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Eating management for adults with diabetes

An Ellyn Satter Institute Position Statement

Eating management as a part of medical nutrition therapy for adults with diabetes and impaired glucose tolerance!

Inés Anchondo, Dr PH, RD, LD, CSP, MPH; Edie Applegate, MS, RD, LDN, CDE; Patty Nell Morse, RD, LDN, CDE; Ellyn Satter, MS, RD, MSSW

Nutrition therapy is an integral part of the treatment of diabetes mellitus and patient self-management. The goals of nutrition therapy are to improve or maintain quality of life, to improve nutritional status and  physiological health, to achieve individually determined target range blood sugars, and to prevent and treat the acute and long-term complications of diabetes and the associated co-morbid conditions.1

Apply ecSatter to adult diabetes management

The position of the Ellyn Satter Institute is that medical nutrition therapy for diabetes, pre-diabetes, and impaired glucose tolerance is best achieved through knowledgeable application of the Satter Eating Competence Model: ecSatter. ecSatter is based on the principle that internal cues of hunger, appetite and satiety, if properly attended to, are reliable and can be depended upon to guide energy balance and body weight and inform food selection. Those internal processes are supported by regular and reliable access to adequate amounts of a variety of rewarding food. Properly attended to and supported, internal cues and management of the eating context are in dynamic equilibrium with predominantly genetically determined body weight, tendencies for movement, and the broader environment.2

Regular eating times are critical

From the ecSatter perspective, the priority for managing diabetes is encouraging regular, structured eating patterns (thereby avoiding extremes of carbohydrate intake), managing food intake in accordance with internal cues, and accepting the weight that evolves from such structured, internally regulated eating. Health-at-every-size, non-diet interventions as well as structured meals have been shown to improve glucose metabolism3 as well as blood lipids.3,4,5

Institute structure; address meal composition

Instituting structure and addressing meal composition comprise the first—and possibly the only—steps for the individual with impaired blood glucose and blood lipids.

  • To improve parameters of carbohydrate metabolism, instead of prescribed calorie levels, grams of carbohydrate, or portion sizes of food, stress structured meals and snacks, include protein, fat and carbohydrate at each eating time, and eat to appetite at those structured times.
  • To increase variety in the diet and improve nutritional status, teach food acceptance skills.
  • Focus on weight stability instead of striving for weight reduction. If the individual’s ability to regulate food intake and stabilize body weight is compromised, prioritize increasing capability with respect to internal regulation of food intake.
  • Teach strategies for using fat rather than imposing a fat limit and prescribing types of fats: Encourage using a variety of fats. Encourage meal-planning to include low and high-fat foods. Depend on appetite cues to guide mealtime fat consumption.

Glucose-monitoring; activity

When partnered with competent eating, blood glucose monitoring is an essential tool in learning how food, activity and medication affect blood sugar. Teach self awareness relative to blood sugar: Too-low blood sugar can make them feel shaky; Too-high blood sugar can make them feel listless and even nauseated. If blood sugar is consistently too low or too high, encourage them to talk with their health care professional about adjusting medication. Enjoyable and sustainable physical activity provides many health benefits including helping to normalize blood sugars.

Strategies for nutrition education

ecSatter is a trust model approach. Wait to give advice until invited. Then address eating patterns in collaboration with the patient, join with individuals right where they are, respect individuals’ life circumstances, honor their choices about feeding themselves and emphasize their eating foods they find enjoyable.

  • Identify and preserve the positives of current food patterns.
  • Change gradually and as little as possible to achieve blood sugars, A1C, insulin and blood lipids that are as close as possible to desirable levels.
  • In recommending change, introduce the possibilities and offer choices, don’t lay out shoulds or oughts.


  1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelinesfor the prevention and management of diabetes in Canada. Can J Diabetes. 2003:S1-S152.
  2. Satter EM. Eating Competence: definition and evidence for the Satter Eating Competence Model. J Nutr Educ Behav. 2007;39 (suppl):S142-S153.
  3. Farshchi HR, Taylor MA, Macdonald IA. Beneficial metabolic effects of regular meal frequency on dietary thermogenesis, insulin sensitivity, and fasting lipid profiles in healthy obese women. Am J Clin Nutr. 2005;81:16-24.
  4. Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105:929-936.
  5. Hammond-Meyer A. Stabilizing Eating and Weight Using a Nondieting Treatment As a Means to Improve Biomedical Health Parameters in an Overweight Population of Women: A Health at Any Size Perspective [Dissertation] . Seattle, WA: Seattle Pacific University; 2005.



Secrets of Feeding a Healthy Family


Ellyn Satter’s ground-breaking Secrets of Feeding a Healthy Family breaks the spell of negativity and fear that permeates our eating. Ellyn Satter empowers and inspires us to love – and cook – our favorite foods and teach our children to do the same. Secrets of Feeding a Healthy Family helps us past the barriers to getting a meal on the table – and eating it. 

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