Food Obstacles in Intensive Diabetes Therapy

Dianne Davis, RD, LDN, CDE, and Janie Lipps, MSN, RN-C, CDE

In the Diabetes Control and Compli-cations Trial (DCCT),1 the goal of intensive diabetes treatment was to achieve normal blood glucose control. When the study began, intensive diabetes therapy was initiated based on a traditional medical model. The physician determined the insulin dose; the nurse educated the patient about such general topics as hypoglycemia, insulin administration, and self-monitoring of blood glucose; and the dietitian gave the patient a meal plan based on insulin requirements. The patient’s preferred lifestyle and eating pattern were considered, but often changed to fit the regimen. Over time, it became obvious to the authors that asking patients to conform to an ideal meal plan and treatment regimen was often unsuccessful in achieving and maintaining blood glucose levels as close to normal as possible.

The DCCT experience illustrated that near-normal blood glucose control can be achieved through an approach to intensive therapy that offers people with diabetes increased flexibility and treatment options with a return to preferred eating habits. Nurses and dietitians can work together to develop customized plans for dealing with lifestyle issues that promote achieving normoglycemia.

Many everyday considerations affect blood glucose levels, including amount of insulin, activity level, illness, medications, and stress level. These lifestyle issues affect each person differently and require a customized treatment plan. The treatment plan should use a problem-solving approach that facilitates achieving normoglycemia.

Most patients identify food as the single most challenging part of balancing all of the elements of intensive therapy. This article provides case studies that describe some of the common food obstacles patients encounter and identifies some of the strategies that have been used successfully to deal with these obstacles.2

SPECIAL SITUATIONS

Alcohol Use
Case study. Tammy is a college student with type 1 diabetes. She went to a party, drank a few beers, danced a little, and ate some peanuts. That night, while asleep, she had a hypoglycemic seizure.

Discussion. Patients believe or have been taught that they cannot drink alcohol because they have diabetes. Some patients will drink alcohol but never tell their health care providers because they feel guilty or fear a negative response. These patients run the risk of severe hypoglycemia because they are not taught appropriate strategies to use when alcohol is ingested.

The danger of alcohol consumption is compounded because the symptoms of hypoglycemia are easily confused with the effects of alcohol. Under normal circumstances, the liver releases blood glucose through gluconeogenesis. Alcohol inhibits gluconeogenesis, resulting in a decline in blood glucose levels. People with diabetes cannot accommodate for decreased insulin needs when less glucose is released from the liver.

Thus, alcohol in conjunction with insulin can cause hypoglycemia several hours after ingestion. Hypo-glycemia can occur even if the alcohol is ingested simultaneously with carbohydrates. Hours later, the alcohol continues to block gluconeogenesis in the liver, and the blood glucose level can continue to drop. Physical activity, such as dancing, can enhance the drop in blood glucose level and increase the risk of severe hypoglycemia.

Strategy. If alcohol is ingested during daytime hours, patients should be instructed to monitor blood glucose levels frequently and to eat carbohydrate-containing foods if their blood glucose level drops. If alcohol ingestion occurs during the evening, patients should be instructed to eat 10–15 grams of carbohydrate for each serving of alcohol they consume before they go to bed, regardless of the bedtime blood glucose level. Patients should also be instructed that 12 ounces of beer, 3–4 ounces of wine, and 1–1.5 ounces of liquor is considered one serving.3

Skipping Meals
Case study. Scott, a salesman who takes premeal regular and ultralente insulin, is often busy with clients through the lunch hour and misses lunch. He is usually not hungry and would like to lose a few pounds. He wonders if he should test his blood glucose level and what to do with his lunch premeal regular insulin bolus if he misses the lunch meal.

Discussion. Eating meals and snacks with consistent amounts of macronutrients at the same time every day is one of the biggest challenges that patients face. Intensive therapy offers patients the option to eat when they are hungry or when their schedule permits.

