Description
The goals of medical nutrition therapy for diabetes mellitus are to improve overall metabolic outcomes (glucose and lipid levels), provide appropriate energy to maintain desirable body weight, and improve overall health through optimal nutrition (1).  The consistent-carbohydrate meal planning approach incorporates consistent carbohydrate intake, fat intake modifications, and consistent timing of meals and snacks (if needed).  The American Diabetes Association recommends the consistent-carbohydrate meal planning approach over the standardized energy-level meal patterns based on the exchange lists (1-3).

Indications and Nutrition Diagnosis
Diabetes is diagnosed and classified based on the results of appropriate medical and laboratory tests.  In 1997, the Expert Committee on Diagnosis and Classification of Diabetes Mellitus established new diagnostic and classification criteria.  (See Diagnosis Criteria for Diabetes Mellitus.)  The classification of diabetes mellitus includes four clinical classes (1):

• type 1 diabetes (caused by beta-cell destruction that usually leads to absolute insulin deficiency)
• type 2 diabetes (caused by progressive insulin secretory defect on the background of insulin resistance)
• other specific types (due to other causes, eg, genetic defects in beta-cell function, genetic defects in insulin action, diseases of the exocrine pancreas, or drug or chemical induced)
• gestational diabetes mellitus (diabetes mellitus diagnosed during pregnancy)

   The type of diabetes and the individual patient’s needs, as presented by the nutrition signs and symptoms, will determine the nutrition diagnosis, medical nutrition therapy, and approach to self-management training.

    The overall goal of nutrition intervention is to assist and facilitate individual lifestyle and behavior changes that will lead to improved metabolic control (2).  The following goals of medical nutrition therapy apply to all persons with diabetes (2):

• Attain and maintain optimal metabolic outcomes including (2):

a)  a blood glucose level in the normal range, or as close to the normal range as safely possible, to reduce the risk of diabetic complications,
b)  a lipid and lipoprotein profile that reduces the risk of macrovascular disease, and
c)  blood pressure levels that reduce the risk of vascular disease.

• Prevent, treat, or delay the development of obesity, dyslipidemia, cardiovascular disease, hypertension, nephropathy, retinopathy, and neurologic complications associated with diabetes mellitus.
• Improve health through healthy food choices and physical activity.
• Address individual nutrition needs, taking into consideration the patient’s personal and cultural preferences and willingness to change.
• Maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.
• Contribute to normal outcomes of pregnancies for women with preexisting diabetes and gestational diabetes.
• Provide adequate energy and nutrients for increased needs during pregnancy and lactation.
• Provide adequate energy to maintain normal growth and development rates in children and adolescents with diabetes.

a These values are generalized to the entire population of individuals with diabetes.  Patients with comorbid diseases, very young children, older adults, and patients with unusual conditions or circumstances may warrant different treatment goals.  These values are for nonpregnant adults.  Additional actions that are suggested depend on the individual patient’s circumstances.  Such actions may include enhanced diabetes self-management education, comanagement with a diabetes team, referral to an endocrinologist, change in pharmacologic therapy, initiation of or increase in self-monitoring blood glucose records, or more frequent contact with the patient.  Hemoglobin A1c values for a nondiabetic person range from 4.0% to 6.0% (mean, 5.0%; SD, 0.5%).
Source: American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2008; 31(suppl 1):3S-54S.

Nutritional Adequacy
The nutrition prescription can be planned to meet the Dietary Reference Intakes as outlined in the Statement on Nutritional Adequacy.

How to Order the Diet
The physician may specify one of the following:

• Consistent-carbohydrate meal plan: The meal plan incorporates consistent carbohydrate intake (±15 g of carbohydrate per meal or snack), fat intake modifications, and consistent timing of meals and snacks, not specific energy levels.  The meal plan provides 1,500 to 1,800 kcal/day, with approximately 50% of the energy from carbohydrate, 20% from protein, and 30% from fat (<7% saturated and trans fat combined) (2-4).  The plan provides four carbohydrate selections at each meal with the remaining selections from vegetables, lean meats, and appropriate fats. This diet is the standard hospital meal plan for people with diabetes. If the patient requests additional food, select choices from the vegetable and lean meat groups.  Between-meal snacks are given based on the individual patient’s nutrition needs and preference or to complement medical treatment (eg, medications) to optimize blood glucose levels; thus, snacks are not automatically provided to patients.  Food intake frequency (for example, three meals vs smaller meals and snacks) is not associated with long-term differences in glucose levels, lipid levels, or insulin responses in type 2 diabetes mellitus (2).  Therefore, division of food intake should be based on the individual’s preferences.  Conditions for which an evening snack may be warranted include pregnancy, lactation, diabetes in a person with higher energy and protein needs, or prescription of medications that increase the risk of hypoglycemia.
• Nutrition prescription per a registered dietitian’s recommendations: The dietitian plans an individualized diet, taking into account the patient’s energy and protein needs, fat restrictions, food preferences, and eating habits.  Snacks are planned for patients taking insulin or are served according to facility protocols.  Meal plans based on exchange lists or carbohydrate counting may be used with this order. Individualization of the meal pattern is emphasized, rather than a specific standard macronutrient distribution.  Fat content of the diet is manipulated according to the blood glucose, lipid, and body weight goals.  Protein, carbohydrate, and mineral content of the diet may be manipulated to achieve individual metabolic and clinical goals.
• Regular diet: This may be considered as an option for patients with increased needs for energy and protein because of other medical conditions, such as pressure ulcers, cancer, burns, sepsis, or surgery.

