |              |
| consistent |              |        |   |            |              |
|     and    |              |        |   |            |              |
|     strong |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     that   |              |        |   |            |              |
|     weight |              |        |   |            |              |
|            |              |        |   |            |              |
|  reduction |              |        |   |            |              |
|            |              |        |   |            |              |
|   improves |              |        |   |            |              |
|            |              |        |   |            |              |
|    insulin |              |        |   |            |              |
|     s      |              |        |   |            |              |
| ensitivity |              |        |   |            |              |
|     and    |              |        |   |            |              |
|            |              |        |   |            |              |
|   glycemic |              |        |   |            |              |
|            |              |        |   |            |              |
|    control |              |        |   |            |              |
|     in     |              |        |   |            |              |
|     type 2 |              |        |   |            |              |
|            |              |        |   |            |              |
|   diabetes |              |        |   |            |              |
|     and    |              |        |   |            |              |
|            |              |        |   |            |              |
|  decreases |              |        |   |            |              |
|     the    |              |        |   |            |              |
|     risk   |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
| developing |              |        |   |            |              |
|     type 2 |              |        |   |            |              |
|            |              |        |   |            |              |
|   diabetes |              |        |   |            |              |
|     in     |              |        |   |            |              |
|     p      |              |        |   |            |              |
| rediabetes |              |        |   |            |              |
|     and    |              |        |   |            |              |
|            |              |        |   |            |              |
|  high-risk |              |        |   |            |              |
|     po     |              |        |   |            |              |
| pulations. |              |        |   |            |              |
|            |              |        |   |            |              |
|  ***Weight |              |        |   |            |              |
|     re     |              |        |   |            |              |
| duction*** |              |        |   |            |              |
|     should |              |        |   |            |              |
|     be     |              |        |   |            |              |
|            |              |        |   |            |              |
| considered |              |        |   |            |              |
|     one of |              |        |   |            |              |
|     the    |              |        |   |            |              |
|     prime  |              |        |   |            |              |
|            |              |        |   |            |              |
| objectives |              |        |   |            |              |
|     of any |              |        |   |            |              |
|            |              |        |   |            |              |
|  nutrition |              |        |   |            |              |
|     recom  |              |        |   |            |              |
| mendations |              |        |   |            |              |
|            |              |        |   |            |              |
|  suggested |              |        |   |            |              |
|     to the |              |        |   |            |              |
|     target |              |        |   |            |              |
|     p      |              |        |   |            |              |
| opulation. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     1)*    |              |        |   |            |              |
|            |              |        |   |            |              |
| 2.  Any    |              |        |   |            |              |
|     meal   |              |        |   |            |              |
|     plan   |              |        |   |            |              |
|     mod    |              |        |   |            |              |
| ifications |              |        |   |            |              |
|     should |              |        |   |            |              |
|     first  |              |        |   |            |              |
|     be     |              |        |   |            |              |
|            |              |        |   |            |              |
|  discussed |              |        |   |            |              |
|     with a |              |        |   |            |              |
|     ***    |              |        |   |            |              |
| Registered |              |        |   |            |              |
|            |              |        |   |            |              |
|  Dietitian |              |        |   |            |              |
|            |              |        |   |            |              |
|    (RD)*** |              |        |   |            |              |
|     or a   |              |        |   |            |              |
|            |              |        |   |            |              |
|  qualified |              |        |   |            |              |
|            |              |        |   |            |              |
| healthcare |              |        |   |            |              |
|            |              |        |   |            |              |
|  provider. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     4)*    |              |        |   |            |              |
|            |              |        |   |            |              |
| 3.  Target |              |        |   |            |              |
|     i      |              |        |   |            |              |
| ndividuals |              |        |   |            |              |
|     should |              |        |   |            |              |
|     meet   |              |        |   |            |              |
|     with   |              |        |   |            |              |
|     an     |              |        |   |            |              |
|            |              |        |   |            |              |
|   ***RD*** |              |        |   |            |              |
|     for    |              |        |   |            |              |
|            |              |        |   |            |              |
| assessment |              |        |   |            |              |
|     and    |              |        |   |            |              |
|     review |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|    medical |              |        |   |            |              |
|            |              |        |   |            |              |
| management |              |        |   |            |              |
|     and    |              |        |   |            |              |
|            |              |        |   |            |              |
|  treatment |              |        |   |            |              |
|     goals  |              |        |   |            |              |
|     to     |              |        |   |            |              |
|     select |              |        |   |            |              |
|            |              |        |   |            |              |
|   approach |              |        |   |            |              |
|     for    |              |        |   |            |              |
|            |              |        |   |            |              |
|    medical |              |        |   |            |              |
|            |              |        |   |            |              |
|  nutrition |              |        |   |            |              |
|            |              |        |   |            |              |
|   therapy. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     2)*    |              |        |   |            |              |
|            |              |        |   |            |              |
| 4.  The    |              |        |   |            |              |
|     diet   |              |        |   |            |              |
|     co     |              |        |   |            |              |
| mposition, |              |        |   |            |              |
|            |              |        |   |            |              |
|  described |              |        |   |            |              |
|     below, |              |        |   |            |              |
|     is for |              |        |   |            |              |
|            |              |        |   |            |              |
|    general |              |        |   |            |              |
|            |              |        |   |            |              |
|   guidance |              |        |   |            |              |
|     only   |              |        |   |            |              |
|     and    |              |        |   |            |              |
|     may be |              |        |   |            |              |
|            |              |        |   |            |              |
|   [individ |              |        |   |            |              |
| ualized]{. |              |        |   |            |              |
| underline} |              |        |   |            |              |
|     by the |              |        |   |            |              |
|     RD or  |              |        |   |            |              |
|     the    |              |        |   |            |              |
|            |              |        |   |            |              |
| healthcare |              |        |   |            |              |
|            |              |        |   |            |              |
|   provider |              |        |   |            |              |
|            |              |        |   |            |              |
|  according |              |        |   |            |              |
|     to     |              |        |   |            |              |
|            |              |        |   |            |              |
|   clinical |              |        |   |            |              |
|            |              |        |   |            |              |
|  judgment. |              |        |   |            |              |
|     (See   |              |        |   |            |              |
|            |              |        |   |            |              |
|   Appendix |              |        |   |            |              |
|     A in   |              |        |   |            |              |
|     the    |              |        |   |            |              |
|            |              |        |   |            |              |
|   original |              |        |   |            |              |
|            |              |        |   |            |              |
|  guideline |              |        |   |            |              |
|            |              |        |   |            |              |
| document). |              |        |   |            |              |
|            |              |        |   |            |              |
| 5.  Meal   |              |        |   |            |              |
|     plans  |              |        |   |            |              |
|     do not |              |        |   |            |              |
|     need   |              |        |   |            |              |
|     to     |              |        |   |            |              |
|            |              |        |   |            |              |
|    include |              |        |   |            |              |
|     be     |              |        |   |            |              |
| tween-meal |              |        |   |            |              |
|     or     |              |        |   |            |              |
|            |              |        |   |            |              |
|    evening |              |        |   |            |              |
|            |              |        |   |            |              |
