DIABETES CONTROL AND COMPLICATIONS TRIAL
Nutrition interventions for intensive
therapy inthe Diabetes Control
and Complications Trial
THEDCCTRESEARCH GROUP
ABSTRACT: As part of an intensive treatment regimen that
had as its goal achieving and maintaining blood glucose levels
in the normal range in individuals with insulin-dependent
diabetes mellitus, dietitians in the Diabetes Control and
Complications Trial implemented varying nutrition
intervention strategies to counsel patients to attain
normoglycemia. Dietary management encompassed
recommendations on altering insulin dosages for varying food
intake. Nutrition intervention was tailored to best meet a
participant's life-style, motivation, ability to grasp information,
diet history, and specific intensive insulin therapy. Dietitians
were integral participants in the team management of
individuals in the intensive treatment group. Selected nutrition
interventions-Healthy Food Choices, exchange systems,
carbohydrate counting, and total available glucose-and
behavior management approaches were coupled with
intensive insulin therapy. Case presentations illustrate each
nutrition intervention in the attainment of normoglycemia.
JAm DietAssoc. 1993; 93:768-772.
Preparedforthe DCCT by: Ellen J Anderson, MS, RD;
Maryanne Richardson,RD; Gay Castle, RD; Susan Cercone,
MS, RD; Linda Delahanty, MS, RD; Rachel Lyon, MS, RD;
Dru Mueller, MS, RD; Linda Snetselaar, PhD,RD
E J Anderson (corresponding author) is with the
DiabetesResearch Center and L. Delahanty is with the
Department ofDietetics, Diabetes Controland
Complications Trial (DCCT), Massachusetts General
Hospital, Boston, MA 02114; M Richardson is with the
DCCT, The New York Hospital, Cornell UniversityMedical
College, New York, NY 10021; G. Castle is with the DCCT,
InternationalDiabetes Center Minneapolis, MN 55416; S.
Cercone is with the DCCT,University of Texas,
Southwestern Medical Center at Dallas,Department of
InternalMedicine, Dallas, TX 75235;R. Lyon is with the
DCCT, ClinicalResearchFacility, University of California-
San Diego, La Jolla, CA 92093; and D Mueller and L.
Snetselaarare with the DCCT, The University of Iowa,
GeneralHospital, Department of InternalMedicine, Iowa
City, IA 52242.
Address reprint requests to: DCCTResearch Group, Box
NDIC/DCCT,Bethesda, MD 20892.
768 / JULY 1993 VOLUME 93 NUMBER 7
atient adherence to therapeutic diets is a critical compo
nent for the effective control of blood glucose levels in
diabetes. Dietary modifications coupled with daily insu-
lin schedules, glucose monitoring, safety measures, and
exercise routines constitute a diabetic regimen that is "com-
plex, of life-long duration, and requires many behavior changes
on the part of the patient" (1, p 594). Meichenbaum and Turk
(2) state that compliance decreases with the complexity of the
regimen; thus, one of the greatest challenges faced by health
professionals who treat individuals with diabetes is to simplify
and streamline nutrition intervention priorities. This need,
coupled with the goal of normoglycemia in the Diabetes Control
and Complications Trial (DCCT) experimental group (3), has
provided DCCT dietitians with a unique opportunity to use a
variety of nutrition interventions as well as behavioral manage
ment approaches.
This article describes how selected nutrition interventions-
Healthy Food Choices, exchange systems, carbohydrate count-
ing, and total available glucose (TAG)-were coupled with
intensive insulin therapy (4-6) to attain normoglycemia in
subjects in the DCCT. Detailed descriptions of the nutrition
interventions can be found elsewhere (7,8). Dietary guidelines
for the DCCT are listed in Figure 1 (9). Dietitian counseling
using these meal-planning approaches helps individuals learn
how to adjust insulin and food intake to achieve target blood
glucose levels. Lower hemoglobin Al, (HbAc) levels in subjects
in the DCCT experimental treatment group have been associ-
ated with three specific dietary behaviors: compliance with the
meal plan, adjustment of insulin dose on the basis of expected
food intake, and appropriate treatment of hypoglycemia (10).
Nutrition intervention for each DCCT participant is deter-
mined according to initial diet history and food records, type
and method of insulin delivery, life-style, motivation, and ability
to grasp information. Each clinical center was encouraged to
implement the strategy with which they were most familiar and
comfortable. Some centers used a single nutrition intervention
uniformly whereas other centers varied the choice of interven
tions for different patients.
NUTRITION INTERVENTIONS
Healthy Food Choices
In the DCCT, Healthy Food Choices is used as the primary
nutrition intervention at 2 of the 29 clinics 50% to 70% of the
time. An additional 11 clinics use this approach 20% to 40% of
the time whereas 9 clinics use Healthy Food Choices less than
10% of the time. Because Healthy Food Choices was designed
for a 6th- to 7th-grade reading level and has a low to moderate
degree of complexity, simplification of a meal plan can facilitate
learning and, therefore, increase consistency in food intake.