Note: “No concentrated sweets” is not recommended, since it conveys the impression that simply avoiding sweets will in itself promote good control of blood glucose(2,3).  

Nutrition Intervention and Planning for Medical Nutrition Therapy

Carbohydrates and Diabetes
The following terms are preferred when describing carbohydrates: sugars, starch (eg, amylase, amylopectin, modified starches), and fiber (eg, cellulose, hemicellulose, pectins, hydrocolloids) (1). Regulation of blood glucose levels to achieve near-normal levels is the primary goal in the management of diabetes (1).  Dietary techniques that limit hyperglycemia following a meal are important in limiting the complications of diabetes (1).  Both the amount (grams) and type of carbohydrate in a food influence blood glucose levels (Grade I)* (1,4,5).  The total amount of carbohydrate consumed at meals and snacks influences the postmeal glucose response to a greater extent than other macronutrients (Grade I) (4,5).  There is a direct relationship between the amount of carbohydrate in a meal, postmeal blood glucose response, and premeal rapid-acting or short-acting insulin requirements to maintain desirable blood glucose goals (Grade I) (4,5).  Therefore, the total amount of carbohydrate consumed is a strong predictor of glycemic response, and monitoring the total grams of carbohydrate (whether by use of exchanges or carbohydrate counting) remains a key strategy in achieving glycemic control (Grade I) (1,4,5).

*The American Dietetic Association has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to evidence and conclusion statements. The grading system is described in Clinical Nutrition Management: A Reference Guide.    
   
    Studies have demonstrated that when persons with type 1 or type 2 diabetes mellitus consume a variety of sugars or starches, there is no substantial difference in the glycemic response when the total amount of carbohydrate remains constant (2,5).  Sucrose intakes of 10% to 35% of total energy intake do not have a negative effect on glycemic or lipid responses in persons with either type 1 to type 2 diabetes when sucrose is substituted for isoenergetic amounts of  starch (4) (Grade I).  Based on these findings, sugar (eg, sucrose) intake does not have to be avoided.  Instead, sugar intake should be based on the total amount of carbohydrate needed to achieve optimal metabolic control and the nutritional contribution to the diet.  Foods containing carbohydrate from whole grains, fruits, vegetables, and low-fat milk are important components and should be included in a healthy diet for persons with diabetes mellitus (Grade I) (2,4).

    Recently, the use of low–glycemic index foods or low-glycemic diets has received renewed interest.  Factors that influence the glycemic response to food include: the type and amount of carbohydrate, type of sugar, nature of starch, cooking and food processing, as well as other food components (eg, fat and natural substances that slow digestion—lectins, phytates, tannins, and starch-protein and starch-lipid combinations) (2,6-9).  Fasting and preprandial glucose concentrations, the severity of glucose intolerance, and the second meal or lente effect are other factors that affect the glycemic response to food (2,10-13).  Because of the variety of factors that can influence a food’s glycemic response and the limited number of long-term studies, there is still insufficient scientific evidence to support the use or nonuse of low-glycemic diets in improving metabolic outcomes (Grade II) (1,2,4,14).  A meta-analysis of low–glycemic index diet trials in diabetic subjects showed that such diets produced a 0.4% decrement in hemoglobin A1C (A1C) when compared with high–glycemic index diets (15).    Some studies have shown short-term improvements in glycemic control by incorporating high-fiber, low–glycemic index foods in meals or snacks (Grade I) (4).  The glycemic index and/or glycemic load used in conjunction with a consideration of total carbohydrate intake may provide greater benefits than consideration of only the total carbohydrate intake (1,2). Therefore, the consideration of the glycemic index may be helpful as an adjunct for select individuals.  Individuals can determine the glycemic index’s usefulness in maintaining their glycemic goals only by measuring their premeal and postmeal blood glucose levels (1,14,15).

The amount of total carbohydrate intake should be individualized based on the individual’s energy goals to achieve or maintain a desirable body weight, eating habits, and glucose and lipid goals (1-3).  In type 2 diabetes mellitus, an individual’s metabolic profile and the need for weight loss should be considered when determining the carbohydrate and monounsaturated fat content of the diet (1,2).  For weight loss, either a low-carbohydrate or low-fat, energy-restricted diet may provide short-term effectiveness (for up to 1 year) (1,2).  For patients on low-carbohydrate diets, it is important to monitor lipid profiles, renal function, and protein intake (in patients with nephropathy) and adjust hypoglycemia therapy as needed (2).  See Energy Balance, Overweight, and Obesity.

