There is no standardised dietary advice that is suitable for all individuals with diabetes.
Individualised nutrition advice should be based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, and willingness and ability to make behavioural changes. It should also address barriers to change.
Nutritional recommendations should be modified to take into account: excess weight and obesity, those who are underweight, disordered eating, hypertension and renal failure.
All patients with diabetes should receive individualised medical nutrition therapy, preferably provided by a registered dietitian who is experienced in providing this type of therapy to diabetes patients.
Carbohydrate counting (with adjustment of insulin dose according to an insulin:carbohydrate ratio) or consistent carbohydrate intake with respect to time and amount may improve glycaemic control. The UK National Institute for Health and Care Excellence (NICE) recommends a low glycaemic index diet to improve blood glucose control in children and young people but does not recommend this approach in adults. Rapid-acting insulins may make timing of meals less crucial than in the past, but regular meals are still important.
Encourage the patient to undertake physical activity on a regular basis.
Patients with type 1 diabetes can safely exercise and manage their glucose levels. Be aware that in practice many patients find exercise challenging, particularly as acute exercise increases the risk of dysglycaemia. Therefore the patient will need access to ongoing support, education, and input from educators.
Pre-exercise carbohydrate intake and insulin doses can be effectively modified to avoid hypoglycaemia during exercise and sports.
Hypoglycaemia can occur up to 24 hours after exercise and may require reducing insulin dosage on days of planned exercise. A carbohydrate snack (10-20g) should be given at the start of exercise if the patient's blood sugar is <5.0 mmol/L (<90 mg/dL).
Bear in mind that people with diabetes might be struggling to manage their diabetes effectively owing to psychological and social challenges; these patients will require an integrated multi-disciplinary approach, including psychologists, psychiatrists and support workers. Specifically consider whether an eating disorder, and associated concerns about body size and weight, might be influencing how the patient uses their insulin.
Advise children (and/or their family members or carers) to routinely perform at least five capillary blood glucose tests every day. More frequent testing will be needed to support safe exercise and during intercurrent illness. Encourage any child or young person with type 1 diabetes to carry or wear something (e.g., a bracelet) that alerts people to their diagnosis.
The patient’s agreed HbA1c target is not met
The frequency of hypoglycaemia episodes increases
There is a legal requirement to do so (e.g., before driving)
While the patient is ill
Before, during, and after sport
While planning pregnancy, during pregnancy, and while breastfeeding
If there is any other reason to know blood glucose levels more than 4 times a day (e.g., impaired awareness of hypoglycaemia; high-risk activities).
Bear in mind that additional testing (more than 10 times a day) might be indicated:
If the patient has impaired awareness of hypoglycaemia
Depending on the patient’s lifestyle (e.g., if they drive for long periods or have a high-risk job).
In practice, most adults with type 1 diabetes are likely to be checking their blood glucose between 4 and 10 times a day.
Advise the patient that hypoglycaemia may occur if they skip a meal, take too much insulin, exercise, or become ill. Alcohol and exercise can cause delayed hypoglycaemia that may appear even up to 24 hours later.
Symptoms include feeling very hungry, nervous, shaky, sweaty, dizzy, or confused.
To raise their blood glucose, the patient can take glucose tablets or gels, or drink juice, depending on how low their blood sugar falls.
The patients should see their physician for adjustment of medication should hypoglycaemia occur.
Ensure the patient (and/or their family/carers, as appropriate) has a glucagon kit for emergencies, in the case of severe hypoglycaemia or when the patient is unable to drink or eat.
Severe hypoglycaemia is defined as any low blood glucose level leading to cognitive impairment requiring assistance from another person for recovery.
Advise the patient to discuss their insulin requirement with their physician prior to skipping any meals (e.g., for a medical test).
Ensure the patient is aware of symptoms of hyperglycaemia, including blurred vision, thirst, frequent urination, or tiredness, and that they should see their physician immediately if these occur. They should seek medical attention if they develop a fever, cough, dysuria, or wounds on the feet.
Give the patient clear and individualised oral and written advice (‘sick-day rules’) about how to adapt management during intercurrent illness. This illness plan should include:
Monitoring blood glucose
Monitoring and interpreting blood ketones (see below)
Adjusting their insulin regimen
Adapting food and drink intake
How to seek further advice.
Offer children and young people with type 1 diabetes blood ketone testing strips and a meter. Advise the patient (and/or their family members or carers) to test for ketonaemia if they are ill or have hyperglycaemia.
Consider ketone monitoring (blood or urine) as part of 'sick-day rules' for adults, to facilitate self-management of an episode of hyperglycaemia.
Recommend blood pressure management at 135/85 mmHg for adults with type 1 diabetes. If the patient has albuminuria or 2 or more features of metabolic syndrome, recommend blood pressure management at 130/80 mmHg.
Support the patient to engage with technologies that empower them to manage their own condition with remote support as a complement to their usual appointments.
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