|    snacks. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     4)*    |              |        |   |            |              |
|            |              |        |   |            |              |
| 6.  Me     |              |        |   |            |              |
| al-to-meal |              |        |   |            |              |
|     c      |              |        |   |            |              |
| onsistency |              |        |   |            |              |
|     in     |              |        |   |            |              |
|     ca     |              |        |   |            |              |
| rbohydrate |              |        |   |            |              |
|     is of  |              |        |   |            |              |
|            |              |        |   |            |              |
|    primary |              |        |   |            |              |
|            |              |        |   |            |              |
| importance |              |        |   |            |              |
|     to     |              |        |   |            |              |
|            |              |        |   |            |              |
|   patients |              |        |   |            |              |
|     with   |              |        |   |            |              |
|     fixed  |              |        |   |            |              |
|            |              |        |   |            |              |
|   medicati |              |        |   |            |              |
| on/insulin |              |        |   |            |              |
|            |              |        |   |            |              |
|  programs. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     4)*    |              |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| **Weight   |              |        |   |            |              |
| R          |              |        |   |            |              |
| eduction** |              |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | 1.  A        |        |   |            |              |
|            |              |        |   |            |              |
|            | [structured] |        |   |            |              |
|            | {.underline} |        |   |            |              |
|            |              |        |   |            |              |
|            |    lifestyle |        |   |            |              |
|            |     plan     |        |   |            |              |
|            |     that     |        |   |            |              |
|            |     combines |        |   |            |              |
|            |     dietary  |        |   |            |              |
|            |              |        |   |            |              |
|            | modification |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     exercise |        |   |            |              |
|            |     is       |        |   |            |              |
|            |              |        |   |            |              |
|            |    necessary |        |   |            |              |
|            |     for      |        |   |            |              |
|            |     weight   |        |   |            |              |
|            |              |        |   |            |              |
|            |   reduction. |        |   |            |              |
|            |              |        |   |            |              |
|            | 2.  A modest |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     gradual  |        |   |            |              |
|            |     weight   |        |   |            |              |
|            |              |        |   |            |              |
|            |    reduction |        |   |            |              |
|            |     of one   |        |   |            |              |
|            |     pound    |        |   |            |              |
|            |     every    |        |   |            |              |
|            |     one to   |        |   |            |              |
|            |     two      |        |   |            |              |
|            |     weeks    |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     be the   |        |   |            |              |
|            |     optimal  |        |   |            |              |
|            |     target.  |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     2)*      |        |   |            |              |
|            |              |        |   |            |              |
|            | 3            |        |   |            |              |
|            | .  Reduction |        |   |            |              |
|            |     of daily |        |   |            |              |
|            |     caloric  |        |   |            |              |
|            |     intake   |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     be by    |        |   |            |              |
|            |     250 to   |        |   |            |              |
|            |     500      |        |   |            |              |
|            |              |        |   |            |              |
|            |    calories. |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     4)*      |        |   |            |              |
|            |     Total    |        |   |            |              |
|            |     daily    |        |   |            |              |
|            |     caloric  |        |   |            |              |
|            |     intake   |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     not be   |        |   |            |              |
|            |     less     |        |   |            |              |
|            |     than     |        |   |            |              |
|            |     1000 to  |        |   |            |              |
|            |     1200 for |        |   |            |              |
|            |     women    |        |   |            |              |
|            |     and 1200 |        |   |            |              |
|            |     to 1600  |        |   |            |              |
|            |     for men, |        |   |            |              |
|            |     or based |        |   |            |              |
|            |     on an RD |        |   |            |              |
|            |              |        |   |            |              |
|            |   assessment |        |   |            |              |
|            |     of usual |        |   |            |              |
|            |     intake.  |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     4)*      |        |   |            |              |
|            |              |        |   |            |              |
|            | 4.  Weight   |        |   |            |              |
|            |              |        |   |            |              |
|            |    reduction |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     be       |        |   |            |              |
|            |     in       |        |   |            |              |
|            | dividualized |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            |    continued |        |   |            |              |
|            |     until    |        |   |            |              |
|            |     BMI      |        |   |            |              |
|            |     reaches  |        |   |            |              |
|            |     the      |        |   |            |              |
|            |     normal   |        |   |            |              |
|            |     range    |        |   |            |              |
|            |     (18.5 to |        |   |            |              |
|            |     25       |        |   |            |              |
|            |     kg/m^2^) |        |   |            |              |
|            |     or until |        |   |            |              |
|            |     an       |        |   |            |              |
|            |     agreed   |        |   |            |              |
|            |     upon BMI |        |   |            |              |
|            |     goal is  |        |   |            |              |
|            |     reached. |        |   |            |              |
|            |              |        |   |            |              |
|            | 5.  Target   |        |   |            |              |
|            |              |        |   |            |              |
|            |  individuals |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     meet     |        |   |            |              |
|            |     with RD  |        |   |            |              |
|            |     to learn |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     practice |        |   |            |              |
|            |     portion  |        |   |            |              |
|            |     control  |        |   |            |              |
|            |     as an    |        |   |            |              |
|            |              |        |   |            |              |
|            |    effective |        |   |            |              |
|            |     way of   |        |   |            |              |
|            |     weight   |        |   |            |              |
|            |     control. |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     4)*      |        |   |            |              |
|            |              |        |   |            |              |
|            | 6.  Meal     |        |   |            |              |
|            |              |        |   |            |              |
|            | replacements |        |   |            |              |
|            |     (MR) in  |        |   |            |              |
|            |     the form |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     shakes,  |        |   |            |              |
|            |     bars,    |        |   |            |              |
|            |              |        |   |            |              |
|            | ready-to-mix |        |   |            |              |
|            |     powders, |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            | pre-packaged |        |   |            |              |
|            |     meals    |        |   |            |              |
|            |     that     |        |   |            |              |
|            |     match    |        |   |            |              |
|            |     these    |        |   |            |              |
|            |              |        |   |            |              |
|            |    nutrition |        |   |            |              |
|            |              |        |   |            |              |
|            |   guidelines |        |   |            |              |
|            |     are      |        |   |            |              |
|            |     helpful  |        |   |            |              |
|            |     for      |        |   |            |              |
|            |     [some]   |        |   |            |              |
|            | {.underline} |        |   |            |              |
|            |     patients |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     2)*.     |        |   |            |              |
|            |     Blood    |        |   |            |              |
|            |     glucose  |        |   |            |              |
|            |     patterns |        |   |            |              |
|            |              |        |   |            |              |
|            |   frequently |        |   |            |              |
|            |     change   |        |   |            |              |
|            |     with the |        |   |            |              |
|            |              |        |   |            |              |
|            |   initiation |        |   |            |              |
|            |     of meal  |        |   |            |              |
|            |     r        |        |   |            |              |
|            | eplacements, |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     diabetes |        |   |            |              |
|            |              |        |   |            |              |
|            |  medications |        |   |            |              |
|            |     may need |        |   |            |              |
|            |              |        |   |            |              |
|            |  adjustment. |        |   |            |              |