Fiber
Fiber consumption recommendations for people with diabetes are the same as for the general population (2).  Daily consumption of 20 to 35 g of dietary fiber from both soluble and insoluble fibers from a variety of food sources is recommended (16).  In a small number of subjects with type 1 diabetes, very large amounts of fiber (>50 g) had a beneficial effect on glycemia.  Based on study outcomes in individuals with type 2 diabetes, it appears that ingestion of very large amounts of fiber (>50 g/day) is necessary to achieve metabolic benefits in glycemic control, hyperinsulinemia, and plasma lipid levels (2,17). To date, there is inconclusive evidence that increasing the amount of dietary fiber will influence the glycemic outcome in persons with diabetes (4) (Grade I).  There is conclusive evidence that higher fiber diets will significantly lower total cholesterol when compared to lower fiber diets (4) (Grade I).  For patients with diabetes complicated by disorders of lipid metabolism, particularly hypercholesterolemia, lower cholesterol levels are an important benefit of consuming a high-fiber diet. Because of the potential gastrointestinal side effects and limited evidence regarding the intake of large amounts of fiber (>35 g/day), it currently does not appear that persons with diabetes mellitus need to consume more than the recommended intake of 20 to 35 g/day to achieve the health benefits associated with dietary fiber. Fiber is not digested and absorbed like sugars or starches.  For purposes of carbohydrate counting, when there are more than 5 g of fiber per serving, half the number of grams of fiber should be subtracted from the total grams of carbohydrate to determine the amount of available carbohydrate (5).

Resistant Starch
Resistant starch (nondigestible oligosaccharides and the starch amylase) is not digested and therefore not absorbed as glucose in the small intestine.  Legumes are the major food source of resistant starch in the diet; 100 g of cooked legumes contain 2 to 3 g of resistant starch, and 100 g (dry weight) of cornstarch contains about 6 g of resistant starch (18).  It has been suggested that resistant starch produces a smaller increase in the postprandial glucose level than digestible starch and corresponds to lower insulin levels (2).  Studies of persons with diabetes have focused on uncooked cornstarch and its potential to prevent nocturnal hypoglycemia.  Some studies have demonstrated less hypoglycemia when cornstarch snacks are used; however, the evidence is limited.  There is currently no established benefit of resistant starch for people with diabetes (2,17).

Timing of Carbohydrate and Food Intake: Type 1 Diabetes
For individuals requiring insulin, the total carbohydrate content of meals and snacks is the first priority and determines the premeal insulin dosage and postprandial glucose response (1-4,19). Individuals receiving intensive insulin therapy can adjust the premeal insulin dose based on the amount of carbohydrate at meals to maintain their blood glucose goals (Grade I) (4). Individual needs should dictate the time when meals and snacks are eaten, how much time elapses between insulin injection and food intake, and the number of meals and snacks (1).  Self-monitoring of blood glucose levels is necessary to achieve optimal blood glucose control and to prevent or delay the onset of diabetic complications (4).  Checking blood glucose levels three to eight times per day has been associated with better glycemic control regardless of diabetes type or therapy (Grade I) (4).  The American Diabetes Association recommends that people with type 1 diabetes or pregnant women who take insulin check their blood glucose levels three or more times daily, so that they can adjust food intake, physical activity level, and/or insulin dosage to meet blood glucose goals (1).  Day-to-day consistency of food consumption is crucial for individuals who inject a fixed daily dosage of insulin (1,2).

    For individuals who are on fixed insulin regimens and do not adjust premeal insulin dosages, consistent carbohydrate intake is the first priority (1,2,20).  Individuals receiving insulin therapy should eat at consistent times that are synchronized with the action time of their insulin preparation and with blood glucose results, and insulin doses should be adjusted for the amount of food usually eaten or required (1-3).  The decision to adjust insulin doses should be based on a review of blood glucose records and discussion with the patient’s physician and coordinating health care team.

Intensified insulin therapy (multiple daily injections or insulin pump therapy): The goal of intensified insulin therapy is to bring the blood glucose levels as close to the normal range as is feasible for the individual. Insulin infusion pumps mimic the normal physiologic insulin delivery and allow flexibility in meal size and timing.  Individuals that use rapid-acting insulin by injection or an insulin pump should adjust their meal and snack insulin doses based on the carbohydrate content of the meals and snacks (2).  Carbohydrate counting, at an advanced level, can greatly increase flexibility in meal planning (21).  The Diabetes Control and Complications Trial found that individuals who adjusted their premeal insulin dosages based on the carbohydrate content of meals had statistically significantly (0.5%) lower A1C levels than individuals who did not adjust preprandial insulin dosages (22).  Potential problems associated with intensified insulin therapy include hypoglycemia and weight gain (2,23-25).  Given the potential for weight gain to adversely affect glycemia, dyslipidemia, blood pressure, and general health, the prevention of weight gain is desirable (2,26).  Reductions in blood glucose levels and A1C may cause hypoglycemia, which occurs more frequently in individuals with type 1 diabetes (2).  Hypoglycemia should be treated appropriately (2).  (See Treatment of Hypoglycemia.)

Adjustments for exercise: Because the amount of physical activity may vary considerably from day to day, individuals with type 1 diabetes may need to make adjustments in energy intake and insulin dosage to avoid hypoglycemia.  Several strategies may be used to avert hypoglycemia during or after exercise.  When exercise is planned, the insulin dose should be adjusted to prevent hypoglycemia (2,17,27).  If exercise is unplanned, additional carbohydrate may need to be consumed (2,17,27).  Carbohydrate supplementation is based on the blood glucose level before exercise, previous experience with the particular form of exercise, and the individual’s insulin regimen (1,2,27).  Moderate-intensity exercise increases glucose uptake by 2 to 3 mg/kg per minute above the usual requirements.  More carbohydrate may be needed for higher intensity activities (1,2,17,27). (See Diabetes Mellitus: Considerations for Exercise.)

