Nutritional Considerations in Type 1 Diabetes Mellitus

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Nutritional considerations in type 1 diabetes mellitus
Authors: Linda M Delahanty, MS, RD, David K McCulloch, MD

Section Editors: Irl B Hirsch, MD, Timothy O Lipman, MD
Deputy Editor: Jean E Mulder, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2017. | This topic last updated: Mar 20, 2017.
INTRODUCTION — Diet and physical activity are critically important in the treatment of type 1 diabetes.
Basic principles of nutritional management, however, are often poorly understood, by both clinicians and
their patients.
The nutrition prescription for patients with type 1 diabetes should aim to optimally manage the "ABCs" of
diabetes control: glycated hemoglobin (A1C), blood pressure and low-density lipoprotein (LDL)-
cholesterol. The prescription must also be tailored for the individual patient to address diabetes
complications and other concomitant conditions. The nutritional goals for people with type 1 diabetes are
to:
● Maintain as near-normal blood glucose levels as possible, by integrating insulin therapy into each
individual's diet and physical activity patterns.
● Achieve optimal blood pressure and lipid levels.
● Provide adequate calories for achieving and maintaining a reasonable body weight, normal growth,
and development.
● Manage risk factors and prevent complications of diabetes, both acute (hypoglycemia and short-term
illness) and long-term (hypertension, hyperlipidemia, renal disease, cardiovascular disease, and other
micro- and macrovascular complications).
● Improve overall health through healthful food choices.
● Address individual nutrition needs, incorporating personal and cultural preferences, willingness to
change, and maintaining the pleasure of eating by restricting choice only when clearly appropriate.
The relative importance of each nutritional goal varies with individual patient characteristics.
The role of nutrition and the development of a medical nutrition therapy (MNT) plan for a patient with type
1 diabetes are discussed here. Nutrition for patients with type 2 diabetes is discussed separately (see
"Nutritional considerations in type 2 diabetes mellitus"). The effects of exercise on patients with diabetes
are discussed separately (see "Effects of exercise in adults with diabetes mellitus"). Insulin management
for type 1 diabetes is also discussed separately (see "General principles of insulin therapy in diabetes
mellitus" and "Management of blood glucose in adults with type 1 diabetes mellitus"). An overview of
management of children and adolescents with type 1 diabetes is presented separately. (See
"Management of type 1 diabetes mellitus in children and adolescents".)
MEDICAL NUTRITION THERAPY — Medical nutrition therapy (MNT) is the process by which the nutrition
prescription is tailored for people with diabetes based on medical, lifestyle, and personal factors and is an
integral component of diabetes management and diabetes self-management education [1].
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Randomized controlled trials of MNT have demonstrated decreases in glycated hemoglobin (A1C) of
approximately 0.3 to 1 percent in patients with type 1 diabetes [1,2]. In the Diabetes Control and
Complications Trial (DCCT), specific diet behaviors were associated with achieving up to a 1 point lower
mean A1C (8 versus 7 percent) in the intensive treatment group [2]:
● Adherence to the negotiated meal plan (diet consistency)

● Adjusting food and/or insulin in response to hyperglycemia
● Adjusting insulin dose for meal size and content
● Appropriate treatment of hypoglycemia (not overtreating hypoglycemia)
● Consistent habits with regard to consumption of a bedtime snack and avoidance of extra nighttime
snacks
Proper attention to diet is a major factor in minimizing hypoglycemia and weight gain while achieving
glycemic control [2-5]. Glycemic control has been shown to markedly diminish the likelihood of
neuropathy, nephropathy, retinopathy, and coronary artery disease (CAD) in patients with type 1 diabetes
[6,7]. (See "Glycemic control and vascular complications in type 1 diabetes mellitus".)
MNT for type 1 diabetes should consider five key aspects:
● Consistency in day-to-day carbohydrate intake at meals and snacks

● Adjusting insulin for variations in blood glucose, food, or activity
● Weight management (caloric intake balanced with caloric expenditure)
● Nutritional content (balance of selected protein, carbohydrates, and fats)
● Meal-insulin timing
CARBOHYDRATE CONSISTENCY — Variations in food intake, particularly carbohydrate intake, can

