The goals of nutrition therapy for the type 1 diabetic patient are listed in Table i. The usual food intake and exercise habits should be determined prior to the initiation of either conventional or intensive insulin therapy, because it is important to integrate insulin therapy into the patient's accustomed routine. It is recommended that all patients starting insulin therapy meet with a registered dietitian to develop an individualized meal plan that incorporates their food preferences, usual pattern of meals and snacks, and exercise habits. An initial meal plan should
Table 1 Goals for Nutrition Strategies
Type 1 diabetes
Type 2 diabetes
The ideal meal plan integrates insulin therapy into usual eating and exercise habits
Patients on conventional insulin therapy need to eat at consistent times to coordinate with the action time of insulin Adequate calories should be provided to maintain a reasonable body weight in adults and meet the nutritional needs for growth, development, pregnancy, lactation, and illness Patients learn to adjust insulin doses by evaluating blood glucose patterns Patients on intensive insulin regimens have more flexibility in timing of meals and snacks and the amount of food eaten
Primary nutrition goals are to achieve and maintain normal blood glucose and lipid levels, and to control blood pressure Spread food intake, especially of carbohydrates, throughout the day
Moderate calorie restriction and weight reduction; weight goals based on a reasonable body weight, not ideal body weight; increased physical activity and exercise level Monitor blood glucose levels to determine whether goals are achieved Nutrition and exercise remain primary therapy, even when oral medication and/or insulin are added
be developed and communicated to the provider initiating the insulin therapy so that the insulin program can be tailored to the patient's usual patterns of eating and exercise. Patients with type 1 diabetes on a conventional insulin program, such as twice-daily injections of short- and intermediate-acting insulin, should exercise and eat their meals and snacks at the same time each day so that the insulin action can be coordinated with their food intake and activity levels. Following a consistent meal plan and exercise program will help optimize glycemic control and decrease the risk of hypoglycemic events in the patient following a conventional insulin program (4).
Type 1 diabetic patients following conventional insulin-therapy programs need to monitor their blood glucose levels, as instructed by their physician or health-care practitioner, to identify blood glucose patterns. Blood glucose patterns are then used to adjust insulin doses and modify the insulin program or meal plan to achieve target blood glucose levels and glycemic control. Although many newly diagnosed type 1 diabetic patients are well managed on a conventional insulin program, many patients change to an intensive insulin program to achieve blood glucose goals and increase the flexibility of their food choices and lifestyle. Intensive insulin therapy allows the patient more flexibility in the timing of meals and exercise as well as in the composition of meals, and the ability to minimize or eliminate snacks. Intensive insulin programs include multiple daily injections with basal insulin and rapid- or short-acting pre-meal insulin or the use of an insulin pump with rapid- or short-acting insulin given as a pre-meal bolus. The amount of pre-meal rapid- or short-acting insulin can be adjusted based on the amount of food eaten (specifically, the carbohydrate content of the meal), the addition of snacks, and changes in exercise or activity levels. The patient can choose if and when to eat a meal or snack and use an algorithm or a carbohydrate-to-insulin ratio to calculate his or her pre-meal dose of rapid- or short-acting insulin (4). While a meal plan is often used as a guide to food choices, the patient who selects intensive therapy is able to enjoy flexibility of food choices and variability in the timing of meals, snacks, and exercise that would not be possible on a conventional insulin program.
A moderate weight loss of 5-10 kg (approximately 10-20 lb), regardless of initial weight, has been shown to improve glycemic control and to reduce serum lipid levels and blood pressure (2). For this reason, weight control continues to be an important strategy in nutrition management of type 2 diabetes.
Patients often experience difficulty in achieving weight loss and maintaining a reasonable body weight through traditional nutrition strategies, such as calorie-restricted diets. Therefore, the focus of nutrition therapy for type 2 diabetes is on achieving target blood glucose levels and improving metabolic control. Type 2 diabetic patients should be encouraged to monitor blood glucose levels because nutrition therapy and lifestyle changes often have a positive effect on blood glucose levels before weight loss goals are achieved. The focus of nutrition assessment and therapy for type 2 diabetes is to identify a reasonable body weight for the patient, and to encourage diet and lifestyle changes to achieve and maintain weight loss goals, blood glucose targets, and blood-pressure levels, and to improve metabolic control. Nutrition strategies encourage a moderate reduction in daily calorie intake, usually a reduction of 250-500 calories per day from the patient's usual daily intake, as assessed by a registered dietitian. In addition to nutrition therapy, a regular program of exercise is also encouraged to promote weight loss, achieve target blood glucose levels, and optimize metabolic control of type 2 diabetes. Increased physical activity can help to decrease insulin resistance, lower blood glucose levels, and improve overall health in addition to facilitating weight loss.
Because of the complex and diverse nature of type 2 diabetes, it is important to individualize the macronutrient composition of the meal plan based on each patient's goals, to improve metabolic control and limit long-term complications of the disease. In patients with hyperlipidemia, a reduction in both total and saturated-fat intake is usually recommended to help achieve serum lipid goals and decrease the risk of cardiac disease. A useful nutrition strategy to both optimize blood glucose control and improve serum lipid levels is to reduce the carbohydrate content of the diet to 40-45% of calories and to space meals and snacks throughout the day. Because carbohydrate-containing foods have the largest effect on blood glucose levels, blood glucose control can often be improved by spacing the carbohydrate intake at regular intervals. These meal-planning strategies can limit the rise in blood glucose levels after meals and snacks and optimize the benefits of endogenous insulin production and hypoglycemic medications in blood glucose control. The results of blood glucose monitoring are often used to adjust the amount of carbohydrates consumed and the timing of meals and snacks to achieve target blood glucose levels (5).
Because many type 2 diabetic patients are unable to achieve optimal metabolic and glycemic control through diet and exercise modifications and oral medications, insulin therapy is often started. However, it is important for both the
patient and the health-care practitioner to recognize the continued benefits of diet, exercise, and lifestyle modifications—too often, patients and health-care practitioners place less emphasis on meal planning and exercise after a type 2 diabetic patient is started on insulin therapy. The key to achieving blood glucose targets with the addition of insulin therapy is for the patient to follow a meal plan with a consistent carbohydrate intake and to eat and exercise at consistent times each day. Consistent food intake and exercise habits will help match blood glucose levels with the action of hypoglycemic medications and insulin to achieve target blood glucose levels and limit hypoglycemic reactions (5).
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