Professional Documents
Culture Documents
www.uptodate.com © 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2022. | This topic last updated: Feb 21, 2022.
INTRODUCTION
Diet is one of the most important behavioral aspects of diabetes treatment. Basic
principles of nutritional management, however, are often poorly understood by
both clinicians and their patients. The role of nutrition and the development of a
medical nutrition therapy (MNT) plan for a patient with type 2 diabetes are
discussed here. Nutrition for patients with type 1 diabetes, as well as diets for the
prevention of diabetes and for weight loss in general, are discussed separately.
Meal content, quantity, and timing are particularly important for patients who are
treated with insulin secretagogues or traditional insulin regimens.
The process of MNT involves selecting an appropriate meal planning approach and
educational materials based on assessment of a person's ability or willingness to
learn, motivation to make changes in eating habits, clinical and nutrition goals,
diabetes medications, activity level, and lifestyle [6,7]. MNT clinical practice
guidelines recommend a series of three to six encounters with a registered dietitian
lasting for 45 to 90 minutes. The series of encounters should ideally begin at
diagnosis of diabetes or at first referral to a dietitian for MNT and should be
completed within six months. The dietitian can then reassess diabetes-related
outcomes and discuss with the patient whether additional MNT encounters are
needed. At least one follow-up MNT encounter is recommended annually to
reinforce lifestyle changes and evaluate and monitor diabetes-related outcomes [1].
Goals — The medical nutrition therapy (MNT) plan for patients with type 2 diabetes
should optimally manage the "ABCs" of diabetes control: glycated hemoglobin
(A1C), blood pressure, and low-density lipoprotein (LDL) cholesterol. The MNT plan
must be tailored for the individual patient to further address existing or at-risk
complications related to diabetes or other concomitant conditions.
The nutritional goals for people with type 2 diabetes are to:
The relative importance of each nutritional goal varies with individual patient
characteristics.
Estimating body mass index — Body mass index (BMI) is now commonly used in
research and clinical care as a classification of weight status and is calculated as:
weight in kg divided by (height in m)2 (calculator 1). Optimal body weight is usually a
BMI between 18.5 and 24.9 kg/m2. BMI targets may vary depending on ethnicity (eg,
lower for Asian populations) and muscularity (eg, higher for very muscular persons).
(See "Obesity in adults: Prevalence, screening, and evaluation", section on 'Body
mass index'.)
Healthy body weight range can also be roughly estimated by adding and
subtracting 10 percent to the weights calculated as follows [8]:
• 100 lb (45 kg) plus 5 lb (2.3 kg) for each additional inch (2.5 cm)
• 100 lb (45 kg) minus 5 lb (2.3 kg) for each additional inch (2.5 cm) under 5
:
feet
• 106 lb (48 kg) plus 6 lb (2.7 kg) for each additional inch (2.5 cm)
Several formulas are available to estimate baseline caloric intake for weight
maintenance. A commonly used formula considers the patient's age, sex, height,
weight, and usual level of physical activity ( table 1) [9].
A rough estimate of daily caloric needs to maintain body weight can be determined
as follows [10]:
If patients have been close to healthy weight for several years, their current caloric
intake is most likely appropriate.
To estimate caloric needs for weight loss of 1 to 2 pounds per week, subtract 500 to
1000 calories from daily weight maintenance calories.
Caloric restriction, even before significant weight loss, will result in short-term
improvement in glycemic control. Fasting blood glucose (FBG) falls within several
days of calorie restriction, possibly due to a fall in hepatic glucose output [2,11,12].
However, long-term reduction in FBG concentration depends upon weight loss;
blood glucose values increase slightly when the patient resumes a weight
maintenance diet [2].
Weight loss goals — For patients with type 2 diabetes who are overweight (BMI
≥25 to 29.9 kg/m2) or obese (BMI ≥30 kg/m2), initial recommendations for weight
loss and physical activity are to lose 5 to 10 percent of initial body weight [13] and to
accumulate at least 30 minutes of moderate physical activity over the course of
most days of the week [14,15]. Once initial weight goals are met, further goals
should be determined based on assessment of the impact of the weight loss on FBG
and the patient's willingness to lose more weight.
