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Medical Nutritional Therapy for the Patient With Diabetes

Page history last edited by Ira D. Goldfine 14 years, 4 months ago


The Web diabetesmanager




Alison Gray, RD, MBA 



Last Revision: 2009





This chapter will summarize the most current information on diet and diabetes for health care practitioners who treat patients with diabetes. The key take away message will be the following: there is no such thing as an 1800 calorie ADA diet! The modern diet for the diabetes patient is based on concepts from clinical research, portion control, and lifestyle changes. It is no longer simply a calorie sheet.


Leading authorities and professional organizations have concluded that proper nutrition is the cornerstone of the treatment of diabetes. However, appropriate nutritional treatment, implementation, and ultimate compliance with the plan remain some of the most vexing problems in diabetic management. This issue emanates from two sources: First, there are different diets to consider, depending on the type of diabetes. Second, a plethora of dietary information is available from many sources: some are right, some are wrong, some are contradictory, and most are confusing. Different types of diabetes require some specialized nutritional intervention; however, many of the basic dietary principles are similar for all patients with diabetes.


The following recommendations are consensus-based, and they emphasize practical suggestions for implementing nutritional advice for all diabetes patients. The major changes from previous recommendations include the following: 1) greater flexibility in the proportion of energy supplied by the macronutrients, particularly carbohydrates and monounsaturated fat, 2) liberalization of sucrose consumption, and 3) a focus on lifestyle changes, especially increased physical activity. Resnick, et al, recently reported that achievement of ADA clinical practice recommendations is far from adequate in U.S. adults with diabetes[1].Thus, much needs to be done to improve overall care of patients with diabetes.





The general goals for the diabetic diet have evolved in the past few years and have become more flexible and user-friendly. The newest goals for nutrition are similar to those for the general population. Those goals include the following:

  1. To attain and maintain optimal metabolic outcomes, including:

    1. Blood glucose values within the normal range or as close to normal as is safely possible to prevent or reduce the risk for micro-and macrovascular complications of diabetes

    2. Lipid and lipoprotein profiles that reduce the risk for macrovascular disease

    3. Blood pressure control that reduces the risk for vascular disease

  2. To prevent and treat the chronic complications of diabetes by attaining and maintaining optimal metabolic outcomes, including control of blood glucose as measured by A1C, LDL and HDL cholesterol and triglyceride concentrations, blood pressure, and body weight.

  3. To improve health through healthy food choices and appropriate physical activity.

  4. To address individual nutritional needs, considering personal and cultural preferences and lifestyle, while respecting the individual’s wishes and willingness to change[2].



The goals of medical nutrition therapy as they apply to specific clinical situations include the following:

  1. For youth with type 1 diabetes, to provide adequate energy to ensure normal growth and development, and to integrate insulin regimens into usual eating and physical activity habits.

  2. For youth with type 2 diabetes, to facilitate changes in eating and physical activity habits that reduce insulin resistance and improve metabolic status.

  3. For pregnant or lactating women, to provide adequate energy and nutrients needed for optimal outcomes.

  4. For older adults, to provide the nutritional and psychosocial needs for the aging individual.

  5. For individuals being treated with insulin or insulin secretatogues, to provide self-management education for treatment (and prevention) of hypoglycemia, acute illnesses, and exercise-related blood glucose problems.

  6. For individuals at risk for diabetes and cardiovascular disease, or both, to decrease those risks by encouraging physical activity and promoting food choices that facilitate moderate weight loss or at least prevent weight gain[3][4].



How should these goals best be put into practice? The following guidelines will address the above goals and help put them to work for your patients. The Diabetes Control and Complications Trial (DCCT) and other studies demonstrated the value individualized consultation with a registered dietitian familiar with diabetes treatments, along with regular follow-up, has on long-term outcomes[5].


The basic principles are similar to those for the general population in that everyone needs daily macronutrients (a chemical required in large amounts) and micronutrients (a chemical required in small amounts) in appropriate proportions for optimal nutritional health and glucose control.




CARBOHYDRATES: Sugars, Fiber and Starch

The primary goal in the management of diabetes mellitus is to achieve as near normalregulation of blood glucose (postprandial and fasting) as possible. The amount and possibly the type of carbohydrate in a food greatly influence overall glucose control. The total amount of CHO (carbohydrate) consumed is the strongest influence on glycemic response. Sucrose has an affect on glycemia similar to other forms of CHO and can be substituted for other CHO sources within the context of a healthy diet. Monitoring total grams of carbohydrate, whether by use of food exchanges or carbohydrate counting, can be a useful tool in achieving good glycemic control, especially for patients with type 1 diabetes. The glycemic index (the scale that ranks carbohydrate rich foods by how quickly they raise blood glucose levels) has also been shown to have a small, but clinically significant effect on improved blood glucose control[6]. Non-digestible (resistant) starch is another form of CHO that may be beneficial when added to a diabetic meal plan, as well as higher intakes of soluble fiber.

  1. How much carbohydrate is recommended? The range of carbohydrate intake should be 45-65% of total calories in agreement with the ADA and National Academy of Sciences-Food and Nutrition Board. Foods containing CHO from whole grains, fruits, vegetables and non-fat dairy products should be emphasized[7].

  2. Low carbohydrate diets are not recommended in the management of diabetes. CHO is an important source of fiber, water-soluble vitamins, minerals and energy. The brain and CNS (central nervous system) have an absolute requirement for glucose, thus intakes <130 g/day are not recommended[8].



Fiber is defined as the structural and storage polysaccharides and lignin in plants that are not digested in the stomach or absorbed in the small intestine, and intake should be encouraged. Fiber (especially cereal fiber) has been shown to have large impact on glycemic response. A fiber rich meal is processed more slowly, which promotes early satiety, may be less caloric, lower in fat and added sugars, which can combat obesity and also may prevent risk of heart disease and colon cancer[9]. Recent studies consistently, but not unanimously, support a 20-30% reduction in the risk of development of type 2 diabetes with increased cereal and whole grain fiber intake. Insulin resistance may be reduced with high intakes of whole grain fiber, but additional studies are needed to determine optimal amounts. There is enough evidence to support the statement that increased whole grain intake can reduce the risk of developing type 2 diabetes[10].