Timing of Carbohydrate and Food Intake: Type 2 Diabetes
Food intake frequency—three meals or smaller meals and snacks—is not associated with long-term differences in glucose levels, lipid levels, or insulin responses (28,29).  Therefore, division of food intake should be based on individual preferences, the lipid profile, and the type of diabetes medications used (Grade I) (2,4,17).  Preprandial and postprandial blood glucose monitoring data levels can be used to determine if adjustments in food or meal planning will be helpful or if medications need to be combined with nutrition therapy (1,2).  If individuals with type 2 diabetes require insulin, the consistency and timing of meals and their carbohydrate content become important, as with type 1 diabetes (1,2,17).  Flexible insulin dosing regimens allow for variations in food intake and a more flexible lifestyle.  Treatment with sulfonylureas and other insulin secretagogues also requires consistency in meal timing and the carbohydrate content of meals (1).  People with type 2 diabetes are more resistant to hypoglycemia than people with type 1 diabetes; however, when a person with type 2 diabetes who is treated with insulin or insulin secretagogues is unable to eat, dosages may need to be modified (1,2).  (See Treatment of Hypoglycemia.)

Adjustments for exercise:Supplemental food before and during exercise is not needed to prevent hypoglycemia and is not recommended except under conditions of strenuous, prolonged exercise, such as endurance sports.  Individuals taking sulfonylurea agents have a slightly increased risk of hypoglycemia during exercise, and supplemental energy intake may be required in some cases (1,27).  The need for supplemental energy intake may be determined by glucose self-monitoring.  Individuals with type 2 diabetes who use insulin should also monitor their blood glucose levels closely during and after exercise.  Several strategies may be used to avert hypoglycemia during and after vigorous, prolonged, or nonhabitual exercise.  These strategies involve the consumption of supplemental carbohydrate-containing foods before, during, and after exercise as well as adjustments in insulin dosage and timing (27). (See Diabetes Mellitus: Considerations for Exercise.)

Protein
The recommended protein intake for individuals with diabetes who have normal renal function is the same as for the general population (1).  This recommendation translates into approximately 15% to 20% of daily energy intake from protein, which can be derived from both animal and vegetable sources (1,2,17).  Individuals with type 2 diabetes and suboptimal glycemic control may have greater protein requirements due to increased protein turnover.  However, the increased requirements do not exceed 20% of total energy intake (2).  Intakes of protein that exceed 20% of daily energy may be a risk factor for the development of diabetic nephropathy (1).  Based on studies of patients with nephropathy, it seems prudent to limit protein intake to the Recommended Dietary Allowances of 0.8 g/kg of body weight, which corresponds to approximately 10% of total energy (1,4,30).  During a catabolic state induced by injury, inflammation, or severe illness, protein needs are 1.0 to 1.5 g/kg of body weight, with the higher end of the range for more stressed patients. Refer to Protein Requirements.

    In individuals with type 1 or type 2 diabetes, microalbuminuria predicts the later development of overt nephropathy (2).  Microalbuminuria greater than 30 mg/day or 20 mg/min is an indicator for nephropathy and increased cardiovascular morbidity and mortality (Grade II) (1,4).  In patients with diabetic nephropathy, reduction of dietary protein to 0.8 g/kg of body weight per day (the Recommended Dietary Allowances) may slow the progression of nephropathy (Grade II) (2,4).  Along with testing for microalbuminuria, the analysis of a spot urine sample to determine the albumin-to-creatinine ratio is strongly encouraged (1).

   Small short-term studies suggest that diets with a protein content >20% of total energy reduce glucose and insulin concentrations, reduce appetite, and increase satiety in patients with diabetes (31,32).  The amount of protein consumed at meals has minimal influence on the glycemic response, lipid levels, and hormones and metabolites, and it has no long-term effect on insulin (4) (Grade II).  As the percentage of protein increases and the percentage of energy from carbohydrate decreases it is difficult to determine whether the higher protein intakes or the lower carbohydrate intakes are responsible for significant effects on metabolic outcomes in studies (4) (Grade II).  The effects of high-protein diets on the long-term regulation of energy intake, satiety, and weight as well as the ability of individuals to follow such diets long term have not been adequately studied; therefore, high-protein diets are not recommended as a strategy to improve glycemic outcomes or promote weight loss (1,2,4) (Grade I).  See the discussion of Energy Balance, Overweight, and Obesity.

Fat Intake and Disorders of Lipid Metabolism
The distribution of energy from fat should be individualized based on the patient’s nutrition assessment, cardiac risk assessment, disorders of lipid metabolism, and treatment goals (1-4,17,33,34).