Patients need not reach ideal body weight to achieve improvement in health status,
particularly if the patient engages in regular exercise [16]. A sustained weight loss of
even 5 to 10 percent of initial body weight in overweight individuals can have a
lasting beneficial impact on serum glucose, dyslipidemia, and hypertension
[13,14,17-19]. In Look AHEAD (Action for Health in Diabetes), a randomized trial of
an intensive lifestyle intervention to increase physical activity and decrease caloric
intake versus standard diabetes education in people with type 2 diabetes, a modest
weight loss of 8.6 percent of initial weight at one year was associated with
significant improvements in blood pressure, glycemic control, FBG, high-density
lipoprotein (HDL) cholesterol, and triglyceride levels and significant reductions in the
use of diabetes, hypertension, and lipid-lowering medications [20]. After a median
follow-up of 9.6 years, the difference in weight loss was attenuated but remained
significant, and there were greater reductions in A1C and improvements in fitness
and some cardiovascular risk factors [21]. The cardiovascular effects of the intensive
lifestyle intervention are reviewed in detail separately. (See "Initial management of
hyperglycemia in adults with type 2 diabetes mellitus", section on 'Intensive lifestyle
modification'.)
:
The Look AHEAD trial and the Diabetes Remission Clinical Trial (DiRECT) both
highlight the potential role of weight loss in achieving diabetes remission. In Look
AHEAD, patients in the lifestyle intervention were more likely to experience
complete or partial remission of diabetes compared with the diabetes support and
education group (11.5 percent during the first year and 7.3 percent at year 4,
compared with 2 percent for the diabetes support and education group at both time
points) [22]. In the DiRECT trial, which included patients with type 2 diabetes with
shorter duration diabetes than in Look AHEAD and not treated with insulin at
baseline, weight loss associated with the lifestyle intervention resulted in diabetes
remission at one year in 46 percent of patients, compared with 4 percent in the
control group [23]. Remission rates were associated with the magnitude of weight
loss, increasing from 7 to 86 percent as weight loss increased from <5 to >15
percent.
Weight loss strategies — Physical activity, diet, and behavioral modification are
important components of all programs to accomplish weight loss. There are
additional options for weight loss, including the addition of medication to promote
weight loss and bariatric surgery. (See "Obesity in adults: Overview of
management".)
● Counting calories and fat grams – Counting calories and fat is a well-
recognized means of weight loss and was the strategy selected for achieving
weight reduction for both the Diabetes Prevention Program (DPP) and Look
AHEAD trials [24,25]. Participants were coached on calorie and fat gram
counting and given reference booklets. Calorie and fat gram targets were
based on initial body weight and targets were selected to promote weight loss
of 1 to 2 pounds per week, providing 25 to 30 percent of calories from fat and
:
<10 percent saturated fat. In Look AHEAD, the calorie and fat gram goals were
as follows:
It is important that low-calorie diets (less than 1200 kcal/day) are not adopted
without review to be sure nutritional needs are met. Very low calorie diets (less
than 800 kcal/day) require medical supervision. (See "Obesity in adults: Dietary
therapy", section on 'Very low calorie diets'.)
• The use of liquid meal replacements for 12 weeks in people with type 2
diabetes resulted in significantly greater weight losses and reductions in
fasting blood glucose than a conventional reducing diet with the same
calorie goal [33].
Meal replacements in the form of liquid shakes and bars and portion-
controlled servings of conventional foods have been used in both the DPP and
Look AHEAD. In the Look AHEAD lifestyle intervention, use of meal
replacements, which was not a randomized intervention, was associated with
significantly more weight loss. Although this association should not be used to
:
suggest causality, it is notable that the lifestyle intervention participants with
the highest meal replacement use (approximately 12 meal replacements per
week) had a mean weight loss of 11.2 percent, and those with the lowest use
(approximately two meal replacements per week) lost 5.9 percent of initial
weight after the first year of the intervention [34].
The food groups have been more recently categorized into three groups, to
simplify the teaching of carbohydrate consistency concepts. These three
groups are carbohydrate, meat and meat substitutes, and fat ( table 2 and
table 3). The exchange lists also identify foods that are good sources of fiber
and foods that have a high sodium content.
The exchange system meal planning approach can be used as a tool to help
patients achieve calorie, fat, and carbohydrate goals (see 'Carbohydrate
consistency' below). However, many patients find that it is a complicated
system to learn.
Patients with diabetes, in particular those treated with medications that can cause
hypoglycemia (such as insulin or sulfonylureas), should check blood glucose levels
before and after exercising, especially in the beginning of an exercise program as
patterns are established. Monitoring of blood glucose can both identify
hypoglycemia and provide feedback to patients on the beneficial impact of exercise
on glycemic control. (See 'Hypoglycemia' below.)