|            |     Patients |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     be told  |        |   |            |              |
|            |     to       |        |   |            |              |
|            |     monitor  |        |   |            |              |
|            |     their    |        |   |            |              |
|            |     blood    |        |   |            |              |
|            |     glucose  |        |   |            |              |
|            |              |        |   |            |              |
|            |    carefully |        |   |            |              |
|            |     to       |        |   |            |              |
|            |     identify |        |   |            |              |
|            |     h        |        |   |            |              |
|            | ypoglycemia. |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     2)*      |        |   |            |              |
|            |              |        |   |            |              |
|            | 7.  U.S.     |        |   |            |              |
|            |     Food and |        |   |            |              |
|            |     Drug     |        |   |            |              |
|            |     Ad       |        |   |            |              |
|            | ministration |        |   |            |              |
|            |     (F       |        |   |            |              |
|            | DA)-approved |        |   |            |              |
|            |     weight   |        |   |            |              |
|            |              |        |   |            |              |
|            |   management |        |   |            |              |
|            |              |        |   |            |              |
|            |  medications |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     be       |        |   |            |              |
|            |              |        |   |            |              |
|            |  prescribed, |        |   |            |              |
|            |     if       |        |   |            |              |
|            |              |        |   |            |              |
|            |   indicated. |        |   |            |              |
|            |     Approved |        |   |            |              |
|            |              |        |   |            |              |
|            |  medications |        |   |            |              |
|            |     are an   |        |   |            |              |
|            |     adjunct  |        |   |            |              |
|            |     to       |        |   |            |              |
|            |     dietary  |        |   |            |              |
|            |     and      |        |   |            |              |
|            |              |        |   |            |              |
|            |    lifestyle |        |   |            |              |
|            |     changes  |        |   |            |              |
|            |              |        |   |            |              |
|            |   (*Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     2)*.     |        |   |            |              |
|            |              |        |   |            |              |
|            | 8            |        |   |            |              |
|            | .  Bariatric |        |   |            |              |
|            |              |        |   |            |              |
|            |    surgeries |        |   |            |              |
|            |     are      |        |   |            |              |
|            |              |        |   |            |              |
|            |    effective |        |   |            |              |
|            |     options  |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     should   |        |   |            |              |
|            |     be       |        |   |            |              |
|            |              |        |   |            |              |
|            |   encouraged |        |   |            |              |
|            |     when     |        |   |            |              |
|            |              |        |   |            |              |
|            |    indicated |        |   |            |              |
|            |              |        |   |            |              |
|            |    (consider |        |   |            |              |
|            |     in       |        |   |            |              |
|            |              |        |   |            |              |
|            |  individuals |        |   |            |              |
|            |     with BMI |        |   |            |              |
|            |     \>40     |        |   |            |              |
|            |     kg/m^2^  |        |   |            |              |
|            |     and      |        |   |            |              |
|            |     those    |        |   |            |              |
|            |     with BMI |        |   |            |              |
|            |     \>35     |        |   |            |              |
|            |     kg/m^2^  |        |   |            |              |
|            |     with     |        |   |            |              |
|            |     other    |        |   |            |              |
|            |     com      |        |   |            |              |
|            | orbidities). |        |   |            |              |
|            |              |        |   |            |              |
|            |   *(Strength |        |   |            |              |
|            |     of       |        |   |            |              |
|            |     evidence |        |   |            |              |
|            |     2)*      |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| **Mac      |              |        |   |            |              |
| ronutrient |              |        |   |            |              |
| Com        |              |        |   |            |              |
| position** |              |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| **Carb     | ***P         | \~40%  |   |            |              |
| ohydrate** | ercentage*** | of     |   |            |              |
|            |              | total  |   |            |              |
|            |              | c      |   |            |              |
|            |              | aloric |   |            |              |
|            |              | i      |   |            |              |
|            |              | ntake. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
|            |              | The    |   |            |              |
|            |              | total  |   |            |              |
|            |              | should |   |            |              |
|            |              | not be |   |            |              |
|            |              | less   |   |            |              |
|            |              | than   |   |            |              |
|            |              | 130    |   |            |              |
|            |              | g/day. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***Glycemic  | Red    |   |            |              |
|            | Index and    | uction |   |            |              |
|            | Glycemic***  | of the |   |            |              |
|            |              | q      |   |            |              |
|            |              | uality |   |            |              |
|            |              | (Gl    |   |            |              |
|            |              | ycemic |   |            |              |
|            |              | Index  |   |            |              |
|            |              | \      |   |            |              |
|            |              | [GI\]) |   |            |              |
|            |              | and    |   |            |              |
|            |              | qu     |   |            |              |
|            |              | antity |   |            |              |
|            |              | (Gl    |   |            |              |
|            |              | ycemic |   |            |              |
|            |              | Load   |   |            |              |
|            |              | \      |   |            |              |
|            |              | [GL\]) |   |            |              |
|            |              | of     |   |            |              |
|            |              | carboh |   |            |              |
|            |              | ydrate |   |            |              |
|            |              | c      |   |            |              |
|            |              | hoices |   |            |              |
|            |              | is     |   |            |              |
|            |              | ess    |   |            |              |
|            |              | ential |   |            |              |
|            |              | for    |   |            |              |
|            |              | blood  |   |            |              |
|            |              | g      |   |            |              |
|            |              | lucose |   |            |              |
|            |              | co     |   |            |              |
|            |              | ntrol. |   |            |              |
|            |              | The    |   |            |              |
|            |              | GI/GL  |   |            |              |
|            |              | c      |   |            |              |
|            |              | oncept |   |            |              |
|            |              | is an  |   |            |              |
|            |              | imp    |   |            |              |
|            |              | ortant |   |            |              |
|            |              | factor |   |            |              |
|            |              | that   |   |            |              |
|            |              | pa     |   |            |              |
|            |              | tients |   |            |              |
|            |              | should |   |            |              |
|            |              | apply  |   |            |              |
|            |              | in     |   |            |              |
|            |              | their  |   |            |              |
|            |              | daily  |   |            |              |
|            |              | sel    |   |            |              |
|            |              | ection |   |            |              |
|            |              | of     |   |            |              |
|            |              | c      |   |            |              |
|            |              | arbohy |   |            |              |
|            |              | drates |   |            |              |
|            |              | foods. |   |            |              |
|            |              | Foods  |   |            |              |
|            |              | with a |   |            |              |
|            |              | low    |   |            |              |
|            |              | gl     |   |            |              |
|            |              | ycemic |   |            |              |
|            |              | index  |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | se     |   |            |              |
|            |              | lected |   |            |              |
|            |              | (e.g., |   |            |              |
|            |              | c      |   |            |              |
|            |              | ereals |   |            |              |
|            |              | based  |   |            |              |
|            |              | on     |   |            |              |
|            |              | oats   |   |            |              |
|            |              | and    |   |            |              |
|            |              | b      |   |            |              |
|            |              | arley, |   |            |              |
|            |              | le     |   |            |              |
|            |              | gumes, |   |            |              |
|            |              | f      |   |            |              |
|            |              | ruits, |   |            |              |
|            |              | green  |   |            |              |
|            |              | salad  |   |            |              |