result in erratic blood sugars and hypoglycemia in patients with type 1 diabetes. Intensive insulin
regimens, which combine a basal insulin with short-acting premeal insulins, do allow for some flexibility in
the carbohydrate content of meals. In one study of patients receiving intensive insulin therapy, as an
example, the total amount of carbohydrate in the meal did not influence glycemic response if premeal
insulin was adjusted for variations in the carbohydrate content of the meal [8]. Patients who use short-
acting insulin analogs or who use insulin pumps may need to take additional bolus insulin injections with
snacks that contain more than 10 to 15 g of carbohydrate.
For patients receiving fixed doses of short- and intermediate-acting insulin, however, day-to-day
consistency in the amount of carbohydrate and source of carbohydrate at meals and snacks is more
important. Carbohydrate consistency for these patients has been associated with lower glycated
hemoglobin (A1C) levels, whereas day-to-day variations in calorie, protein, or fat intakes were not
significantly related to A1C [9].
Meal planning — There are several meal planning approaches to achieve carbohydrate consistency,
including basic and advanced carbohydrate counting, the exchange system, and sample menus. The best
approach for individual patients is determined by an assessment of their lifestyle and learning capabilities.
Basic carbohydrate counting — In its simplest form, the goal of carbohydrate counting is to promote
glycemic control by implementing a consistent pattern of carbohydrate consumption with meals and
snacks day-to-day. Since carbohydrate intake directly determines postprandial blood sugar, management
of carbohydrate consumption and appropriate insulin adjustments for identified quantities of carbohydrate
can improve glycemic control [10].
Patients who have been instructed in carbohydrate counting consume a predetermined total amount of
carbohydrate at meals and snacks each day, calculated in grams of carbohydrate per food portion. The
calculated carbohydrate intake is derived from an optimal percentage of total calories from carbohydrates,
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based on nutrition goals and the usual eating pattern.
Patients need to be comfortable with simple arithmetical computations. Most patients will require specific
training in carbohydrate counting, usually by a dietitian, to set appropriate meal and snack targets and
learn to measure or estimate portion sizes and read food labels (table 1).
Exchange system — The exchange system was developed in 1950 by the American Dietetic
Association, the American Diabetes Association (ADA), and the United States Public Health Service as an
educational tool to provide consistency in meal planning and allow a wider variety of food choices for
people with diabetes [11]. Originally, the exchange lists categorized foods into six groups: starch/bread,
meat and meat substitutes, vegetables, fruit, milk, and fat. Each portion of food listed within a group was
"exchangeable" because it contained approximately the same nutritional value in terms of calories,
carbohydrate, protein, and fat.
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 [11].
The exchange system meal planning approach can be used as a tool to help patients achieve calorie, fat,
and carbohydrate goals. However, many patients find that it is a complicated system to learn.
Sample menus — Sample menus are defined meal menus that specify the time and amounts of food
to be eaten at each meal and snack. For patients with type 1 diabetes, menus are developed to meet
calorie needs and provide consistent carbohydrate intake at meals and snacks. Dietitians typically tailor
the menus to incorporate food preferences and medical nutrition therapy (MNT) goals. Sample menus are
created after review of a person's typical food intake; they are best suited for patients who have fairly
routine eating habits and who do not eat a wide variety of foods. They also are appropriate for patients
who need structured guidance on what to eat.
Insulin adjustments
Advanced carbohydrate counting — At a more advanced level, carbohydrate counting focuses on

adjustment of food, insulin, and activity based on patterns from detailed logs. The patient needs to record
time of meals and snacks, the amount and type of food eaten, amount of carbohydrate consumed, insulin
dose, physical activity, and blood glucose results. Patients should first practice eating consistent amounts
of carbohydrate at meals and snacks so that baseline insulin requirements can be matched to usual
carbohydrate intake using pre- and postprandial blood glucose testing results. When pre- and postprandial
blood glucose levels are in the target range, then insulin-to-carbohydrate ratios can be determined as
follows:
Divide the number of grams of carbohydrate eaten at the meal by the number of units of pre-meal insulin
(eg, 45 g carbohydrate divided by 3 units of insulin is a 1 to 15 ratio). Insulin to carbohydrate ratios can
vary with time of day, and are affected by stress, illness, and variations in physical activity.
Two other methods to calculate insulin-to-carbohydrate ratios are the 450 to 500 rule and the weight
method [11]. These methods do not take into account individual variation and therefore are not as
accurate as using detailed records.
● 450 to 500 rule – Calculate the insulin-to-carbohydrate ratio as follows:
Regular insulin-to-carbohydrate ratio = 450 divided by total daily dose (TDD) of insulin.
Rapid acting insulin-to-carbohydrate ratio = 500 divided by TDD of insulin.
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As an example, if the TDD is 50 units and the patient uses a regimen with rapid-acting insulin, then
each unit of insulin should cover approximately 10 g of carbohydrate (500 divided by 50 = 10). The
insulin-to-carbohydrate ratio is 1:10.
● Weight method – The weight method uses the data in the table (table 4) to calculate the insulin-to-
carbohydrate ratio [11].
Elevated blood glucose levels — An insulin correction factor can be used to adjust insulin dose for
hyperglycemia before meals or between meals. To calculate the insulin correction factor:
● For regular insulin, divide 1500 by TDD

● For rapid-acting insulin, divide 1800 by TDD
As an example, if a patient using rapid-acting insulin has a TDD of 45 units, then the insulin correction
factor would be 1 unit for every 40 mg/dL reduction in blood sugar (1800 divided by 45). If the patient had
a premeal blood sugar of 180 mg/dL and wanted to correct to a premeal blood glucose of 100 mg/dL, then
the patient would take an extra 2 units of rapid-acting insulin to correct to the target of 100 mg/dL and add
the number of units needed to cover the carbohydrates consumed.
Treatment of hypoglycemia — If the patient were hypoglycemic (blood glucose <70 mg/dL), then the
patient would treat the hypoglycemia with 10 to 15 g of fast-acting carbohydrate for glucose levels of 51 to
70 mg/dL, and with 20 to 30 g of fast-acting carbohydrate for blood glucose levels ≤50 mg/dL. Retest 15
minutes after ingestion and repeat treatment as needed based on blood sugar levels. 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. A pattern of overtreating hypoglycemia can result in a
greater than desired rise in blood glucose and increased calorie intake, resulting in weight gain.
PHYSICAL ACTIVITY/EXERCISE — Exercise is a significant component of diabetes management.