Blood glucose levels can rise between meals for a variety of reasons, such as miscalculating the previous meal bolus, inactivity, or insufficient basal insulin. Supplemental insulin may be required to maintain normoglycemia even if a meal is skipped.

Strategy. Patients need to learn a system to quantify the carbohydrate in their food. This system could be the traditional exchange system, carbohydrate exchanges, carbohydrate gram counting, or total available glucose. Meal planning systems such as these allow patients to match their meal-specific rapid-acting insulin dose to their food.

Intensive therapy also offers flexibility in meal timing. Fast- or rapid-acting insulin is taken before each meal. However, patients have the option of skipping meals if they desire.

Patients who choose to skip a meal should still check their blood glucose level. This allows them an opportunity to take supplemental insulin in the absence of food intake if their blood glucose level is elevated. Thus, monitoring at usual meal times, even if food will not be eaten, is recommended so patients can make adjustments if necessary.

Each patient should have an insulin algorithm for elevated blood glucose levels. The amount of supplemental insulin may be different for each person, depending on the patient’s desire to eat, skip a meal, or engage in physical activity.1 Table 1 provides a plan that works for many people.

If Scott is not eating his lunch, he should check his blood glucose level. If his blood glucose level is normal, he should not take insulin at lunch time. If his blood glucose level is >120 mg/dl, he should adjust the dose of short-acting insulin for the elevated blood glucose. If he eats only a snack, he should test his blood glucose level, apply his algorithm if his blood glucose level is above his target range, and then apply his insulin/carbohydrate ratio to calculate the dose for the carbohydrate content of his snack.

Snacking
Case study. Sue is a homemaker who has been on a conventional insulin regimen of two injections per day. She has been eating a midafternoon and bedtime snack to prevent hypoglycemia. She will soon begin a regimen of multiple daily insulin injections and is excited about the opportunity for improved glycemic control. But she is concerned about maintaining her weight. She feels it will be easy to delete her midafternoon snack, but she is concerned that, occasionally, she might want to eat a bedtime snack with her family.

Discussion. Conventional diabetes management, which typically involves two daily injections of intermediate- and short-acting insulin, often requires patients to eat snacks between meals and at bedtime to prevent hypoglycemia. While some adults enjoy snacking, others find that eating between meals or during the day is inconvenient, time consuming, or a source of additional unwanted or unneeded calories.

Intensive therapy involves either using a long- or intermediate-acting insulin to meet basal insulin needs and regular or lispro insulin before meals or using an insulin infusion pump that provides a continuous infusion of short-acting insulin to meet basal insulin needs, as well as boluses of insulin before meals. These insulin regimens do not usually require snacks.

An appropriate basal insulin dose should provide coverage between meals and overnight without the need for additional carbohydrate snacks, even at bedtime. Carbohydrates eaten as meals or snacks will usually require a short- or rapid-acting insulin in the amount of 0.5–2.0 U/15 g carbohydrate (the average dose is 1.0 U/15 g carbohydrate). Patients can choose to eat or skip meals as long as they take the appropriate dose of regular or lispro insulin and monitor blood glucose levels.

Strategy. If patients desire food between meals or at bedtime, they should test their blood glucose level to determine whether they need to take a snack-related dose of short-acting insulin based on the amount of carbohydrate in the snack. Most people can eat snacks without losing blood glucose control if they match their insulin to the amount of carbohydrate eaten.

A starting dose of insulin can be determined by calculating the insulin-to-carbohydrate ratio at meals. For many people, the dose would be 1 U of short- or rapid-acting insulin per 10–15 g carbohydrate. For safety, a lower ratio of insulin to carbohydrate at the bedtime snack may be necessary, such as 1 U of short- or rapid-acting insulin per 20 g carbohydrate.4

Sucrose
Case study. Jill is a secretary who often eats sweet treats, such as donuts, that her co-workers bring in for coffee breaks. Her blood glucose level is usually elevated after eating these treats. She has been told that she should avoid sweets and sugar, and, consequently, she does not share the information about snacking on sweets with her health care team.