High fiber containing carbohydrate sources (>5g/serving) should be chosen over lower fiber choices. A variety of high fiber foods such as legumes, whole grain breads and cereals, whole fruits and vegetables should be included as part of the daily carbohydrate intake. A good source of fiber should be included in each meal and/or snack. The goal for the diabetic population is 25 g/day, which is the same as for the non-diabetic population. This may be difficult for some people with diabetes, as large amounts of fiber can cause negative GI effects, such as bloating and gas. If the patient is not accustomed to larger amounts of fiber in their diet, it should be added slowly. An over the counter product called “Beano” can help with gas/bloating.


The National Cholesterol Education Program (NCEP) has issued guidelines that increase dietary soluble fiber intake recommendations to between 10 and 25 gms/day[11].


Table 1. Food Sources of Soluble Fiber

Food Source

Soluble Fiber (g)

Total Fiber (g)

CEREAL GRAINS (1/2 cup cooked)







Oat bran




Psyllium seeds, ground (1 Tbsp)



FRUIT (1 medium fruit)







Blackberries (½ cup)



Citrus Fruit (orange, grapefruit)















Prunes (¼ cup)



LEGUMES (½ cup cooked)


Black Beans



Kidney Beans



Lima Beans



Navy Beans



Northern Beans



Pinto Beans



Lentils (yellow, green, orange)




Chick Peas



Black eyed Peas



VEGETABLES (½ cup cooked)




Brussels Sprouts






From the National Heart, Lung and Blood Institute /NIH website



Foods containing plant stanols and sterols are also a rich source of soluble fiber. Plant sterols are naturally occurring cholesterol derivatives from vegetable oils, nuts, corn, woods and beans. Hydrogenation of sterols produces stanols. The LDL lowering property of both sterols and stanols is considered equivalent. The generic term to describe both sterols, stanols and their esters is phytosterols[12]. An important role of phytosterols is their ability to block absorption of cholesterol from the gastrointestinal tract. Some manufacturers have started adding them to foods for their cholesterol lowering effects. You can now get phytostenols in margarine spreads, orange juice, cereals, and even granola bars.


Over 20 studies have documented the safety and efficacy for decreasing LDL cholesterol concentrations by the use of phytostenols. Some studies have shown that 2-3 servings/day of phytostenols can reduce LDL cholesterol up to 20 mg/dL. In 2000, the FDA approved this health claim. Two margarines containing phytosterols are approved by the Food and Drug Administration (FDA) to lower cholesterol. Benecol (McNeil Nutritionals, Fort Washington, PA) contains plant stanols, whereas Take Control (Unilver/Lipton, Englewood, NJ) contains plant sterols. The National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) advocates use of plant sterol/stanol esters in amounts of 2 g/day, which equates to approximately 2 tablespoons/day. The taste of these fortified margarines is comparable to regular margarine, but they cost 3-4 times more than regular spread, ranging from $14/month for Take Control to $24/month for Benecol[13].



Policosanols are another natural alternative lipid lowering agent for patients. Policosanol is an anitlipemic agent that includes mixtures of aliphatic alcohols extracted from sugarcane wax. It is used in 25 other countries, mainly South America and the Caribbean, to lower LDL cholesterol. Clinical studies have shown efficacy without any apparent toxicity issues. In a recent meta-analysis of natural therapies for hyperlipidemia, policosanol was shown to reduce LDL cholesterol by a 23% weighted average percent change using a 12 mg average dose/day; vs phytosterols which reduced LDL cholesterol by an 11% weighted average percent change at a dose of 3.4 gms/day. Policosanol is not FDA approved for reduction of LDL levels in the United States, but many consumers purchase policosanol as a nutritional supplement over the counter or through various Internet sources. A bottle of 30 soft gels costs approximately $7, and 120 tablets of 10 mg policosanol cost approximately $35 (~$7-9/month) on the Internet and in health food stores[14].


Nutritive Sweeteners

1. Sucrose, also known as “table sugar” is a disaccharide composed of one glucose and one fructose molecule. On average, the daily intake of sucrose in the U.S. is 94g/day, or 22% of total energy intake. Available evidence from clinical studies shows dietary sucrose has no more effect on diabetes control than does equivalent caloric amounts of starch.

2. Fructose is a common, naturally occurring monosaccharide. Fructose accounts for 9% of the average energy intake in the U.S. Corn syrup is high in fructose. Several studies in patients with diabetes have demonstrated a reduction in post-prandial glycemia when fructose was used in place of starch or sucrose as the CHO source. However, the observation that consuming large amounts (15-20% of total daily energy) of fructose increases fasting total and LDL cholesterol may decrease the benefit of fructose. Thus, recommendations about the optimal amount of dietary fructose remain controversial due to potential metabolic and hormonal consequences that could lead to insulin resistance and obesity[15].


Sugar alcohols (polyols)

Polyols are hydrogenated monosaccharides, and include such sugars as sorbitol, mannitol, and xylitol, as well as the hydrogenated disaccharides isomalt, maltitol, lactitol and tagatose. Polyols are used as sweeteners and bulking agents, and designated GRAS (generally recognized as safe) by the FDA. Polyols are only partially absorbed from the small intestine, allowing for the claim of reduced energy per gram. Polyols contain, on average, 2 calories/gm, or 1/2 the calories of other nutritive sweeteners. Studies of subjects with and without diabetes have shown that sugar alcohols cause less of a postprandial glucose response than sucrose or glucose[16]. However, polyols can cause diarrhea, especially in children. Although a diet high in polyols could reduce overall energy intake or provide long-term improvement in glucose control in diabetes, such studies have yet to be done.


