Quick Links

  • Increase Font Size
  • Decrease Font Size
  • View as PDF

Recommendations Summary

DM: Carbohydrate Management Strategies (2015)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    Diabetes (DM) Type 1 and 2: Carbohydrate Management Strategies

    The registered dietitian nutritionist (RDN) should educate adults with type 1 diabetes or type 2 diabetes on multiple daily injections (MDI) of insulin or insulin pump therapy on carbohydrate counting using insulin-to-carbohydrate ratios based on his or her abilities, preferences and management goals. Research reports that carbohydrate counting using insulin-to-carbohydrate ratios resulted in significant decreases in A1C of 0.4% to 1.6% and significant increases in quality of life, as well as continued maintenance of these improvements for up to 44 months. The majority of research reported no significant change in weight as a result of this carbohydrate management strategy.

    Rating: Strong
    Conditional

    DM: Educate Adults with Type 1 or Type 2 Diabetes on Fixed Insulin Doses or Adults with Type 2 Diabetes on Insulin Secretagogues

    The registered dietitian nutritionist (RDN) should educate adults with type 1 diabetes or type 2 diabetes on fixed insulin doses or adults with type 2 diabetes on insulin secretagogues, based on his or her abilities, preferences and management goals, on carbohydrate consistency (timing and amount) using one of the following carbohydrate management strategies: 

    • Carbohydrate counting alone
    • Plate method, portion control and simplified meal plan
    • Food lists (such as Choose Your Foods. Food Lists for Diabetes) and carbohydrate choices.
    For individuals using fixed insulin doses (or insulin secretagogues), consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia. Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control. A simple diabetes healthful eating plan approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes who have low health literacy or numeracy concerns.
     

    Rating: Fair
    Conditional

    DM: Educate Adults with Type 2 Diabetes on MNT Alone or Non-Insulin Secretagogues

    The registered dietitian nutritionist (RDN) should educate adults with type 2 diabetes on medical nutrition therapy (MNT) alone or on diabetes medications other than insulin secretagogues, based on his or her abilities, preferences and management goals, on one of the following carbohydrate management strategies:

    • Carbohydrate counting alone
    • Plate method, portion control and simplified meal plan
    • Food lists (such as Choose Your Foods. Food Lists for Diabetes) and carbohydrate choices.
    Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control. A simple diabetes healthful eating plan approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes who have low health literacy or numeracy concerns.

    Rating: Fair
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Hypoglycemia, hyperglycemia or weight gain may result if the registered dietitian nutritionist does not select or the adults with diabetes cannot implement the appropriate carbohydrate management strategy.

