Nutritional therapy for patients with diabetes has undergone several changes since the first precalculated meal plans and exchange lists were created in the 1950s. These early plans called for a 40% carbohydrate, 20% protein, and 40% fat distribution of calories for all meals. These plans were consistently used until the discovery of a link between high-fat diets and cardiovascular disease. Today, diet plans for diabetes are higher in complex carbohydrates and lower in protein and fat.



With each change, the approach to nutritional therapy has become more individualized and more closely linked to a patient's blood glucose levels, lifestyle, and food preferences. Patients are no longer given standard lists of foods to avoid and sent on their way.

Nutritional therapy today is comprehensive and ongoing, and it involves assessment, goal setting, intervention, and regular reevaluation. Patients learn to monitor their blood glucose levels at home and to make diet, exercise, and medication dosage choices based on those levels. This close monitoring of blood glucose levels postpones the onset and progression of microvascular and macrovascular complications and neuropathy.

Other changes have taken place as well. For years, for example, starches were considered the preferred form of carbohydrates for patients with diabetes, who were instructed to avoid all simple sugars. Studies have shown, however, that blood glucose levels don't respond any better to complex carbohydrates, such as starches, than to simple ones, such as sugars. This finding gives patients far more freedom in selecting foods. Allowing patients with diabetes to include up to 5% of their carbohydrate intake as sugar represents a major change in philosophy that many health care workers may find harder to accept than their patients.

Out of habit, however, many patients and health care practitioners continue to use the more conventional regimens. Patients who have followed conventional nutritional therapy for years may be afraid to learn a new method or may simply be tired of learning new techniques related to diabetes. Those patients need your teaching and encouragement as they strive to adopt a healthier, more flexible way to use their diets to keep their disease under control. You may need the support of colleagues yourself as you become increasingly familiar with new goals and recommendations and begin to use and teach them exclusively.

Because food plays a vital role in every patient's self-care, you'll have a great deal to teach. Don't try to tell your patient everything in one or two sessions; she must understand this information well before she can implement it every day. During your sessions, you'll cover these subjects:

* weight control

* major dietary components, such as carbohydrates, proteins, and fats

* nutritional guidelines for choosing foods, such as how to read food labels

* nutritional plans, including setting goals, adapting plans for cultural and ethnic considerations and for the special needs of elderly and debilitated patients, and planning sick days.