Non-nutritive sweeteners

The four (4) non-nutritive, FDA-approved sweeteners have been found to be safe when consumed within FDA acceptable daily intake amounts. Non-nutritive sweeteners elicit a sweet sensation to taste buds without increasing blood glucose or insulin concentrations[17][18].

  1. Aspartame (Equal, Nutrasweet) is the most widely used non-nutritive sweetener. Aspartame is heat labile, breaking down into phenylalanine and aspartic acid, and thus can’t be used in cooking. In a minority of people who use aspartame, headache has been reported[19][20].

  2. Sucralose (Splenda) is synthesized from regular sucrose such that the body does not recognize it, and is not absorbed. Sucralose is 600 times sweeter than sucrose. It is heat stable and can be used in cooking. It was approved for use by the FDA in 1999[21][22].

  3. Acesulfame K (Ace K, Sunette) is combined with aspartame and available in Canada. The bitter aftertaste of acesulfame can be greatly decreased or eliminated by combining acesulfame with another sweetener[23][24].

  4. Cyclamate (Sugar Twin) remains available in Canada, although it was banned in the U.S in 1970. The controversy centered around the role cyclamate might play in the development of bladder cancer in rats. In human studies over a period of 30 yeas, no association has been observed between the use of cyclamate and bladder tumors[25][26].

  5. Stevia, derived from the plant stevia rebaudiana, is another non-caloric, natural sweetener. Widely used in Asia for many years, Stevia is now available in U.S. health food stores. Stevia appears to be well-tolerated. It has an intensely sweet taste, and some studies have suggested that Stevia may stimulate insulin release from the pancreas[27][28].


Resistant starches

Resistant starches are defined as non-digestible oligosaccharides that are not digested and absorbed as glucose. Resistant starches are completely fermented in the colon, producing 2 calories/gram of energy. About 2-5% of the total carbohydrate in the U.S. diet is comprised of resistant starch. Legumes and corn starch are the major food sources. Resistant starches may produce smaller increases in postprandial glucose than digestible starch, but studies to date have been inconclusive on this subject[29].



The goal for dietary fat intake (amount and type) is similar for patients with heart disease but without diabetes and those with diabetes, due to the high risk of coronary vascular disease in patients with diabetes. Most recent guidelines from the NCEP recommend total fat intake of 25-35% of total calories (from mono or polyunsaturated sources) and saturated fat intake of <7%. Intake of trans fat should be minimized[30].


Monounsaturated Fats

Monounsaturated fats are typically found in vegetable oils such as olive oil, peanut oil and canola oil and remain liquid at extremely low temperatures. Consuming monounsaturated fat has been observed to decrease total cholesterol, primarily by its lowering effect on LDL cholesterol, without an effect on HDL cholesterol. It should be kept in mind that too much of any type of fat will, as a general rule, increase overall caloric intake, with resultant increase in body weight and total cholesterol[31][32].


Omega-3 Fatty Acids

Some types of fish contain unique polyunsaturated fats called omega-3 fatty acids. These fatty acids decrease the risk of artery blockage and heart attacks by their effect on decreasing platelet aggregation. Fish with high amounts of omega-3 include salmon, albacore, tuna, mackerel, sardines, herring and rainbow trout[33][34].


Polyunsaturated Fats

Polyunsaturated fats are usually liquid at room temperature, and are found in vegetable oils such as corn oil, safflower oil, soybean oil, and sunflower oil. Polyunsaturated fats are also present in fish and fish oils, both of which help to decrease triglyceride levels. While polyunsaturated fats decrease LDL cholesterol and total cholesterol, they unfortunately also decrease serum HDL cholesterol. Therefore, polyunsaturated fat intake should be limited[35][36].


Saturated Fats

Saturated fats are usually solid or almost solid at room temperature. All animal fats, such as those in meat, poultry, and dairy products, are saturated. Processed and fast foods contain high amounts of saturated fats. Vegetable oils also can be saturated, and include palm, palm kernel and coconut oils.

In general, saturated fats are unhealthy because they increase LDL-cholesterol and total cholesterol concentrations. Diets high in saturated fats have been implicated in an increased risk of cardiovascular disease. Indeed, the cholesterol content of the food may be less important than the amount of saturated fat contained in that food. Saturated fats raise cholesterol levels and LDL-cholesterol levels more than dietary cholesterol itself[37][38].


Trans Fats

Trans fats are also called hydrogenated fats, which are fats created when oils are "partially hydrogenated". The process of hydrogenation changes the chemical structure of unsaturated fats by adding hydrogen atoms, or “saturating” the fat. Hydrogenation converts liquid oil into stick margarine or shortening. Manufacturers use hydrogenation to increase product stability and shelf-life. Thus, a larger quantity can be produced at one time, saving manufacturing costs. Unfortunately, hydrogenation contributes to increased cholesterol levels and increases heart disease risk[39][40].



Type of Fat

Main Source

State at Room Temperature

Effect on Cholesterol Levels


Olives; olive oil, canola oil, peanut oil; cashews, almonds, peanuts, and most other nuts; avocados


Lowers LDL; no effect on HDL


Corn, soybean, safflower, and cottonseed oils


Lowers both LDL and HDL


Whole milk, butter, cheese, and ice cream; red meat; chocolate; coconuts, coconut milk, and coconut oil


Raises both LDL and HDL


Most margarines; vegetable shortening; partially hydrogenated vegetable oil; deep-fried chips; many fast foods; most commercial baked goods

Solid or semi-solid

Raises LDL; lowers HDL



Relative insulin deficiency is associated with increased protein breakdown and gluconeogenesis, the process through which certain amino acids are converted into glucose. However, most adults eat at least 50% more protein than the recommended daily allowance (RDA), which is 0.8 grams high quality protein/kg of body weight/day. There is no risk of developing protein malnutrition when consuming a usual diet of approximately 20% protein. Due to an increase in albumin excretion rate, intake of protein above this range may be a risk factor in developing diabetic nephropathy[41]. To minimize this risk, consumption of protein should be kept at RDA level, providing approximately 10% of total daily caloric intake[42]. There is no strong evidence to suggest benefit from plant protein over animal protein, however there is evidence that renal function, glucose, lipids, and blood pressure can improve from following weight loss/maintenance diets that meet guidelines for a healthy diet.



