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t least 20% of persons 65 years of age or above and 26% of long-term care facility residents have diabetes, while the annual cost of caring for residents with diabetes in nursing facilities is estimated at $6 billion.^1,2 But can the health and medical management of residents with diabetes in long-term care be better controlled through the use of a “diabetes diet”? And, if so, which guidelines should the diet follow?
       The diabetes diet has been the subject of numerous research projects.² Even though the research is available, there continue to be many misconceptions concerning nutrition and diabetes. In clinical practice, nutrition recommendations that have little or no supporting evidence have been, and still are being, given to persons with diabetes.^3,4 After years of restricting certain foods and following complicated diet plans, health practitioners and residents with diabetes and their families are finding it difficult to give up the old dietary rules and regimens.

Results of Research

       A recent study² in long-term care did not show a significant change in the blood glucose control between 2 groups of residents with diabetes. One group received a “no concentrated sweets” diet and the second received the regular facility diet.
       Long-term care residents eat better when they are given a less restrictive diet of regular foods rather than a calorie-controlled diet. According to the American Diabetes Association (ADA)’s most recent position statement, “The imposition of dietary restrictions on elderly residents with diabetes in long-term health facilities is not warranted.” Additionally, there is no evidence to support “no concentrated sweets” or “no sugar added” diets. It is preferable to make medication changes rather than implement food restrictions to control blood glucose.⁴ It is important to understand the effects of the following types of nutrition on residents with diabetes.
       Carbohydrates. With regard to the effect of carbohydrates (eg, starches, sugar, and fiber) on the blood glucose level (also called the glycemic effect), the total amount of carbohydrates in meals and snacks is more important than the source or type of carbohydrate.³
       Restricting foods containing sucrose (eg, common table sugar) does not lead to improved glycemic control.² For individuals receiving fixed dosages of insulin, day-to-day consistency in the amount of carbohydrate consumed is important.³ There is no reason to recommend that residents with diabetes avoid naturally occurring fructose in fruits, vegetables, and other foods.³
       Protein. For residents with diabetes, there is no evidence to suggest that usual protein intake (ie, 15–20% of total daily energy) should be modified if renal function is normal.³ The effects of protein on regulation of energy intake, satiety, and long-term weight loss have not been adequately studied. The long-term efficacy and safety of high-protein, low-carbohydrate diets remain unknown. The long-term effects of such diets on plasma low-density lipoprotein (LDL) cholesterol is also a concern.³
       Fat. The primary dietary fat goal in persons with diabetes is to limit saturated fat and dietary cholesterol intake.³
       Micronutrients. Residents with diabetes should be educated about the importance of consuming adequate amounts of vitamins and minerals from natural food sources as well as the potential toxicity of very large doses of vitamin and mineral supplements.³ Supplementation with a daily multivitamin may be beneficial.³
       In residents with diabetes, there is no evidence to suggest long-term benefit from herbal preparations. Such preparations also have the potential to interact with medications. Therefore, it is important for healthcare providers to be aware when residents with diabetes are using these products.³
       Alcohol. If individuals choose to drink alcohol, daily intake should be limited to 1 drink for adult women and 2 drinks for adult men. (A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits).³ To reduce risk of hypoglycemia, alcohol should be consumed with food.³
      Dietetic Foods. Residents with diabetes do not have to eat “special” foods or “diet” foods.³

One Resident’s Story

       Take for example the wife of a resident with dementia who has been transferred from home to a long-term care facility. The physician ordered a “no concentrated sweets” diet and advised the resident’s wife to omit “all white foods.” The resident’s wife is upset with her husband’s recent elevated blood sugar levels in the long-term care facility and feels they are due to the long-term care facility menus. An interview by the registered dietitian (RD) reveals that the resident’s wife has been giving her husband a low-carbohydrate diet at home in attempt to control his blood glucose levels and that the resident had experienced a significant weight loss of 20 lbs prior to his admission to the long-term care facility.
       The resident’s last adjustment of diabetes medication was more than 6 months ago. The resident’s wife visits the long-term care facility daily and continues to “control” her husband’s diet by eliminating foods with carbohydrates from his meals and limiting snack foods on his meal plan. She does allow him to have sugar-free snack foods at night, which she perceives to be healthy. The resident has continued to lose weight in the long-term care facility, and he is experiencing hypoglycemic and hyperglycemic episodes. His height is 6 feet, and his weight is now 145 lbs.
       The negative outcomes are, however, apparent and include poor control of glucose levels due to the unbalanced nutrient intake in correlation with the prescribed medication regimen and unplanned weight loss due to limited calorie intake driven by the belief that severely restricting certain foods will improve blood glucose control.

The Need for Education

       To educate the resident and his or her family, encourage and reinforce a plan—one that includes a variety of foods and appropriate timing of meals and snacks and takes into consideration the resident’s physical activity level. Consistent timing of meals and carbohydrates is essential for control of blood sugar levels. In the long-term care setting, meals are served on a regular schedule, serving sizes are standardized, and menus are planned with the recommended distribution of carbohydrates, protein, and fat. Residents and their family members need to be reassured that the meals provided in the long-term care setting are meeting the current recommendations of the ADA.
       Residents and their family members often focus primarily on food as the culprit of elevated glucose levels. However, education that other factors have been shown to cause elevated glucose levels including stress and infections is needed.⁴ The fact that dietary restriction may be harmful to the resident’s quality of life needs to be communicated to the attending physician.² Provide the physician with current literature from the American Medical Directors Association (AMDA) or ADA that emphasizes the physician’s greater responsibility to control unacceptable blood glucose levels by pharmacological means and in consideration of the individual’s food consumption and activity level—not by an overly restrictive diet order.
       Nurses need to better understand current research and how it translates to what is served to residents at mealtime in order to properly reinforce diabetes education for residents and their families. Too often, nurses offer antiquated or conflicting information about foods that are not allowed and inappropriately influence the diabetic resident’s food choices.

Effective Strategies

       Obtaining, addressing, and abiding by the resident’s food preferences and eating habits are the first issues the facility must address for the long-term care resident. A meal plan should be developed with the resident and/or his or her family. Special circumstances like bringing food from home should be discussed. The goal is a mutually acceptable meal plan.
       The need for snacks should be based on the resident’s schedule and preference in conjunction with a medication regimen if hypoglycemia between meals, inconsistency in meal timing, and carbohydrate content are concerns. The timing of meals and snacks should be at regular intervals every day. Residents should not wait more than 4–5 hours without eating while awake and should not skip meals. It is important for them to eat a variety of foods and incorporate all of the food groups, including foods that provide carbohydrates (eg, starches, fruit, milk, no-starch vegetables, meats, fats, etc.).
       They should eat roughly the same amount of food each day and keep meals moderate in size. The actual amount of food needed depends on the resident’s size, age, and activity level. Residents should maintain a healthy weight; if overweight, they should consider a safe weight-reduction plan.

Conclusion

       New research and new medications have changed diabetes management, diabetes education, and the diabetes diet. The ADA diet is no longer appropriate. Eating healthfully, timing meals regularly, following menus consistent in the amount of carbohydrates, and watching a resident’s weight continue to be important to manage diabetes. Because of the complexity of nutrition issues for long term care residents, it is recommended for an RD knowledgeable and skilled in implementing nutrition therapy into diabetes management and education to be a member of the physician’s coordinated team.²