Manual of Clinical Nutrition

Medical Nutrition Therapy for Diabetes Mellitus

Manual of Clinical Nutrition Management C- 9 Copyright © 20 13 Compass Group, Inc.

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.

Table C-3: Carbohydrate Content of Substitutions

15 g of Carbohydrate

Apple juice ½ cup Jelly beans nine

Applesauce, sweetened ¼ cup Jelly, jam 1 tbsp

Applesauce, unsweetened ½ cup Lifesavers candy five or six

Cooked cereal ½ cup Orange juice ½ cup

Cranberry juice 1/3 cup Pineapple juice ½ cup

Cream soup, made with water 1 cup Popsicle bar (3 oz) one

Custard ½ cup Regular soda ½ cup

Gelatin ½ cup Sherbet ¼ cup

Grape juice 1/3 cup Sugar, granulated 4 tsp

Ice cream ½ cup Syrup 1 tbsp

12 g of Carbohydrate

Milk (whole, reduced-fat, nonfat) 1 cup

Eggnog ½ cup

Plain yogurt 1 cup

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