Nutritional counseling for all patients with type 2 diabetes — Nutritional issues
for consideration in all patients with type 2 diabetes include consistency with
carbohydrate intake and meal timing, macronutrient content of meals, avoidance of
hypoglycemia, and dietary compliance.
Consistency with carbohydrate intake and meal timing day to day, to avoid erratic
blood glucose levels and hypoglycemia, is most important when patients with type 2
diabetes are treated with some insulin regimens, sulfonylureas, or other
secretagogues [1].
Carbohydrate consistency may also be helpful for patients with erratic blood
glucose patterns, including problems with hypoglycemia. In addition, reducing
overall carbohydrate content at meals and snacks has been shown to improve
glycemic control and can be applied in a variety of eating patterns [37]. Pre- and
post-meal blood glucose monitoring data can then help to determine if adjustments
to carbohydrate intake at meals and snacks will be sufficient, or if medication(s)
need to be combined with MNT [1].
For those who are not able to do basic carbohydrate counting, another option
is to teach the diabetes plate method. This commonly used approach provides
basic meal planning guidance and has been shown to help achieve improved
glycemic control [38]. This method uses a simple graphic of a 9-inch plate to
show how to portion foods (one-half plate as non-starchy vegetables, one-
quarter plate as lean protein, and one-quarter plate for carbohydrates such as
:
starches or grains). This balanced plate method is a viable option for those
who have challenges with numeracy and food literacy or for those who need a
simplified approach for achieving moderation of carbohydrate intake and
better carbohydrate consistency [37].
In patients with diabetes, there is not one ideal percentage of calories from
carbohydrate, protein, and fat for all people [1]. In a systematic review of studies
evaluating macronutrient composition in the management of patients with
diabetes, several different dietary approaches with different macronutrient
distributions improved glycemia and/or CVD risk factors [42].
The Mediterranean diet has also been shown to reduce the incidence of major
cardiovascular events in patients at high risk for CVD, including those with
diabetes [46]. (See "Prevention of cardiovascular disease events in those with
established disease (secondary prevention) or at very high risk", section on
'Diet'.)
● Dietary fat – People with type 2 diabetes typically consume diets that are
higher in total fat, saturated fat, and cholesterol than is recommended. Median
intake of saturated fat is reported to be approximately 13 percent of calories,
with 85 percent of persons exceeding the saturated fat recommendation of
less than 10 percent [52]. Patients with diabetes who are consuming diets
higher in fat must reduce saturated fat intake and also assure that their diet is
adequate in sources of lean protein, fiber content, and essential vitamins and
minerals. The type of fat consumed is critical for the prevention and treatment
of CVD. Trans fat (hydrogenated fats) are atherogenic, while mono- and
polyunsaturated fats (particularly omega-3 fatty acids) are protective. Different
saturated fatty acids and different food sources of saturated fat have divergent
effects on cardiovascular and metabolic health. There is some evidence that
replacing saturated fat with polyunsaturated fat reduces fasting glucose, A1C,
and insulin resistance and that replacing carbohydrates, saturated fat, or
monounsaturated fat with polyunsaturated fat improves insulin secretion
:
capacity [53]. (See "Dietary fat", section on 'Diabetes mellitus'.)
Glycemic index and glycemic load — Foods containing the same amount of
carbohydrate can have significantly different glycemic effects. In general, foods with
higher fiber content have a lower glycemic index. These differences led to the
development of the concepts of glycemic index and glycemic load. A more detailed
discussion of the glycemic index is presented separately. (See "Dietary
carbohydrates" and "Nutritional considerations in type 1 diabetes mellitus", section
on 'Glycemic index and glycemic load'.)
For patients with type 2 diabetes, low glycemic index diets may provide a modest
benefit in terms of controlling postprandial hyperglycemia, especially in individuals
previously consuming a high glycemic index diet [37]. However, in recent systematic
reviews, low glycemic index diets in individuals with diabetes or at risk for diabetes
had equivocal impact on A1C compared with other diets [1,5,55]. Increasing fiber
intake preferably through food (vegetables, fruits, legumes, and intact whole grains)
may help to modestly lower A1C and at the same time promote eating lower
glycemic index foods [1,56].