In patients with diabetes who have no underlying deficiencies, there is no clear evidence of benefit from vitamin or mineral supplements. Exceptions include folate for prevention of birth defects (strong evidence) and calcium for prevention of osteoporosis (some evidence). Although deficiencies are difficult to determine, once identified, supplementation can be beneficial. Specific populations, such as the elderly, pregnant or lactating women, strict vegetarians or vegans, and patients on calorie-restricted diets may benefit from a multivitamin mineral supplement[43].



Since diabetes is a state of increased oxidative stress, interest in recommending large doses of antioxidant vitamins has been high. However, routinely supplementing the diet with the antioxidant vitamins A, C and E is not recommended due to lack of evidence showing benefit in large, placebo-controlled clinical trials and concerns regarding potential long-term safety[44]. On the other hand, there is growing interest in the role folate supplementation may have in potentially lowering homocysteine levels; studies are ongoing. There is also interest in a role for niacin in preserving beta cell mass in newly diagnosed type 1 patients[45].





In hypertensive, salt-sensitive individuals, reduced sodium intake can lower blood pressure. The goal should be to reduce sodium intake to 2400 mg per day[46], which can be accomplished by not adding salt to foods and decreasing the use of pre-prepared and other salty foods. The DASH (Dietary Approaches to Stop Hypertension) diet, which is high in fruit and vegetables, low-fat dairy products, and low in saturated and total fat; has been shown in large, randomized, controlled trials to significantly reduce blood pressure[47].



There is some evidence that dietary magnesium may help prevent type 2 diabetes, in both men and women[48]. Dietary sources of magnesium include nuts, whole grains, and green leafy vegetables.



Several recent studies have demonstrated a potential role for chromium supplementation in the management of insulin resistance, body weight, gestational diabetes and corticosteroid-induced diabetes. The FDA has recently issued a statement that there is not sufficient evidence at this time to support any of the proposed health claims for chromium supplementation[49]. Therefore, routinely supplementing chromium cannot be recommended for diabetes or obesity[50].





Both the amount and type of carbohydrate (CHO) in a food can influence blood glucose levels. Monitoring total grams of CHO by use of CHO counting or exchanges is a key strategy in achieving blood glucose control[51]. CHO counting is based on the concept that each choice of CHO equals approximately 15 gms of CHO. The average person needs about 3 to 4 choices (45-60 gms) of CHO each meal. This number could be more or less depending on calorie needs, medication, and activity. Carbohydrate counting is routinely taught to patients with diabetes, so that they can more easily estimate the amount (grams) of CHO in a particular food. Furthermore, setting CHO counting goals for each meal allows the patient to more easily match their CHO intake to the appropriate mealtime insulin dose. Advantages of CHO counting include improved glucose control, flexibility in food choices, and simplification of meal planning. Disadvantages include potential weight gain, unhealthy eating, hypoglycemia and high lipid levels. There are no evidence-based studies showing superiority over other dietary management methods, and CHO counting requires motivation on the patient’s part.



The use of the GLYCEMIC INDEX (GI)(a scale that ranks carbohydrate rich foods by how much they raise blood glucose levels) has been studied and developed to identify and classify over 600 foods and their blood glucose raising potential. It has been demonstrated that high fiber, low glycemic index foods can help delay the absorption of glucose into the bloodstream, consequently helping to control blood glucose levels. As a general rule, refined grain products and potatoes have a higher GI, legumes and whole grains have a moderate GI, and non-starchy fruits and vegetables have a low GI. Many factors can influence the GI of a food, such as methods of cooking, physical state of a food, and how much fat and protein are consumed with that food. A recent analysis of the glycemic index from randomized controlled trials indicates that using the glycemic index may provide an additional benefit over total carbohydrate intake alone[52]. It is important that persons with diabetes who want to use the GI to better manage their glucose control need to be taught how specific foods and meals affect their own blood glucose levels, rather than adhering only to the existing GI. For example, a patient could compare a low GI food, such as oatmeal (GI = 50) with cornflakes (GI = 84) to determine the relative effect of each on blood glucose.


The basic technique for following low GI guidelines is simply a "this for that” approach – i.e.: swapping high GI foods for low GI foods. One need not count numbers or do any sort of mental arithmetic to make sure they are eating a healthy, low GI diet[53].

  1. Use breakfast cereals based on increased oat, barley and bran content

  2. Use breads with whole grain, stone-ground flour

  3. Reduce the amount of potatoes you eat

  4. Increase the amount of all other types of fruit and vegetables eaten

  5. Use Basmati, or brown rice

  6. Pasta, (especially whole grain) and quinoa can be included



The glycemic load (GL) combines the GI and the total CHO content of an average serving of a food. It is defined as the weighted mean of the dietary GI multiplied by the percentage of total energy from CHO. The GL attempts to incorporate both the quality and quantity of CHO consumed. The GL corresponds rather closely to the grams of carbohydrate in a serving, not the actual GI of the food. There is not enough evidence currently to use either the GI or GL as a method of meal planning alone for people with diabetes, but a recent randomized controlled study demonstrated that diets high in carbohydrates (high GL) with low glycemic index (GI) are best for cardiovascular risk reduction[54]. The editorialist suggested that it is time to incorporate the concepts of GI and GL into clinical practice to help reduce cardiovascular risk. That is, to recommend that patients consume a high GL, low GI diet.



