Medical Nutrition Therapy for Diabetes Mellitus
Manual of Clinical Nutrition Management C- 12 Copyright © 2 013 Compass Group, Inc.
In selected patients, drug therapy as an adjunct to lifestyle change may be appropriate to achieve weight
loss (1). However, it is common for patients to regain weight after the discontinuation of medications (1,57). In
patients with severe obesity, surgical options, such as gastric bypass and gastroplasty, may be appropriate
and allow significant improvement in glycemic control with reduction or discontinuation of medications (1,58).
For further information, refer to:
Section IB: Nutrition Management of Bariatric Surgery,
Section IC: Calorie-Controlled Diet for Weight Management,
Section II: Body Mass Index (BMI),
Section II: Estimation of Energy Expenditures, and
Section III: Obesity and Weight Management.
For medical nutrition therapy outcomes monitoring and suggested delivery of care in the acute care setting,
refer to “Morrison Nutrition Practice Guideline – Diabetes Mellitus (Uncontrolled and Complications)” (59).
Special Populations
Children and adolescents with diabetes: Nutrient requirements for children and adolescents with type 1 or
type 2 diabetes are similar to the requirements for children and adolescents who do not have diabetes. The
primary goal for children and adolescents with type 1 diabetes is achieving blood glucose goals that maintain
normal growth and development without excessive hypoglycemia. Individualized food/meal plans and
intensive insulin regimens can provide flexibility to accommodate irregular meal times and schedules as well
as varying appetite and activity levels (1,2). Withholding food or having a child eat consistently without an
appetite, in an effort to control blood glucose levels, should be discouraged (1,2). Nutrition for children and
adolescents with type 2 diabetes should focus on healthy lifestyle changes that normalize glycemia (1,2).
Cessation of weight gain with normal linear growth is a primary outcome that will help achieve glycemic
goals in overweight and obese children with diabetes (1,2).
Pregnancy and lactation with preexisting diabetes: Nutrient requirements during pregnancy and lactation
are similar for women with and without diabetes (1,2). The distribution of energy intake and carbohydrates in
the meal plan of a pregnant woman with preexisting type 1 or type 2 diabetes should be based on her eating
habits, blood glucose levels, and stage of pregnancy. Regular meals and snacks are important to avoid
hypoglycemia due to the continuous fetal draw of glucose from the mother (1,2). An evening snack is usually
necessary to decrease the potential for overnight hypoglycemia and fasting ketosis (1,2). (Refer to the
discussion on pregnant women with preexisting diabetes and gestational diabetes, presented later in this
section.)
Older adults with diabetes: The American Geriatrics Society emphasizes the importance of medical
nutrition therapy for older adults with diabetes (1,2). Obese older adults with diabetes may benefit from
modest energy restriction and an increase in physical activity to promote modest weight loss of 5% to 10% of
body weight (1,2,59-63). Lifestyle modifications, and weight loss goals established for younger adults are also
suggested for older adults. However, an involuntary weight loss of >10 lb or 10% of body weight in <6
months should be addressed in the nutrition assessment and medical nutrition therapy evaluation (2,64).
Older nursing home residents who have diabetes tend to be underweight rather than overweight (2,3). Low
body weight has been associated with greater morbidity and mortality in this population (3). Therefore, the
imposition of dietary restrictions on elderly patients with diabetes in long-term care facilities is not
warranted (2). Residents with diabetes should be served a regular menu with consistency in the amount and
timing of carbohydrate intake (2). There is no evidence to support prescribing diets such as “no concentrated
sweets” or “no sugar added” (2). In the institutionalized elderly, undernutrition is likely and caution should be
exercised when prescribing weight loss diets (2). The treatment team should consider the resident’s age, life
expectancy, comorbidities, and preferences when outlining a plan for care (2). Adjusting the resident’s
medications to control glucose levels, lipid levels, and blood pressure rather than implementing food
restrictions can reduce the risk of iatrogenic malnutrition (2,65).
*The Academy of Nutrition and Dietetics has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to
evidence and conclusion statements. The grading system is described in Section III: Clinical Nutrition Management A Reference Guide,
page III-1.
References
- American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1): 11S-66S.
- American Diabetes Association. Nutrition recommendations and interventions for diabetes. Diabetes Care. 2008;31(suppl1): 61S-
78S. (under revision in 2013)