Abbreviations25(OH)D25-hydroxyvitamin DAACEAmerican Association of Clinical EndocrinologistsBEL“best evidence” rating levelBMIbody mass indexBPblood pressureCKDchronic kidney diseaseCPGclinical practice guidelineCVDcardiovascular diseaseDMdiabetes mellitusEAAessential amino acidsESKDend-stage kidney diseaseGFRglomerular filtration rateGIglycemic indexHBVhigh-biological-valueIUinternational unitsMUFAsmonounsaturated fatty acidsNEno evidence (theory, opinion, consensus, and review)PUFApolyunsaturated fatty acidQquestionRrecommendationRRTrenal replacement therapyT1DMtype 1 diabetes mellitusT2DMtype 2 diabetes mellitusTOSThe Obesity Society 25-hydroxyvitamin D American Association of Clinical Endocrinologists “best evidence” rating level body mass index blood pressure chronic kidney disease clinical practice guideline cardiovascular disease diabetes mellitus essential amino acids end-stage kidney disease glomerular filtration rate glycemic index high-biological-value international units monounsaturated fatty acids no evidence (theory, opinion, consensus, and review) polyunsaturated fatty acid question recommendation renal replacement therapy type 1 diabetes mellitus type 2 diabetes mellitus The Obesity Society The American Association of Clinical Endocrinologists (AACE) and The Obesity Society (TOS) are professional organizations dedicated to improve the lives of patients with endocrine and metabolic disorders. Chronic diseases demand treatment, but a focus on primary, secondary, and tertiary prevention strategies is important as well. Central to this approach is behavior modification to achieve consistent healthy eating and physical activity. Yet, to date there is no evidence-based clinical practice guideline (CPG) to define the standards of care for healthy eating in the management and prevention of metabolic and endocrine disorders. This joint effort of AACE and TOS addresses this deficit. For most clinical endocrinologists, nutrition education is not structured. Many of the endocrinology training programs in the United States lack a dedicated nutrition curriculum. The same problem affects physicians with a focus of practice in bariatric medicine (1.McClave S.A. Mechanick J.I. Bistrian B. et al.What is the significance of a physician shortage in nutrition medicine?.JPEN J Parenter Enteral Nutr. 2010; 34: 7S-20SCrossref PubMed Scopus (17) Google Scholar; 2.McClave S.A. Mechanick J.I. Kushner R.F. et al.Compilation of recommendations from summit on increasing physician nutrition experts.JPEN J Parenter Enteral Nutr. 2010; 34: 123S-132SCrossref PubMed Scopus (13) Google Scholar). As a result, nutritional counseling and management for our patients is often delegated to other health care professionals. There are many obstacles that preclude patient access to nutritional education. Federal institutions have not paid for nutrition education except for a limited number of conditions, including medical nutrition therapy for diabetes mellitus (DM) and nutrition counseling for chronic kidney disease (CKD) stage 5. Although Medicare has recently approved counseling for obesity, most overweight patients or patients with obesity, dyslipidemia, polycystic ovarian syndrome, hypertension, osteopenia and osteoporosis, hyperuricemia, earlier stages of CKD, eating disorders, malnutrition, and prediabetes are marginalized from this important component of health care. Other obstacles to implementing healthy eating strategies on a large scale include: •unawareness of the importance of health promotion and wellness care in the general population to prevent disease, including endocrine and metabolic disorders,•the relative paucity of healthy nutritional principles and eating patterns taught in American schools, higher education institutions, and even workplaces,•the relative scarcity and increased expense of healthy foods,•the easy accessibility, low cost, and palatability of less-healthy foods,•mass-media marketing of foods with low nutritional value,•lack of oversight of food marketing, and inadequate and/or ineffective food policies,•the perishability of foods, increased need for preservatives, and decreased awareness of food safety,•the variability of nutrient-gene interactions (nutrigenomics