The following guidelines are the starting point for the nutritional component of patients on intensified insulin management regimens, usually patients with type 1 diabetes, regardless of what meal plan approach is chosen:

  1. The initial diabetes meal plan should be based on the patient’s normal intake with respect to calories, food choices, and times meals eaten.

  2. Choose an insulin regimen that is compatible with the patient’s normal pattern of meals, sleep and physical activity.

  3. Synchronize insulin with meal times based on the time action curve of the particular type of prandial insulin (rapid-acting analog insulin vs regular insulin).

  4. Monitor blood glucose levels and adjust the dose of basal insulin and prandial insulin as needed for usual intake.

  5. Monitor A1C, weight, lipids, blood pressure, and other parameters of interest, modifying the meal plan as necessary to meet goals[55].

With type 2 diabetes, the emphasis may need to be on making lifestyle changes to rectify metabolic abnormalities and meet weight loss goals.



While medical nutrition therapy provided by registered dietitians resulted in better glycemic control in subjects with newly diagnosed type 1 diabetes, a recent survey of 45 pediatric clinics revealed that only 25 clinics had a pediatric dietitian available for children with diabetes[56]. The goals of children and adolescents with diabetes include the following:

  1. Providing appropriate energy and nutrient intake to ensure optimal growth and development

  2. Promoting healthy lifestyle habits while preserving social, cultural and physiological well being

  3. Achieving and maintaining the best possible glycemic control

  4. Achieving and maintaining appropriate body weight and promoting regular exercise[57]

Dietary advice should start gradually:

  1. Emphasis on establishing supportive rapport with the family with simple instructions, more detailed guidelines later administered by the entire team, with focus on consistency in message. Nutritional advice needs to be given to all caregivers; teachers, babysitters, extended family, etc.

  2. Nutrition guidelines should be based on dietary history of the family and child’s meal pattern and habits prior to the diagnosis of diabetes.

  3. Activity/exercise schedules need to be assessed, along with 24 hour recall and 3 day food diary to determine energy intake. Growth patterns and weight gain need to be assessed every 3-6 months and recommended dietary advice adjusted accordingly[58].

Dietary recommendations can be illustrated by use of the food pyramid: slices of the pyramid consist of fats and sweets (used sparingly), next slice includes milk, cheese, meat, fish, egg and nuts (2-3 servings/day); then fruits and vegetables (5 servings/day), and the largest slice for bread, cereals, rice, potato and pasta (6-11 servings/day). The general guidelines for macronutrients are similar to that of the adult diabetic population[59].


Figure 1.  www.mypyramid.gov




Prevention of hypoglycemia

Hypoglycemia usually occurs in patients taking insulin, but can occur in patients taking oral diabetes agents, especially a sulfonylurea. To help prevent hypoglycemia, the following guidelines may be followed:

  1. Do not omit or delay meals or snacks.

  2. Adjust insulin dose and food intake before changing the amount of physical activity. Increasing the amount or duration of exercise can significantly decrease blood glucose. As a result, the insulin dose may need to be reduced by 1/3 or more, depending on person’s insulin sensitivity.

  3. Understand onset, peak, and duration of the insulin being used and the effect of increasing or decreasing the insulin dose.

  4. Self-monitor blood glucose daily, both preprandial and postprandial[60].


Sick Day Management

The main rules for sick day management are:

  1. Take diabetes medication (insulin or oral agent)

  2. Self-monitor blood glucose

  3. Test urine ketones

  4. Eat the usual amount of carbohydrate, divided into smaller meals and snacks if necessary; if glucose is 250 mg/dL or >, all of the usual amount of carbohydrate is not necessary

  5. Drink fluids frequently

  6. Call the diabetes care team

A list of sick foods, including sugar containing items, such as soft drinks and jello, should be provided[61].


Missed/Delayed Meals

For patients using multiple daily injections (MDI), missed or delayed meals have greater consequence compared with patients on conventional insulin regimens. Also, patients who work or participate in activities that make it difficult to plan or control meal times will have fewer issues if placed on a regimen that allows more flexibility in eating times. All patients whose treatment regimen includes a sulfonylurea or insulin should be educated regarding management of meal time with their respective pharmacological approach. Carrying a source of carbohydrate at all times is mandatory, and use of food to prevent hypoglycemia when a meal is missed or delayed should be taught[62]. All patients who use insulin should have a glucagon emergency kit on hand to be used in case of severe hypoglycemia.



Blood glucose monitoring is necessary to adjust insulin dosing and carbohydrate intake, as well as to reduce hypoglycemic risk during exercise. To reduce the risk of hypoglycemia, it is preferable to adjust the dose of insulin before the exercise begins. On the other hand, if the exercise is unplanned, a carbohydrate supplement should be taken before the exercise begins. Depending on the blood glucose level at the start of exercise, as well as length and intensity of the activity, a snack should be consumed before, during and after the exercise. Moderate intensity exercise can increase glucose uptake by 8-13 g/h, which may call for an addition of 15 gms of carbohydrate for every 30-60 minutes of exercise above the normal routine. Intense or prolonged exercise may call for an additional snack after the exercise or before bedtime. Lastly, reduction of insulin dose after longer, more intense periods of exercise may be necessary to prevent hypoglycemia[63].


Timing of Insulin and Meals

The greatest risk for hypoglycemia results when the peak insulin action does not coincide with the peak postprandial glucose. For example, the longer duration of action of regular insulin may lead to increased risk of late postprandial hypoglycemia, compared with rapid-acting insulin analogs. In addition, when the premeal insulin dose is too large for a particular meal relative to its CHO content, hypoglycemia can result. Such a mismatch may occur due to errors in estimating CHO or food intake in patients on multiple daily injections (MDI) or on insulin pumps. Insulin calculations can be based on food exchanges, carbohydrate counting, or predefined, set menus. If meals and the insulin regimen remain static, then no problems will usually result. However, any changes in insulin or food intake requires further adjustment of one or the other, or both. Whatever regimen is employed, it must be individualized to the patient. Patients taking rapid-acting insulin may choose to give their insulin dose after the meal, if unsure of amount of food to be consumed. This approach can be especially helpful in children, nausea related to pregnancy, or other illness. If a smaller than normal meal is eaten, guidelines are available for reducing the insulin dose, or carbohydrate replacement in the form of fruit or fruit juice can be given, depending on the patient’s particular insulin regimen[64].