Benefits of exercise include improved glycemic control, weight control, reduction in co-morbidities
(hypertension, dyslipidemia, and cardiovascular disease), improved mood, and quality of life. The Institute
of Medicine recommends that most adults engage in 30 minutes or more of moderate intensity physical
activity on most days of the week [12]. Individuals for whom weight loss and weight maintenance are a
concern may need more than this, and 60 to 90 minutes of moderate to vigorous intensity activity is
encouraged. (See "Effects of exercise in adults with diabetes mellitus".)
Although exercise has not been consistently shown to improve glycemic control for patients with type 1
diabetes [13,14], patients who learn to self-adjust their diet or insulin to accommodate exercise can
achieve near-normal glycated hemoglobin (A1C) levels without undue hypoglycemia. For patients who are
trying to lose weight, it is preferable to adjust insulin doses rather than increase food intake to compensate
for exercise. Timing of exercise in relation to insulin dose, type, mode of delivery, and time of injection
should be considered. Patients with diabetes should check blood sugar levels before and after exercising,
especially in the beginning of an exercise program, to evaluate glycemic response to exercise and adjust
insulin regimen. Patients should be advised to have a snack handy, in case blood sugar levels drop too
low.
WEIGHT MANAGEMENT — The relative importance of caloric intake for an individual patient is
dependent on several factors, including:
● Current weight in relationship to desirable and healthy body weight

● Weight history
● Fat distribution and waist circumference
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● Muscle mass
● Genetics
● Glycated hemoglobin (A1C)
Lowering caloric intake and inducing weight loss are of major importance for overweight (body mass index
[BMI] ≥25 to 29.9) and obese (BMI ≥30) patients with type 1 diabetes, since the risk of comorbidities
associated with excess adipose tissue increases with BMI in these ranges. If patients have been close to
ideal weight for several years and have a near normal A1C, then their current caloric intake is most likely
appropriate.
Weight gain with intensive therapy — Weight gain is a potential adverse effect of intensive diabetes
therapy in type 1 diabetes, and occurs when insulin dosing matches nutritional intake and glycosuria is
eliminated [15,16]. The mean increase in weight in patients in the Diabetes Control and Complications
Trial (DCCT) was 5.1 kg in the intensive therapy group and 2.4 kg in the conventional therapy group [16].
At study end, 33 percent of the intensive therapy group was overweight compared with 19 percent of the
conventional treatment group [17].
If A1C is high enough to promote glycosuria, then lowering calorie intake by an additional 250 to 300
calories per day is necessary to prevent weight gain with intensification of diabetes therapy [3]. Other
strategies to minimize weight gain with intensive therapy are to reduce insulin doses preferentially for
patterns of hypoglycemia rather than increasing meal size or adding an undesired snack. To reduce
calories further, it is helpful to reduce fat intake and try to keep carbohydrate intake consistent to minimize
risk of hypoglycemia.
Weight gain is most prominent in women, especially those with high A1C values at baseline, and has been
a cause of noncompliance with insulin therapy. As examples, approximately 30 percent of women with
type 1 diabetes in one study occasionally omitted insulin injections intentionally [18]; in a second study, 9
percent did so on a regular basis in order to avoid weight gain [19]. (See 'Eating disorders' below.)
Estimating desirable body weight — Desirable body weight range can be roughly estimated by adding
and subtracting 10 percent to the weights calculated as follows [20]:
● For women over 5 feet (152 cm):
• 100 lb (45 kg) plus 5 lb (2.3 kg) for each additional inch (2.5 cm)
● For women under 5 feet (152 cm):
• 100 lb (45 kg) minus 5 lb (2.3 kg) for each additional inch (2.5 cm) under 5 feet
● For men over 5 feet (152 cm):
• 106 lb (48 kg) plus 6 lb (2.7 kg) for each additional inch (2.5 cm)
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 ÷ (height in m)2]. Optimal body weight is a BMI between 18.5
and 24.9 (calculator 1).
Estimating caloric intake — 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 5) [21].
A rough estimate of caloric needs to maintain body weight can be determined as follows [22]:
● Men, active women – 15 kcal/lb
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● Most women, sedentary men, and adults over 55 years – 13 kcal/lb