|            |              | with   |   |            |              |
|            |              | olive  |   |            |              |
|            |              | oil    |   |            |              |
|            |              | -based |   |            |              |
|            |              | dre    |   |            |              |
|            |              | ssing, |   |            |              |
|            |              | and    |   |            |              |
|            |              | veget  |   |            |              |
|            |              | ables, |   |            |              |
|            |              | except |   |            |              |
|            |              | pot    |   |            |              |
|            |              | atoes) |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***R         | Vege   |   |            |              |
|            | ecommended*\ | tables |   |            |              |
|            | \            | and    |   |            |              |
|            | *Not         | fruits |   |            |              |
|            | re           | (pref  |   |            |              |
|            | commended*** | erably |   |            |              |
|            |              | f      |   |            |              |
|            |              | resh), |   |            |              |
|            |              | le     |   |            |              |
|            |              | gumes, |   |            |              |
|            |              | whole  |   |            |              |
|            |              | and    |   |            |              |
|            |              | min    |   |            |              |
|            |              | imally |   |            |              |
|            |              | pro    |   |            |              |
|            |              | cessed |   |            |              |
|            |              | g      |   |            |              |
|            |              | rains\ |   |            |              |
|            |              | \      |   |            |              |
|            |              | R      |   |            |              |
|            |              | efined |   |            |              |
|            |              | c      |   |            |              |
|            |              | arbohy |   |            |              |
|            |              | drates |   |            |              |
|            |              | or     |   |            |              |
|            |              | pro    |   |            |              |
|            |              | cessed |   |            |              |
|            |              | grains |   |            |              |
|            |              | and    |   |            |              |
|            |              | s      |   |            |              |
|            |              | tarchy |   |            |              |
|            |              | foods  |   |            |              |
|            |              | espe   |   |            |              |
|            |              | cially |   |            |              |
|            |              | pasta, |   |            |              |
|            |              | white  |   |            |              |
|            |              | bread, |   |            |              |
|            |              | low    |   |            |              |
|            |              | -fiber |   |            |              |
|            |              | c      |   |            |              |
|            |              | ereal, |   |            |              |
|            |              | and    |   |            |              |
|            |              | white  |   |            |              |
|            |              | po     |   |            |              |
|            |              | tatoes |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | co     |   |            |              |
|            |              | nsumed |   |            |              |
|            |              | in     |   |            |              |
|            |              | very   |   |            |              |
|            |              | l      |   |            |              |
|            |              | imited |   |            |              |
|            |              | quan   |   |            |              |
|            |              | tities |   |            |              |
|            |              | (e.g., |   |            |              |
|            |              | pasta  |   |            |              |
|            |              | \~2    |   |            |              |
|            |              | oz.)   |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 1)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***Fiber***  | A      |   |            |              |
|            |              | m      |   |            |              |
|            |              | inimum |   |            |              |
|            |              | of 20  |   |            |              |
|            |              | to 35  |   |            |              |
|            |              | g of   |   |            |              |
|            |              | fiber  |   |            |              |
|            |              | per    |   |            |              |
|            |              | day is |   |            |              |
|            |              | recomm |   |            |              |
|            |              | ended. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 1)* If |   |            |              |
|            |              | tole   |   |            |              |
|            |              | rated, |   |            |              |
|            |              | \~50   |   |            |              |
|            |              | g/day  |   |            |              |
|            |              | is     |   |            |              |
|            |              | eff    |   |            |              |
|            |              | ective |   |            |              |
|            |              | in     |   |            |              |
|            |              | imp    |   |            |              |
|            |              | roving |   |            |              |
|            |              | postpr |   |            |              |
|            |              | andial |   |            |              |
|            |              | h      |   |            |              |
|            |              | ypergl |   |            |              |
|            |              | ycemia |   |            |              |
|            |              | and    |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | encou  |   |            |              |
|            |              | raged. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
|            |              | Fiber  |   |            |              |
|            |              | from   |   |            |              |
|            |              | unpro  |   |            |              |
|            |              | cessed |   |            |              |
|            |              | food,  |   |            |              |
|            |              | such   |   |            |              |
|            |              | as     |   |            |              |
|            |              | fresh  |   |            |              |
|            |              | vege   |   |            |              |
|            |              | tables |   |            |              |
|            |              | and    |   |            |              |
|            |              | f      |   |            |              |
|            |              | ruits, |   |            |              |
|            |              | is     |   |            |              |
|            |              | pref   |   |            |              |
|            |              | erable |   |            |              |
|            |              | but,   |   |            |              |
|            |              | if     |   |            |              |
|            |              | n      |   |            |              |
|            |              | eeded, |   |            |              |
|            |              | fiber  |   |            |              |
|            |              | suppl  |   |            |              |
|            |              | ements |   |            |              |
|            |              | such   |   |            |              |
|            |              | as     |   |            |              |
|            |              | ps     |   |            |              |
|            |              | yllium |   |            |              |
|            |              | and    |   |            |              |
|            |              | beta-  |   |            |              |
|            |              | glucan |   |            |              |
|            |              | can be |   |            |              |
|            |              | added. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 3)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| **Fat**    | ***P         | \~30   |   |            |              |
|            | ercentage*** | to 35% |   |            |              |
|            |              | of     |   |            |              |
|            |              | total  |   |            |              |
|            |              | c      |   |            |              |
|            |              | aloric |   |            |              |
|            |              | i      |   |            |              |
|            |              | ntake; |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
|            |              | sat    |   |            |              |
|            |              | urated |   |            |              |
|            |              | fat    |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | l      |   |            |              |
|            |              | imited |   |            |              |
|            |              | to     |   |            |              |
|            |              | \<10%  |   |            |              |
|            |              | of     |   |            |              |
|            |              | total  |   |            |              |
|            |              | c      |   |            |              |
|            |              | aloric |   |            |              |
|            |              | intake |   |            |              |
|            |              | or     |   |            |              |
|            |              | \<7%   |   |            |              |
|            |              | in     |   |            |              |
|            |              | indiv  |   |            |              |
|            |              | iduals |   |            |              |
|            |              | with   |   |            |              |
|            |              | LDL    |   |            |              |
|            |              | -chole |   |            |              |
|            |              | sterol |   |            |              |
|            |              | \>100  |   |            |              |
|            |              | mg/dL. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 1)*    |   |            |              |
|            |              | Pol    |   |            |              |
|            |              | yunsat |   |            |              |
|            |              | urated |   |            |              |
|            |              | fat    |   |            |              |
|            |              | should |   |            |              |
|            |              | co     |   |            |              |
|            |              | mprise |   |            |              |
|            |              | up to  |   |            |              |
|            |              | 10% of |   |            |              |
|            |              | total  |   |            |              |
|            |              | cal    |   |            |              |
|            |              | ories, |   |            |              |
|            |              | and    |   |            |              |
|            |              | mon    |   |            |              |
|            |              | ounsat |   |            |              |
|            |              | urated |   |            |              |
|            |              | fat up |   |            |              |
|            |              | to 15  |   |            |              |