Alcohol intake greater than in moderation can lead to hypoglycemia through several mechanisms, including the inability of alcohol to be converted into glucose, the inhibitory effect of alcohol on new glucose production from the liver, and its interference in normal counterregulatory hormonal responses to impending hypoglycemia. However, one drink for women and 2 drinks for men per day can usually be incorporated into the diet for patients with type 1 diabetes with no untoward effects on blood glucose. One drink is defined as 12 oz beer, 5 oz wine or 1.5 oz of hard liquor. To decrease the risk of hypoglycemia, it is best to have the alcohol with food. Consuming alcohol in a fasting state may contribute to hypoglycemia in patients with type 1 diabetes. When calculating the need for meal related boluses of insulin, one should account for the carbohydrate content of the alcohol if drinking sweet wines, liqueurs, or drinks made with regular juice or soda[65].


Oral Replacement Guidelines

When blood glucose dips below 70 mg/dL, patients should be advised to have one of the following "quick fix" foods right away to raise the glucose:

  1. 2 or 3 glucose tablets

  2. 1/2 cup (4 ounces) of any fruit juice

  3. 1/2 cup (4 ounces) of a regular (not diet) soft drink

  4. 1 cup (8 ounces) of milk

  5. 5 or 6 pieces of hard candy

  6. 1 or 2 teaspoons of sugar or honey

After 15 minutes, blood glucose should be checked again to make sure that it is increasing. If it is still too low, another serving is advised. Repeat these steps until blood glucose is at least 70 mg/dL. Then, a snack should be consumed if it will be an hour or more before the next meal[66].

Patients who take insulin or an oral hyperglycemic agent that can cause hypoglycemia, such as a sulfonylurea, should be advised to always carry one of the quick-fix foods with them. Wearing a medical ID bracelet or necklace is also a good idea, as well as having a glucagon emergency kit handy.



Driven by the explosive increase in the prevalence of obesity, the number of patients with known diagnosis of type 2 diabetes has reached massive proportions in the U.S. and worldwide. The number of persons with diabetes has tripled since 1985. Lack of exercise and an overabundance of readily available foods (usually containing too much fat) lead to obesity and in many cases the metabolic, or insulin-resistance syndrome[67]. But adults are not alone in this problem, as there is also an increased rate of the diagnosis of type 2 diabetes in young persons[68]. Obesity and insulin resistance are key factors, but not the only variables, that can increase the risk of developing type 2 diabetes .


In a study by Van Dam, et al, the Western dietary pattern (high in processed meat, red meat, French fries, refined grains, high-fat dairy products, and sweets), was associated with a 59% greater risk of diabetes in adult men, while a prudent diet (high in fruits and vegetables, whole grains, fish, and poultry) was associated with a 16% lower risk of diabetes in adult men. For men who ate a Western diet, the risk for diabetes was even greater if they were also obese or had a low level of physical activity. While these results do not prove that eating a Western diet causes type 2 diabetes, they certainly add to existing evidence that eating these types of food increases the risk for developing type 2 diabetes, and that being overweight and lack of exercise increases the risk even further[69].


Two other widely publicized studies, the Finland Diabetes Prevention Study[70] and the initial results of the Diabetes Prevention Program[71], confirmed the importance of exercise and nutrition therapy as primary treatment after the initial diagnosis of type 2 diabetes is made.



While the general principles discussed in the first section apply to all patients with diabetes, those patients with type 2 diabetes and obesity (BMI 30.0 and greater) should have the major focus placed on weight loss and increased physical activity. With so many weight loss “diets” available, confusion abounds. Most patients are looking for the quickest and easiest way to lose weight, and most have unrealistic expectations. Obesity does not occur overnight, and its treatment requires lifetime adjustments to food (energy) intake and energy expenditure (increased activity). Energy consumed is either stored or burned. The cause of the obesity epidemic is that most people consume more energy than they burn, and the excess energy is stored as fat. The old adage remains true: “to lose weight ‘calories in’ must be less than ‘calories out’”. In other words, for weight loss to occur there simply must be a daily caloric deficit. One pound of fat is roughly equal to 3,500 kcal. Thus, a modest decrease in caloric balance (500-1000 kcals/day) will result in a slow but progressive weight loss of 1-2 lbs/week. It is a simple premise, but extremely difficult to achieve in the long term. Weight loss is a major challenge for most patients who, in our fast-paced environment, don’t eat properly and fail to establish patterns of regular physical activity. The key to success is having a patient with diabetes commit to establishing a healthy lifestyle that emphasizes and incorporates more healthy food choices and a daily exercise routine, taking into account the presence of possible complications. Initial physical activity recommendations should be moderate, gradually increasing the duration and frequency to 30-45 min of moderate aerobic activity 3-5 days/week. Developing an individualized weight loss program preferably with a registered dietitian familiar with diabetes management, along with regular follow-ups, will help promote success. It is always important that a patient check with their physician before starting an exercise program.


The individualized approach to dieting shows powerful proof through the Weight Loss Registry, a roster of successful long-term dieters started 12 years ago. To be included, members must have maintained a 30-pound weight loss for at least a year. At 4,800 members, the Registry is now the largest collection to date of long-term weight-loss data. Common keys to losing weight and keeping it off, according to data from the registry, include:

  1. Eat breakfast.

  2. Eat a calorie-aware, moderately low-fat diet that includes complex carbohydrates.

  3. Get plenty of exercise at moderate intensity. Walk!

  4. Self-monitor through frequent weigh-ins and a food and exercise diary[72].



Type 2 diabetes is becoming increasingly prevalent among young people who are driven, as is the case in adults, by lifestyle factors leading to increased body weight. The diabetogenic process may begin as early as fetal life, with low birth weight and poor nutrition combining with sedentary lifestyle and dietary factors to produce an insulin-resistant phenotype that may accelerate the development of renal pathology and cardiovascular disease[73]. It is important for children and adolescents to be physically active as well as following healthy eating guidelines to promote normal growth patterns, without exceeding recommended weight ranges for age and/or height.