Insulin adjustment The use of Healthy Food Choices may

make adjustment of premeal insulin boluses less precise;
however, it is accurate enough to devise insulin algorithms that
provide adequate insulin coverage for food eaten so that
normoglycemia is achieved. Furthermore, it is a simple way to
teach patients to adjust insulin in response to occasional
dietary deviations.

Considerations Dietitians within the DCCT have found that

Healthy Food Choices is a useful tool with individuals for whom
simplification of the diabetes regimen is necessary. These
individuals may find alternative approaches too complex and
the amount of information overwhelming. In addition, the effect
on blood glucose of various food items and portion sizes can be
identified so that the meal plan can be refined on the basis of
individual preferences.

Case scenario E.D.F is a 39-year-old man who has had type I

diabetes for 12 years. He was randomized to the DCCT
experimental treatment group with a baseline HbA 1 c of 8.0%.
He had previously been instructed on how to use an exchange
diet, but had difficulty understanding his diet. E.D.F was
hospitalized for 1 week to initiate insulin pump therapy.
The nutrition education component was kept very basic. On
the first day, the importance of the diet in achieving nor-
moglycemia was discussed. The subject's meal plan was devel-
oped on the basis of food records and diet history. Healthy Food
Choices was explained, and E.D.F. was asked to complete a
worksheet that asked for examples and appropriate amounts of
foods to equal one serving of each of the six food groups. On the
second day, favorite foods and portion sizes were added to the
Healthy Food Choices. E.D.F planned a 3-day sample menu
using the Healthy Food Choices. On the third day, his previous
food records were reviewed and appropriate changes were
made so that foods and portions matched the new meal plan. A
few fast-food menus were planned. E.D.F. memorized his meal
plan and serving sizes at discharge. He was instructed to trans-
late his meal plan into day-to-day food choices and was asked to
keep records of foods eaten, blood glucose levels (11), insulin
dosages, and exercise after discharge.
For 2 months after discharge, E.D.F. was seen weekly by the
clinical nurse specialist and dietitian, then biweekly He kept
daily food records initially for several months and then peri-
odically thereafter. Education about fiber, the step 1 (National
Cholesterol Education Program) diet, sweeteners, label reading,
and adjustment of insulin for varying meals was gradually
introduced over many months. Other dietary topics were also
covered as questions arose.
One year later, E.D.E's HbA,. was 6.3%. During the year, he
did not experience severe hypoglycemia and his weight had
remained at 100% of ideal. He reported that Healthy Food
Choices is simple and flexible enough to follow in most
situations and still achieve nearly normal blood glucose control.
Exchange System
DCCT dietitians use the exchange system for meal planning
(12,13) to provide a variety of food choices while maintaining
the consistency in meal content necessary to achieve glycemic
control and a well-balanced intake. The exchange system was
used more often than Healthy Food Choices. Nine DCCT clinics
used exchanges 10% to 40% of the time, 11 centers 50% to 70%,
and 6 centers used the exchanges 80% or more.
FIG 1. Dietary guidelinesfor the Diabetes Control and
Complications Trial (9). aThe study protocol was
amended July 1988 consistent with the National
CholesterolEducation Programstep guidelines, ie,
intake of cholesterol <300mg/day, totalfat <30% oj'
total energy, saturatedfatty acids <10% of total energy,
polyunsaturatedfattyacids up to 10% of total energy,
monounsaturatedfattyacids 10% to 15% of total energy.
The DCCT participant and dietitian work together to formu-
late an exchange system meal plan according to energy needs,
life-style and schedule, insulin type and regimen, and food
preferences. Once blood glucose goals are met, the DCCT
participant may experiment with more flexibility in the meal
plan. Because carbohydrate affects blood glucose levels more
than protein or fat, the starch/bread, fruit, and milk groups are
emphasized. Because the carbohydrate content of one starch,
fruit, or milk exchange is similar, these foods can be substituted
for one another, although attention to the macronutrient
composition should be considered. This provides more flex-
ibility but continues to promote a consistent carbohydrate
intake and a predictable blood glucose response.
Insulin adjustment Food intake can be increased or decreased
and corresponding adjustments made in insulin dose. Some
dietitians use as a rule of thumb one unit of Regular insulin to
cover 10 to 15 g carbohydrate (or one starch, fruit, or milk
exchange) as a starting point and then individualize the
supplement on the basis of food intake and blood glucose
records. For example, if an individual planned to eat a pasta
dinner with garlic bread containing two additional starch
exchanges, two to three units of Regular insulin would be added
to the usual dose of insulin taken at dinner, Conversely, if an
individual wished to omit one fruit exchange from a meal
without substituting another carbohydrate-containing food,
one unit of Regular insulin would be subtracted from the usual

JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 769

 DIABETES CONTROL AND COMPLICATION8 TRIAL
_ I
FIG 2. Carbohydratecounting planforsubject X YZ
meal dose. After insulin adjustments are made, it is important to
look at postprandial blood glucose values to assess how well the
adjustment appeared to work. Written notes on how much
Regular insulin was required to cover favorite or frequently
consumed meals are encouraged as reference for future use.
Considerations The exchange system can be an effective
meal-planning method to achieve normoglycemia while provid-
ing life-style flexibility as well as structure to promote consist-
ent intake of carbohydrate, protein, fat, and energy.A consistent
energy intake is beneficial in helping to minimize the weight
gain sometimes observed in intensive therapy The structure
provided by the protein and fat exchange lists also helps meet
the goals for reducing intake of dietary cholesterol and satu-
rated fat to reduce the risk of cardiovascular disease in
individuals with diabetes. However, individuals applying this
method need to be aware of the carbohydrate variability of food
items within an exchange group and the effect that such
differences may have on glycemic control. Adjustments may
need to be made in insulin dose or food intake on the basis of
these observed effects.
Case scenario A.B.C. is a 34-year-old woman who has had type
I diabetes for 6 years. When A.B.C. entered the DCCT, her insulin
regimen consisted of one injection of insulin per day, and her
only dietary practice was to avoid sweets. Her weight was 116%
of ideal and her HbAIC was 10.2%.
After randomization into the experimental treatment group,
A.B.C. was hospitalized for initiation of intensive insulin therapy
and diabetes education. Nutrition assessment revealed that
A.B.C. was a very structured person who was determined to
meet the treatment goals of the experimental treatment group.
The dietitian and A.B.C. worked out an initial meal plan using
the exchange lists, according to A.B.C.'s life-style, likes and
dislikes, and desire for weight control. The meal plan consisted
of 1,600 kcal/day with 45% energy intake from carbohydrate,
20% from protein, and 35% from fat. A.B.C. began an insulin
regimen consisting of NPH and Regular insulin in the morning,
Regular at dinner, and NPH at bedtime. By the time A.B.C. was
discharged from the hospital, she was able to choose foods from
a menu according to her meal plan, and was able to write out
sample menus using the exchange lists.
A.B.C. was seen monthly by the dietitian and consistently
reported that she was having no problems with the meal plan.
Her readiness to learn allowed her to become adept at using the
exchange lists with her own recipes and when she ate out. At the
end of 1 year, her HbA, level was 6.1%, but her weight had
climbed to 130% of ideal. During the following months, glycemic
control remained steady, and A.B.C. decided that she was ready
to lose weight. She followed a meal plan of 1,000 kcal/day,
continued to use the exchange system, and paid close attention
to accurate portion control. Further education in the exchange
system was minimal at this point; A.B.C. simply decided to apply
770 / JULY 1993 VOLUME 93 NUMBER 7
the knowledge she had. She also increased her activity level, and
slowly lost weight without compromising glycemic control.
Carbohydrate Counting
Carbohydrate counting is a meal-planning approach focusing
on the amount of carbohydrate eaten. It follows the assumption
