Medical Nutrition Therapy for Diabetes Mellitus
Manual of Clinical Nutrition Management C- 10 Copyright © 2 013 Compass Group, Inc.
hospital can result from factors including stress and decompensation of type 1 diabetes, type 2 diabetes, or
other forms of diabetes; hyperglycemia may also be iatrogenic due to the administration or withholding of
pharmacologic agents, including glucocorticoids and vasopressors (1). Insulin therapy should be initiated for
treatment of persistent hyperglycemia starting at a threshold of not greater than 180 mg/dL (1). Once insulin
therapy is started, the blood glucose levels of a majority of critically ill patients should target a range of 140 to
180 mg/dL (1). These revised ranges are currently suggested as the protocol for treatment to promote safety
in achieving the desired glucose range without increasing risk for severe hypoglycemia (1). For non-critically
ill patients’ there is no clear evidence for specific blood glucose goals (1). If treated with insulin, the premeal
blood glucose levels should generally be < 140 mg/dL with random blood glucose < 180 provided these
targets can be safely achieved (1). More stringent targets may be appropriate in stable patients with previous
tight control. Less stringent targets may be appropriate in those with severe comorbidities (1). Insulin should
be initiated when necessary to achieve target values (1). Scheduled prandial insulin doses should be
given in relation to meals and should be adjusted according to point-of-care glucose levels. The traditional
sliding-scale insulin regimens are ineffective and are not recommended (1). In addition, glucose monitoring
should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for
hyperglycemia, including high dose glucocorticoid therapy, initiation of enteral or parenteral nutrition,
octreotide or immunosuppressive medications. If hyperglycemia is documented and persistent, treatment
should be provided using the same glycemic goals as patients without known diabetes (1).
See Section III: Clinical Nutrition Management, Diabetes Mellitus: Considerations for Acute Illness
Diabetes Nutrition Management: Meal Planning Approaches (21)
Familiarity with the variety of meal planning approaches available can help dietitians more effectively teach
patients how to reach their nutrition goals. The type of approach selected should depend on the goals for
metabolic outcomes and the patient’s nutrition needs, literacy, motivation, and lifestyle. The American
Diabetes Association patient education publications are based on current diabetes treatment guidelines.
Approaches that can be used for teaching meal planning include:
Basic nutrition guidelines These guidelines provide the patient with an understanding of the basic
principles of nutrition and guidance in selecting an adequately balanced
diet for optimal health, eg, Dietary Guidelines for Americans, Food Guide
Pyramid, and Guide to Good Eating.
Basic diabetes guidelines These guidelines provide the patient with an understanding of the
connection between food intake and metabolic outcomes. They give the
patient direction in making appropriate food choices for managing
diabetes, eg, the American Diabetes Association/American Dietetic
Association’s The First Step in Diabetes Meal Planning for the Newly
Diagnosed, Diabetes Food Guide Pyramid, and Healthy Food Choices.
Menu approaches to meal
planning
These approaches provide simple examples to assist patients with meal
planning, eg, The New Family Cookbook for People with Diabetes and the
American Diabetes Association’s Month of Meals cookbook series and
individualized menus.Exchange lists for meal planning This approach is designed to provide patient structure and guidance in
meal planning. Exchanges are organized by calorie levels which is helpful
in designing calorie-controlled meal plans. Food groups are organized
based on foods that provide similar amounts of carbohydrate, protein and
fat content. This helps to assist the patient in meal planning and meeting
target nutrient and carbohydrate intake goals. The most common
exchange list is the American Diabetes Association/Academy of Nutrition
and Dietetics’ Eating Healthy with Diabetes: An Easy Read Guide; Choose
Your Foods: Exchange List for Diabetes; and Exchange List for Weight
Management.
Counting approaches These approaches provide structure with specific rules that are clearly
identified. They allow optimal flexibility with food choices and meal
planning, eg, American Diabetes Association/Academy of Nutrition and
Dietetics’ Basic Carbohydrate Counting, Advanced Carbohydrate Counting,
and The Diabetes Carbohydrate & Fat Gram Guide.