|            |              | to 20% |   |            |              |
|            |              | of     |   |            |              |
|            |              | total  |   |            |              |
|            |              | cal    |   |            |              |
|            |              | ories. |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***R         | Mono-  |   |            |              |
|            | ecommended*\ | and    |   |            |              |
|            | \            | pol    |   |            |              |
|            | \            | yunsat |   |            |              |
|            | \            | urated |   |            |              |
|            | *Not         | fats   |   |            |              |
|            | re           | (e.g., |   |            |              |
|            | commended*** | olive  |   |            |              |
|            |              | oil,   |   |            |              |
|            |              | canola |   |            |              |
|            |              | oil,   |   |            |              |
|            |              | nuts/  |   |            |              |
|            |              | seeds, |   |            |              |
|            |              | and    |   |            |              |
|            |              | fish,  |   |            |              |
|            |              | partic |   |            |              |
|            |              | ularly |   |            |              |
|            |              | those  |   |            |              |
|            |              | high   |   |            |              |
|            |              | in     |   |            |              |
|            |              | o      |   |            |              |
|            |              | mega-3 |   |            |              |
|            |              | fatty  |   |            |              |
|            |              | a      |   |            |              |
|            |              | cids). |   |            |              |
|            |              | Oily   |   |            |              |
|            |              | fish   |   |            |              |
|            |              | (e.g., |   |            |              |
|            |              | s      |   |            |              |
|            |              | almon, |   |            |              |
|            |              | he     |   |            |              |
|            |              | rring, |   |            |              |
|            |              | trout, |   |            |              |
|            |              | sar    |   |            |              |
|            |              | dines, |   |            |              |
|            |              | fresh  |   |            |              |
|            |              | tuna)  |   |            |              |
|            |              | 2      |   |            |              |
|            |              | time   |   |            |              |
|            |              | s/week |   |            |              |
|            |              | is an  |   |            |              |
|            |              | ample  |   |            |              |
|            |              | source |   |            |              |
|            |              | of     |   |            |              |
|            |              | o      |   |            |              |
|            |              | mega-3 |   |            |              |
|            |              | fatty  |   |            |              |
|            |              | a      |   |            |              |
|            |              | cids.\ |   |            |              |
|            |              | \      |   |            |              |
|            |              | Foods  |   |            |              |
|            |              | high   |   |            |              |
|            |              | in     |   |            |              |
|            |              | sat    |   |            |              |
|            |              | urated |   |            |              |
|            |              | fat,   |   |            |              |
|            |              | inc    |   |            |              |
|            |              | luding |   |            |              |
|            |              | beef,  |   |            |              |
|            |              | pork,  |   |            |              |
|            |              | lamb,  |   |            |              |
|            |              | and    |   |            |              |
|            |              | hi     |   |            |              |
|            |              | gh-fat |   |            |              |
|            |              | dairy  |   |            |              |
|            |              | pr     |   |            |              |
|            |              | oducts |   |            |              |
|            |              | (e.g., |   |            |              |
|            |              | cream  |   |            |              |
|            |              | c      |   |            |              |
|            |              | heese, |   |            |              |
|            |              | whole  |   |            |              |
|            |              | milk,  |   |            |              |
|            |              | or     |   |            |              |
|            |              | y      |   |            |              |
|            |              | ogurt) |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | co     |   |            |              |
|            |              | nsumed |   |            |              |
|            |              | only   |   |            |              |
|            |              | in     |   |            |              |
|            |              | small  |   |            |              |
|            |              | amo    |   |            |              |
|            |              | unts.\ |   |            |              |
|            |              | Foods  |   |            |              |
|            |              | high   |   |            |              |
|            |              | in     |   |            |              |
|            |              | tran   |   |            |              |
|            |              | s-fats |   |            |              |
|            |              | (e.g., |   |            |              |
|            |              | fast   |   |            |              |
|            |              | foods, |   |            |              |
|            |              | commer |   |            |              |
|            |              | cially |   |            |              |
|            |              | baked  |   |            |              |
|            |              | goods, |   |            |              |
|            |              | some   |   |            |              |
|            |              | marga  |   |            |              |
|            |              | rines) |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | av     |   |            |              |
|            |              | oided. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 1)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***Ch        | \<300  |   |            |              |
|            | olesterol*** | mg/day |   |            |              |
|            |              | or     |   |            |              |
|            |              | \<200  |   |            |              |
|            |              | mg/day |   |            |              |
|            |              | in     |   |            |              |
|            |              | indiv  |   |            |              |
|            |              | iduals |   |            |              |
|            |              | with   |   |            |              |
|            |              | LDL    |   |            |              |
|            |              | -chole |   |            |              |
|            |              | sterol |   |            |              |
|            |              | \>100  |   |            |              |
|            |              | mg/dL. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 4)*\   |   |            |              |
|            |              | Egg    |   |            |              |
|            |              | yolks  |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | l      |   |            |              |
|            |              | imited |   |            |              |
|            |              | to 2   |   |            |              |
|            |              | to 3   |   |            |              |
|            |              | per    |   |            |              |
|            |              | week;  |   |            |              |
|            |              | other  |   |            |              |
|            |              | foods  |   |            |              |
|            |              | high   |   |            |              |
|            |              | in     |   |            |              |
|            |              | d      |   |            |              |
|            |              | ietary |   |            |              |
|            |              | choles |   |            |              |
|            |              | terol, |   |            |              |
|            |              | such   |   |            |              |
|            |              | as red |   |            |              |
|            |              | meat,  |   |            |              |
|            |              | who    |   |            |              |
|            |              | le-fat |   |            |              |
|            |              | dairy  |   |            |              |
|            |              | foods, |   |            |              |
|            |              | shel   |   |            |              |
|            |              | lfish, |   |            |              |
|            |              | and    |   |            |              |
|            |              | organ  |   |            |              |
|            |              | meats  |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | li     |   |            |              |
|            |              | mited, |   |            |              |
|            |              | as     |   |            |              |
|            |              | well.  |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| *          | ***P         | \~20   |   |            |              |
| *Protein** | ercentage*** | to 30% |   |            |              |
|            |              | of     |   |            |              |
|            |              | total  |   |            |              |
|            |              | c      |   |            |              |
|            |              | aloric |   |            |              |
|            |              | i      |   |            |              |
|            |              | ntake. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***Favorable | Fish,  |   |            |              |
|            | Protein***   | sk     |   |            |              |
|            |              | inless |   |            |              |
|            |              | po     |   |            |              |
|            |              | ultry, |   |            |              |
|            |              | nonfat |   |            |              |
|            |              | or     |   |            |              |
|            |              | l      |   |            |              |
|            |              | ow-fat |   |            |              |
|            |              | dairy, |   |            |              |
|            |              | le     |   |            |              |
|            |              | gumes, |   |            |              |
|            |              | tofu,  |   |            |              |
|            |              | t      |   |            |              |
|            |              | empeh, |   |            |              |
|            |              | and    |   |            |              |
|            |              | s      |   |            |              |
|            |              | eitan. |   |            |              |
|            |              | It is  |   |            |              |
|            |              | not    |   |            |              |
|            |              | recom  |   |            |              |
|            |              | mended |   |            |              |
