Any rigid plan for managing diabetes is now considered both inadequate and unrealistic. Today, instead of requiring that a patient change her lifestyle to accommodate the plan, a nutritional specialist will adapt a plan to the patient's physiologic needs and lifestyle.

Your patient should learn self-management techniques from a registered dietitian, preferably one who is also a certified diabetes educator. A registered dietitian possesses the tools and techniques for teaching nutritional self-management and counseling patients about making dietary changes. Your role is to reinforce what the dietitian teaches your patient.

The first step in creating a nutritional plan is to assess your patient's needs, compiling the following information -

Height, weight, blood pressure, blood glucose levels, lipid profiles, and glycosylated hemoglobin levels

Diet history, focusing on your patient's current nutritional intake and habits, likes and dislikes, and cultural or ethnic influences

Social history, including lifestyle, daily schedule, finances, and activity level

Current diet, including calories, nutrient distribution, and types of carbohydrate, protein, and fat ingested.

The next step is mutual goal setting, which directly involves your patient in her own care. Nutritional goals are created in light of your patient's preferences and concerns.

Once goals have been set, the patient implements the nutritional plan. For a person with Type 1 diabetes, the plan should stress consistency in daily food intake, maintenance of desirable body weight, and integration of insulin therapy with the type and amount of food eaten. Matching insulin doses with the type and amount of food requires the patient to eat her meals at the same time every day; eat the appropriate amounts of fat, carbohydrates, and protein, and consume the appropriate number of calories.

Your patient should monitor her blood glucose levels before meals. She should also check her blood glucose levels after meals to evaluate the patterns that emerge after she eats certain foods. She can then adjust her insulin when her routine changes for instance, when she eats out, eats more or less food than usual, exercises, or is sick.

If your patient has Type 2 diabetes, the nutritional plan focuses on the types of foods she eats, the timing of meals, the distribution of calories among a day's meals and snacks, and the number of calories ingested. When the dietitian plans the composition of a patient's meals, she will also consider the patient's medication regimen.

If your patient needs to lose weight, a dietitian will set realistic goals. As your patient loses weight, her carbohydrate tolerance will improve. If hypercholesterolemia, hypertriglyceridemia, and poor glucose control persist, the dietitian will have to revaluate your patient's calorie intake and make necessary adjustments in her cholesterol, fat, and carbohydrate intake. You'll be in an excellent position to observe the course of treatment and to inform the dietitian when changes are necessary.