● Sedentary women, obese adults – 10 kcal/lb
● Pregnant, lactating women – 15 to 17 kcal/lb
To estimate caloric needs for weight loss of one to two pounds per week, subtract 500 to 1000 calories
from weight maintenance calories. 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.
NUTRITIONAL CONTENT — The optimal macronutrient composition of the diet for patients with diabetes
is controversial [1]. The best mix of carbohydrate, protein, and fat may vary depending on the individual.
American Diabetes Association (ADA) nutritional guidelines do not give specific total dietary compositional
targets, except for the following recommendations [1,23]:
● A diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk is
encouraged.
The ideal amount of carbohydrate intake is uncertain. However, monitoring carbohydrate intake (basic
or advanced carbohydrate counting) is important in patients with diabetes, as carbohydrate intake
directly determines postprandial blood sugar, and appropriate insulin adjustment for identified
quantities of carbohydrate is one of the most important factors that can improve glycemic control.
When considered in addition to total carbohydrates, meals with low glycemic index and glycemic load
may provide a modest additional benefit for glycemic control.
● A variety of eating patterns (low fat, low carbohydrate, Mediterranean, vegetarian) are acceptable.
● Fat quality is more important than fat quantity. Saturated fat and trans fat contribute to coronary heart
disease (CHD), while monounsaturated and polyunsaturated fats are relatively protective. Saturated
fats (eg, in meats, cheese, ice cream) can be replaced with monounsaturated and polyunsaturated
fatty acids (eg, in fish, olive oil, nuts). Trans fatty acid consumption should be kept as low as possible.
● The role of dietary protein restriction is uncertain, particularly in view of problems with compliance in
patients already being treated with saturated fat and simple carbohydrate restriction. Furthermore, it
is uncertain if a low protein diet is significantly additive to other measures aimed at reducing
cardiovascular risk and preserving renal function, such as angiotensin-converting enzyme (ACE)
inhibition and aggressive control of blood pressure and blood glucose. Thus, protein intake goals
should be individualized. An automatic reduction of dietary protein intake (eg, 15 to 19 percent of
calories) below usual protein intake in patients who develop diabetic kidney disease is not
recommended. The usual daily intake of protein should be approximately 10 to 25 percent of total
caloric intake. Patients should be encouraged to substitute lean meats, fish, eggs, beans, peas, soy
products, and nuts and seeds for red meat.
● 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. For individuals with hypertension, further reduction in sodium may be necessary.
● 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 should be counted in the total carbohydrate content of
the food.
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● Intake of sucrose does not need to be restricted, although care should be taken to avoid excess
calories; sucrose can be substituted for other carbohydrate sources in the meal plan or, if added,
covered with insulin. Use of added fructose as a sweetener is not recommended, as it may adversely
affect lipids, but there is no need to avoid fructose occurring naturally in fruits and vegetables.
The relative importance of other dietary factors is also uncertain; these include protein, types of fat, fiber
(especially soluble), acid content of foods, particle size, food processing regimens, and rate and efficiency
of digestion and absorption of different nutrients [24,25]. People with type 1 diabetes typically consume
more saturated fat than is recommended. Among intensively treated patients with type 1 diabetes in the
Diabetes Control and Complications Trial (DCCT), saturated fat intake was close to 13 percent of calories
during the trial and diets higher in total and saturated fat and lower in carbohydrate were associated with
worse glycemic control independent of exercise and BMI [26].
Glycemic index and glycemic load — Foods containing the same amount of carbohydrate can have
significantly different glycemic effects. These differences led to the development of the concepts of
glycemic index and glycemic load:
● Glycemic index is an in vivo measure of the relative impact of carbohydrate-containing foods on blood
glucose. A particular food's glycemic index is determined by evaluating the incremental rise in blood
glucose after ingestion of a portion of the test food containing 50 g of carbohydrate, compared with
the same amount of carbohydrate from a reference food, which is usually white bread or glucose
[27,28]. Some examples of low-glycemic index foods include non-starchy vegetables, nuts, legumes,
and certain grains such as barley and converted rice. High glycemic index foods include potatoes,
candies, white bread, and other refined products made from grains (table 6).
● Glycemic load is the product of the glycemic index value of a food and its total carbohydrate content
[29,30]. The concept of the glycemic load was developed because the blood glucose response is
influenced not only by the quality of the carbohydrate consumed (ie, the glycemic index), but also by
the quantity of carbohydrate consumed.
The glycemic index and glycemic load may have far greater health implications than glycemic control
alone. Several prospective studies have associated diets high in glycemic index and glycemic load with an
increased risk of developing type 2 diabetes, coronary heart disease, and some cancers [31-33]. Data
also suggest that low-glycemic load diets are particularly effective among the most susceptible individuals,
those who are already overweight and insulin resistant [32]. In a meta-analysis of 14 randomized trials in
patients with type 1 and type 2 diabetes mellitus, low-glycemic index diets resulted in a reduction in
glycated hemoglobin (A1C) of 0.43 percent (95% CI 0.13-0.72), compared with a standard ADA diet that
had a high glycemic index [34]. In a cross-sectional study of patients with type 1 diabetes (n = 2810) from
31 clinics throughout Europe, the dietary glycemic index independently and positively correlated with A1C
level [33]. A more detailed discussion of these effects can be found elsewhere. (See "Dietary
carbohydrates".)
The glycemic index and glycemic load can be difficult to understand and implement for most patients,
although many patients in research studies have been taught to average their intake to a glycemic index
of less than 55 (referenced to glucose = 100). Information is lacking from food labels and other sources,
and mixing foods in a recipe further complicates calculations.
Alcohol intake — Moderate amounts of alcohol, when ingested with food, do not significantly increase
plasma glucose or serum insulin; the carbohydrate content of the non-alcohol component of a mixed drink
may raise blood glucose, however [1]. If patients choose to ingest alcohol, they should limit their intake to
no more than one drink per day for women or two drinks per day for men; alcohol should be consumed
with food. Patients with type 1 diabetes should use blood glucose monitoring to assess any immediate or
delayed effects of alcohol intake on blood glucose levels.
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Dietary recommendations — In view of these observations, we recommend customizing dietary

recommendations to the patients' abilities and lifestyle, with changes centered on managing total
carbohydrate intake at meals and snacks, and use of whole grains in preference to refined grains and
starches.
Carbohydrate counting, as recommended by the ADA, is the most common meal planning approach for
patients with type 1 diabetes [5]. For patients with the ability to take additional steps to manage diabetes
and prevent complications, learning to adjust insulin doses for variations in food intake or changes in
activity will be beneficial.
It is also crucial to distinguish between types of fat in the diet, lowering saturated and avoiding
hydrogenated fats, while consistently including monounsaturated and omega-3 fatty acids in the diet [1].
Protein intake should be appropriate to medical condition. In addition, patients with diabetes also need to
assure that their diet is adequate in fiber content, and essential vitamins and minerals. There is no clear
evidence of benefit from vitamin and mineral supplementation in people with diabetes who do not have
underlying deficiencies [23].
MEAL-INSULIN TIMING — Traditionally, consistent timing of food intake was an important aspect of
nutrition in patients treated with insulin regimens to attain goals for glycemic control without undue
hypoglycemia [2,10,35]. Meal timing at regular intervals is most important for patients receiving fixed
doses of short- and intermediate-acting insulin. Newer rapidly-acting insulin preparations, however, allow
for more flexibility in meal schedules and content.
Traditional insulin regimens were based on the injection of roughly the same amount of insulin at the same
time each day. If the amount and timing of carbohydrate intake varied widely, blood glucose profiles
fluctuated, with little chance of achieving target glycated hemoglobin (A1C) values without a substantial
risk of hypoglycemia. (See "Management of blood glucose in adults with type 1 diabetes mellitus" and
"Cases illustrating problems with insulin therapy for diabetes mellitus", section on 'Lack of control due to
diet'.)
An alternative approach for patients receiving intensive insulin therapy is to determine how much short- or
rapid-acting insulin is needed to cover a certain amount of carbohydrate. Patients vary considerably in the
amount of insulin required to cover a set amount of carbohydrate; some patients need a different
carbohydrate-to-insulin ratio at different meals. Once the ratio is established, patients have flexibility to
vary the amount of carbohydrate ingested at particular meals.
As an example, a patient may have been told to eat 60 grams of carbohydrate with their evening meal and
precede this with 4 units of rapid-acting insulin. This means that they are using 1 unit to cover every 15
grams, and can decrease their insulin dose proportionately if they plan to eat less carbohydrate at a meal.
Facility with carbohydrate counting strategies becomes essential in making these adjustments.
EATING DISORDERS — Eating disorders are relatively common in patients with diabetes, especially in
female adolescents and young adults with type 1 diabetes [36]. Eating disorders have a deleterious
impact on glycemic control and on long-term outcome in these patients. One study evaluated 91 females
with type 1 diabetes (mean age 15 years) at baseline and at follow-up four to five years later [37]. The
following findings were noted:
● Twenty-six (29 percent) had a self-reported eating disorder at baseline, which persisted in 16 (18
percent) at follow-up.
● Among the patients with normal eating patterns at baseline, 15 percent had disordered eating at
follow-up.
● Dieting or omission of insulin for weight loss and binge eating were the most common eating
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disorders.
● Disordered eating was associated with adverse outcomes [37,38]. At baseline, glycated hemoglobin
(A1C) values were significantly higher in those with highly disordered eating than in those with
moderately disordered or normal eating (11.1 versus 8.9 and 8.7 percent, respectively). Patients with
eating disorders were more likely to have retinopathy at follow-up.
It is important to evaluate patients with diabetes, especially young women, for an eating disorder (or
misreporting of insulin administration) and arrange appropriate psychological and nutritional counseling
and support when indicated.
PROMOTING DIETARY COMPLIANCE — While nutritional counseling by clinicians in the diabetes