Discussion. Many people avoid sucrose or sugar as a dietary strategy in an attempt to manage their diabetes. Sucrose-containing foods may contain more carbohydrate than foods without sucrose. However, total carbohydrate intake—not the specific source of carbohydrate—is primarily responsible for changes in blood glucose levels. Many studies have demonstrated that sucrose does not raise the blood glucose level faster or higher than do other sources of carbohydrate.5

If a patient has avoided sucrose for many years, learning that it can be incorporated into the diet often leads to excessive sucrose ingestion. Patients may begin eating sucrose several times a day; however, they usually taper their sucrose ingestion after the novelty has worn off.

Strategy. Patients should be taught to calculate the amount of carbohydrate to be ingested, regardless of its source, and to adjust their premeal short- or fast-acting insulin dose appropriately. Explain that sugar is an empty source of calories that can result in weight gain. Patients should also be taught how to include sucrose into the meal plan (i.e., substituting sucrose for other carbohydrates to avoid adding more calories to the meal plan).

Calculating Recipes
Case study. Jesse enjoys eating his wife’s cooking. He usually counts carbohydrates, but he guesses the amount of carbohydrate in her famous casseroles. His blood glucose levels are often elevated after these casserole meals.

Discussion. Favorite recipes can be included in any meal plan. People who use recipes made with a variety of ingredients need information on how to determine the carbohydrate exchanges or grams in their recipes. They also need advice about the appropriate amount of insulin to take when eating their favorite recipes.

Strategy. The grams of carbohydrate in ingredients such as flour, milk, and sugar are listed on the food labels. Patients can list the carbohydrate for each ingredient and add the carbohydrate grams to determine the total for the recipe. They can then divide that sum by the number of servings to find the carbohydrate grams per serving. Patients may want to note the carbohydrate grams per serving size on their written recipes so that they have that information when the recipe is prepared again.

High-Fat Meals
Case study. William, a teenager, ate pizza on Friday night with his friends. Since his bedtime blood glucose level was normal, he took only his usual bedtime dose of 12 U of ultralente insulin. He did not eat a bedtime snack. His fasting blood glucose level the next morning was 265 mg/dl.

Discussion. A high fat content can slow the absorption of all the nutrients in a meal. This slowed absorption can result in a mismatch in the timing of the action of the meal bolus and the peak absorption time of the carbohydrate in the meal. The result can be a low or normal blood glucose level 2–3 hours after the meal, but a very elevated fasting blood glucose level up to 8 hours later.

If a high-fat meal is eaten at supper, the blood glucose level may not be elevated until the next morning. This effect can be seen even if the patient doesn’t eat a bedtime snack. Short-acting or rapid-acting insulin is needed when the carbohydrate is released into the bloodstream.

Strategy. Patients may be able to divide their premeal insulin bolus into a premeal portion and a postmeal portion to provide coverage for the delayed carbohydrate absorption. They can safely begin with 75% of their meal bolus before the meal and 25% 1 hour after eating a high-fat meal. Patients using an insulin infusion pump can spread their premeal bolus over several hours (while the basal rate continues) in an attempt to match insulin action and carbohydrate absorption.

Monitoring blood glucose levels before and after a high-fat meal and during the night (3:00 a.m.) can help to determine the appropriate dose for a given situation. Different high-fat meals may require different doses. Patients may require a different bolus dose and bolus distribution (timing before and after the high-fat food) for pizza, peanuts, ice cream, and so forth. Blood glucose results should be recorded so that adjustments in the dose can be made as needed for similar situations in the future.

Sick Days
Case study. Bobby is 22 years old and has had type 1 diabetes for 3 years. Overnight, he developed a fever, body aches, nausea, and had one episode of vomiting. Upon awakening, he decided not to take his insulin, since he was not eating due to the nausea. He checked his blood glucose level and urine ketones at noon and was surprised to find that his blood glucose level was 400 mg/dl with moderate urine ketones.