|            |              | to     |   |            |              |
|            |              | *inc   |   |            |              |
|            |              | rease* |   |            |              |
|            |              | p      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | from   |   |            |              |
|            |              | high   |   |            |              |
|            |              | sat    |   |            |              |
|            |              | urated |   |            |              |
|            |              | fat    |   |            |              |
|            |              | animal |   |            |              |
|            |              | s      |   |            |              |
|            |              | ources |   |            |              |
|            |              | (e.g., |   |            |              |
|            |              | beef,  |   |            |              |
|            |              | pork,  |   |            |              |
|            |              | lamb   |   |            |              |
|            |              | and    |   |            |              |
|            |              | hi     |   |            |              |
|            |              | gh-fat |   |            |              |
|            |              | dairy  |   |            |              |
|            |              | prod   |   |            |              |
|            |              | ucts), |   |            |              |
|            |              | as it  |   |            |              |
|            |              | may be |   |            |              |
|            |              | asso   |   |            |              |
|            |              | ciated |   |            |              |
|            |              | with   |   |            |              |
|            |              | inc    |   |            |              |
|            |              | reased |   |            |              |
|            |              | ca     |   |            |              |
|            |              | rdiova |   |            |              |
|            |              | scular |   |            |              |
|            |              | risk.  |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*\   |   |            |              |
|            |              | \      |   |            |              |
|            |              | Em     |   |            |              |
|            |              | erging |   |            |              |
|            |              | data   |   |            |              |
|            |              | s      |   |            |              |
|            |              | uggest |   |            |              |
|            |              | that   |   |            |              |
|            |              | p      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | aids   |   |            |              |
|            |              | in the |   |            |              |
|            |              | sen    |   |            |              |
|            |              | sation |   |            |              |
|            |              | of     |   |            |              |
|            |              | fu     |   |            |              |
|            |              | llness |   |            |              |
|            |              | and    |   |            |              |
|            |              | that   |   |            |              |
|            |              | low-p  |   |            |              |
|            |              | rotein |   |            |              |
|            |              | meal   |   |            |              |
|            |              | plans  |   |            |              |
|            |              | are    |   |            |              |
|            |              | asso   |   |            |              |
|            |              | ciated |   |            |              |
|            |              | with   |   |            |              |
|            |              | inc    |   |            |              |
|            |              | reased |   |            |              |
|            |              | h      |   |            |              |
|            |              | unger. |   |            |              |
|            |              | Thus,  |   |            |              |
|            |              | lean   |   |            |              |
|            |              | p      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | to     |   |            |              |
|            |              | gether |   |            |              |
|            |              | with   |   |            |              |
|            |              | h      |   |            |              |
|            |              | ealthy |   |            |              |
|            |              | fats   |   |            |              |
|            |              | may    |   |            |              |
|            |              | serve  |   |            |              |
|            |              | to     |   |            |              |
|            |              | reduce |   |            |              |
|            |              | ap     |   |            |              |
|            |              | petite |   |            |              |
|            |              | and    |   |            |              |
|            |              | assist |   |            |              |
|            |              | pa     |   |            |              |
|            |              | tients |   |            |              |
|            |              | in     |   |            |              |
|            |              | ach    |   |            |              |
|            |              | ieving |   |            |              |
|            |              | and    |   |            |              |
|            |              | maint  |   |            |              |
|            |              | aining |   |            |              |
|            |              | a      |   |            |              |
|            |              | lower  |   |            |              |
|            |              | c      |   |            |              |
|            |              | alorie |   |            |              |
|            |              | level. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 1)*    |   |            |              |
|            |              | P      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | also   |   |            |              |
|            |              | helps  |   |            |              |
|            |              | to     |   |            |              |
|            |              | ma     |   |            |              |
|            |              | intain |   |            |              |
|            |              | lean   |   |            |              |
|            |              | body   |   |            |              |
|            |              | mass   |   |            |              |
|            |              | during |   |            |              |
|            |              | weight |   |            |              |
|            |              | redu   |   |            |              |
|            |              | ction. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
|            | ***Patients  | Al     |   |            |              |
|            | with Renal   | though |   |            |              |
|            | Issues***    | re     |   |            |              |
|            |              | ducing |   |            |              |
|            |              | total  |   |            |              |
|            |              | ca     |   |            |              |
|            |              | lories |   |            |              |
|            |              | may    |   |            |              |
|            |              | result |   |            |              |
|            |              | in a   |   |            |              |
|            |              | red    |   |            |              |
|            |              | uction |   |            |              |
|            |              | of the |   |            |              |
|            |              | ab     |   |            |              |
|            |              | solute |   |            |              |
|            |              | total  |   |            |              |
|            |              | amount |   |            |              |
|            |              | of     |   |            |              |
|            |              | p      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | i      |   |            |              |
|            |              | ntake, |   |            |              |
|            |              | any    |   |            |              |
|            |              | p      |   |            |              |
|            |              | atient |   |            |              |
|            |              | with   |   |            |              |
|            |              | signs  |   |            |              |
|            |              | of     |   |            |              |
|            |              | kidney |   |            |              |
|            |              | d      |   |            |              |
|            |              | isease |   |            |              |
|            |              | (i.e., |   |            |              |
|            |              | one or |   |            |              |
|            |              | more   |   |            |              |
|            |              | of the |   |            |              |
|            |              | foll   |   |            |              |
|            |              | owing: |   |            |              |
|            |              | albumi |   |            |              |
|            |              | nuria, |   |            |              |
|            |              | protei |   |            |              |
|            |              | nuria, |   |            |              |
|            |              | crea   |   |            |              |
|            |              | tinine |   |            |              |
|            |              | cle    |   |            |              |
|            |              | arance |   |            |              |
|            |              | \<60   |   |            |              |
|            |              | m      |   |            |              |
|            |              | L/min) |   |            |              |
|            |              | should |   |            |              |
|            |              | c      |   |            |              |
|            |              | onsult |   |            |              |
|            |              | a      |   |            |              |
|            |              | nephro |   |            |              |
|            |              | logist |   |            |              |
|            |              | before |   |            |              |
|            |              | incr   |   |            |              |
|            |              | easing |   |            |              |
|            |              | total  |   |            |              |
|            |              | or     |   |            |              |
|            |              | perc   |   |            |              |
|            |              | entage |   |            |              |
|            |              | p      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | in     |   |            |              |
|            |              | their  |   |            |              |
|            |              | diet.  |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 2)*    |   |            |              |
|            |              | P      |   |            |              |
|            |              | rotein |   |            |              |
|            |              | intake |   |            |              |
|            |              | for    |   |            |              |
|            |              | these  |   |            |              |
|            |              | pa     |   |            |              |
|            |              | tients |   |            |              |
|            |              | should |   |            |              |
|            |              | be     |   |            |              |
|            |              | mod    |   |            |              |
|            |              | ified, |   |            |              |