healthcare team is essential, ultimately the patient determines what he or she is willing or able to do to
achieve improved glycemic control.
The dietary prescription should begin by determining the patient's dietary preferences, physical activity
patterns, medication dosing and adherence, social support, education level, time constraints, and other
challenges. A dietary history, along with several days of food records, is helpful in an assessment of
caloric intake, dietary content, 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 ideal diet
and eating pattern. It is important to remember that the more marked the changes are from what the
patient likes to eat, the less likely that the patient will adhere with the dietary prescription [10]. The
patient's own food records and motivation to learn can be helpful in guiding decisions for meal planning
approaches; choices between a detailed exchange system, sample menus, basic or more advanced
carbohydrate counting approaches, or a low-glycemic index diet can be made on an individual basis
based on an assessment of lifestyle and learning capabilities [39].
A diet consistent in carbohydrate is desired in patients with type 1 diabetes interested in intensive insulin
therapy. The patient about to begin intensive insulin therapy must be cautioned about the potential to gain
weight, and the need for weight monitoring [16].
Motivating a patient to make a long-term commitment to dietary alterations is a challenge. Achieving and
maintaining weight reduction is difficult in any obese patient. Compliance can occasionally be enhanced
by the rapid and often dramatic improvements in glycemic control.
Teaching is best done 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 carbohydrate content of foods
commonly eaten. This is often best accomplished in dietary workshops for small groups of patients [40].
During follow-up visits, it is important for the clinician to ask specifically about diet and exercise to
reinforce their importance. Ideally, a patient should be able to quote his or her nutrition and exercise
prescription in detail. Patients with type 1 diabetes 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. Most patients should also be able to
specify their insulin correction factor and carbohydrate-to-insulin ratios for meals. Patients should be well-
trained in methods to treat hypoglycemia to prevent over-compensation.
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
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exercise (90 versus 34 percent) [41]. (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 [42]. 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) [41].
● 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 [43].
● 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
[44,45].
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
clinician needs to maintain awareness of the patient's changing lifestyle patterns, and help the patient
make adaptations in their plan accordingly.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: Diabetes
mellitus in adults" and "Society guideline links: Diabetes mellitus in children".)
INFORMATION FOR PATIENTS — 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 1 diabetes (The Basics)" and "Patient education:
Diabetes and diet (The Basics)" and "Patient education: Counting carbs if you do not use insulin (The
Basics)" and "Patient education: My child has diabetes: How will we manage? (The Basics)" and
"Patient education: Keeping your child's blood sugar under control (The Basics)" and "Patient
education: Carb counting and your child's diet (The Basics)" and "Patient education: Managing
diabetes in school (The Basics)".)
● Beyond the Basics topics (see "Patient education: Diabetes mellitus type 1: Overview (Beyond the
Basics)" and "Patient education: Type 1 diabetes mellitus and diet (Beyond the Basics)" and "Patient
education: Self-blood glucose monitoring in diabetes mellitus (Beyond the Basics)" and "Patient
education: Diabetes mellitus type 1: Insulin treatment (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● The five key aspects of the nutritional management of type 1 diabetes are (see 'Medical nutrition
therapy' above):
• Consistency in day-to-day carbohydrate intake