Cinnamon supplementation has also been touted as a natural treatment for type 2
diabetes [59-65]. However, meta-analyses have shown conflicting results [66-69]. As
an example, a meta-analysis of 10 clinical trials of cinnamon (Cinnamomum cassia,
mean dose 2 g daily for 4 to 16 weeks) in patients with diabetes (predominantly type
2) did not show a significant beneficial effect of cinnamon on A1C, postprandial
glucose, or serum insulin levels [66]. The effect of cinnamon on FBG levels was
inconclusive due to significant heterogeneity among the point estimates. In
contrast, another meta-analysis of eight trials found a significant lowering in FBG
(-8.8 mg/dL [-0.49 mmol/L]) in patients with type 2 diabetes randomly assigned to
cinnamon [67]. This meta-analysis was also limited by heterogeneity and the small
sample size of the included trials. Thus, the available data are inadequate to provide
any reliable conclusions regarding a beneficial effect of cinnamon.
Dietary history — The development of the nutrition care plan should begin by
obtaining a dietary history, including:
● Dietary preferences
● Dietary content
● Patterns of physical activity
● Social support
:
● Education level
● Time constraints
● Other challenges
The dietary history, along with several days of food records, is helpful in an
assessment of caloric intake and carbohydrate consistency. Recognizing that this is
not always possible in the context of the clinician visit, a brief 24-hour recall will
usually provide an assessment that will serve as a basis for initial changes and can
be improved upon at follow-up visits.
Once sufficient data are obtained, changes can be advised to move the patient
toward a more healthful diet. The patient's own food, activity, medication dosing
and adherence, blood glucose records, and readiness to change can be helpful in
guiding choices between a detailed exchange system, calorie and fat gram counting,
use of meal replacements, a focus on carbohydrate counting, the diabetes plate
method, or individualized behavioral goals; decisions between these options are
made on an individual basis [71]. It is important to remember that the more marked
the changes are from what the patient likes to eat, the less likely the patient is to
comply with the dietary prescription [36]. (See 'Promoting dietary adherence' below.)
● Fat quality is more important than fat quantity. Trans fats contribute to
coronary heart disease, while mono- and polyunsaturated fats (eg, those found
in fish, olive oil, nuts) are relatively protective. Saturated fatty acids and
different food sources of saturated fat have divergent effects on cardiovascular
and metabolic health. Trans fatty acid consumption should be kept as low as
possible.
● Fiber intake should be at least 14 grams per 1000 calories daily; higher fiber
:
intake may improve glycemic control.
● A reduced sodium intake of 2300 mg per day with a diet high in fruits,
vegetables, and low-fat dairy products is prudent and has demonstrated
beneficial effects on blood pressure.
● Sugar alcohols and non-nutritive sweeteners are safe when consumed within
daily levels established by the US Food and Drug Administration (FDA). When
calculating carbohydrate content of foods, one-half of the sugar alcohol
content can be counted in the total carbohydrate content of the food. Use of
sugar alcohols needs to be balanced with their potential to cause
gastrointestinal side effects in sensitive individuals.
● Perform nutrition education in a setting where real food can be used, so that
:
the patient can become familiar with household measures and can improve his
or her ability to estimate the calorie, fat, or carbohydrate content of foods
commonly eaten. This is often best accomplished in dietary workshops for
small groups of patients [73].
● During follow-up visits, ask specifically about diet and exercise to reinforce
their importance. Ideally, a patient should be able to quote his or her dietary
and exercise prescription in detail. Patients requiring insulin and using
carbohydrate counting will also need to be able to specify how many grams of
carbohydrate they aim to eat at each meal and snack during the day.
Periodic adjustments are necessary in the patient's comprehensive plan for diet,
exercise, stress, and pharmacologic interventions to achieve and maintain glycemic
control and prevent complications. The four critical times for providers to make
medical nutrition therapy (MNT) referrals are at diagnosis; annually and/or when not
meeting treatment targets; when medical, physical, or psychological complicating
factors develop; and when transitions in life and care occur [75]. The clinician needs
to maintain awareness of the patient's changing life circumstances, motivation, and
lifestyle patterns and help the patient make adaptations in their plan accordingly.
Many patient factors influence the likelihood of successful dietary intervention. The
following observations have been made concerning the likelihood of inducing and
maintaining weight loss:
● Exercise can increase the degree of weight loss and the likelihood that it will be
maintained. In one study of 74 patients, as an example, the patients who
maintained weight loss were more likely to exercise (90 versus 34 percent) [76].
(See "Effects of exercise in adults with diabetes mellitus".)
● Self-monitoring for weight and dietary intake, in conjunction with goal setting
and individualized problem-solving, can be helpful in achieving and
:
maintaining weight loss [77]. Patients who were more successful with weight
loss were conscious of their eating behaviors (70 versus 30 percent), used
available social supports (70 versus 38 percent), and confronted problems
directly (90 versus 10 percent) [76].
