Medical Nutrition Therapy for Diabetes MellitusManual of Clinical Nutrition Management C- 5 Copyright © 20 13 Compass Group, Inc.
bedtime, prior to exercise (1). In addition SMBG should be done when a patient suspects low blood glucose,
after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving (1).
Adjustments should be made in food intake or medication based on SMBG results. Hypoglycemia should be
treated appropriately (2). See discussion on Treatment of Hypoglycemia in this section.
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. For individuals on these therapies, added carbohydrate should be ingested if pre-exercise
glucose levels are < 100 mg/dL (1). When exercise is planned, the insulin dose may need to be adjusted to
prevent hypoglycemia (2,27). If exercise is unplanned, additional carbohydrate may need to be consumed (2,27).
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 (1,2,27). See Section III: 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).
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). 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 discussion on Treatment of Hypoglycemia in this section.
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).
For further information, refer to Section III: Clinical Nutrition Management
Diabetes Mellitus: Considerations for Exercise
Diabetes Mellitus: Oral Glucose-Lowering Medications And Insulin
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
Section II: Estimation of 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 g/min is an indicator for nephropathy and
increased cardiovascular morbidity and mortality (Grade II) (1,4). In patients with diabetic nephropathy,