American Diabetes Association Guide to Nutrition Therapy for Diabetes. Marion J. Franz

Guidelines for Americans, 2010. Available at: http://www.cnpp.usda.gov/dgas2010-dgacreport.htm

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       Marion J. Franz, MS, RD, CDE, is a Nutrition/Health Consultant at Nutrition Concepts by Franz, Inc., Minneapolis, MN.

Chapter 5 Nutrition Therapy for Adults with Type 1 and Insulin-Requiring Type 2 Diabetes

      Alison B. Evert, MS, RD, CDE

Highlights

       Insulin Therapy

       Nutrition Therapy for Type 1 Diabetes and Insulin-Requiring Type 2 Diabetes

       Summary

Highlights Nutrition Therapy for Adults with Type 1 and Insulin-Requiring Type 2 Diabetes

      • Carbohydrate intake and available insulin are the primary determinants of postprandial glucose levels. Management of carbohydrate intake is therefore a primary strategy for achieving glycemic control.

      • Adjusting prandial insulin doses to match desired carbohydrate intake (using a meal-planning approach such as carbohydrate counting) in people with type 1 diabetes results in improved glycemic control.

      • For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount.

      • Prandial and blood glucose correction insulin-dosing algorithms may help people with type 1 and insulin-requiring type 2 diabetes to achieve glycemic control when using flexible intensive insulin therapy.

      • Timing of prandial insulin dose 15–20 min before initiation of the meal may help to reduce postprandial hyperglycemia.

      • Postprandial hyperglycemia and glucose variability occur frequently in people with diabetes, and this result may convey increased risk of cardiovascular morbidity and mortality. Nutrition therapy interventions may help to reduce postprandial hyperglycemia and reduce glycemic variability.

      Nutrition Therapy for Adults with Type 1 and Insulin-Requiring Type 2 Diabetes

      Nutrition therapy plays an integral role in the treatment and self-management of type 1 diabetes and insulin-requiring type 2 diabetes. The Centers for Disease Control and Prevention (CDC) estimates that 25.8 million people are affected by diabetes. Out of these people, 12% of adults with diagnosed diabetes (type 1 or type 2) are treated with insulin and an additional 14% take insulin and oral medication(s) (CDC 2011).

      For centuries, the only therapeutic option for type 1 diabetes was “starvation diets”; thankfully, this strategy was ultimately short-lived. After 1922, insulin became available and, in the 1980s, the technology for self-monitoring blood glucose (SMBG). However, despite all the advances in the treatment of insulin-requiring diabetes, nutrition therapy continues to be a difficult strategy for individuals to implement. For the individual with type 1 (or type 2) diabetes, learning how to administer an injection of insulin is a skill that is often quickly mastered, whereas mastering the ability to “count carbohydrates” and match insulin to food intake is usually more difficult.

      There are two types of normal physiological insulin secretion: continuous basal insulin secretion and incremental prandial insulin secretion, controlling meal-related glucose excursions. People with type 1 and insulin-requiring type 2 diabetes lack both basal and meal-related prandial secretion. Historically, conventional treatment included predetermined or “fixed” insulin doses and following a rigid calorie- and carbohydrate-controlled meal plan based on the insulin regimen. Some people with type 1 and insulin-requiring diabetes still use this method for a variety of reasons, such as age, cost, fewer required injections, lack of access to insulin analogs, personal preference, or prescribing habits of the health care provider.

      In the 1990s, the Diabetes Control and Complications Trial (DCCT) showed unequivocally that intensive insulin therapy using multiple daily injections reduced the risk of complications when compared to conventional treatment (DCCT 1993). Improved glycemic control was achieved through an intensive program of multiple daily insulin injections (at least three injections per day) or the use of an insulin pump. Intensive insulin therapy DCCT participants performed SMBG (four times per day) and were taught how to adjust their insulin using treatment algorithms based on glucose test results, food choices, and physical activity. Carbohydrate counting was used as one of the meal-planning approaches and was found to be effective in helping people achieve glycemic control (DCCT 1993).

      Outside of the United States, flexible intensive insulin therapy (FIIT) for the management of type 1 diabetes was developed in Düsseldorf in the late 1970s (Mühlhauser 1983). FIIT is now taught as a part of many structured education programs, such as the Dose Adjustment for Normal Eating (DAFNE) course in the United Kingdom and in Australia (DAFNE 2002; Lowe 2008).

      Both the DCCT and DAFNE research trials involved frequent follow-up with members of the diabetes team that included registered dietitians (RDs) and nurses to assist the person