● Patients who refuse food when offered by others and are able to stop eating
when appropriate are more likely to maintain weight loss and achieve glycemic
control [78].
● Providing structured meal plans and grocery lists is very effective, but no
additional benefit appears to be obtained by providing the actual food (even if
free) or giving financial incentives to lose weight [27,79].
Other education
● Once blood glucose is >70 mg/dL, the patient should use the appropriate
insulin dose to cover carbohydrate intake at the meal. If the meal following the
:
hypoglycemic episode is going to be delayed, a snack containing another 15
grams of carbohydrate should be consumed.
In one study, the average weight gain in patients with type 2 diabetes treated with
an insulin regimen was 8.7 kg [81]. In the United Kingdom Prospective Diabetes
Study (UKPDS), the average weight gain after 10 years of insulin therapy was
approximately 7 kg for patients with type 2 diabetes, with the most rapid weight
gain occurring when insulin was first initiated [82]. Less intensive therapy with
either insulin or a sulfonylurea (which increases endogenous insulin secretion) was
associated with a 3.5 to 4.8 kg weight gain at three years versus no change with
metformin monotherapy [83].
UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical
jargon.
Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)
● Basics topics (see "Patient education: Type 2 diabetes (The Basics)" and
"Patient education: Diabetes and diet (The Basics)" and "Patient education:
Carb counting for adults with diabetes (The Basics)")
● Beyond the Basics topics (see "Patient education: Type 2 diabetes: Overview
(Beyond the Basics)" and "Patient education: Type 2 diabetes and diet (Beyond
the Basics)")
● Medical nutrition therapy plan – The medical nutrition therapy (MNT) plan is
the process by which a registered dietitian-nutritionist (RDN) tailors a meal
planning approach for people with diabetes based on medical, lifestyle, and
personal factors. It is an integral component of diabetes management and
:
diabetes self-management education. The five components of MNT are weight
management and physical activity, caloric intake, day-to-day carbohydrate
consistency, nutritional content, and meal timing. (See 'Definition' above.)
The MNT for patients with type 2 diabetes should optimally manage the "ABCs"
of diabetes control: glycated hemoglobin (A1C), blood pressure, and low-
density lipoprotein (LDL) cholesterol. The nutrition care plan must be tailored
for the individual patient to further address existing or at-risk complications
related to diabetes or other concomitant conditions. (See 'Goals' above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges David McCulloch, MD, who contributed
to earlier versions of this topic review.
REFERENCES
1. Evert AB, Dennison M, Gardner CD, et al. Nutrition Therapy for Adults With
Diabetes or Prediabetes: A Consensus Report. Diabetes Care 2019; 42:731.
:
2. UK Prospective Diabetes Study 7: response of fasting plasma glucose to diet
therapy in newly presenting type II diabetic patients, UKPDS Group. Metabolism
1990; 39:905.
3. Andrews RC, Cooper AR, Montgomery AA, et al. Diet or diet plus physical activity
versus usual care in patients with newly diagnosed type 2 diabetes: the Early
ACTID randomised controlled trial. Lancet 2011; 378:129.
5. Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics Nutrition
Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Systematic Review
of Evidence for Medical Nutrition Therapy Effectiveness and Recommendations
for Integration into the Nutrition Care Process. J Acad Nutr Diet 2017; 117:1659.
8. Close EJ, Wiles PG, Lockton JA, et al. The degree of day-to-day variation in food
intake in diabetic patients. Diabet Med 1993; 10:514.
9. Institute of Medicine, Food and Nutrition Board. Dietary reference intakes for e
nergy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids,
National Academies Press, Washington DC 2002.
11. Henry RR, Scheaffer L, Olefsky JM. Glycemic effects of intensive caloric
restriction and isocaloric refeeding in noninsulin-dependent diabetes mellitus. J
Clin Endocrinol Metab 1985; 61:917.
12. Wing RR, Blair EH, Bononi P, et al. Caloric restriction per se is a significant factor
in improvements in glycemic control and insulin sensitivity during weight loss
in obese NIDDM patients. Diabetes Care 1994; 17:30.
:
13. NHLBI Obesity Education Initiative - Expert Panel on the Identification, Evaluati
on, and Treatment of Overweight and Obesity in Adults. Clinical Guidelines on t
he Identification, Evaluation, and Treatment of Overweight and Obesity in Adult
s: The Evidence Report, September 1998. http://www.nhlbi.nih.gov/guidelines/o
besity/ob_gdlns.pdf (Accessed on April 12, 2012).
