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Recent randomized controlled trials examining diets of varying carbohydrate composition recommended for people with diabetes and cardiovascular disease and those at risk are summarized.Severe carbohydrate restriction results in appreciable initial weight loss and improvement in risk factors. After a year, however, the beneficial effects are equal to or less than those achieved on conventional alternatives. Some people develop elevations of LDL cholesterol. Modest carbohydrate restriction with relatively high intakes of cis-unsaturated fatty acids and protein is acceptable to many people and is more likely to produce sustained benefit in terms of weight loss and cardiovascular risk indicators.Diets involving moderate carbohydrate restriction are suitable alternatives to high-carbohydrate, high-fibre diets for weight loss and reduction of cardiovascular disease and diabetes risk, as well as to treat individuals with the conditions. As such diets are generally high in protein and unsaturated fatty acids, they are not recommended for those with established or incipient nephropathy. High-carbohydrate, high-fibre diets remain appropriate for use in all those situations, provided carbohydrate is derived principally from minimally processed wholegrain breads and cereals and intact vegetables and fruit. Lower carbohydrate options may be preferable for markedly insulin-resistant individuals.