|            |              | but    |   |            |              |
|            |              | not    |   |            |              |
|            |              | l      |   |            |              |
|            |              | owered |   |            |              |
|            |              | to a   |   |            |              |
|            |              | level  |   |            |              |
|            |              | which  |   |            |              |
|            |              | may    |   |            |              |
|            |              | jeop   |   |            |              |
|            |              | ardize |   |            |              |
|            |              | their  |   |            |              |
|            |              | o      |   |            |              |
|            |              | verall |   |            |              |
|            |              | health |   |            |              |
|            |              | or     |   |            |              |
|            |              | in     |   |            |              |
|            |              | crease |   |            |              |
|            |              | their  |   |            |              |
|            |              | risk   |   |            |              |
|            |              | for    |   |            |              |
|            |              | m      |   |            |              |
|            |              | alnutr |   |            |              |
|            |              | ition. |   |            |              |
|            |              | *(St   |   |            |              |
|            |              | rength |   |            |              |
|            |              | of     |   |            |              |
|            |              | ev     |   |            |              |
|            |              | idence |   |            |              |
|            |              | 4)*    |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| **Physical |              |        |   |            |              |
| Activity   |              |        |   |            |              |
| and        |              |        |   |            |              |
| Behavioral |              |        |   |            |              |
| Modi       |              |        |   |            |              |
| fication** |              |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+
| 1.         |              |        |   |            |              |
|   Physical |              |        |   |            |              |
|            |              |        |   |            |              |
|  activity, |              |        |   |            |              |
|            |              |        |   |            |              |
|   behavior |              |        |   |            |              |
|     mod    |              |        |   |            |              |
| ification, |              |        |   |            |              |
|     and    |              |        |   |            |              |
|     good   |              |        |   |            |              |
|            |              |        |   |            |              |
|    support |              |        |   |            |              |
|            |              |        |   |            |              |
|    systems |              |        |   |            |              |
|     are    |              |        |   |            |              |
|            |              |        |   |            |              |
|  extremely |              |        |   |            |              |
|            |              |        |   |            |              |
|  important |              |        |   |            |              |
|     and    |              |        |   |            |              |
|     should |              |        |   |            |              |
|     be     |              |        |   |            |              |
|            |              |        |   |            |              |
|   included |              |        |   |            |              |
|     in the |              |        |   |            |              |
|            |              |        |   |            |              |
|  nutrition |              |        |   |            |              |
|     pr     |              |        |   |            |              |
| escription |              |        |   |            |              |
|            |              |        |   |            |              |
|  described |              |        |   |            |              |
|     above. |              |        |   |            |              |
|            |              |        |   |            |              |
|  Increased |              |        |   |            |              |
|            |              |        |   |            |              |
|   physical |              |        |   |            |              |
|            |              |        |   |            |              |
|  activity, |              |        |   |            |              |
|     in     |              |        |   |            |              |
|     p      |              |        |   |            |              |
| articular, |              |        |   |            |              |
|     should |              |        |   |            |              |
|     be an  |              |        |   |            |              |
|            |              |        |   |            |              |
|   integral |              |        |   |            |              |
|            |              |        |   |            |              |
|  component |              |        |   |            |              |
|     of any |              |        |   |            |              |
|     weight |              |        |   |            |              |
|            |              |        |   |            |              |
|  reduction |              |        |   |            |              |
|     plan   |              |        |   |            |              |
|     to     |              |        |   |            |              |
|            |              |        |   |            |              |
|   maximize |              |        |   |            |              |
|     the    |              |        |   |            |              |
|            |              |        |   |            |              |
|   benefits |              |        |   |            |              |
|     of     |              |        |   |            |              |
|     weight |              |        |   |            |              |
|            |              |        |   |            |              |
|  reduction |              |        |   |            |              |
|     on     |              |        |   |            |              |
|            |              |        |   |            |              |
|   diabetes |              |        |   |            |              |
|            |              |        |   |            |              |
|    control |              |        |   |            |              |
|     and to |              |        |   |            |              |
|            |              |        |   |            |              |
|    prevent |              |        |   |            |              |
|            |              |        |   |            |              |
|   coronary |              |        |   |            |              |
|     and    |              |        |   |            |              |
|            |              |        |   |            |              |
|   cerebral |              |        |   |            |              |
|            |              |        |   |            |              |
|   vascular |              |        |   |            |              |
|            |              |        |   |            |              |
|   disease. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     1)*    |              |        |   |            |              |
|            |              |        |   |            |              |
| 2.  A      |              |        |   |            |              |
|            |              |        |   |            |              |
|    minimum |              |        |   |            |              |
|     of 150 |              |        |   |            |              |
|     to 175 |              |        |   |            |              |
|            |              |        |   |            |              |
|    minutes |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   moderate |              |        |   |            |              |
|            |              |        |   |            |              |
|  intensity |              |        |   |            |              |
|            |              |        |   |            |              |
|   physical |              |        |   |            |              |
|     act    |              |        |   |            |              |
| ivity/week |              |        |   |            |              |
|     should |              |        |   |            |              |
|     be     |              |        |   |            |              |
|            |              |        |   |            |              |
|   achieved |              |        |   |            |              |
|     unless |              |        |   |            |              |
|     contra |              |        |   |            |              |
| indicated. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     1)* A  |              |        |   |            |              |
|     target |              |        |   |            |              |
|     of 60  |              |        |   |            |              |
|     to 90  |              |        |   |            |              |
|            |              |        |   |            |              |
|    minutes |              |        |   |            |              |
|     most   |              |        |   |            |              |
|     days   |              |        |   |            |              |
|     of the |              |        |   |            |              |
|     week   |              |        |   |            |              |
|     is     |              |        |   |            |              |
|     e      |              |        |   |            |              |
| ncouraged. |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     4)*    |              |        |   |            |              |
|            |              |        |   |            |              |
| 3.         |              |        |   |            |              |
|   Exercise |              |        |   |            |              |
|     should |              |        |   |            |              |
|     be a   |              |        |   |            |              |
|     mix of |              |        |   |            |              |
|     cardi  |              |        |   |            |              |
| ovascular, |              |        |   |            |              |
|     s      |              |        |   |            |              |
| tretching, |              |        |   |            |              |
|     and    |              |        |   |            |              |
|            |              |        |   |            |              |
| resistance |              |        |   |            |              |
|            |              |        |   |            |              |
|  exercises |              |        |   |            |              |
|     to     |              |        |   |            |              |
|            |              |        |   |            |              |
|   maintain |              |        |   |            |              |
|     or     |              |        |   |            |              |
|            |              |        |   |            |              |
|   increase |              |        |   |            |              |
|     lean   |              |        |   |            |              |
|     body   |              |        |   |            |              |
|     mass.  |              |        |   |            |              |
|            |              |        |   |            |              |
| *(Strength |              |        |   |            |              |
|     of     |              |        |   |            |              |
|            |              |        |   |            |              |
|   evidence |              |        |   |            |              |
|     2)*    |              |        |   |            |              |
+------------+--------------+--------+---+------------+--------------+