14. Albright A, Franz M, Hornsby G, et al. American College of Sports Medicine
position stand. Exercise and type 2 diabetes. Med Sci Sports Exerc 2000;
32:1345.
15. US Department of Health and Human Services. Physical activity and health: A re
port of the Surgeon General, 1996. http://www.cdc.gov/nccdphp/sgr/index.htm
(Accessed on July 31, 2012).
16. Dasgupta K, Grover SA, Da Costa D, et al. Impact of modified glucose target and
exercise interventions on vascular risk factors. Diabetes Res Clin Pract 2006;
72:53.
17. Wing RR, Jeffery RW. Effect of modest weight loss on changes in cardiovascular
risk factors: are there differences between men and women or between weight
loss and maintenance? Int J Obes Relat Metab Disord 1995; 19:67.
18. Wing RR, Marcus MD, Epstein LH, Salata R. Type II diabetic subjects lose less
weight than their overweight nondiabetic spouses. Diabetes Care 1987; 10:563.
21. Look AHEAD Research Group, Wing RR, Bolin P, et al. Cardiovascular effects of
intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369:145.
22. Gregg EW, Chen H, Wagenknecht LE, et al. Association of an intensive lifestyle
intervention with remission of type 2 diabetes. JAMA 2012; 308:2489.
23. Lean ME, Leslie WS, Barnes AC, et al. Primary care-led weight management for
remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.
Lancet 2018; 391:541.
24. Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention
:
Program (DPP): description of lifestyle intervention. Diabetes Care 2002;
25:2165.
25. Ryan DH, Espeland MA, Foster GD, et al. Look AHEAD (Action for Health in
Diabetes): design and methods for a clinical trial of weight loss for the
prevention of cardiovascular disease in type 2 diabetes. Control Clin Trials 2003;
24:610.
26. Metz JA, Stern JS, Kris-Etherton P, et al. A randomized trial of improved weight
loss with a prepared meal plan in overweight and obese patients: impact on
cardiovascular risk reduction. Arch Intern Med 2000; 160:2150.
27. Jeffery RW, Wing RR, Thorson C, et al. Strengthening behavioral interventions
for weight loss: a randomized trial of food provision and monetary incentives. J
Consult Clin Psychol 1993; 61:1038.
28. Haynes RB, Kris-Etherton P, McCarron DA, et al. Nutritionally complete prepared
meal plan to reduce cardiovascular risk factors: a randomized clinical trial. J Am
Diet Assoc 1999; 99:1077.
29. Pi-Sunyer FX, Maggio CA, McCarron DA, et al. Multicenter randomized trial of a
comprehensive prepared meal program in type 2 diabetes. Diabetes Care 1999;
22:191.
30. Quinn Rothacker D. Five-year self-management of weight using meal
replacements: comparison with matched controls in rural Wisconsin. Nutrition
2000; 16:344.
31. Ditschuneit HH, Flechtner-Mors M, Johnson TD, Adler G. Metabolic and weight-
loss effects of a long-term dietary intervention in obese patients. Am J Clin Nutr
1999; 69:198.
32. Flechtner-Mors M, Ditschuneit HH, Johnson TD, et al. Metabolic and weight loss
effects of long-term dietary intervention in obese patients: four-year results.
Obes Res 2000; 8:399.
33. Yip I, Go VL, DeShields S, et al. Liquid meal replacements and glycemic control
in obese type 2 diabetes patients. Obes Res 2001; 9 Suppl 4:341S.
34. Wadden TA, West DS, Neiberg RH, et al. One-year weight losses in the Look
AHEAD study: factors associated with success. Obesity (Silver Spring) 2009;
17:713.
:
35. Pastors JG, Waslaski J, Gunderson H. Diabetes meal-planning strategies. In: Ame
rican Dietetic Association guide to diabetes medical nutrition therapy and educ
ation, Ross TA, Boucher JL, O'Connell BS (Eds), American Dietetic Association, Ch
icago, IL 2005. p.201.
36. Nuttall FQ. Carbohydrate and dietary management of individuals with insulin-
requiring diabetes. Diabetes Care 1993; 16:1039.
38. Bowen ME, Cavanaugh KL, Wolff K, et al. The diabetes nutrition education study
randomized controlled trial: A comparative effectiveness study of approaches
to nutrition in diabetes self-management education. Patient Educ Couns 2016;
99:1368.