and nutrigenetics), and•transcultural factors, including religious, social, ethnic, and economic factors, as well as individual food preferences, culinary styles, and belief systems. This CPG proposes an evidence-based, standardized context for healthy eating recommendations. Throughout this document, the word “diet” is avoided, and the terms “meal plan” (what patients are taught to eat) and “eating or dietary pattern” (the structure or composition of the meals) are preferred instead. This CPG does not formally address healthy eating for pediatric or hospitalized patients but makes reference to them when appropriate. The AACE Board of Directors mandated a CPG on healthy eating for the prevention and treatment of metabolic and endocrine diseases in adults. The project was approved for co-authorship with TOS by the leadership of both organizations. This CPG was developed in accordance with the AACE Protocol for Standardized Production of Clinical Practice Guidelines - 2010 Update. Reference citations in the text of this document include the reference number, numerical descriptor (evidence level; EL 1-4), and semantic descriptor (see Table 1, Table 2, Table 3, Table 4). Recommendations are assigned Grade levels based on the supporting clinical evidence and subjective factors. The format of this CPG is based on specific and relevant clinical questions.Table 12010 AACE Protocol for Production of Clinical Practice Guidelines. Step I: Evidence Rating1Meta-analysis of randomized controlled trials (MRCT)1Randomized controlled trials (RCT)2Meta-analysis of nonrandomized prospective or case-controlled trials (MNRCT)2Nonrandomized controlled trial (NRCT)2Prospective cohort study (PCS)2Retrospective case-control study (RCCS)3Cross-sectional study (CSS)3Surveillance study (registries, surveys, epidemiologic study, retrospective chart review, mathematical modeling of database) (SS)3Consecutive case series (CSS)3Single case reports (SCR)4No evidence (theory, opinion, consensus, or review) (NE)Abbreviations: AACE = American Association of Clinical Endocrinologists. 1 = strong evidence; 2 = intermediate evidence; 3 = weak evidence; 4 = no evidence. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283. Open table in a new tab Table 22010 AACE Protocol for Production of Clinical Practice Guidelines. Step II: Evidence Analysis and Subjective FactorsStudy designData analysisInterpretation of resultsPremise correctnessIntent-to-treatGeneralizabilityAllocation concealment (randomization)Appropriate statisticsLogicalSelection biasIncompletenessAppropriate blindingValidityUsing surrogate end points (especially in “first in class” intervention)Sample size (beta error)Null hypothesis versus Bayesian statisticsAbbreviation: AACE = American Association of Clinical Endocrinologists. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283. Open table in a new tab Table 32010 AACE Protocol for Production of Clinical Practice Guidelines. Step III: Grading of Recommendations - How Different Evidence Levels Can be Mapped to the Same Recommendation GradeaStarting with the left column, BEL, subjective factors, and consensus map to recommendation grades in the right column. When subjective factors have little or no impact (“none”), then the BEL is directly mapped to recommendation grades. When subjective factors have a strong impact, then recommendation grades may be adjusted up (“positive” impact) or down (“negative” impact). If a two-thirds consensus cannot be reached, then the recommendation grade is D. NA regardless of the presence or absence of strong subjective factors, the absence of a two-thirds consensus mandates a recommendation grade D. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283.BELSubjective factor impactTwo-thirds consensusMappingRecommendation grade1NoneYesDirectA2PositiveYesAdjust upA2NoneYesDirectB1NegativeYesAdjust downB3PositiveYesAdjust upB3NoneYesDirectC2NegativeYesAdjust downC4PositiveYesAdjust upC4NoneYesDirectD3NegativeYesAdjust downD1, 2, 3, 4NANoAdjust downDAbbreviations: AACE = American Association of Clinical Endocrinologists; BEL = best evidence level; NA = not applicable.a Starting with the left column, BEL, subjective factors, and consensus map to recommendation grades in the right column. When subjective factors have little or no impact (“none”), then the BEL is directly mapped to recommendation grades. When subjective factors have a strong impact, then recommendation grades may be adjusted up (“positive” impact) or down (“negative” impact). If a two-thirds consensus cannot be reached, then the recommendation grade is D. NA regardless of the presence or absence of strong subjective factors, the absence of a two-thirds consensus mandates a recommendation grade D. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283. Open table in a new tab Table 42010 American Association of Clinical Endocrinologists Protocol for Production of Clinical Practice Guidelines. Step IV: Examples of Qualifiers that may be Appended to RecommendationsCost effectivenessRisk-benefit analysisEvidence gapsAlternative physician preferences (dissenting opinions)Alternative recommendations (“cascades”) Resource availability Cultural factorsRelevance (patient-oriented evidence that matters)Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283. Open table in a new tab Abbreviations: AACE = American Association of Clinical Endocrinologists. 1 = strong evidence; 2 = intermediate evidence; 3 = weak evidence; 4 = no evidence. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283. Abbreviation: AACE = American Association of Clinical Endocrinologists. Adapted from Mechanick et al. Endocr Pract. 2010;16:270-283. Abbreviations: AACE = American Association of Clinical Endocrinologists; BEL = best evidence level; NA = not applicable. All primary writers have made disclosures regarding multiplicities of interest. In addition, all primary writers are credentialed experts in the fields of nutrition, endocrinology, or both. This CPG has been reviewed and approved by the primary writers, other invited experts, the AACE Publications and Nutrition Committees, and the AACE Board of Directors prior to submission for peer review in Endocrine Practice. This CPG has also been approved by selected members of TOS prior to submission for peer review in Obesity, The Official Journal of TOS. This CPG expires in 2016. Clinical questions are labeled “Q” and recommendations are labeled “R”. Recommendation grades are based on four intuitive levels: (grades A [strong], B [intermediate], and C [weak]) or expert opinion when there is a lack of conclusive clinical evidence (grade D). The “best evidence” rating level (BEL), which corresponds to the best conclusive evidence found in the discussion section in the appendix, accompanies the recommendation grades in the Executive Summary. There are also four intuitive levels of evidence: 1 = strong, 2 = intermediate, 3 = weak, and 4 = no evidence. Comments may be appended to recommendations regarding relevant subjective factors that may have influenced the grading process. The consensus level of experts for each recommendation may also be explicitly provided in appropriate instances. Thus, the process leading to a final recommendation and grade is not dogmatic but rather incorporates a complex expert integration of objective and subjective factors meant to reflect optimal real-life clinical decision-making to enhance patient care. Where appropriate, cascades of recommendations are provided (settings with limited resources, unique patient attributes, etc. (3.Mechanick J.I. Camacho P.M. Cobin R.H. et al.American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Practice Guidelines--2010 update.Endocr Pract. 2010; 16: 270-283Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar). •R1.All patients should be instructed on healthy eating and on proper meal planning by qualified health care professionals (Grade A, BEL 1). Essential macronutrients and micronutrients, fiber, and water should be provided by well-chosen foods and beverages that can be enjoyed and constitute a healthy eating pattern. Macronutrients should be recommended in the context of a calorie-controlled meal plan (Grade A, BEL 1). All patients should also be counseled on other ways to achieve a healthy lifestyle, including regular physical activity (150 minutes or more per week), ways to avoid a sedentary lifestyle, appropriate sleep time (6 or more hours every