    Type 2 diabetes is associated with a twofold to fourfold excess risk of coronary heart disease (CHD) (Grade I) (4,33).  The most common disorders of lipid metabolism in patients with type 2 diabetes are elevated triglycerides levels and decreased high-density lipoprotein cholesterol levels (33).  The concentration of low-density lipoprotein (LDL) cholesterol in patients with type 2 diabetes is similar to that in nondiabetic individuals (33).  The National Cholesterol Education Program (NCEP) Adult Treatment Panel III categorizes persons with diabetes mellitus in the high-risk category with therapeutic goals to reduce LDL cholesterol levels to less than 100 mg/dL through therapeutic lifestyle changes (diet and physical activity) and cholesterol-lowering drug therapy (34).  A subcategory of high risk, very high risk, consists of persons with existing cardiovascular disease and diabetes as well as persons with cardiovascular disease and severe or poorly controlled multiple risk factors (34).  The very high–risk category has a therapeutic option to reduce LDL cholesterol levels to less than 70 mg/dL (34).  These lower LDL cholesterol goals, in combination with initiating cholesterol-lowering drug therapy at lower thresholds, are based on evidence from five randomized controlled trials that demonstrated a significantly reduced risk for cardiac events at these lower thresholds (34).  Pharmacologic therapy is integral in achieving these lower LDL thresholds and is recommended by the NCEP to achieve a 30% to 40% reduction in baseline LDL cholesterol levels in all high-risk patients (34).    

    The recommended percentage of energy from fat depends on the patient’s lipid levels and treatment goals for glucose, disorders of lipid metabolism, and weight.  Because persons with diabetes mellitus are at high risk of CHD and cardiovascular mortality (33,34), they should target the lowest LDL cholesterol goal (<100 mg/dL, or <70 mg/dL if categorized as very high risk) (2,33-35).  Based on risk factor assessment, a person with diabetes mellitus should follow the recommendations of the NCEP Adult Treatment Panel III, the American Heart Association Dietary Guidelines 2000, and the American Diabetes Association Standards of Medical Care 2008 (1,35,36).  The NCEP recommends that individuals with increased risk and/or disorders of lipid metabolism limit their fat intake to less than 35% of total energy, with saturated and trans fat combined targeting less than 7% of total energy (4), polyunsaturated fat restricted to less than 10% of total energy, and monounsaturated fat targeting 10% to 15% of total energy (Grade I) (4,33).

    Several studies have investigated the optimal mix of macronutrients to best support metabolic outcomes in persons with diabetes and cardiovascular disease.  Diets that are high in monounsaturated fat have not been shown to improve fasting plasma glucose levels or A1C values (2).  Low–saturated fat (<10% of energy), high-carbohydrate diets increase postprandial levels of plasma glucose and insulin and increase plasma triglycerides levels (37); in some studies, these diets decrease plasma high-density lipoprotein cholesterol levels when compared with isoenergetic high–monounsaturated fat diets (2,37,38).  When saturated-fat energy is replaced with either energy from carbohydrate or monounsaturated fat, there is a reduction in plasma LDL cholesterol levels (2).  In other studies, when energy intake was reduced, the adverse effects of high-carbohydrate diets were not observed (2).  Individual variability in response to higher carbohydrate diets (~55% of total energy) suggests that the plasma triglyceride response to dietary modifications should be monitored carefully, particularly in the absence of weight loss (2).   An individual’s metabolic profile and the need for weight loss should determine the medical nutrition therapy recommendations and nutrition prescription.   Consumption of omega-3 fatty acids from fish or from supplements reduces adverse cardiovascular disease outcomes (2,39).   In addition, fish consumption displaces foods that are high in saturated fat from the diet (2).  Two or more servings of fish per week (with the exception of fried fish fillets) are recommended for persons with diabetes (2,40,41). 

a Pharmacologic therapy should be initiated as an adjunct to behavioral interventions to achieve a 30% to 40% decrease in LDL cholesterol from baseline values for moderately high risk, and very high risk patients (34).
b Trans fatty acids increase LDL cholesterol (4).  The American Heart Association (2006) recommends <1% of energy from trans fatty acids.
c See discussion of omega-3 fatty acids in Medical Nutrition Therapy for Disorders of Lipid Metabolism.

Sodium
Recommendations regarding dietary sodium are the same for people with diabetes and the general population.  Both normotensive and hypertensive individuals should limit sodium consumption to 2,400 mg/day.  For people with mild to moderate hypertension, less than 2,400 mg/day of sodium is recommended, as are the principles of the Dietary Approaches to Stop Hypertension Diet and weight reduction to lower blood pressure as an adjunct to pharmacotherapy (2,42).  For people with hypertension and nephropathy, less than 2,000 mg/day of sodium is recommended (1,2). People with diabetes should maintain blood pressure levels less than 130/80 mm Hg (1). (See Sodium-Controlled Diets.)

Alcohol
The precautions regarding alcohol consumption that apply to the general population also apply to people with diabetes.  The US Dietary Guidelines for Americans recommends no more than two drinks per day for men and no more than one drink per day for women (1,2).  Abstention from alcohol is advised for people with a history of alcohol abuse or dependence, pregnant women, and people with medical problems such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia (2).

    The effect of alcohol on blood glucose levels depends not only on the amount of alcohol ingested but also on the relationship to food intake.  Alcohol used in moderation and ingested with food does not affect blood glucose levels when diabetes is well controlled (2).   Alcoholic beverages should be considered an addition to the regular food/meal plan for patients with diabetes. Food should not be omitted because of the possibility of alcohol-induced hypoglycemia. When energy from alcohol needs to be calculated as a part of the total energy intake, alcohol should be substituted for fat exchanges or fat energy. 