that carbohydrate is the major factor influencing postprandial
glucose excursions. The amount of carbohydrate in a meal
affects insulin requirements more than the amount of protein or
fat (14). Carbohydrate counting is the primary dietary strategy
used in the United Kingdom (15). This regimen is used by five
DCCT clinics as the nutrition intervention approach for 70% or
more of their subjects.
Consistent carbohydrate intake facilitates insulin adjustment
and minimizes blood glucose variability secondary to variable
food intake. Carbohydrate counting provides greater precision
in estimating carbohydrate intake than either Healthy Food
Choices or the exchanges.
Insulin adjustment Participants in the DCCT experimental
treatment group who use carbohydrate counting are taught
how to adjust insulin dose on the basis of a ratio of Regular
insulin to gram carbohydrate intake. The ratio of Regular insulin
to gram carbohydrate intake is individualized and determined
by blood glucose results and may vary from meal to meal. For
example, an individual may need one unit for each 10 g
carbohydrate at breakfast, but may need one unit for each 15 g
carbohydrate at dinner. For each 15 g carbohydrate added or
subtracted from each meal or snack, an adjustment of 1 to 2
units of Regular is typically suggested (16-19). However, be
cause insulin requirements can vary dramatically with body
weight and activity, each person's requirement must be individ-
ualized. Where one person needs one unit per 10 g carbohy-
drate, another may need 4 units. Multiple factors, such as insulin
type(s), weight gain or loss, and activity level, will affect these
ratios.
The amount of protein and fat may also affect this ratio but to
a lesser degree than carbohydrate. If the patient is being closely
followed and blood glucose values are evaluated with ongoing
discussions about food intake, this effect will be noted. For
example, an atypical increase or decrease in the amount of
protein in a meal may increase or decrease insulin require-
ments. An individual who doubles his or her protein intake may
be able to note an increased insulin requirement.
Considerations Carbohydrate counting attempts to reduce
regimen complexity while focusing on the major contributor to
blood glucose levels. Simplifying the regimen allows the individ-
ual to focus on some of the other changes in behavior mandated
by the DCCT experimental treatment regimen. For individuals
who have been discouraged or frustrated by previous dietary
methods, carbohydrate counting may provide renewed interest
and motivation. Diabetes self management is encouraged by
allowing the patient to observe the relationship between
quantities of carbohydrate consumed and insulin dose in
relation to blood glucose levels. Although carbohydrate count
ing ignores variations in glycemic effect of different carbohy
drate sources, the significance of the glycemic index in a mixed
meal may be minimal (20). Attention must also be given to the
percentage of energy from protein and fat. Persons using
carbohydrate counting have been shown to have a higher
contribution of energy from fat (51%) and a lower percentage of
energy from carbohydrate (34%) (16).
Because carbohydrate counting is not the traditional ap
proach for nutrition management of diabetes, physicians and
health care team members have challenged and questioned the
reliability of this approach. DCCT dietitians have demonstrated
that the carbohydrate counting approach can facilitate the
attainment of blood glucose goals.