night), and budgeting time for recreation or play, stress reduction, and happiness (Grade A, BEL 1). •R2. In a healthy eating meal plan, carbohydrates should provide 45 to 65% of ingested energy, with due diligence to limit simple sugars or foods that have a high glycemic index (GI). Regardless of the macronutrient mix, total caloric intake must be appropriate for individual weight management goals. Patients should consume 6 to 8 servings of carbohydrates (one serving is 15 grams of carbohydrate) per day with at least half (3 to 4 servings) being from high-fiber, whole-grain products (Grade A, BEL 1). Consumption of fruits (especially berries) and vegetables (especially raw) (≥4.5 cups per day) will increase fiber, increase phytonutrient intake, and facilitate calorie control (Grade B, BEL 2). Patients should be instructed to consume whole grains in place of refined grains, which will add fiber and micronutrients to meals and help lower blood pressure (BP) (Grade A, BEL 1).•R3. Protein from both plant and animal sources (15 to 35% of calories depending on total intake) can replace a portion of saturated fat and/or refined carbohydrates in the meal plan to help improve blood lipids and BP (Grade A, BEL1). The meal plan should include a maximum of 6 ounces per day of reduced-fat animal protein to increase the nutrient-to-calorie ratio (Grade B, BEL 1). Reduced-fat dairy (2 to 3 servings per day) should be recommended as a source of high-quality protein for patients who are not intolerant or allergic to lactose because it lowers BP and helps reduce weight while also providing important micronutrients (Grade A, BEL 1). Plant protein (e.g., pulses, including beans, lentils, and some nuts; and certain vegetables, including broccoli, kale, and spinach) should be emphasized in meal planning, as it is not commonly consumed in Western meals; plant proteins confer many health benefits, including improved blood lipid levels and BP (Grade B, BEL 2).•R4. Patients should be counseled to consume unsaturated fats from liquid vegetable oils, seeds, nuts, and fish (including omega-3 fatty acids) in place of high-saturated fat foods (butter and animal fats), providing 25 to 35% of daily calories to reduce the risk for cardiovascular disease (CVD) (Grade A, BEL 1). It should be recommended that patients consume natural foods high in monounsaturated fat, such as olive oil in the Mediterranean dietary pattern, since this is strongly associated with improved health outcomes (Grade A, BEL 1. It should be recommended that patients eat at least 2 servings of cold-water, fatty fish (such as salmon or mackerel) every week because they contain greater amounts of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (Grade B, BEL 2). •R5. With the exception of proven therapies for documented specific vitamin deficiency states or diseases, or pregnancy, there are insufficient data to recommend supplemental vitamin intake above the recommended dietary allowances (Grade D, BEL 4). Vitamin E supplementation to decrease cardiovascular (CV) events or cancer is not recommended (Grade B, BEL 2). Lifelong regular follow-up and individualized therapy are recommended in diseases known to cause intestinal malabsorption (e.g., after malabsorptive bariatric surgery, ileo-colic resection, short bowel syndrome, celiac disease, inflammatory bowel disease, exocrine pancreatic insufficiency, CKD, and chronic liver disease) to detect and treat vitamin and mineral deficiencies (Grade B, BEL 2).•R6. Vitamin B12 levels should be checked periodically in older adults and patients on metformin therapy (Grade A, BEL 1). With the exception of early treatment of patients with neurologic symptoms, pernicious anemia, or malabsorptive bariatric surgery requiring parenteral (intramuscular or subcutaneous) vitamin B12 replacement, patients with vitamin B12 deficiency can generally be treated with oral vitamin B12 (1,000 pg per day of oral crystalline cobalamin) and may benefit from increasing the intake of vitamin B12 in food (Grade A, BEL 1).