Micronutrients and Diabetes
There is no clear evidence that vitamin or mineral supplementation benefits people with diabetes who do not have underlying deficiencies (2).  Chromium supplements have been reported to have beneficial effects on glycemia (1,17).  However, due to study limitations and other studies that have not found these benefits in people with diabetes, the benefit of chromium supplementation has not been conclusively demonstrated (1,2,17,43).  Increased consumption of folate by women of childbearing age to prevent birth defects as well as calcium consumption for the prevention of bone disease are recommended for people with or without diabetes. 

Treatment of Hypoglycemia
Hypoglycemia is primarily an issue for diabetics who take insulin and insulin secretagogues.  Changes in food intake, physical activity level, and medications can contribute to hypoglycemia.  According to the American Diabetes Association’s evidence-based guidelines, a glucose level of less than 70 mg/dL should be treated immediately (eg, carbohydrate ingestion, exercise delay, change in insulin dose) (1,2,44).  The primary treatments for hypoglycemia are carbohydrate ingestion and medication adjustment.  Glucose ingestion is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used (1,2).  The glycemic response has a greater correlation with total glucose content than with total carbohydrate content of food (41).  For example, treatment of insulin-induced hypoglycemia with 20 g of glucose results in a greater rise in the plasma glucose level than treatment with 20 g of carbohydrate from orange juice or milk (45).  The form of the carbohydrate—liquid or solid—does not impact the outcome of the glycemic response.  The addition of protein to the carbohydrate does not assist in the treatment of hypoglycemia or prevent subsequent hypoglycemia episodes (1,2).  The amount of protein consumed at meals has a minimal influence on the glucose response; however, the insulin response to protein is similar to carbohydrate (Grade II) (4).  The addition of fat may retard the acute glycemic response (2,45).  Ingestion of 15 to 20 g of glucose or total carbohydrate is an effective treatment of hypoglycemia; but, the blood glucose level may be only temporarily corrected (1,2).  Ten grams of oral glucose raises plasma glucose levels by ~ 40 mg/dL over 30 minutes, while 20 g of oral glucose raises plasma glucose levels by ~ 60 mg/dL over 45 minutes.  The initial response to treatment should be seen in approximately 10 to 20 minutes, and blood glucose levels should be evaluated again in 10- to 15-minute increments and again at 60 minutes when glucose levels often begin to fall to determine if additional treatment is necessary (1).  Sulfonylurea-induced hypoglycemia in patients with type 2 diabetes differs from insulin-induced hypoglycemia.  Sulfonylurea-induced hypoglycemia can be prolonged and can recur, and therefore requires more persistent treatment (2).  For mild to moderate hypoglycemic reactions, the following items, which contain about 15 g of carbohydrate, may be given (46,47).  These food items are used because they are readily available and/or easy to carry when away from home, not because they are fast-acting (46,47):

• 4 to 6 oz fruit juice
• 4 to 6 oz regular soda
• three or four glucose tablets (4 g of glucose each)
• 2 tbsp raisins
• five or six Lifesavers candies
• 1 tbsp honey or corn syrup
• 4 tsp or four packets of granulated sugar

    Retest the patient’s blood glucose level 15 to 20 minutes after ingestion of the food.  If the patient’s blood glucose level is still low, give an additional 15 g of carbohydrate and retest in 15-minute increments until stabilized (1).  Glucagon should be prescribed for all patients at significant risk of severe hypoglycemia (1).  Individuals who have hypoglycemia unawareness or who experience one or more episodes of severe hypoglycemia should be advised to increase their glycemic targets to strictly avoid further hypoglycemia for at least several weeks (1).

Carbohydrate Replacement for Acute Illness, Missed Meals, or Delayed Meals

Acute illness or missed meals:Acute illness in persons with type 1 diabetes can increase the risk of diabetic ketoacidosis (1,2).  During acute illness, the need for insulin continues and actually may increase due to an increased level of counterregulatory hormones associated with stress (2). Measuring blood glucose levels, measuring blood or urine ketones levels, drinking adequate amounts of fluids, and ingesting carbohydrate, especially if the blood glucose level is less than 100 mg/dL, are all important during acute illness (2).  When illness or diagnostic tests prevent a diabetic individual from consuming the usual diet, systematic replacement of carbohydrate is appropriate.  In adults, the daily ingestion of 150 to 200 g of carbohydrate (or 45 to 50 g every 3 to 4 hours), along with medication adjustments, should be sufficient to keep the glucose level in the goal range and prevent starvation ketosis (2).  The carbohydrate value of the foods in the missed meal can be replaced with easily consumed liquids or soft foods as tolerated.  Usually a missed meal may be satisfactorily replaced by at least 50 g of carbohydrate (or three to four carbohydrate choices) taken by mouth.  The consumption of at least 50 g of carbohydrate every 3 to 4 hours has been recommended (1,2).  If the patient is incapable of taking food by mouth, alternative nutrition support should be evaluated.

Delayed meals: When the meal is delayed and the blood glucose level is normal, carbohydrate should be given.  Usually 15 g of carbohydrate (one fruit or bread exchange) every 30 to 45 minutes until the meal is served, or 15 to 30 g of carbohydrate for a 1- or 2-hour delay, protects the patient from hypoglycemia.