Case scenario X.YZ. was randomized into the experimental

treatment group at the age of 20 with a baseline HbAlc of 9.8%.
He was 5 feet 8 inches tall and at his desired weight of 142 lb.
X.Y.Z. had had diabetes for 18 months and before the DCCT had FIG 3. Total availableglucose (TAG) system using the
not received nutrition intervention. At randomization, he at- Exchange Listsfor Meal Planning(11).
tended school and worked evenings. He lived with his mother,
who prepared traditional ethnic meals that included many
foods the patient could not identify in English. In addition to Total Available Glucose
home-cooked meals, food was consumed at diners or a friend's The total available glucose (TAG) (21) meal-planning strategy
home or was purchased at convenience stores and fast-food defines foods in terms of the amount of glucose derived from
outlets. The number and frequency of meals and snacks was foods consumed. TAG is based on research on the glu-
based on appetite. During his hospitalization after randomiza- coneogenic properties of certain proteins (22). The TAG
tion, X.YZ. was taught blood glucose monitoring, insulin approach assumes that 100% of carbohydrate, 58% of animal
kinetics with appropriate meal and snack timing, signs and protein, and 10% of fat will be available as glucose for cellular
appropriate treatment of hypoglycemia, use of glucagon, and use. By giving each meal and snack a total TAG allotment,
sick-day management. He was begun on 3 to 4 daily insulin individuals can vary intake without going over the recom-
injections-NPH/Regular at breakfast and dinner; Regular at mended grams of TAG. TAG can be applied to the exchange
lunch and evening snack as necessary. system (Figure 3).
In addition, he received an overview of the effect of nutrients TAG, in combination with an exchange system, can result in
on blood glucose levels, emphasizing the difference among blood glucose control in compliant individuals who desire
carbohydrate, protein, and fat. In light of all the new behaviors specific knowledge of the glucose contribution of carbohydrate,
X.Y.Z. had to integrate into his life-style, the carbohydrate protein, and fat. For most DCCT participants, the nutrition
counting approach was selected for its simplicity. This ap- education received before the DCCT was based on the ex-
proach was preferred as X.YZ. consumed many foods that were change system. The rationale for using both systems was the
difficult to identify because of the ethnic nature of his diet, as hope that starting with the familiar and relating it to a newer
well as his lack of familiarity with food preparation. For X.Y.Z, a regimen would help to ensure success with new concepts. TAG
meal plan was devised based on 30 kcal/kg (1,900 kcal) with was used by two centers as the primary nutrition intervention.
50% of total energy distributed as carbohydrate. To simplify In other centers, TAG was used in selective patient situations
carbohydrate counting, each meal and snack portion was that might include the use of TAG for individuals with evening
rounded off (Table 2). X.Y.Z. was instructed to focus on his snacks consisting of animal protein.
carbohydrate portions, and to continue consuming protein and
fat in his usual portion sizes. He was provided with a list of Insulin adjustment Several guidelines help cover TAG intake
carbohydrate-containing foods in 15-g carbohydrate portions, with insulin. As a general rule, one unit of Regular insulin covers
grouped as breads, cereals, crackers, grains, starchy vegetables, approximately 10 to 15 g TAG; however, in practice, as with
and fruit. X.Y.Z. was asked to keep written records of blood carbohydrate counting, this algorithm is unique to the individ-
glucose, insulin, food intake in grams of carbohydrate, and ual. For each subject, the ratio of TAG to insulin depends on the
activity At the time of discharge, he verbalized anxiety about time of day and activity. The ratio may be different at breakfast
incorporating the many new behaviors into his life-style. than at lunch or supper, and the timing of peak actions of
Two weeks after hospitalization, X.YZ. had complete and intermediate insulins must be considered.
thorough documentation of food intake, insulin, and blood When introducing TAG to a patient, the determination of this
glucose data. He asked questions that demonstrated consider- ratio requires frequent interaction between the individual and
able analysis of his blood glucose fluctuations. The major dietitian using food records and blood glucose results to find the
problem at this time was his difficulty in including all three right match of insulin for TAG to achieve target blood glucose
snacks consistently After a review of the rationale for snacks, he levels. For example, in a given patient with a preprandial blood
chose to continue trying to incorporate them until his next glucose of 3.9 to 6.7 rrmmol/L x, three units of Regular insulin may
follow-up visit in 2 weeks. X.YZ. demonstrated considerable be given to cover 45 g TAG at breakfast, equivalent to one unit of
ability to grasp this simplified approach to food intake. insulin for every 15 g TAG. If this patient planned to increase
X.YZ. continued to follow his gram carbohydrate meal plan food intake at this meal to 60 g TAG or an increase of 15 g over
although planned monthly follow-up visits with the dietitian the recommended TAG, one additional unit of Regular insulin
were overshadowed by a medical crisis. At the patient's visit 12 would be needed. Alternatively, only 2 units would be needed for
months after randomization, his HbA, was 6.6% and his weight a smaller breakfast containing 30 g TAG.
had increased by 4 lb. Nutrition assessment documented that
X.Y.Z. was following the prescribed grams carbohydrate, and Considerations As a consequence of the flexibility associated
was continuing to consume appropriate amounts of protein and with using TAG, several areas require additional monitoring.
fat. Foods causing exaggerated or unexpected blood glucose Unlike the exchange system, the TAG system does not take into
excursions were identified and discussed in detail. For X.YZ., a consideration the fat or vegetable protein calories contributed
ratio of 1 unit Regular insulin to 20 g carbohydrate was observed
for lunch and dinner; with a ratio of 1 unit to 15 g carbohydrate
at breakfast.
Over the next year, monthly HbA, levels were between 5.8)/o 'To convert mmol/L glucose to mg/dL, multiply mmol/L by 18.0. To
and 6.6% and the patient remained at approximately 100% ideal convert mg/dL glucose to mmol/L, multiply mg/dL by 0.555. Glucose of
body weight. 6.0 mmol/L = 108 mg/dL.