**[Definitions]{.underline}**:

**Strength of Scientific Evidence**

1.  Indicates strong scientific evidence to support this recommendation

2.  Indicates some scientific evidence to support this recommendation

3.  Indicates limited scientific evidence to support this recommendation

4.  Indicates no available evidence but clinical experience and expert
    consensus support this recommendation

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate individualized nutritional management of overweight and
obese adults with type 2 diabetes and prediabetes resulting in gradual
weight reduction, improved metabolic control, improved postprandial
hyperglycemia and hypertriglyceridemia, reduced cardiovascular risk, and
prevention of diabetes complications

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline focuses on the unique needs of adult, non-pregnant
patients with type 2 diabetes or individuals at high risk for developing
type 2 diabetes and complements the 2005 Dietary Guidelines for
Americans, which is jointly developed by the Department of Health and
Human Services and the Department of Agriculture. It is not intended to
replace sound medical judgment or clinical decision-making and may need
to be adapted for certain patient care situations where more or less
stringent interventions are necessary.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Joslin Diabetes Center & Joslin Clinic clinical nutrition guideline for
overweight and obese adults with type 2 diabetes, prediabetes or those
at high risk for developing type 2 diabetes. Boston (MA): Joslin
Diabetes Center; 2005 Sep 30. 6 p. \[61 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005

#### GUIDELINE DEVELOPER(S)

Joslin Diabetes Center - Hospital/Medical Center

#### SOURCE(S) OF FUNDING

Joslin Diabetes Center

#### GUIDELINE COMMITTEE

Clinical Nutrition Task Force\
Joslin Clinical Oversight Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Clinical Nutrition Task Force Members*: Osama Hamdy, MD, PhD
(*Co-Chairperson*); Cathy Carver, ANP, CDE (*Co-Chairperson*); Richard
Beaser, MD; Amy Campbell, MS, RD, CDE; Karen Chalmers, MS, RD, CDE; Chan
Cooppan, MD; Om Ganda, MD; Judy Giusti, MS, RD, CDE; Edward S. Horton,
MD; Sharon Jackson, MS, RD, CDE; Melinda Maryniuk, MEd, RD, CDE; Robert
Stanton, MD; Emmy Suhl, MS, RD, CDE

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Joslin Diabetes
Center](http://www.joslin.org/Files/Nutrition_ClinGuide.pdf).

Print copies: Available from the Joslin Diabetes Center, One Joslin
Place, Boston, MA 02215

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on September 22, 2006. The
information was verified by the guideline developer on November 3, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
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Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
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Date Modified: 11/10/2008