Discussion. People with type 1 diabetes sometimes mistakenly believe that they should not take insulin when they have a gastrointestinal virus and are unable to eat due to nausea. With illness, the body releases stress hormones that oppose the action of insulin and cause hyperglycemia. Without adequate insulin, ketones can result. Hyperglycemia also induces the loss of fluid through increased urine output and places patients at risk for dehydration.

Strategy. Patients who are ill should increase their frequency of blood glucose monitoring to at least every 2–4 hours. Urine ketones should also be checked until they are negative.

If a patient is vomiting or has diarrhea, electrolytes can be replaced using fluid replacement sports drinks. At least 8 ounces of caffeine-free fluid should be consumed each hour to replace fluids.

If a patient’s blood glucose level is low or if the illness lasts several days, using liquid carbohydrates, such as a sports drink, can provide carbohydrate and calories. Sports drinks have ~50 calories or 15 g carbohydrate/ cup. If a patient is unable to eat, 1–2 cups per hour during the day would supply a total of 400–800 calories per day or 15–30 g carbohydrate each hour.

Basal insulin, such as NPH, ultralente, or the pump basal rate should always be continued. Supplemental doses of regular or lispro insulin may be given every 2–4 hours based on blood glucose or urine ketone levels. Some patients require 50–100% more insulin when they are sick and spilling urine ketones.

Contact with the health care team is necessary, especially with persistent vomiting. If a patient is unable to retain fluids, he should be instructed to go to a hospital emergency room.

Activity
Case study 1. Mary is a 35-year-old accountant whose weekday job entails desk work with occasional walking. For exercise, she takes a brisk walk 2-3 times per week. Before her walk, she eats a snack or reduces her lispro insulin that she takes just before the activity. On Saturdays, she watches television, goes to the movies, and eats more at lunch and dinner. On Sundays, Mary cleans her house and cooks meals for the week.

Mary uses a multiple daily insulin regimen with ultralente and premeal lispro. Her HbA1c remains at 8.8%.

A complete analysis of her blood glucose records using a computer-generated print-out derived from her memory glucose meter, reveals that Mary’s blood glucose levels during the week are close to normal before lunch and supper and that she often goes to bed shortly after supper without testing her blood glucose level. Her fasting blood glucose level is variable. On Saturdays, Mary’s blood glucose levels are elevated before supper and at bedtime. On Sundays, she has hypoglycemia 2–3 times during the day.

Case study 2. Karl is a landscaper. On most days he mows grass, digs holes to plant trees, or climbs trees to trim them. On rainy days, he may do desk work. From spring until fall, Karl is extremely busy from daylight till dark, but in the winter he may only work a few hours each day.

Discussion. When the word "exercise" is used to refer to activity, many patients think only of going to a health club, running, or engaging in a sport. Many other physical activities can lower blood glucose levels and require adjustments in the usual regimen.

The effects of activity may vary based on the activity or the person. The length of time these activities are performed also affects blood glucose level. Everyday activities that can lower a person’s blood glucose level include shopping, doing yard work, cleaning house, playing with children, and moving furniture. Conversely, less of such physical activity than usual can cause hyperglycemia.

Strategy. Mary may need different doses of lispro insulin on the weekend. She eats more on Saturdays, so she may need additional lispro that day for lunch and supper. Food, insulin, and blood glucose records can help sort this out. On Sundays, the energy she expends cleaning house lowers her insulin requirements, so she should lower her premeal dose of lispro at the meal before she begins house cleaning.

If Mary used an insulin pump, she could lower her basal rate on Sundays. Mary is concerned about weight gain and would prefer not to eat more to compensate for her activity level on Sundays.

Karl and others whose activities vary from day to day may improve their glycemic control using an insulin infusion pump. This will allow them to vary basal rates as their schedule demands.

Patients can make changes in their insulin regimen for increased activity or exercise. Intense exercise for as long as 45 minutes can lower blood glucose levels as much as 100 mg/dl. Patients who exercise within 2 hours after a meal may decrease their premeal regular or lispro insulin by a prescribed amount. The size of the decrease depends on the length of their exercise, their previous blood glucose response to exercise, and the carbohydrate intake at their previous meal. People may need to lower their short- or rapid-acting insulin as much as 25–50% for intense activity.

