Food and exercise are powerful tools in diabetes control. Before the discovery of insulin, nutrition therapy was the treatment for diabetes. Medical nutrition therapy (MNT) continues as the foundation of management even as more insulin and medication options become available for diabetes (Pastors, Warshaw, DaIy, Franz, Kulkarni, 2002). Consulting a registered dietitian, with the certified diabetes educator (CDE) credential if possible, provides the assessment, education and lifestyle recommendations that are necessary to manage diabetes on a daily basis. Patient education to understand the effects of food, exercise, medication, stress, illness and diabetes complications is provided by Diabetes Self-Management Education (DSME)

The American Diabetes Association has published clinical nutrition recommendations as follows (ADA nutrition principles, 2004):

“Goals of Medical Nutrition Therapy for Diabetes”

1. Attain and maintain optimal metabolic outcomes including:

* Blood glucose levels in the normal range or as close to normal as is safely possible to prevent or reduce the risk for complications of diabetes.

* A lipid and lipoprotein profile that reduces the risk for macrovascular disease.

* Blood pressure levels that reduce the risk for vascular dis ease.

2. Prevent and treat the chronic complication of diabetes. Modify nutrient intake and lifestyle as appropriate for the prevention and treatment of obesity, dyslipidemia, cardiovascular dis ease, hypertension and nephropathy.

3. Improve health through healthy food choices and physical activity.

4. Address individual nutritional needs taking into consideration personal and cultural preferences and lifestyle while respecting the individual ’s wishes and willingness to change.

The ADA nutrition principles (2004) indicate that there is no standard diet or ADA diet because there are many methods of meal planning. A plan may be exchanges, calorie points, carbohydrate counting, menus or guidelines. Some people with diabetes want a meal plan to follow every day to match the medication and blood glucose goals. Others prefer to learn to adjust insulin to the amount of food they choose to eat. A dietitian can calculate calorie needs based on a person’s height, weight, age, gender and activity. The body mass index (BMI) is calculated to determine the goals of the patient to gain, lose, or maintain weight. A person with a BMI over 25 would benefit from a plan for weight loss. All diabetes meal plans should be individualized according to food preferences, calorie needs and lifestyle. Adjustments must be made according to blood glucose level, weight and client satisfaction with the plan (Pastors et al, 2002).

Meal plans are based on the fact that all food raises blood glucose and insulin lowers blood glucose. The goal then is to match the amount of food with insulin or diabetes pills to meet blood glucose goals. Too much food or too little diabetes medication will cause high blood glucose. Too little food or too much diabetes medication will cause low blood glucose. The blood glucose result two hours after the meal is the best check to know whether the diabetes medication and food at that meal are in the right amount.

The amount of the foods may be prescribed, usually by a dietitian, using calories, calorie points, exchanges, carbohydrate choices or grams. The client is given a list of food with the carbohydrate, calorie or calorie point content. The client will also be given the amount of calorie points, calories or carbohydrate for each meal and snack or a ratio of insulin/carbohydrate or calories or points. Most people eat better, feel better and have more energy if they eat regular meals and distribute food throughout the day. The food guide pyramid is one guideline for choosing what to eat (United States Department of Agriculture, 1992). The food pyramid emphasizes healthy carbohydrates such as whole grains, fruit, beans, milk and vegetables. Other good choices on the pyramid are lean meat, low fat dairy products such as cheese and yogurt, nuts and seeds. Desserts and fats (especially the unsaturated fats such as olive, peanut and canola oil) can be included in the context of a healthy diet and within the calories to maintain a healthy weight. When implementing a meal plan, the portion size is more important than the specific food a person eats. There are not lists of do and don’t eat foods because a combination of any foods can make a healthy menu.

Snacks depend on the diabetes medications. Snacks might include vegetables, vegetable juice, milk, crackers, yogurt or fruit. These are healthier choices than fried foods, sweets and sugarsweetened drinks such as soda pop, sports drinks and fruit drinks. If a person is on Lantus (glargine) and a rapid-acting insulin such as Novolog (aspart) or Humalog (lispro), they may need an insulin injection to prevent high blood glucose if they eat more than 120 calories (1 ½ calorie points) in a snack (Guthrie, Childs & Guthrie, 2003). Therefore, snacks are often not recommended for persons taking Lantus and rapid-acting insulin except in children or with exercise.