• Adjusting insulin for variations in blood glucose, food or activity
10 de 20 2/6/17 19:22
• Weight management
• Nutritional content
• Meal-insulin timing
● Maintaining a consistent day-to-day carbohydrate intake at meals and snacks allows insulin
adjustments to be made to usual carbohydrate intake. Learning to adjust insulin in response to
hyperglycemia and variations in carbohydrate intake at meals is a more advanced skill. (See
'Carbohydrate consistency' above.)
● Modifying caloric intake is important for the overweight patient with type 1 diabetes or the patient with
a high glycated hemoglobin (A1C) and glycosuria who is about to intensify diabetes management.
Approximate caloric intake and estimates of desirable body weight can be made by formulas
presented above. (See 'Estimating caloric intake' above and 'Estimating desirable body weight'
above.)
● The impact of specific dietary composition on glycemic control and cardiovascular risk remains
uncertain. The optimal macronutrient composition of the diet for patients with diabetes should be
individualized, based upon weight loss goals, other metabolic needs (eg, hypertension, dyslipidemia,
nephropathy), and food preferences. A diet that includes carbohydrates from fruits, vegetables, whole
grains, legumes, and low-fat milk is encouraged. (See 'Nutritional content' above.)
● Eating disorders are common among young female patients with type 1 diabetes, manifested most
commonly as bulimia and weight loss due to purposely missed or reduced insulin doses; poor
glycemic control and increased retinopathy are consequences. (See 'Eating disorders' above.)
● Promoting dietary compliance is a challenge, and a registered dietitian can be helpful in developing
and monitoring a nutrition prescription. Compliance can be fostered by tailoring the nutrition
prescription to the individual patient's preferences and lifestyle, reviewing food diaries, and providing
positive feedback with improved glycemic control. (See 'Promoting dietary compliance' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of
adults with diabetes. Diabetes Care 2013; 36:3821.
2. Delahanty LM, Halford BN. The role of diet behaviors in achieving improved glycemic control in
intensively treated patients in the Diabetes Control and Complications Trial. Diabetes Care 1993;
16:1453.
3. Delahanty L, Simkins SW, Camelon K. Expanded role of the dietitian in the Diabetes Control and
Complications Trial: implications for clinical practice. The DCCT Research Group. J Am Diet Assoc
1993; 93:758.
4. Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes
Care 1995; 18:361.
5. Anderson EJ, Richardson M, Castle G, et al. Nutrition interventions for intensive therapy in the
Diabetes Control and Complications Trial. The DCCT Research Group. J Am Diet Assoc 1993;
93:768.
6. Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, et al. The effect
of intensive treatment of diabetes on the development and progression of long-term complications in
insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977.
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7. Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease
in patients with type 1 diabetes. N Engl J Med 2005; 353:2643.
8. Rabasa-Lhoret R, Garon J, Langelier H, et al. Effects of meal carbohydrate content on insulin
requirements in type 1 diabetic patients treated intensively with the basal-bolus (ultralente-regular)
insulin regimen. Diabetes Care 1999; 22:667.
9. Wolever TM, Hamad S, Chiasson JL, et al. Day-to-day consistency in amount and source of
carbohydrate intake associated with improved blood glucose control in type 1 diabetes. J Am Coll
Nutr 1999; 18:242.
10. Nuttall FQ. Carbohydrate and dietary management of individuals with insulin-requiring diabetes.
Diabetes Care 1993; 16:1039.
11. Pastors JG, Waslaski J, Gunderson H. Diabetes meal-planning strategies. In: Diabetes Medical
Nutrition Therapy and Education, Ross TA, Boucher JL, O'Connell BS (Eds), American Diabetes
Association, Chicago, IL 2005.
12. Brooks GA, Butte NF, Rand WM, et al. Chronicle of the Institute of Medicine physical activity
recommendation: how a physical activity recommendation came to be among dietary
recommendations. Am J Clin Nutr 2004; 79:921S.
13. American Diabetes Association. Physical activity/exercise and diabetes. Diabetes Care 2004; 27
Suppl 1:S58.
14. Wasserman DH, Davis SN, Zinman B. Fuel metabolism during exercise in health and diabetes. In:
Handbook of Exercise in Diabetes, Ruderman N, Devlin JT, Schneider SH, Kriska A (Eds), American
Diabetes Association, Alexandria, VA 2002. p.63.
15. Ness-Abramof R, Apovian CM. Drug-induced weight gain. Drugs Today (Barc) 2005; 41:547.
16. Weight gain associated with intensive therapy in the diabetes control and complications trial. The
DCCT Research Group. Diabetes Care 1988; 11:567.
17. Adverse events and their association with treatment regimens in the diabetes control and
complications trial. Diabetes Care 1995; 18:1415.
18. Polonsky WH, Anderson BJ, Lohrer PA, et al. Insulin omission in women with IDDM. Diabetes Care
1994; 17:1178.
19. Biggs MM, Basco MR, Patterson G, Raskin P. Insulin withholding for weight control in women with
diabetes. Diabetes Care 1994; 17:1186.
20. 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.
21. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate,
Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids, The National Academies Press,
Washington, DC 2002.
22. Escott-Stump S. Nutrition and Diagnosis-Related Care, 5th, Lippincott Williams & Wilkins,
Hagerstown, MD 2002.
23. Standards of Medical Care in Diabetes-2017: Summary of Revisions. Diabetes Care 2017; 40:S4.
24. Wolever TM. Carbohydrate and the regulation of blood glucose and metabolism. Nutr Rev 2003;
61:S40.
25. Johnston CS, Buller AJ. Vinegar and peanut products as complementary foods to reduce
postprandial glycemia. J Am Diet Assoc 2005; 105:1939.
26. Delahanty LM, Nathan DM, Lachin JM, et al. Association of diet with glycated hemoglobin during
intensive treatment of type 1 diabetes in the Diabetes Control and Complications Trial. Am J Clin
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Nutr 2009; 89:518.

