New Delphi Consensus Guideline Published
A new peer-reviewed guideline gives healthcare professionals practical guidance for implementing therapeutic carbohydrate reduction and demonstrates a remarkable level of agreement among experienced clinicians and researchers.
The Society of Metabolic Health Practitioners (SMHP™) is pleased to announce the publication of “A Delphi consensus-based guideline for the implementation of therapeutic carbohydrate reduction in metabolic disorders” in the Journal of Metabolic Health.
The new paper represents an important milestone for therapeutic carbohydrate reduction (TCR).
It brings together current research, years of clinical experience from a global clinical community, and a formal Delphi consensus process to provide healthcare professionals with practical guidance for implementing TCR safely and effectively.
Metabolic disorders represent a growing global health burden, with a large percentage of adults demonstrating features of metabolic dysfunction. As TCR has become increasingly used in practice worldwide, The SMHP recognized the need to update the expert panel-derived document first published in 2019 by incorporating newer evidence and applying a formal consensus methodology.
The level of consensus was striking: 15 of the guideline’s 18 summary statements achieved 100% agreement among the Delphi panel.
For clinicians who have been interested in carbohydrate reduction but uncertain about how to put it into practice, or who want a peer-reviewed resource to share with colleagues, the guideline provides something the field has needed: a comprehensive implementation framework in one published document.
“Since the original document was published in 2019, the evidence base and practical experience with TCR have continued to develop. The goal was to bring that newer evidence into a structured consensus process and produce practical guidance that reflects where the field is today.” said Sarah Rice, BSc. (Hons), MCOptom (UK), MHP, the paper’s first author, who coordinated its research and contributed the majority of its framework and writing.
From Evidence to Implementation
Therapeutic carbohydrate reduction is the deliberate reduction of dietary carbohydrates for therapeutic purposes. The appropriate degree of carbohydrate reduction can vary according to an individual’s needs, goals, preferences, metabolic response and circumstances.
Understanding the concept of TCR, however, is very different from implementing it with patients.
Clinicians face practical questions:
- What should be evaluated before beginning?
- How much carbohydrate reduction is appropriate?
- What contraindications and cautions should be considered?
- How should medications be managed as glucose or blood pressure improves?
- What should clinicians monitor?
- How should common adaptation effects be addressed?
- How can the approach be individualized so patients can sustain it?
- When is additional caution or specialist involvement warranted?
Those implementation questions are at the heart of the new guideline.
Importantly, the guideline does not prescribe one rigid version of carbohydrate reduction.
It describes a whole-food TCR approach centered on protein, fats from whole foods and vegetables that can be adapted to different cultures, preferences, clinical circumstances and therapeutic goals.
The paper concludes that a well-formulated TCR approach can be nutritionally sufficient, safe and effective for a range of metabolic disorders while recognizing areas where additional research is needed.
More Than Expert Opinion
One of the most important features of the new guideline is how it was developed.
The Delphi method is a structured process designed to develop and measure agreement among experts.
The project began with a steering committee reviewing and substantially expanding the original 2019 document. A Delphi panel then challenged, reviewed and refined the material through multiple rounds.
Development of the statements was informed by a targeted review of human research, and the resulting paper draws on 213 references.
After three rounds of review, feedback and revision, panel members independently evaluated the final recommendations through an anonymous survey. The result was an unusually high degree of agreement across the guideline’s summary statements.
That does not mean every scientific question surrounding TCR has been settled.
It does mean that the recommendations emerged from a documented process involving extensive review, debate, revision and independent evaluation, rather than simply reflecting the opinions of one author or a small informal group.
Built for Clinicians at Every Stage
One of the strengths of the guideline is that it is not only for clinicians already practicing carbohydrate reduction.
It can serve three different groups:
- The curious clinician can use it to understand TCR, explore the research and see how carbohydrate reduction is being implemented in clinical practice.
- The cautious clinician can examine important concerns surrounding TCR, including contraindications, medication adjustment, monitoring, adaptation effects and patient safety.
- The experienced clinician gains an updated, peer-reviewed resource that can support existing practice and be shared with colleagues who want to understand the evidence and implementation framework.