•R7. The prevalence of vitamin D deficiency and insufficiency warrants case finding by measurement of 25-hydroxyvitamin D (25[OH]D) levels in populations at risk, including institutionalized elderly patients, people with hyperpigmented skin, and people with obesity (Grade B BEL 2). Older adults, people with increased skin pigmentation, and those exposed to insufficient sunlight should increase vitamin D intake from vitamin D-fortified foods and/or supplements to at least 800 to 1,000 international units (IU) daily (Grade A, BEL 1). •R8. Overweight and obesity should be managed as a long-term chronic disease (Grade A, BEL 1. Overweight and obesity should be managed using a multidisciplinary team approach (Grade A, BEL 1). Nutrition counseling for overweight and obesity should be aimed to decrease fat mass and also to correct adipose tissue dysfunction (adiposopathy) (Grade A, BEL 1). Adult feeding behavior is solidly rooted from childhood, so it is important to counsel adult patients to include their families, especially their children, in healthy eating behavior changes (Grade B, BEL 2). Nutrition counseling should be culturally, linguistically, and educationally provided to meet individual patient needs (Grade D, BEL 4).•R9. The weight-loss goal for overweight or obese patients is 5 to 10% of current body weight over the ensuing 6 to 12 months. This goal is perennial until an acceptable body mass index (BMI) is achieved (Grade A, BEL 1). Combined therapy utilizing a low-calorie meal plan (LCMP), increased physical activity, behavior therapy, and appropriate pharmacotherapy provides the most successful intervention for weight loss and weight maintenance and is also recommended as an adjunct to bariatric surgery (Grade A, BEL2. Expert panel experience and consensus). •R10. Sustained behavior modification must be achieved for long-term success with weight management. Food and activity recordkeeping should be recommended to help patients achieve the best results (Grade A, BEL 1). Behavioral group therapy is a cost-effective way of providing nutrition counseling to patients and should be incorporated into weight management treatment programs (Grade B, BEL 2). Use of portion-controlled prepackaged meals should be considered as a way to achieve a lower caloric intake (Grade A, BEL 1). •R11. When first treating a patient with overweight or obesity, emphasis should be placed on maintaining a healthy meal plan and avoiding fad diets while including food choices from all major food groups (Grade A, BEL 2). A healthy, LCMP with a deficit of 500 to 1,000 kcal/day should be an integral part of any program aimed at achieving a total weight-loss rate of 1 to 2 pounds/week (which may include lean muscle mass as well as fat mass weight loss) (Grade A, BEL 1). All meal plans of <1,200 kcal/day should be carefully selected so that nutrient requirements are met. When particular food groups are severely restricted or omitted, the use of dietary supplements to meet nutrient requirements should be implemented (Grade D, EL 4). •R12. Very low-calorie meal plans (VLCMPs) (≤800 kcal/day or ~6 to 10 kcal/kg), which can produce weight losses up to 1.5 to 2.5 kg/week and up to 20 kg in 12 to 16 weeks, may be recommended for patients with a BMI >30 kg/m2 who have significant comorbidities or who have failed other nutritional approaches to weight loss (Grade B, BEL 2). VLCMP treatment requires nutritional supplementation and medical monitoring for complications, including electrolyte imbalances, hepatic transaminase elevation, and gallstone formation, and the duration of treatment should not exceed 12 to 16 weeks (Grade A, BEL 1). •R13. All patients at risk for CVD should implement healthy eating patterns, which provide calorie control, adequate nutrients, beneficial bioactive compounds, and result in weight loss or weight maintenance (Grade D, BEL 4). To help control calorie intake, patients should eat meals that are low in energy density (Grade A, BEL1). All patients should also be advised to increase caloric expenditure to at least 150 minutes of moderate- intensity activity every week (e.g., walking) or 75 minutes of vigorous-intensity activity every week (e.g., running) (Grade A, BEL 1). Successful weight loss and maintenance to decrease CV risk must include both a change in meal plan as well as frequent physical activity (Grade A, BEL 1). •R14. The therapeutic lifestyle changes (TLC) meal