JOURNAL OF THE AMERICAN DIETETIC ASS()IATION 771

by the diet. Patients may be consuming a high-caloric diet but
have normal blood glucose levels. Many individuals may misuse
the idea that fat contributes little to blood glucose elevation. If
fat is "free," individuals may think that fat may be added to
meals when a TAG limitation is exhausted in the meal plan. In
addition, TAG can achieve optimal blood glucose results without
adequate nutrient intake. The combination of TAG with the
exchange system ensures more adequate nutrient intake.
The TAG system is a precise way of calculating the available
glucose in foods. It allows for the most precise adjustment of
premeal insulin boluses of any of the methods discussed
previously. Although it is similar to the carbohydrate counting
system, the TAG system has the added advantage of including
the available glucose coming from animal protein. Experience
with this system has shown that patients can control their blood
glucose levels effectively.
Case scenario C.P.D. is a 30-year-old man who has had
diabetes for 12 years and who had a HbA,1 of 7.2% at
randomization. His HbA1, was 5.9% after he had been using the
TAG regimen and insulin pump therapy for 1 year. A dietitian,
along with the team, saw him once a month with calls from a
nurse 1 to 3 times a week. Recommended meal and snack
patterns were constructed for his daily nutrient intake. C.P.D.'s
blood glucose levels were near normal but fat intake was
causing weight gain and elevation of lipids. His diet was checked
very carefully to determine where caloric intake was contribut-
ing to weight gain. The patient was doing everything requested
in terms of following TAG; but the breakfast contained 127 kcal
more than the recommended meal plan and a saturated fat
intake of 14.4 g.
After in-depth nutrition education on the fat and saturated
fat content of breakfast food selections, C.P.D. was able to alter
breakfast intake to reduce saturated fat and energy levels.
Calculated TAG for the low-fat breakfast is approximately 5.4
TAG less than his high-fat breakfast. With the decrease in TAG,
Regular insulin for his breakfast meal might be reduced to avoid
hypoglycemia after breakfast. An alternative suggestion might
be to add 4.6 g TAG, such as one third fruit exchange. For C.PD.,
decreasing Regular insulin was recommended because weight
gain was a concern and to be consistent in the nutrition
message of controlling blood glucose with less TAG and,
therefore, less energy. With C.PD.'s adherence to the low-fat
breakfast pattern and emphasis on the fat content of frequently
eaten foods his weight has come down. He is able to maintain a
low HbA, while avoiding hypoglycemia when altering his food
selections. The TAG system works well in keeping blood glucose
levels in control, but an emphasis on fat intake is also essential.
SUMMARY
Following a consistent meal plan and the ability to adjust insulin
dose with planned food variations seems to be critical in
maintaining normoglycemia. Dietary variation may be influ-
enced by premeal/presnack blood glucose and/or planned/
spontaneous exercise. The different nutrition interventions
have distinctive and varying characteristics of structure and
complexity. The choice of nutrition intervention depends on
both the dietitian's experience with the different strategies and
on which approach best meets the individual needs of the
DCCT participant. ·
The DCCT is supported by the Division of Diabetes,
Endocrinology and Metabolic Disease of the National
Institute of Diabetesand Digestive and Kidney Diseases,
NationalInstitutes of Health, through cooperative
agreements and a researchcontract.Additional support or
772 / JULY 1993 VOLUME 93 NUMBER 7
technicalassistance has been provided by the National
Institute of Neurologic and Communicative Disordersand
Stroke; the NationalHeart, Lung,andBlood Institute;,the
NationalEye Institute, and the Division ofResearch
Resources, National Institutes ofHealth.
David M Nathan, MD, is Chairman f the DCCTEditorial
Board.
A complete listing of the DCCTResearchGroup is
availableas NTIS document PB-882339108, DCCT
Research Group, 1988.
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