Some people prefer to increase their carbohydrate intake before exercise. Liquid carbohydrates, such as a sports drink or carbohydrate replacement drink, can be used if preferred. Carbohydrate replacement beverages have 50 g carbohydrate in each 8 ounce serving. Approximately 10–15 grams of carbohydrate can raise the blood glucose level about 50 mg/dl.

Activity can lower blood glucose levels many hours after the activity. Patients may need a bedtime snack even if their bedtime blood glucose level is normal because of the additional, delayed, blood glucose lowering effect of the activity. Blood glucose checks at 3:00 a.m. can help patients decide what action they should take at bedtime when this situation occurs again in the future.

Regimen adjustments for activity may include short-term changes for a single half-hour walk, weekly changes for regular weekend activities, or more long-term changes for seasonal differences in activity levels.

Patients can be taught to use problem-solving to determine what action to take to prevent hypoglycemia due to various activities. Blood glucose monitoring before and after an activity will help evaluate the action taken and determine whether further changes are needed for similar activities in the future.6

Severe Hypoglycemia
Case study 1. Bill has enjoyed the ease of taking an insulin bolus with his insulin pump when he snacks. One night, after working overtime at his school supply store, he did not check his bedtime blood glucose level. He decided to eat an ice cream sandwich at bedtime, and he took 4 U of regular insulin for this 20-gram carbohydrate snack. Bill’s wife found him in bed confused during the night. His blood glucose level was 25 mg/dl after his wife forced him to drink orange juice.

Case study 2. Because of her husband’s work schedule, Barbara usually eats a late dinner. She often has crackers or pretzels when she arrives home from work. Her blood glucose levels before supper are usually elevated from the snacks. Barbara applies her algorithm for elevated blood glucose levels and adds supplemental short- or fast-acting insulin to her premeal dose. Because of the late dinners, Barbara often goes to bed shortly after supper without a bedtime blood glucose test. She repeatedly experiences nocturnal hypoglycemia.

Discussion. Hypoglycemia is a significant adverse effect of intensive diabetes therapy. In the DCCT, the risk of severe hypoglycemia was three times higher with intensive diabetes therapy.7 Most severe hypoglycemic episodes occurred during sleep. This is often due to the inability to recognize hypoglycemia that occurs while sleeping.

As people approach normoglycemia, their symptoms of hypoglycemia may become less obvious. Anticipatory planning is necessary to decrease the incidence of severe hypoglycemia. A small miscalculation of the amount of insulin needed can quickly result in hypoglycemia when the blood glucose level is near normal.

Bedtime blood glucose checks are essential to prevent nocturnal hypoglycemia. The evening meal is usually the most varied and offers the most opportunity for miscalculation that can result in nocturnal or fasting hyper- or hypoglycemia. If the bedtime blood glucose test is missed, there is no blood glucose monitoring for as many as 12–14 hours.

It is helpful to explore the reasons why a patient misses the bedtime check. Checking bedtime blood glucose levels may not be a habit, and patients may simply forget. Or, a patient may not understand the value of a postprandial blood glucose reading.

Strategy. Training patients to be aware of subtle symptoms of hypoglycemia can be helpful in preventing severe hypoglycemia. Some of the subtle symptoms patients may note are difficulty concentrating, numbness of the lips, headache, irritability, sweating, visual changes, or just feeling "different" or "weird."

Blood glucose levels should be verified when patients feel like they might be low, so they can learn the specific subtle symptoms they may have with hypoglycemia. Obtaining a second meter to keep at the bedside or next to their toothbrush may help patients establish bedtime monitoring as a habit.