plan with viscous fiber and plant sterols and stanols is recommended for individuals with elevated low-density-lipoprotein cholesterol (LDL- C) (Grade A, BEL 1). The Mediterranean meal plan (or a TLC meal plan that provides 30 to 35% of calories from total fat with an emphasis on mono- and polyunsaturated fatty acids [PUFAs]) is recommended for individuals who have abnormal non-LDL-C lipid values (Grade A, BEL 1). •R15. Attaining and maintaining a healthy body weight is recommended to prevent and treat hypertension. Obese and overweight individuals should accomplish a 10% weight loss to decrease their BP (Grade A, BEL 1). All patients should be counseled to adhere to the Dietary Approaches to Stop Hypertension (DASH) meal plan, which is high in fruits, vegetables, whole grains, and reduced-fat dairy (Grade A, BEL 1). Sodium intake should be reduced to <2,300 mg/day, and potassium intake should be increased to >4,700 mg/day with implementation of a DASH-type meal plan (Grade A, BEL 1). Sodium intake should be further reduced (<1,500 mg/day; or 3,800 mg/day of table salt) for people age 51 years and above, all people who are African American, regardless of age, and for patients who have hypertension, DM, or CKD (Grade A, BEL 1). •R16. Added sugars should be limited to <100 calories per day for women and <150 calories per day for men (Grade A, BEL 1). Sugar-sweetened beverage intake should be reduced as an effective way to reduce added sugar intake (Grade B, BEL 2. Saturated fat intake should be limited to <7% for reduction of CVD risk (Grade A, BEL 1). It is recommended that processed red meat intake be limited to less than 2 servings per week and that lean or very lean red meat cuts be consumed while controlling for saturated fat intake (Grade B, BEL 2. Whole grain products should be substituted for refined grain products when possible, such that at least one-half of daily servings of grains are from whole grains (Grade B, BEL 2). •R17. Medical nutrition therapy provided by a physician, physician extender, registered dietician (RD), and/or certified diabetes educator is recommended for all patients with DM (Grade A, BEL 1). Patients with DM who experience difficulty achieving glycemic targets should keep a personal food diary (Grade D, BEL 4). •R18. Patients with DM should consume total daily calories at amounts sufficient to attain or maintain a normal BMI of 18.5 to 24.9 kg/m2, which is generally in the 15 to 30 kcal/kg/day range, depending on level of physical activity (Grade A, BEL 1. Patients with DM should consume protein in the 0.8 to 1.0 g/kg/day range, and protein should account for about 15 to 35% of the total calorie consumption for the day (Grade C, BEL 3). •R19. Medical nutrition therapy should be implemented to control the glycemic response to meals and to achieve hemoglobin A1c and blood glucose levels as close to the target range as possible without risk to the individual patient (Grade A, BEL 1). Carbohydrates should account for about 45 to 65% of the total calorie consumption for the day, including low-fat dairy products and sucrose (Grade C, BEL 3). Patients with DM should consume carbohydrate primarily from unprocessed carbohydrates, which are provided by a target of 8 to 10 servings per day of vegetables (particularly raw), fruits, and legumes, with due diligence to limit simple sugars or foods that have a high GI (Grade A, BEL 1). Regardless of the macronutrient mix, total caloric intake must be appropriate for individual weight management goals. Patients with DM should consume 20 to 35 g of fiber from raw vegetables and unprocessed grains (or about 14 g of fiber per 1,000 kcal ingested) per day (the same as the general population) (Grade B, BEL 2). Patients with type 1 DM (T1DM), or insulin-treated type 2 DM (T2DM) should synchronize insulin dosing with carbohydrate intake (Grade A, BEL 1). Patients with T2DM treated with short-acting oral hypoglycemic agents (nateglinide, repaglinide) should also synchronize carbohydrate intake with administration of these medications (Grade A, BEL 1). Patients with DM may safely consume artificial sweeteners within the guidelines of the U.S. Food and Drug Administration (Grade D, BEL 4). •R20. For patients