39. Franz MJ. Finding the right fit for meal planning. Diabetes Care 1993; 16:1043.
40. Wolever TM. Carbohydrate and the regulation of blood glucose and
metabolism. Nutr Rev 2003; 61:S40.
41. Johnston CS, Buller AJ. Vinegar and peanut products as complementary foods
to reduce postprandial glycemia. J Am Diet Assoc 2005; 105:1939.
42. Wheeler ML, Dunbar SA, Jaacks LM, et al. Macronutrients, food groups, and
eating patterns in the management of diabetes: a systematic review of the
literature, 2010. Diabetes Care 2012; 35:434.
45. Esposito K, Maiorino MI, Petrizzo M, et al. The effects of a Mediterranean diet
on the need for diabetes drugs and remission of newly diagnosed type 2
diabetes: follow-up of a randomized trial. Diabetes Care 2014; 37:1824.
48. Nuttall FQ, Gannon MC. The metabolic response to a high-protein, low-
carbohydrate diet in men with type 2 diabetes mellitus. Metabolism 2006;
55:243.
49. Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on blood
glucose control in people with type 2 diabetes. Diabetes 2004; 53:2375.
50. Bloch AS. Low carbohydrate diets, pro: time to rethink our current strategies.
Nutr Clin Pract 2005; 20:3.
51. Kirkpatrick CF, Bolick JP, Kris-Etherton PM, et al. Review of current evidence and
clinical recommendations on the effects of low-carbohydrate and very-low-
carbohydrate (including ketogenic) diets for the management of body weight
and other cardiometabolic risk factors: A scientific statement from the National
Lipid Association Nutrition and Lifestyle Task Force. J Clin Lipidol 2019; 13:689.
52. Vitolins MZ, Anderson AM, Delahanty L, et al. Action for Health in Diabetes
(Look AHEAD) trial: baseline evaluation of selected nutrients and food group
intake. J Am Diet Assoc 2009; 109:1367.
53. Imamura F, Micha R, Wu JH, et al. Effects of Saturated Fat, Polyunsaturated Fat,
Monounsaturated Fat, and Carbohydrate on Glucose-Insulin Homeostasis: A
Systematic Review and Meta-analysis of Randomised Controlled Feeding Trials.
PLoS Med 2016; 13:e1002087.
55. Vega-López S, Venn BJ, Slavin JL. Relevance of the Glycemic Index and Glycemic
Load for Body Weight, Diabetes, and Cardiovascular Disease. Nutrients 2018;
10.
56. Reynolds AN, Akerman AP, Mann J. Dietary fibre and whole grains in diabetes
management: Systematic review and meta-analyses. PLoS Med 2020;
17:e1003053.
:
57. Deng R. A review of the hypoglycemic effects of five commonly used herbal
food supplements. Recent Pat Food Nutr Agric 2012; 4:50.
58. Balk EM, Tatsioni A, Lichtenstein AH, et al. Effect of chromium supplementation
on glucose metabolism and lipids: a systematic review of randomized
controlled trials. Diabetes Care 2007; 30:2154.
59. Khan A, Safdar M, Ali Khan MM, et al. Cinnamon improves glucose and lipids of
people with type 2 diabetes. Diabetes Care 2003; 26:3215.
60. Blevins SM, Leyva MJ, Brown J, et al. Effect of cinnamon on glucose and lipid
levels in non insulin-dependent type 2 diabetes. Diabetes Care 2007; 30:2236.
66. Leach MJ, Kumar S. Cinnamon for diabetes mellitus. Cochrane Database Syst
Rev 2012; :CD007170.
67. Davis PA, Yokoyama W. Cinnamon intake lowers fasting blood glucose: meta-
analysis. J Med Food 2011; 14:884.
68. Allen RW, Schwartzman E, Baker WL, et al. Cinnamon use in type 2 diabetes: an
updated systematic review and meta-analysis. Ann Fam Med 2013; 11:452.
70. Jeyaraman MM, Al-Yousif NSH, Singh Mann A, et al. Resveratrol for adults with
type 2 diabetes mellitus. Cochrane Database Syst Rev 2020; 1:CD011919.
71. Green JA. Meal planning approaches for nutritional management of diabetes. In
: Handbook of diabetes nutritional management, Powers MA (Ed), Aspen Publis
hers, Rockville, MD 1987.
