Use shared decision-making for optimizing eating plans for adults with diabetes



Evert AB. 2-BM-MS02. Presented at: American Diabetes Association Scientific Sessions; June 3-7, 2022; New Orleans (hybrid meeting).

Evert reports no relevant financial disclosures.

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NEW ORLEANS — Providers should take a shared decision-making approach when creating a nutrition plan for people with diabetes, according to a speaker at the American Diabetes Association Scientific Sessions.

Alison Evert, MS, RDN, CDCES, manager of the nutrition and diabetes education programs at the University of Washington Neighborhood Clinics, reviewed published evidence on the structure, timing and macronutrient composition of eating patterns among people with diabetes. Different eating patterns can have different benefits, and it is important for providers to determine a person’s goal to create a nutrition plan that works best for them.

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“Utilize shared decision-making,” Evert said during the presentation. “If you don’t have time to do this during a 20-minute appointment, refer your patient to a registered dietitian or a diabetes education program. Individualize the meal plan. Ultimately, the eating plan your patient is willing and able to follow will likely be the most effective.”

Creating a meal plan

A few common questions providers get from people with diabetes is how often and how much they should eat. Evert noted it is common for providers to recommend that people with diabetes eat three meals and three snacks per day. However, evidence supporting this is lacking, with most trials being small in size, lasting a short duration and being inconclusive in their findings.

Alison Evert

“Promotion of three meals a day and three snacks a day without any robust evidence is likely going to provide unnecessary calories, especially if they are not hungry,” Evert said. “When we look at the pathophysiology of type 2 diabetes, reduced beta-cell function, insulin resistance as well as first phase of insulin response, telling somebody to eat frequently throughout the day may result in chronic hyperglycemia. Larger fluctuations in glucose may occur following infrequent, sizeable meals that are not planned.”

Evert recommended providers coordinate a meal plan for people with type 2 diabetes to align with their medications to optimize clinical outcomes and reduce medication side effects.

There is more evidence surrounding meal frequency for people with type 1 diabetes. Multiple studies have shown smaller, more frequent meals, along with avoiding snacks, are associated with better glycemic management in type 1 diabetes.

Multiple studies support eating breakfast as well as consuming more calories early in the day vs. late in the day. In a review of systematic reviews and meta-analyses, skipping breakfast may increase one’s risk for cardiovascular disease and type 2 diabetes. For those with type 2 diabetes, data from a 1-week controlled feeding study showed those who ate a large breakfast had a larger reduction in postprandial hyperglycemia during the day than those who ate a small breakfast.

For people who are participating in intermittent fasting or time-restricted eating, Evert said, providers need to get specifics on the eating patterns, such as whether intermittent fasting is alternate-day fasting or normal eating for 5 days followed by fasting for 2 days. Time-restricted eating can also vary based on a person’s desired mealtimes. Evert said more studies are needed on the efficacy, mechanisms and sustainability of time-restricted eating.

Individualizing macronutrients

The macronutrient percentages consumed by people with diabetes in the US are similar to what is consumed by the general public. According to data from the Look AHEAD trial and the National Health and Nutrition Examination Survey, about 45% of the macronutrients consumed by people with diabetes are carbohydrates, 36% to 40% are fat, and 16% to 18% are protein.

In the ADA Nutrition Consensus Report published in 2019, there is no evidence supporting an ideal percentage of macronutrients for people with diabetes. Similarly, no evidence supports a set number of calories per day for people with diabetes.

To come up with a diet that works best, Evert said, providers should ask open-ended questions to allow the patient to voice their goals in a shared decision-making session.

“What is it that you want to do with your health? Is it glucose management? Is it something to do with improving your lipid profile, blood pressure or weight loss?” Evert said.

For people with diabetes, glucose management with a diet is less about rules and formulas and more about trial and error, according to Evert. She described glucose monitoring as a way to assess how certain foods affect glucose levels that can help inform changes in the type or amount of foods one eats moving forward.

For those trying to lose weight, any approach should include behavior modification, Evert said. Patients should aim for a minimum weight loss of 5%, and the benefits increase with the greater amount of weight loss. Some eating patterns with evidence supporting weight loss include the Diabetes Remission Clinical Trial’s very low calorie eating pattern, a Mediterranean-style eating pattern and a low-carbohydrate eating pattern.

“For weight loss, you can prescribe some pharmacotherapy by optimizing diabetes medications or adding weight-loss medications,” Evert said. “There’s also bariatric surgery.”


  • Evert AB, et al. diabetes care. 2019;doi:10.2337/dci19-0014.

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