Some people go to bed soon after supper and avoid the bedtime test either because they know it will be elevated or because they do not believe that it will be of use. Developing rules for bedtime insulin dosing and bedtime snacks when the bedtime blood glucose level is 1.5–2 hours after the evening meal is helpful in this situation. The postprandial blood glucose target 1.5–2 hours after eating should be 150–180 mg/dl. For pregnant patients, a postprandial blood glucose level should be lower, at about 130–150 mg/dl. Patients should work with their diabetes educator to develop strategies and identify actions to take when their blood glucose levels exceed their individual goals.

If patients feel that their blood glucose readings are useful in making decisions, they are more likely to comply. Obviously, knowing the carbohydrate content of the snack is essential to deciding how much insulin to take.

A patient’s use of regular versus lispro insulin should also be considered when determining the insulin dose needed for elevated premeal blood glucose readings that are within 2 hours of a snack for which insulin was taken. Lispro peaks earlier and has a shorter duration of action than regular insulin. Therefore, a patient may require more insulin for an elevated premeal blood glucose level that occurs 2 hours after a snack if lispro was used before the snack, since most of the activity of the lispro will have abated by 2 hours after the snack. On the other hand, since the duration of activity of regular insulin is 4–6 hours, there may be additional insulin activity remaining 2 hours after it is injected. Thus, less regular insulin may be required for an elevated postprandial blood glucose reading that occurs before another meal when regular insulin is used.

Additional Causes of Hypoglycemia
Weight loss can lower the total daily insulin dose required. Dieting patients should know that their insulin needs will probably decrease with as little as a 5-pound weight loss. The increased attention to quantifying food may also increase the frequency of hypoglycemia, since patients are then much more aware of portion size. Beginning an exercise program may also require a decrease in insulin dose. Alcohol has been discussed earlier as another factor that may lower blood glucose levels.

Overtreatment of Hypoglycemia
Case study. Marge has occasional hypoglycemia due to miscalculation of insulin or additional activity. When her blood glucose level is low, Marge is frightened and eats glucose tablets plus snack cakes, crackers, candy and juice. Hours later, Marge’s blood glucose level is high.

Discussion. When patients feel the symptoms of hypoglycemia, they often overtreat out of fear or hunger and consume more food than necessary to raise their blood glucose levels. The recommended treatment is 10–15 grams of fast-acting carbohydrate, such as glucose tablets, glucose gel, juice, honey, or regular soda. If patients ingest more than 10–15 grams of carbohydrate without adding insulin, their blood glucose level may be elevated for many hours afterwards.

When fear and hunger are the driving factors, recommending that patients resist overeating to treat hypoglycemia is usually not effective. Patients may use hypoglycemia as an opportunity to eat foods they think are forbidden, such as candy, ice cream, and other sweets. Because of their fat content, these foods do not raise blood glucose levels fast enough and, therefore, are not an ideal treatment for hypoglycemia. In addition, the extra carbohydrates in these foods contribute to hyperglycemia afterwards.

Patients should be taught how to include these foods into their usual meal plans as substitutes for other carbohydrates, or they should be taught how to adjust insulin to accommodate the extra calories when they eat these foods.

Strategy. Patients can be taught to compensate for overtreating hypoglycemia. After their blood glucose level rises to normal, patients can calculate the total amount of carbohydrate eaten. After subtracting the 10–15 grams of carbohydrates that is recommended for treatment of hypoglycemia from the total carbohydrates, patients should then take supplemental insulin using the same insulin-to-carbohydrate ratio they would use for meals or snacks (i.e., 1 U for every additional 15 grams of carbohydrate eaten).8

Weight Gain
Case study. Betty is a 35-year-old-mother who enjoys snacking and has an HbA1c of 9.2%. She began intensive diabetes therapy using an insulin infusion pump to lower her HbA1c level. Betty enjoyed the freedom of being able to snack and easily administer a bolus dose of insulin with the pump to cover the snack. In 6 months, her HbA1c was 6.8%. How-ever, she had also gained 15 pounds.

