Medical Nutrition Therapy for Diabetes Mellitus
Manual of Clinical Nutrition Management C- 8 Copyright © 2 013 Compass Group, Inc.
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