There are many meal planning guidelines available for patients with diabetes. Listed in the chart below are some of the basic guideline and more in-depth approaches. A brief explanation of the approaches, along with the resource list to obtain copies of these meal plans, is included in this section.








Adapted from Nutritional Care of Diabetes, 5th edition, August 2004
































































Guideline approaches are less in-depth and complex, but they can offer the foundation for basic nutrition information. In some cases, guidelines alone may be enough to change eating behaviors in some patients with diabetes. Guideline approaches focus on making healthy food choices without weighing or measuring foods, using exchanges, or counting calories, fat or carbohydrate. Regardless of whether they are used alone, or in combination with a specific meal plan, guidelines are a good choice for beginning education about nutrition. Recognize that, due to education level, lack of motivation, etc. it may not be appropriate to move some patients beyond this initial stage[74].

  1. The Food Guide Pyramid contains general guidelines for healthy eating. An explanation and picture of the guide is listed earlier in this chapter under section E, Children and Adolescents.

Diabetes Nutrition Guidelines illustrate the connection between diabetes and nutrition in a simplified format. They assist the patient in making appropriate food choices. Examples of these resources are listed below:

1. Healthy Food Choices is a pamphlet primarily used for the initial stage of diabetes meal planning. It includes an overview of diabetes nutritional management within the framework of basic eating guidelines. Other resources may be added to this tool, as appropriate, to move the patient toward more in-depth management.

  1. The First Step in Diabetes Meal Planning is a modified food pyramid that includes diabetic meal planning goals. It can be used as a “stand alone” guideline for a patient unable or unwilling to see a dietitian, or for a patient who has an unusual delay before individualized meal planning education can begin. Created by a working group of the American Diabetes Association Nutrition Education Resources Steering Committee, this tool is written at a 5th to 7th grade reading level.

  2. Single Topic Diabetes Resources include 21 diabetes/nutrition related topics printed as reproducible masters. They are designed to be interactive, with the emphasis on problem solving and setting goals. Examples of topics include “Older persons with diabetes”, “Supermarket smarts” and “What about sugars?” A professional guide is included with the resources.

  3. Diabetes Placemat Kit and The Plate Method

The Diabetes Place Mat is a sturdy, heavily laminated, 11" by 17" place mat that can be easily used over and over to apply the meal plan.


Figure 2. 



Here's how it works:One side of the Diabetes Place Mat lists food choices and individual portion sizes for each food category of the meal plan. This list replaces easily misplaced or damaged paper lists, which are often given to diabetes patients.

When planning the meal, a wipe-off marker is used to write down the number of servings for each food category, as indicated on the plan. Then circle or tally the food choices in each category to track progress toward the plan’s targets. Carbohydrate categories - starch and bread, fruit, milk and other carbohydrates - which affect blood sugar and which can be exchanged for each other, are color coded in yellow for easy identification and proper selection. Other food categories - vegetables, meat, fat and free foods - are individually color-coded.

When the meal is finished, simply use a dry cloth or tissue to erase the Diabetes Place Mat. Then it's ready for use at the next meal or snack.


Figure 3.  

The other side of the Diabetes Place Mat illustrates the "Plate Method" of managing a diet for proper nutrition and control of blood sugar and weight. It shows the proportions of each food category that are appropriate for a healthy, balanced diet.

TIPKeep the Diabetes Place Mat on your tabletop or refrigerator. Then it's always in plain sight, ready to guide you through food choices for each meal or snack - keeping you on your healthy meal plan!

The food groups shown on the top half of the Plate Method side are carbohydrates, which affect blood sugar - fruit, milk, and starch & bread. These are colored in yellow to distinguish them from the other food groups that don't significantly affect blood sugar (meat, vegetables, fat and free foods). The food categories are shown in proportion to how much of each might be eaten in a healthy, balanced diet.


The plate method is a great plan for patients who have poor math or reading skills, or are non-English speaking.




Individualized Menus

Many patients like to have examples to follow when setting up meal plans. The menu describes in writing what foods and in what quantities should be consumed over a period of days. A dietitian creates an individualized menu based on the nutritional counseling plan chosen and incorporates the patient’s unique preferences, schedule, etc. The patient then has written examples to follow, and will learn how to create independently their own menus over time[75].


Month of Meals 1-5

These menus were created by committees of the Council on Nutritional Science and Metabolism of the American Diabetes Association, and staff of members of the American Diabetes Association National Service Center in response to frequent requests for menus from persons with diabetes and their families. The menus are designed to follow the exchange groups and provide 45-50% of calories from CHO, 20% protein and about 30% fat. The menus provide 1200 or 1800 calories, and instructions are provided on how to adjust caloric levels upward or downward. Each menu provides 28 days of breakfast, lunch, dinner and snacks with a different focus. For example, Month of Meals 1 has a special occasion section, while Month of Meals 2 has ethnic foods and easy to prepare food items, and dining out.


Exchange List Approach

The Exchange Lists for Meal Planning were developed by the American Diabetes Association and the American Dietetic Association, and have been in existence since 1950. The concept is that foods are grouped according to similar nutritional value, and can be exchanged or substituted in the portion size listed within the same group. In 1995, the exchange lists were revised from 6 groups to 3. They include:

  1. Carbohydrate group – includes starches, fruit, milk and vegetables.

  2. Meat and Meat Substitutes group – four meat categories based on the amount of fat they contain.

  3. Fat group – contains three categories of fats based on the major source of fat contained: saturated, polyunsaturated or monounsaturated.