Discussion. In the DCCT, subjects using intensive diabetes therapy gained an average of 10 pounds more than those using the conventional therapy. This weight gain may be the result of better blood glucose control, which in turn results in the efficient storage of all calories ingested. It may also be a result of the increased flexibility that allows patients the freedom to adjust insulin to accommodate additional calories consumed.9

Strategy. The need to avoid excessive calorie intake to prevent weight gain should be discussed with each person beginning intensive therapy. Since losing weight is so difficult, preventive strategies should be incorporated at the initiation of intensive therapy.

Patients may choose to eliminate snacks, since long-acting insulin or an insulin infusion pump for basal coverage usually does not require them. If patients are accustomed to snacking, negotiating lower-calorie snacks can reduce their contribution to total caloric intake.

Ensure that the basal rate is appropriate and is not contributing to hypoglycemia that causes patients to consume extra calories to treat.

Patients can also decrease insulin before exercise rather than increasing carbohydrate intake, thus avoiding unneeded calories as discussed in the activity section.

Patients often use hypoglycemia as an opportunity to eat foods that are high in fat and calories, such as candy bars and cake. Patients should be instructed on the proper treatment for hypoglycemia. Using only 10–15 grams of a fast-acting carbohydrate, such as glucose tablets, will raise the blood glucose level more rapidly than foods with fat and will prevent the ingestion of unnecessary calories.

To discourage bingeing on high calorie foods, explain to patients how to incorporate small amounts of these treats into their usual meal plan. Use accepted weight reduction strategies, such as identifying high-fat foods, negotiating low-calorie substitutions for favorite foods, using smaller portion sizes of calorie-dense foods, modifying the calorie content of recipes, negotiating healthy food choices when eating out, and increasing activity.

SUMMARY

Patients will encounter many lifestyle obstacles as they attempt to achieve and maintain near-normal blood glucose levels. As people learn to become the primary decision maker in their diabetes care, the diabetes team can help them devise strategies to become more adept at this role.

Changing behavior is difficult, and incorporating new behaviors into one’s lifestyle takes time. A mental health professional may be helpful in assisting patients to adopt new behaviors.

Even the most skilled patients encounter obstacles that can interfere with achieving treatment goals. In addition, new situations may arise requiring a different approach to the treatment plan. Ongoing feedback, reinforcement, and encouragement from the health care team is needed to help patients sustain safe and effective self-management practice.

References

1The DCCT Research Group: The effect of intensive diabetes treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus: the Diabetes Control and Complications Trial. N Engl J Med 329:977-86, 1993.

2The DCCT Research Group: Implementation of conventional and intensive treatment in the Diabetes Control and Complications Trial. Diabetes Care 18:361-75, 1995.

3Kulkarni K: Adjusting nutrition for special situations. In Handbook of Diabetes Medical Nutrition Therapy. Powers MA, Ed. Gaithersburg, Md., Aspen Publishers, Inc., 1996, p. 437-41.

4Delahanty L: Blood glucose monitoring for nutrition-focused care. In Handbook of Diabetes Medical Nutrition Therapy. Powers MA, Ed. Gaithersburg, Md., Aspen Publishers, Inc., 1996, p. 150-61.

5Franz MJ: Avoiding sugar: doesn’t research support traditional beliefs? Diabetes Educ 19:144-50, 1994.

6Lorenz R, Bubb J, Davis D, Jacobson A, Jannasch K, Kramer R, Lipps J, Schlundt D: Changing behavior: practical lessons from the DCCT. Diabetes Care 19:648-52, 1996.

7The DCCT Research Group: Hypoglycemia in the DCCT. Diabetes 46:271-86, 1997.

8Brackenridge B: Counting carbohydrate for diabetes nutrition therapy. In Handbook of Diabetes Medical Nutrition Therapy. Powers MA, (Ed.) Gaithersburg, Md., Aspen Publishers, Inc., 1996, p. 257-58.

9The DCCT Research Group: Adverse events and their association with treatment regimens in the Diabetes Control and Complications Trial. Diabetes Care 18:1415-27, 1995.