Enteral nutrition:  For tube feedings, either a standard enteral formula (50% carbohydrate) or a lower-carbohydrate content formula (33% to 40% carbohydrate) may be used (2).  Care should be taken not to overfeed patients because of the risk of exacerbating hyperglycemia (1,2).

Carbohydrate Content of Foods
Foods selected from the following list can be used as substitutes for foods of similar carbohydrate content in the missed meal or during illness.

Note: Patients who experience hypoglycemia and are being treated with acarbose (Precose) or miglitol (Glyset) should be treated with glucose.

Glycemic Goals in a Hospital Setting
A rapidly growing body of evidence supports targeting glucose control in the hospital setting with the potential for reduced mortality and morbidity and improved health care outcomes (1).  Studies of surgical patients, neurological patients, and patients acutely managed for myocardial infarction have demonstrated significant improvement in outcomes when glycemic goals are tightly managed (1). Hyperglycemia in the hospital can result from factors including stress and decompensation of type 1 diabetes, type 2 diabetes, or other forms of diabetes; hyperglycemia may also be iatrogenic due to the administration or withholding of pharmacologic agents, including glucocorticoids and vasopressors (1).  The blood glucose levels of critically ill patients should be kept as close as possible to 110 mg/dL and generally <180 mg/dL without increasing the risk of hypoglycemia (1).  In many cases, patients will require intravenous insulin to achieve these target ranges (1).  Non-critically ill patients’ premeal blood glucose levels should be kept as close as possible to 90 to 130 mg/dL (midpoint of range, 110 mg/dL) given the clinical situation and the postprandial blood glucose level target of <180 mg/dL.  Insulin should be initiated when necessary to achieve target values (1).  Scheduled prandial insulin doses should be given in relation to meals and should be adjusted according to point-of-care glucose levels.  The traditional sliding-scale insulin regimens are ineffective and are not recommended (1).

Diabetes Nutrition Management: Meal Planning Approaches (21)
Familiarity with the variety of meal planning approaches available can help dietitians more effectively teach patients how to reach their nutrition goals.  The type of approach selected should depend on the goals for metabolic outcomes and the patient’s nutrition needs, literacy, motivation, and lifestyle.  The American Diabetes Association patient education publications are based on current diabetes treatment guidelines.  Approaches that can be used for teaching meal planning include:

Energy Balance, Overweight, and Obesity in Diabetes
Overweight and obesity affect insulin resistance and metabolic outcomes; therefore, weight loss is recommended for persons with diabetes who are overweight or obese as well as persons at risk for developing diabetes who are overweight or obese (1,2,4).  Short-term studies have demonstrated that weight loss in subjects with type 2 diabetes is associated with decreased insulin resistance, improved measures of glycemia and dyslipidemia, and reduced blood pressure (Grade II) (4).  The evidence-based nutrition guidelines encourage setting goals for a reasonable body weight, defined as a weight that the patient and the health care team acknowledge as being achievable and maintainable (1,2,4).  A weight loss of 5% to 10% from baseline has positive effects on metabolic outcomes.  The body mass index may be used to identify healthy weight ranges and estimate the desirable body weight.  National guidelines for weight management can be applied to persons with diabetes who are overweight or obese and for whom weight loss is a primary health outcome (1,48).

    A standard weight-loss diet that adjusts total energy intake to achieve an energy deficit of 500 to 1,000 kcal/day will initially achieve 1 to 2 lb of weight loss per week (48).  Although many people can lose weight (as much as 10% of initial weight in 6 months) with these standard diets, without continued support and follow-up, people usually regain the weight that was lost (2,48).  Low-fat, low-energy diets have traditionally been promoted for weight loss; however, three randomized controlled trials found that subjects on low-carbohydrate diets lost more weight at 6 months than subjects on low-fat diets (49-51).  A meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglycerides levels and high-density lipoprotein cholesterol concentrations than low-fat diets; however, the LDL cholesterol level was significantly higher on the low-carbohydrate diets (52).  A more recent meta-analysis of restricted-carbohydrate diets in patients with type 2 diabetes revealed similar findings, with the exception of elevated LDL levels (53).  The analysis showed that a decrease in carbohydrate intake from 65% to 35% of total energy yields an expected decrease of approximately 23% in the triglycerides level (53).    A comparison of the studies demonstrated variable carbohydrate intakes (4% to 45% of total energy), and in most studies the carbohydrate intake fell below the Recommended Daily Allowance of 130 g/day (53).  The authors concluded that a lower-carbohydrate diet can be beneficial in treating type 2 diabetes due to beneficial effects on the levels of glucose, A1C, and triglycerides; however, the impact of these diets on cardiovascular outcomes remains to be determined (53). 