The exchange lists also give information on fiber and sodium content. They can be utilized for patients with type 1 or 2 diabetes. The emphasis with type 1 patients is on consistency of timing and amount of food eaten, while with type 2 patients, the focus is on controlling the caloric and fat values of food consumed.


Basic Carbohydrate Counting

Basic carbohydrate counting was discussed in Section V; A. CHO counting has become the most commonly used method for diabetes meal planning over the past few years.


Advanced Carbohydrate Counting

At the more advanced level, the focus is to finely tune food intake, medication and activity based on patterns from daily food intake and blood glucose records.

Record keeping is an important first part of advanced carbohydrate counting. The meal time, amount and type of food eaten, estimates of CHO intake for each food item containing CHO, and total amount of CHO for each meal and snack must be recorded. Also, insulin dose, physical activity and blood glucose levels must be accurately documented for several weeks. Any unusual circumstances should be noted such as illness, stress, menstrual cycle, etc.

Ratio and correction factor calculation is another aspect of advanced CHO counting. The insulin-to-CHO ratio relays to the person with diabetes how much rapid or short-acting insulin is needed to metabolize the CHO that is consumed at a meal or snack. It allows greater flexibility in lifestyle and can improve glucose control.

To calculate the I:C (insulin to carbohydrate) ratio, divide the number of grams of CHO eaten at the meal by the units of prandial insulin. For example, if a person with diabetes takes 5 units of prandial insulin and ate 75 gms CHO, the I:C ratio is 75 divided by 5, which is 15. One unit of insulin is needed per 15 gms of CHO, assuming that the person’s blood glucose is within target range. If not, an additional correction factor will be necessary[76].

An "average" I:C ratio can be 1 unit of insulin for every 10 to 15 grams of CHO for an adult, or 1 unit for every 20 to 30 grams of carbohydrate for a school-age child.

A correction factor is used to correct a high or low blood glucose level before a meal. The correction factor is added or subtracted to the prandial bolus insulin dose. For example, a factor of 1800 is used for rapid-acting insulin, and 1500 for regular insulin. Thus, if a person uses 60 units of total daily insulin and rapid insulin before meals, the correction factor would be 30 (1800 divided by 60). This means that 1 additional unit of insulin will lower blood glucose by approximately 30 mg/dL. Thus, if the pre-meal blood glucose is 169, and the target glucose is 130 or less, 1 extra unit of insulin should be given with the meal (169-130 = 39)[77].

Two other methods that can be used to calculate the I:C ratio are the “weight method” or the “450 to 500 rule”. Because they are estimates and not based on food records or amount of actual CHO consumed, these approaches are not as accurate as other methods.

The diabetes management team can help establish personal I:C ratios, specific amount of CHO in grams that are consumed, and appropriate correction factors. For further education on this and other meal planning methods, please see the Diabetes Education Resources at the end of the chapter.


Calorie Counting and Fat Counting

These are meal planning methods that can be useful for people with type 2 diabetes who want to lose weight. Knowledge regarding the amount of total calories and fat grams in a given food (including pre-prepared and fast foods) and becoming adept at label reading, can help promote weight loss when incorporated into other lifestyle changes.





Adapted from Nutritional Care of Diabetes, 5th edition, Nutrition Dimension, 2004



USDA Center for Nutrition Policy and Promotion, 3101 Park Center Drive, Room 1034, Alexandria, VA 22302-1594



Order from: Superintendent of Documents, US Govt Printing Office, Washington DC, 20401; 1-202-512-1800; www.access.gpo.gov ($40.60 pkg of 25) OR

Consumer Information Center, Pueblo, CO, 1-719-948-3334; www.pueblo.gsa.gov


Oder from: American Dietetic Assoc., 216 W. Jackson Blvd, Chicago, IL 60606, 1-800-877-1600; www.eatright.org OR

American Diabetes Assoc., Diabetes Info Service Center, PO Box 930850, Atlanta, GA 31193, 1-800-232-6733; http://store.diabetes.org


Order from: American Dietetic Assoc., or American Diabetes Assoc., same contact info as above.


Order from: International Diabetes Center, 1-888-637-2675; www.IDCPublishing.com


Table Top Nutrition, LLC at 1-425-898-9431, www.tabletopnutrition.com


  1. Month of Meals 1: Old-Time Favorites

  2. Month of Meals 2: Ethnic Delights

  3. Month of Meals 3: Meals in Minutes

  4. Month of Meals 4: Classic Cooking

  5. Month of Meals 5: Vegetarian

Available from: American Diabetes Association, 1-800-232-6733; http://store.diabetes.org



Order from: American Dietetic or American Diabetes Associations;

www.eatright.org OR http://store.diabetes.org




Order from American Dietetic or Diabetes Associations; www.eatright.org or http://store.diabetes.org


Order from International Diabetes Center; www.IDCPublishing.com



Warshaw, H., 2001, Order from American Diabetes Association, http://store.diabetes.org


Warshaw, H.; 2001. Order from American Diabetes Association.


Holzmeister, L.; 2000. Order from American Diabetes Association.

FAT COUNTER, Roth, H.; 2nd edition

Oder from http://www.penguinputnam.com


21 nutrition-related topics to be sold as 1 page double-sided reproducible masters. Examples of topics include “Hypoglycemia”, “When you can’t Eat” and “Older persons with Diabetes”.

Order from American Dietetic Association or American Diabetes Association.



Knowledge and application of core nutrition principles is one of the most important aspects of diabetes lifestyle management. There is no longer such a thing as an 1800 calorie ADA diet! The dietary goals covered here, along with other lifestyle changes, if consistently applied, can help to improve metabolic profiles and ultimately prevent long-term complications associated with diabetes. Motivating the person with diabetes to make changes by working with a diabetes management team to implement an individualized program may help to elicit positive outcomes.




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