27. Jenkins DJ, Wolever TM, Taylor RH, et al. Glycemic index of foods: a physiological basis for
carbohydrate exchange. Am J Clin Nutr 1981; 34:362.
28. Wolever TM, Nguyen PM, Chiasson JL, et al. Determinants of diet glycemic index calculated
retrospectively from diet records of 342 individuals with non-insulin-dependent diabetes mellitus. Am
J Clin Nutr 1994; 59:1265.
29. Liu S. Insulin resistance, hyperglycemia and risk of major chronic diseases: a dietary perspective.
Proceedings of the Nutrition Society of Australia 1998; 22:140.
30. Liu S, Willett WC, Stampfer MJ, et al. A prospective study of dietary glycemic load, carbohydrate
intake, and risk of coronary heart disease in US women. Am J Clin Nutr 2000; 71:1455.
31. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for
the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25:148.
32. Dumesnil JG, Turgeon J, Tremblay A, et al. Effect of a low-glycaemic index--low-fat--high protein diet
on the atherogenic metabolic risk profile of abdominally obese men. Br J Nutr 2001; 86:557.
33. Buyken AE, Toeller M, Heitkamp G, et al. Glycemic index in the diet of European outpatients with
type 1 diabetes: relations to glycated hemoglobin and serum lipids. Am J Clin Nutr 2001; 73:574.
34. Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of
diabetes: a meta-analysis of randomized controlled trials. Diabetes Care 2003; 26:2261.
35. Franz MJ. Finding the right fit for meal planning. Diabetes Care 1993; 16:1043.
36. Mannucci E, Rotella F, Ricca V, et al. Eating disorders in patients with type 1 diabetes: a meta-
analysis. J Endocrinol Invest 2005; 28:417.
37. Rydall AC, Rodin GM, Olmsted MP, et al. Disordered eating behavior and microvascular
complications in young women with insulin-dependent diabetes mellitus. N Engl J Med 1997;
336:1849.
38. Peveler RC, Bryden KS, Neil HA, et al. The relationship of disordered eating habits and attitudes to
clinical outcomes in young adult females with type 1 diabetes. Diabetes Care 2005; 28:84.
39. Green JA. Meal planning approaches for nutritional management of diabetes. In: Handbook of
Diabetes Nutritional Management, Powers MA (Ed), Aspen Pub, Rockville, MD 1987.
40. Heller SR, Clarke P, Daly H, et al. Group education for obese patients with type 2 diabetes: greater
success at less cost. Diabet Med 1988; 5:552.
41. Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral
aspects. Am J Clin Nutr 1990; 52:800.
42. Foster GD, Makris AP, Bailer BA. Behavioral treatment of obesity. Am J Clin Nutr 2005; 82:230S.
43. 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.
44. 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.
45. 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.
Topic 1765 Version 20.0
13 de 20 2/6/17 19:22
GRAPHICS
Carbohydrate counting: getting started
Step 1: Know the goal

Eating about the same amount of carbohydrate at meals and snacks each day will help to keep blood glucose
levels from getting too high or too low.
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.
Step 2: Monitoring intake and blood glucose

Keeping a daily food and blood glucose record will help inform what affects blood glucose levels.
Measuring or weighing foods is helpful in the beginning to learn what common food portions look like.
Step 3: Methods of counting carbohydrate

To count carbohydrates, there are two methods. Patients may also blend the two methods.
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).
Graphic 51729 Version 2.0
14 de 20 2/6/17 19:22
Calories and macronutrient content of exchange lists
Carbohydrate, Protein, Fat, Calories,

Group
grams grams grams grams
Carbohydrate group
Starch 15 3 0 to 1 80
Fruit 15 0 0 60
Milk 12 8 varies 90 to 150
Other carbohydrates 15 varies varies varies
Non-starchy 5 2 0 25
vegetables
Meat and meat substitutes
Very lean 0 7 0 to 1 35
Lean 0 7 3 55
Medium fat 0 7 5 75
High fat 0 7 8 100
Fat group 0 0 5 45
15 de 20 2/6/17 19:22
Sample exchange system meal plan
Time Exchange pattern Sample menu Carbohydrate count (g)
8 AM 3 carbohydrate group
2 starch 1 English muffin 30
1 fruit 1 1/4 c strawberries 15
1 protein group 1/4 c cottage cheese -
1 fat group 1 tsp margarine -
Total: 45
12 PM 4 carbohydrate group
2 starch 2 slices of bread 30
1 fruit 1 orange 15
1 vegetable 1 c salad -
1 milk 8 oz skim milk 12
3 protein group 3 oz chicken -
1 fat group 1 tbsp low fat mayo -
Total: 57
1 fruit or 1 starch 1 apple or 6 crackers 15
Total: 15
2 starch 1 c potato 30
1 fruit 1/2 c fruit salad 15
1 vegetable 1 c salad -
1 milk 8 oz skim milk 12
6 protein group 6 oz fish -
1 fat group 2 tbsp low fat salad dressing -
Total: 57
1 starch 6 crackers 15
1 protein 2 tbsp peanut butter -
Total: 15
16 de 20 2/6/17 19:22
Insulin-to-carbohydrate ratio calculation
Weight, lbs Ratio
120 to 129 1:15
130 to 139 1:14
140 to 149 1:13
150 to 169 1:12
170 to 179 1:11
180 to 189 1:10
190 to 199 1:9
>200 1:8
17 de 20 2/6/17 19:22
Estimating calories for weight maintenance
Men:
662 - (9.53 x age [year]) + PA* x (15.91 x weight [kg] + 539.6 x height [m])
* The PA coefficient is:
Sedentary = 1.0
Low active = 1.11
Active = 1.25
Very active = 1.48
Women:
354 - (6.91 x age [year]) + PA ¶ x (9.36 x weight [kg] + 726 x height [m])
¶ The PA coefficient is:
Sedentary = 1.0
Low active = 1.12
Active = 1.27
Very active = 1.45
PA: physical activity.
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.
18 de 20 2/6/17 19:22
Dietary glycemic indices and glycemic load for the top 20 carbohydrate-
contributing foods in the Nurses' Health Study in 1984
Glycemic index*, Carbohydrate per Glycemic load per