    • Conditions of Application

      • The recommendation DM: Educate Adults with Type 1 or Type 2 Diabetes on Multiple Daily Injections (MDI) of Insulin or Insulin Pump Therapy applies to adults with diabetes on multiple daily injections (MDI) of insulin or insulin pump therapy
      • The recommendation DM: Educate Adults with Type 1 or Type 2 Diabetes on Fixed Insulin Doses or Adults with Type 2 Diabetes on Insulin Secretagogues applies to adults with diabetes on fixed insulin doses or insulin secretagogues
      • The recommendation DM: Educate Adults with Type 2 Diabetes on MNT Alone or Non-Insulin Secretagogues applies to adults with diabetes on medical nutrition therapy alone or diabetes medications other than insulin secretagogues
      • The registered dietitian nutritionist (RDN) should select the carbohydrate management strategy in collaboration with the patient based on his or her abilities, preferences and management goals.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions and reimbursement vary. However, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • Eight studies based on carbohydrate counting using insulin-to-carbohydrate ratios for three to six months reported significant decreases in A1C of -1.6% to -0.4% in adults with type 1 diabetes and type 2 diabetes on multiple daily injections of insulin (MDI) or insulin pump therapy, as well as continued maintenance of the significant improvement for up to 44 months (Diabetes Control and Complications Trial Research Group, 1993; DAFNE Study Group, 2002; Bergenstal et al, 2008; Franc et al, 2009; Speight et al, 2010; Laurenzi et al, 2011; Trento et al, 2011; Rankin et al, 2012). Four studies reported mixed effects on glucose levels when using this carbohydrate management strategy (Bergenstal et al, 2008; Franc et al, 2009; Laurenzi et al, 2011; Trento et al, 2011). No studies evaluating effectiveness of carbohydrate counting alone; carbohydrate consistency; plate method; or exchange lists, food lists and carbohydrate choices as carbohydrate management strategies on glycemia were identified. Long-term studies are needed investigating these approaches. Grade I
      • Three studies based on carbohydrate counting using insulin-to-carbohydrate ratios reported that insulin doses increased as needed by one to two doses per day or the insulin amount varied depending on the planned carbohydrate intake in adults with type 1 diabetes and type 2 diabetes on multiple daily injections of insulin (MDI) or insulin pump therapy (Diabetes Control and Complications Trial Research Group, 1993; DAFNE Study Group, 2002; Bergenstal et al, 2008). In addition, three other studies reported that no changes were needed in the amount of the total daily dose of insulin (Franc et al, 2009; Laurenzi et al, 2011; Trento et al, 2011). No studies evaluating effectiveness of carbohydrate counting alone; carbohydrate consistency; plate method; or exchange lists, food lists and carbohydrate choices as carbohydrate management strategies on medication usage were identified. No studies were identified that reported on the impact of implementing carbohydrate management strategies on glucose-lowering medications. Long-term studies are needed to investigate these approaches. Grade II
      • The majority of studies based on carbohydrate counting using insulin-to-carbohydrate ratios reported no significant impact of this carbohydrate management strategy on total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and blood pressure in adults with type 1 diabetes and type 2 diabetes on multiple daily injections of insulin (MDI) or insulin pump therapy (Diabetes Control and Complications Trial Research Group, 1993; DAFNE Study Group, 2002; Bergenstal et al, 2008; Speight et al, 2010; Trento et al, 2011). No studies evaluating effectiveness of carbohydrate counting alone; carbohydrate consistency; plate method; or exchange lists, food lists and carbohydrate choices as carbohydrate management strategies on CVD risk factors were identified. Subjects did not have or were not described as having any disorders of lipid metabolism or hypertension. Long-term studies are needed investigating these approaches, especially in adults with diabetes who have disorders of lipid metabolism and hypertension. Grade II
      • Four studies based on carbohydrate counting using insulin-to-carbohydrate ratios reported significant improvements in quality of life at six and 12 months, which were maintained at 30 months and 44 months, in adults with type 1 diabetes on multiple daily injections of insulin (MDI) or insulin pump therapy (DAFNE Study Group, 2002; Speight et al, 2010; Laurenzi et al, 2011; Trento et al, 2011). No studies evaluating effectiveness of carbohydrate counting alone; carbohydrate consistency; plate method; or exchange lists, food lists and carbohydrate choices as carbohydrate management strategies on quality of life were identified. No research was identified on carbohydrate management strategies and quality of life in subjects with type 2 diabetes. Long-term studies are needed investigating these approaches. Grade I
      • Three studies based on carbohydrate counting using insulin-to-carbohydrate ratios reported either no significant changes or a decrease in weight, waist circumference and BMI in adults with type 1 diabetes and type 2 diabetes on multiple daily injections of insulin (MDI) or insulin pump therapy (DAFNE Study Group, 2002; Laurenzi et al, 2011; Trento et al, 2011). However, one study reported a modest increase in weight of approximately 2.3% over six months in subjects with type 2 diabetes (Bergenstal et al, 2008) and one study reported a modest increase of approximately 1.5kg over 44 months in subjects with type 1 diabetes (Speight et al, 2010). No studies evaluating effectiveness of carbohydrate counting alone; carbohydrate consistency; plate method; or exchange lists, food lists and carbohydrate choices as carbohydrate management strategies on weight management were identified. Long-term studies are needed investigating these approaches. Grade II
      From the 2013 American Diabetes Association Nutrition Therapy Recommendations
      • For individuals with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate-counting meal planning approach can result in improved glycemic control. Grade A
      • For individuals using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia. Grade B
      • A simple diabetes meal planning approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes identified with health and numeracy literacy concerns. This may also be an effective meal planning strategy for older adults. Grade C
      • The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. Grade A
      • Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control. Grade B
      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization
      • For individuals with type 1 diabetes, participation in an intensive, flexible insulin therapy education program using the carbohydrate-counting meal planning approach can result in improved glycemic control. Grade A
      • For individuals using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce hypoglycemia risk. Grade B
      • A simple diabetes meal-planning approach, such as portion control or healthful food choices, may be better suited to individuals with type 2 diabetes with health and numeracy literacy concerns. This strategy also may be effective for older adults. Grade C
      • Carbohydrate amount and available insulin may be the most important factors influencing glycemic response after eating and should be considered when developing the eating plan. Grade A
      • Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains critical in achieving glycemic control. Grade B
      Approaches to Glycemic Treatment
      • Most people with type 1 diabetes should be treated with multiple-dose insulin (MDI) injections (three to four injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII). Grade A
      • Most people with type 1 diabetes should be educated in how to match prandial insulin dose to carbohydrate intake, pre-meal blood glucose and anticipated activity. Grade E
      • Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. Grade A
      • Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacological agent for type 2 diabetes. Grade A
      • In patients with newly diagnosed type 2 diabetes and markedly symptomatic or elevated blood glucose levels or A1C, consider initiating insulin therapy (with or without additional agents). Grade E
      • If non-insulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target over three months, add a second oral agent, a GLP-1 receptor agonist or basal insulin. Grade A
      • A patient-centered approach should be used to guide choice of pharmacological agents. Considerations include efficacy, cost, potential side effects, weight, co-morbidities, hypoglycemia risk and patient preferences. Grade E
      • Due to the progressive nature of type 2 diabetes, insulin therapy is eventually indicated for many patients with type 2 diabetes. Grade B

    • Recommendation Strength Rationale

      • Conclusion Statements in support of this recommendation were given Grades I and II
      • The 2013 American Diabetes Association Nutrition Therapy Recommendations received Grades of A, B and C
      • The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades of A, B, C and E.

    • Minority Opinions

      Consensus reached.