75. Powers MA, Bardsley JK, Cypress M, et al. Diabetes Self-management Education
and Support in Adults With Type 2 Diabetes: A Consensus Report of the
American Diabetes Association, the Association of Diabetes Care & Education
Specialists, the Academy of Nutrition and Dietetics, the American Academy of
Family Physicians, the American Academy of PAs, the American Association of
Nurse Practitioners, and the American Pharmacists Association. Diabetes Care
2020; 43:1636.
76. Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in
women: behavioral aspects. Am J Clin Nutr 1990; 52:800.
77. Foster GD, Makris AP, Bailer BA. Behavioral treatment of obesity. Am J Clin Nutr
2005; 82:230S.
78. Guare JC, Wing RR, Marcus MD, et al. Analysis of changes in eating behavior and
weight loss in type II diabetic patients. Which behaviors to change. Diabetes
Care 1989; 12:500.
79. Wing RR, Jeffery RW, Burton LR, et al. Food provision vs structured meal plans in
the behavioral treatment of obesity. Int J Obes Relat Metab Disord 1996; 20:56.
80. Ness-Abramof R, Apovian CM. Drug-induced weight gain. Drugs Today (Barc)
2005; 41:547.
:
81. Henry RR, Gumbiner B, Ditzler T, et al. Intensive conventional insulin therapy for
type II diabetes. Metabolic effects during a 6-mo outpatient trial. Diabetes Care
1993; 16:21.
82. Intensive blood-glucose control with sulphonylureas or insulin compared with
conventional treatment and risk of complications in patients with type 2
diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet
1998; 352:837.
83. United Kingdom Prospective Diabetes Study (UKPDS). 13: Relative efficacy of
randomly allocated diet, sulphonylurea, insulin, or metformin in patients with
newly diagnosed non-insulin dependent diabetes followed for three years. BMJ
1995; 310:83.
84. Poon T, Nelson P, Shen L, et al. Exenatide improves glycemic control and
reduces body weight in subjects with type 2 diabetes: a dose-ranging study.
Diabetes Technol Ther 2005; 7:467.
Topic 1766 Version 34.0
:
GRAPHICS
Men:
662 - (9.53 x age [year]) + PA* x (15.91 x weight [kg] + 539.6 x height [m])
Sedentary = 1.0
Active = 1.25
Women:
354 - (6.91 x age [year]) + PA ¶ x (9.36 x weight [kg] + 726 x height [m])
Sedentary = 1.0
Active = 1.27
Data from: Institutes of Medicine, Food and Nutrition Board. Dietary reference intakes for energy,
carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National
Academy Press 2002.
Carbohydrate group
Starch 15 3 0 to 1 80
Fruit 15 0 0 60
Non-starchy 5 2 0 25
vegetables
Very lean 0 7 0 to 1 35
Lean 0 7 3 55
Medium fat 0 7 5 75
Fat group 0 0 5 45
Carbohydrate count
Time Exchange pattern Sample menu
(g)
8 AM 3 carbohydrate group
Total: 45
12 PM 4 carbohydrate group
1 fruit 1 orange 15
1 vegetable 1 c salad –
Total: 57
3 PM 1 carbohydrate group
Total: 15
6 PM 4 carbohydrate group
2 starch 1 c potato 30
1 vegetable 1 c salad –
Total: 57
:
9 PM 1 carbohydrate group
1 starch 6 crackers 15
Total: 15
Focus on keeping the amount of carbohydrate intake moderate to keep your blood
glucose levels from going too high. Remember, it is not healthy to cut out all
carbohydrate foods; the body, especially your brain, needs some every day.
Measuring or weighing foods is helpful in the beginning to learn what common food
portions look like.
Read food labels: Look at the grams of total carbohydrate on the label. Remember,
the nutrition information on food labels is for the standard serving size. If the portion
is larger or smaller, it is necessary to adjust the carbohydrate information.
Use the exchange system: Estimation of carbohydrate content can be broken down
into food groups that are standardized for carbohydrate content according to
particular portions. For example, one serving from the Bread/Starch, Fruit, or Milk
group each contains between 12 and 15 grams of carbohydrate. Most vegetables do
not contain a significant number of carbohydrates and do not need to be counted,
although there are exceptions (eg, corn, potatoes).
3 or 4 glucose tablets
2 tablespoons of raisins
4 or 5 saltine crackers
1 tablespoon of sugar
6 to 8 hard candies
These sources of sugar act quickly to treat low blood sugar levels. People with diabetes
who use insulin or certain other diabetes medicines should carry at least 1 of these
items at all times.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and through requirements
for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.