Foods
percent serving, g serving
1. Cooked potatoes 102 37 38

(mashed or baked)
2. White bread 100 13 13
3. Cold breakfast cereal Varies by cereal Varies by cereal Varies by cereal
4. Dark bread 102 12 12
5. Orange juice 75 20 15
6. Banana 88 27 24
7. White rice 102 45 46
8. Pizza 86 78 68
9. Pasta 71 40 28
10. English muffins 84 26 22
11. Fruit punch 95 44 42
12. Cola 90 39 35
13. Apple 55 21 12
14. Skim milk 46 11 5
15. Pancake 119 56 67
16. Table sugar 84 4 3
17. Jam 91 13 12
18. Cranberry juice 105 19 20
19. French fries 95 35 33
20. Candy 99 28 28
* Standard reference is white bread, which has a glycemic index of 100 percent. All other glycemic index values are
relative to white bread.
Adapted from: Liu S, Willett WC. Dietary glycemic load and atherothrombotic risk. Curr Atheroscler Rep 2002; 4:454.
19 de 20 2/6/17 19:22
Contributor Disclosures
Linda M Delahanty, MS, RD Consultant/Advisory Boards: Boehringer Ingelheim [Diabetes
(Empagliflozin)]; Eli Lilly [Diabetes (Insulin, exenatide, empagliflozin)]; Jana Care [Prediabetes, diabetes
(Mobile device for lifestyle intervention aimed at weight loss)]; Janssen Pharmaceuticals [Diabetes
(Canagliflozin)]; Nutrisystem [Weight loss (Proportioned prepared meals)]; Omada Health [Prediabetes,
diabetes [Online lifestyle intervention for weight loss]. Equity Ownership/Stock Options: Jana Care
[Prediabetes, diabetes (Lifestyle intervention mobile app)]; Omada Health [Prediabetes, diabetes [Online
lifestyle intervention for weight loss]. David K McCulloch, MD Nothing to disclose Irl B Hirsch,
MD Consultant/Advisory Boards: Abbott [Diabetes (Blood glucose meters)]; Intarcia Therapeutics
[Diabetes (Exenatide)]; Roche [Diabetes (Blood glucose meters)]; Valeritas, Inc [Diabetes (Insulin
pumps)]. Timothy O Lipman, MD Nothing to disclose Jean E Mulder, MD Nothing to disclose
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.
Conflict of interest policy
20 de 20 2/6/17 19:22

Nutritional Considerations in Type 1 Diabetes Mellitus - UpToDate 2017

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Nutritional considerations in type 1 diabetes mellitus - UpToDate https://www-uptodate-com.aure.unab.edu.co/contents/nutritional-consi...

Official reprint from UpToDate®

Authors: Linda M Delahanty, MS, RD, David K McCulloch, MD

● Achieve optimal blood pressure and lipid levels.

● Improve overall health through healthful food choices.

● Adherence to the negotiated meal plan (diet consistency)

MNT for type 1 diabetes should consider five key aspects:

● Consistency in day-to-day carbohydrate intake at meals and snacks

CARBOHYDRATE CONSISTENCY — Variations in food intake, particularly carbohydrate intake, can

based on nutrition goals and the usual eating pattern.

Advanced carbohydrate counting — At a more advanced level, carbohydrate counting focuses on

● 450 to 500 rule – Calculate the insulin-to-carbohydrate ratio as follows:

Rapid acting insulin-to-carbohydrate ratio = 500 divided by TDD of insulin.

● For regular insulin, divide 1500 by TDD

PHYSICAL ACTIVITY/EXERCISE — Exercise is a significant component of diabetes management.

● Current weight in relationship to desirable and healthy body weight

● For women over 5 feet (152 cm):

● For women under 5 feet (152 cm):

● For men over 5 feet (152 cm):

● Men, active women – 15 kcal/lb

● Most women, sedentary men, and adults over 55 years – 13 kcal/lb

Dietary recommendations — In view of these observations, we recommend customizing dietary

PROMOTING DIETARY COMPLIANCE — While nutritional counseling by clinicians in the diabetes

SUMMARY AND RECOMMENDATIONS

• Consistency in day-to-day carbohydrate intake

Use of UpToDate is subject to the Subscription and License Agreement.

Nutr 2009; 89:518.

Topic 1765 Version 20.0

Carbohydrate counting: getting started

Step 1: Know the goal

Step 2: Monitoring intake and blood glucose

Step 3: Methods of counting carbohydrate

Graphic 51729 Version 2.0

Calories and macronutrient content of exchange lists

Carbohydrate, Protein, Fat, Calories,

Milk 12 8 varies 90 to 150

Other carbohydrates 15 varies varies varies

Meat and meat substitutes

High fat 0 7 8 100

Graphic 52063 Version 3.0

Sample exchange system meal plan

Time Exchange pattern Sample menu Carbohydrate count (g)

2 starch 1 English muffin 30

1 fruit 1 1/4 c strawberries 15

1 protein group 1/4 c cottage cheese -

1 fat group 1 tsp margarine -

2 starch 2 slices of bread 30

1 milk 8 oz skim milk 12

3 protein group 3 oz chicken -

1 fat group 1 tbsp low fat mayo -

1 fruit or 1 starch 1 apple or 6 crackers 15

1 fruit 1/2 c fruit salad 15

1 milk 8 oz skim milk 12

6 protein group 6 oz fish -

1 fat group 2 tbsp low fat salad dressing -

1 protein 2 tbsp peanut butter -

Graphic 75559 Version 3.0

Insulin-to-carbohydrate ratio calculation

Weight, lbs Ratio

120 to 129 1:15

130 to 139 1:14

140 to 149 1:13

150 to 169 1:12