“This paper represents a major step forward for the field. It brings current research, extensive clinical experience and a rigorous consensus process together in one published document. That should give TCR greater credibility and help move the conversation forward throughout the medical community.” said Douglas B. Reynolds, BSc (Elec Eng), MHP, president of The SMHP, who led the project.
The Work Began in 2018
The new publication has an important history.
Work on the first TCR implementation document started in 2018 and was published on the SMHP website in May 2019 after Adele Hite, PhD, MPH, RD, coordinated and synthesized expert input from an international advisory panel of practitioners and researchers.
That work provided an important early resource for clinicians seeking practical guidance on therapeutic carbohydrate reduction.
The new Delphi concensus-based guideline carries that work forward. It updates the earlier document with a new structure, incorporates evidence published since its development and places the revised recommendations within a formal consensus-development and peer-review framework.
Learn more about Adele Hite’s role in the first project.
Patient Safety Remains Central
TCR can produce clinically meaningful metabolic changes, and those changes can require active medical management.
This is particularly important for patients taking medications for diabetes or hypertension. The guideline contains detailed medication considerations, including circumstances in which medications may require adjustment as carbohydrate intake changes.
Practitioners without prescribing or deprescribing privileges should ensure that patients have access to an appropriately qualified professional who can monitor and adjust medications when necessary.
The guideline is not a substitute for professional judgment. Rather, it is designed to give clinicians a stronger framework for applying that judgment responsibly.
A Resource Worth Reading and Sharing
The significance of this publication goes beyond clinicians who already practice therapeutic carbohydrate reduction.
For years, many healthcare professionals interested in metabolic health have had to assemble information about TCR from individual studies, clinical experience, educational programs and separate resources.
This guideline brings much of that implementation knowledge together in a single peer-reviewed publication.
For clinicians already using TCR, it provides additional support.
For clinicians who remain uncertain, it provides a serious resource to examine.
For clinicians encountering therapeutic carbohydrate reduction for the first time, it provides a place to begin.
Healthcare professionals are encouraged to read the paper, examine the evidence and methodology and, perhaps most importantly, share it with a colleague.
Publication Details
Published: October 2, 2026
Journal: Journal of Metabolic Health
DOI: 10.4102/jmh.v9i1.152
Citation: Rice SM, Buchanan LA, Calkins MW, et al. A Delphi consensus-based guideline for the implementation of therapeutic carbohydrate reduction in metabolic disorders. J. metab. health. 2026;9(1), a152. https://doi.org/10.4102/jmh.v9i1.152
Authors and Steering Committee
Sarah M. Rice, BSc. (Hons), MCOptom (UK), MHP
Laura A. Buchanan, MD, MHP
Matthew W. Calkins, MD, MHP
Mark T. Cucuzzella, MD, MHP, Professor of Medicine
Robert Cywes, MD, PhD
Pamela L. Devine, MHP
Miriam Kalamian, EdM, MS, CNS
Tro Kalayjian, DO
Douglas B. Reynolds, BSc (Elec Eng), MHP
Eric C. Westman, MD, Associate Professor of Medicine
Delphi Panel
Nadir Ali, MD
Amy Berger, CNS
Lori Calabrese, MD, MHP
Dr. David Cavan, MD, FRCP
Dr. Gary Fettke, M.B.,B.S., F.R.A.C.S.(Orthopaedic Surgery), F.A.Orth.A.
Tony Hampton, MD, MBA, ABOM, CPE, MSHNFM
Lily E. Johnston, MD, MPH, MHP
Brian Lenzkes, MD, MHP
Barbara Levy, MD
Prof Tim Noakes
Roshani Sanghani, MD, MHP
Bret Scher, MD
Franziska Spritzler, RD, CDCES
Dr. David Unwin, FRCGP
William S. Yancy, Jr., MD, MHS
About the Society of Metabolic Health Practitioners
The Society of Metabolic Health Practitioners (SMHP™) is a nonprofit organization dedicated to advancing metabolic health by educating, supporting and connecting healthcare professionals.
The SMHP provides evidence-based education, professional resources, accreditation and a global community for practitioners seeking to improve metabolic health through nutrition and lifestyle interventions.
Through initiatives such as the TCR implementation guideline, The SMHP works to help translate emerging metabolic health science into responsible, practical clinical care.
Learn more at: The SMHP