Dietary Prescriptions Based on the Patient's Diabetes

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Dietary Prescriptions Based on the Patient's Diabetes Medication Mary Johnson, MS RD LDN CDE BC-ADM Geisinger Health System, Danville, PA Introduction

Considerations for Dietary Carbohydrate Prescriptions

There are many factors that need to be considered when prescribing a nutrition care plan for the management of diabetes. As clinicians, we need to take into account: • Individual nutritional needs • Willingness to change • Cultural preferences • Other health issues • Lifestyle

Individual Blood Glucose Goals

Historically, dietary treatment for diabetes dates back to 3,500 BC, with the modern “Diabetes Exchange Diet” emerging in the 1950’s followed by carbohydrate counting in the 1990’s. Recommendations for “what one eats” for the diabetes control have been updated as new research on the role of micro and macronutrients in diabetes management evolved. However “when one eats” for diabetes control has consistently been prescribed as three meals of consistent carbohydrates spaced throughout the day. I hypothesize that this was due to the high risk of hypoglycemia with early medications for the treatment of diabetes (NPH and regular insulin and first generation sulfonylureas), availability of self monitoring glucose meters, and lifestyles of the times. Beginning with the approval of Glucophage ® (metformin) in 1995, new medications have continued to emerge changing the face of diabetes treatment. The reduced risk of hypoglycemia with these new medications, along with the technology to test glucose levels pre and post meals via glucose meters and continuous glucose monitoring systems, reduces the need for structured meal guidelines. This is important given that our society has evolved into a 24/7 community and that a large percentage of our population’s work schedules makes eating consistent carbohydrates at traditional meal times obsolete. A person’s diabetes medications are now a key component in determining nutrition care prescriptions.

Dietary Prescriptions for Post Prandial Blood Glucose Control The number one goal for MNT (Medical Nutrition Therapy) that apply to individuals with diabetes is to achieve and maintain blood glucose levels in normal range or as close to normal as is safely possible.1 While all the macro and micronutrient requirements of an individual need to be considered in MNT, the carbohydrate level of a meal will have the greatest effect on the glucose level and is the focus of initial diabetes control. 1

Diabetes Care. 2008;31(suppl 1):S61-S78

Measurement Normal Preprandial <100 Postprandial (2 h) <140 *Peak level 1-2 hours post prandial 2 3

ADA Goal 2 70–130 <180*

Chart on Dietary Considerations Based on Medications

AACE / ACE Goal 3 <110 <140

ADA Guidelines. Diabetes Care. 2011;34(suppl 1):S19-S21 AACE/ACE medical guidelines. Endocr Pract. 2011;17(suppl 2):12

Peak Levels of Post Prandial Glucose. To best assess peak postprandial glucose levels, the optimal time for blood glucose monitoring is about 1h and 15 min after the start of the meal, albeit with wide interpatient variability. Nevertheless, 80% of postmeal blood glucose peaks were observed at less than 90 min after the start of the meal 4 4

Daenen S, Sola-Gazagnes A, M'Bemba J, Dorange-Breillard C, Defer F, Elgrably F, Larger E, Slama G. Peak-time determination of post-meal glucose excursions in insulin-treated diabetic patients. Diabetes Metab. 2010 Apr;36(2):165-9.

Diabetes Medication Considerations Risk of hypoglycemia with the medication Mode of action of the medication Peak action time and duration of medication Combination of diabetes medications

Note: If on more than one medication, the dietary prescription would be based on the most restrictive medication's dietary prescription. Set meal times: Individual must eat at predetermined times based on the action of their medication Consistent carbohydrate: Individual must eat the same number of carbohydrates at a meal. This can be a set number of carbohydrates based on set insulin dose or based on a carbohydrate ratio established by post prandial glucose levels. Maximum dose of carbohydrates: Individual may eat up to a certain amount of carbohydrate established by post prandial glucose levels. Due to low risk of hypoglycemia with the given medication, the individual does not have to eat any certain amount of carbohydrate. Hold medication if meal is missed: Certain medication for diabetes control are for post prandial glucose control at a given meal. If the individual chooses not to eat the meal, the medication is not needed.