with DM, total fat intake should account for about 30% of the total daily calories (Grade B, BEL 2). Consumption of saturated fat should be less than 7% of total daily calories regardless of the serum total cholesterol level, and PUFAs should be up to 10% of the total daily calories (examples of food sources include vegetable oils high in n-6 PUFA, soft margarine, salad dressings, mayonnaise, and some nuts and seeds) (Grade B, BEL 2). The n-3 PUFAs are most desirable, and dietary recommendations for EPA and DHA can be achieved with two or more servings of fresh fish per week (Grade B, BEL 2). In patients with DM, monounsaturated fatty acids (MUFAs) should be up to 15 to 20% of the total daily calories (Grade B, BEL 2). Dietary cholesterol should be less than 200 mg/day (Grade A, BEL 1). Patients with DM should avoid consumption of trans fats (Grade C, BEL 3). •R21. There is insufficient evidence to specifically recommend a “low-GI” meal plan in patients with DM (Grade D, BEL 4). There is insufficient evidence to support the routine use of antioxidants, chromium, magnesium, and/or vanadium in patients with DM (Grade C, BEL 3).•R22. Patients with DM who choose to drink alcohol should ingest it with food and limit intake to 2 servings per day for men or 1 serving per day for women. Alcohol intake should not be increased for any purported beneficial effect (Grade D, BEL 4). There is insufficient evidence, based on long-term risks and benefits, to support the use of fad diets in patients with DM (Grade D, BEL 4). •R23. There is insufficient evidence to support nutrition changes to specifically prevent T1DM (Grade D, BEL 4). However, women with a personal or family history of T1DM who may be HLA-DR3 and DR4 carriers should be counseled on the medical evidence suggesting that the use of infant formula derived from cow’s milk in the first 6 months of life increases a baby’s risk of T1DM by stimulating antibody formation to the beta-cells (Grade B, BEL2). Patients at high risk for the development of T2DM should implement lifestyle interventions to achieve a minimum of 7% weight loss followed by weight maintenance, and a minimum of 150 minutes of weekly physical activity, similar in intensity to brisk walking (Grade A, BEL 1). •R24. Patients with CKD should have a meal plan low in protein, sodium, potassium, and phosphorus, which slows the progression of kidney disease (Grade A, BEL1). All patients with CKD should receive nutrition education by qualified health care professionals (Grade A, BEL 1). •R25. In CKD stages 1, 2, or 3, protein intake should be limited to 12 to 15% of daily calorie intake or 0.8 g of high-biological-value (HBV) protein/kg body weight/day (Grade A, BEL 1). In CKD stage 4, protein intake should be reduced to 10% of daily calorie intake or 0.6 g of high- quality protein/kg body weight/day, provided an essential amino acid (EAA) deficiency does not occur (Grade A, BEL 1). For nondialyzed CKD patients with a glomerular filtration rate (GFR) <25 mL/min, 0.6 g of protein/kg body weight/ day should be prescribed, with at least 50% of the protein intake from HBV sources to ensure a sufficient amount of EAAs (Grade A, BEL 1). For patients with CKD stage 5 or patients on renal replacement therapy (RRT), protein intake should be 1.3 g/kg/day (peritoneal dialysis) or 1.2 g/kg/ day (hemodialysis) (Grade A, BEL 1). Urinary protein losses in the nephrotic syndrome should be replaced, and a low-normal protein dietary reference intake of 0.8 to 1.0 g/kg body weight/day should be recommended (Grade C, BEL 3).•R26. Patients with CKD stages 1, 2, or 3 should ingest 35 kcal/kg body weight/day in order to maintain neutral nitrogen balance and to prevent catabolism of stored proteins for energy needs (Grade B, BEL 2). Patients with CKD and a GFR <25 mL/min should ingest 35 kcal/kg body weight/day if they are younger than age 60 years or 30 to 35 kcal/kg body weight/day if they are age 60 years or above (Grade B, BEL 2). •R27. All patients with CKD, regardless of CKD stage, should limit sodium intake to 2.0 g/day (Grade A, BEL 1). When potassium levels are elevated, potassium intake (including salt substitutes) should be limited to 2 to 3 g/day (Grade A, BEL 1). When diarrh