    In a majority of studies, a low-carbohydrate diet begins with an induction phase of <30 g of carbohydrate per day with incremental increases to achieve ~30% to 40% of energy from carbohydrate (54).   The American Diabetes Association recommends either a low-carbohydrate or low-fat, energy-restricted diet as an effective option for short-term (up to 1 year) weight loss in overweight and obese persons with type 2 diabetes (1,2).  However, the American Diabetes Association does not recommend a low-carbohydrate diet in which the total carbohydrate intake is restricted to less than 130 g/day (2,53).  Low-carbohydrate diets are broadly defined in the literature; the macronutrient composition from carbohydrate ranges from 4% to 45% in these diets (53).  A review of popular diets by the U.S. Department of Agriculture defined a low-carbohydrate diet as containing <30% of energy from carbohydrate, a medium-carbohydrate diet as 30% to 55% of energy from carbohydrate, and a high-carbohydrate diet as >55% of energy from carbohydrate (54).    Because considerable variations exist for low-carbohydrate diets, it is important for the dietitian to work collaboratively with the physician and patient in designing an optimal meal pattern that best supports desired metabolic outcomes.  When prescribing a low-carbohydrate diet to diabetic patients, it is prudent to provide a carbohydrate amount that meets the Recommended Daily Allowance of 130 g/day because lower intakes eliminate many foods that are important sources of energy; fiber; water-soluble vitamins folate, thiamin, and pyridoxine; fat-soluble vitamins A and E; and minerals including calcium, potassium, and magnesium (53).  The safety concerns that surround low-carbohydrate diets include increased uric acid levels in gout patients as well as other related side effects including constipation, diarrhea, dizziness, halitosis, headaches, and insomnia (55,56).  Low-carbohydrate diets may not be suitable for children, reproductive-age women, and hypertensive individuals (55).   In addition, the American Diabetes Association does not advocate the use of high-protein diets due to increased risks of glomerular hyperfiltration and accelerated renal complications associated with diabetes (2,53).  Therefore, the ratio of protein generally should not exceed 20% of total energy when determining the macronutrient distribution for a low-carbohydrate meal plan.  Patients who are prescribed a low-carbohydrate meal plan should be closely monitored and have frequent assessments of their lipid profile, renal function, protein intake, urine levels of ketones and glucose, as well as uric acid levels in patients at risk for gout.  In addition, the hypoglycemic risk must be assessed to prevent episodes of hypoglycemia (1,2).  

    In selected patients, drug therapy as an adjunct to lifestyle change may be appropriate to achieve weight loss (1).  However, it is common for patients to regain weight after the discontinuation of medications (1,57). In patients with severe obesity, surgical options, such as gastric bypass and gastroplasty, may be appropriate and allow significant improvement in glycemic control with reduction or discontinuation of medications (1,58).   

    See Calorie-Controlled Diet for Weight Management and Gastric Bypass, Body Mass Index (BMI), Estimation of Energy Expenditures , and Obesity and Weight Management.

    For medical nutrition therapy outcomes monitoring and suggested delivery of care in the acute care setting, refer to “Diabetes mellitus uncontrolled/complications medical nutrition therapy protocol” (59).

Special Populations

Children and adolescents with diabetes: Nutrient requirements for children and adolescents with type 1 or type 2 diabetes are similar to the requirements for children and adolescents who do not have diabetes.  The primary goal for children and adolescents with type 1 diabetes is achieving blood glucose goals that maintain normal growth and development without excessive hypoglycemia.  Individualized food/meal plans and intensive insulin regimens can provide flexibility to accommodate irregular meal times and schedules as well as varying appetite and activity levels (1,2).  Withholding food or having a child eat consistently without an appetite, in an effort to control blood glucose levels, should be discouraged (1,2).  Nutrition for children and adolescents with type 2 diabetes should focus on healthy lifestyle changes that normalize glycemia (1,2).  Cessation of weight gain with normal linear growth is a primary outcome that will help achieve glycemic goals in overweight and obese children with diabetes (1,2).

Pregnancy and lactation with preexisting diabetes: Nutrient requirements during pregnancy and lactation are similar for women with and without diabetes (1,2).  The distribution of energy intake and carbohydrates in the meal plan of a pregnant woman with preexisting type 1 or type 2 diabetes should be based on her eating habits, blood glucose levels, and stage of pregnancy.  Regular meals and snacks are important to avoid hypoglycemia due to the continuous fetal draw of glucose from the mother (1,2).  An evening snack is usually necessary to decrease the potential for overnight hypoglycemia and fasting ketosis (1,2).  (See information on gestational diabetes.)

Older adults with diabetes:  The American Geriatrics Society emphasizes the importance of medical nutrition therapy for older adults with diabetes (1,2).   Obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity to promote modest weight loss of 5% to 10% of body weight (1,2,59-63).  Lifestyle modifications, and weight loss goals established for younger adults are also suggested for older adults. However, an involuntary weight loss of >10 lb or 10% of body weight in <6 months should be addressed in the nutrition assessment and medical nutrition therapy evaluation (2,64).  Older nursing home residents who have diabetes tend to be underweight rather than overweight (2,3).  Low body weight has been associated with greater morbidity and mortality in this population (3).  Therefore, the imposition of dietary restrictions on elderly patients with diabetes in long-term care facilities is not warranted (2).  Residents with diabetes should be served a regular menu with consistency in the amount and timing of carbohydrate intake (2).   There is no evidence to support prescribing diets such as “no concentrated sweets” or “no sugar added” (2).  In the institutionalized elderly, undernutrition is likely and caution should be exercised when prescribing weight loss diets (2).  The treatment team should consider the resident’s age, life expectancy, comorbidities, and preferences when outlining a plan for care (2).  Adjusting the resident’s medications to control glucose levels, lipid levels, and blood pressure rather than implementing food restrictions can reduce the risk of iatrogenic malnutrition (2,65).

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