Carbohydrate Counting for Patients With Diabetes

Carbohydrate Carbohydrate Counting Counting

for Patients With for Patients With DiabetesDiabetes

Review Date 4/08 D-0503

Program PurposeProgram Purpose

To increase knowledge of To increase knowledge of carbohydrate-counting skills for carbohydrate-counting skills for those caring for patients with those caring for patients with diabetes diabetes

All health professionals should hAll health professionals should have ave a sound knowledge base of a sound knowledge base of carbohydrate counting—a skill carbohydrate counting—a skill needed by all health care needed by all health care professionals caring for patients professionals caring for patients with diabetes with diabetes

Program ObjectivesProgram Objectives

At the end of the session you will know At the end of the session you will know how to:how to:

Define carbohydrate countingDefine carbohydrate counting Identify the relationship between Identify the relationship between

carbohydrates and blood sugarcarbohydrates and blood sugar Determine the grams of carbohydrate Determine the grams of carbohydrate

in foods when using the nutritional in foods when using the nutritional food label and other carbohydrate-food label and other carbohydrate-counting toolscounting tools

Calculate the total grams of Calculate the total grams of carbohydrate/mealcarbohydrate/meal

Carbohydrate (CHO) Carbohydrate (CHO) Counting DefinedCounting Defined

A meal-planning approach for A meal-planning approach for all patients with diabetes, all patients with diabetes, based on the following ideas:based on the following ideas:

– Carbohydrate is the main nutrient Carbohydrate is the main nutrient affecting postprandial glycemic affecting postprandial glycemic responseresponse

– Total amount of carbohydrates Total amount of carbohydrates consumed is more important than consumed is more important than the source of carbohydratesthe source of carbohydrates

Benefits of Carbohydrate Benefits of Carbohydrate CountingCounting

More flexible than other meal-More flexible than other meal-planning methodsplanning methods

Sugar is not forbiddenSugar is not forbidden Focuses attention on the foods Focuses attention on the foods

that are most likely to make that are most likely to make blood glucose levels go upblood glucose levels go up

Foods That Contain Foods That Contain CarbohydratesCarbohydrates

Breads, cereals, pasta, and grainsBreads, cereals, pasta, and grains Rice, beans, and starchy vegetables Rice, beans, and starchy vegetables

(potatoes, corn, peas)(potatoes, corn, peas) Fruit and fruit juicesFruit and fruit juices Milk and yogurt Milk and yogurt Regular soda, fruit drinks, jelly Regular soda, fruit drinks, jelly

beans, and gum dropsbeans, and gum drops Cakes, cookies, and chocolate Cakes, cookies, and chocolate

candycandy

Grams of CarbohydrateGrams of Carbohydrate((per Food Categoryper Food Category))

Starch and Fruit: Starch and Fruit: 1 serving equals 1 serving equals about 15 g carbohydrateabout 15 g carbohydrate

Milk: Milk: 1 serving equals about 12 g 1 serving equals about 12 g carbohydrate carbohydrate

Vegetables: Vegetables: 1 serving equals about 5 1 serving equals about 5 g carbohydrateg carbohydrate

*Please see handout on *Please see handout on carbohydrate foodscarbohydrate foods

StarchesStarches

Starch GroupStarch Group

Each amount listed below=15 g carbohydrate1 oz of bagel, bread, roll (1 slice of bread, one fourth of a bagel)

¾ C unsweetened cereal (Cheerios®, Rice Krispies®, corn flakes)

⅓ C higher-carbohydrate cereals (raisin bran)

One half of an English muffin

⅓ C cooked pasta, spaghetti, macaroni and cheese

⅓ C cooked brown or white rice

½ C mashed potatoes

½ C corn, beans, chickpeas, peas

1 small baked potato (3 oz)

Fruits and Fruit JuicesFruits and Fruit Juices

Fruit GroupFruit Group

Each amount listed below=15 g carbohydrate1 small fresh fruit (4 oz)

½ C canned fruit (in natural juice)

2 Tbsp raisins

17 grapes

½ C fruit juice

1 C fresh fruit (cut up)

1 Tbsp jelly, jam

Milk and YogurtMilk and Yogurt

Milk GroupMilk Group

Each amount listed below=approximately 12 g carbohydrate

8 fl oz of skim, 1%, 2%, or whole milk

1 C plain yogurt

1 C plain or vanilla soy milk

Vegetables Vegetables

VegetablesVegetables

Vegetables are counted as 5 g Vegetables are counted as 5 g carbohydrate for the following carbohydrate for the following servings sizes:servings sizes: ½ C cooked vegetables ½ C cooked vegetables 1 C raw vegetables1 C raw vegetables

Foods Without Foods Without CarbohydrateCarbohydrate

Examples:Examples: Protein:Protein: Meat, fish, poultry, cheese, Meat, fish, poultry, cheese,

eggs, peanut butter, cottage cheese, tofueggs, peanut butter, cottage cheese, tofu Fat:Fat: Butter, oils, margarine, mayonnaise, Butter, oils, margarine, mayonnaise,

cream cheese, sour cream, nuts, seeds, cream cheese, sour cream, nuts, seeds, avocado, salad dressingavocado, salad dressing

Protein and fat groups contain 0 g Protein and fat groups contain 0 g carbohydratecarbohydrate

Carbohydrate and Carbohydrate and Noncarbohydrate Noncarbohydrate

CategoriesCategories Groups/Lists CHO Protein Fat Calories

Starch 15 3 ≤1 80

Fruit 15 0 0 60

Milk Skim Low fat Whole

121212

888

0-358

90120150

Other Carbohydrates 12 varies varies varies

Vegetables 5 2 0 25

Meat and Substitute Group Very lean Lean Medium fat High fat

0000

7777

0-1358

355575100

Fat Group 0 0 5 45

Relationship Between Relationship Between Carbohydrate and Blood Carbohydrate and Blood

SugarSugar The digestive system converts most The digestive system converts most digestible carbohydrates into glucose digestible carbohydrates into glucose (also known as blood sugar) (also known as blood sugar)

Cells are designed to use this as a Cells are designed to use this as a universal energy sourceuniversal energy source

As blood sugar levels rise in a As blood sugar levels rise in a nondiabetic individual, beta cells in the nondiabetic individual, beta cells in the pancreas churn out more and more pancreas churn out more and more insulin, a hormone that signals cells to insulin, a hormone that signals cells to absorb blood sugar for energy or absorb blood sugar for energy or storagestorage

Carbohydrate and Blood Carbohydrate and Blood Sugar in DiabetesSugar in Diabetes

Individuals with type 1 diabetes—the Individuals with type 1 diabetes—the pancreas does not make any insulin so pancreas does not make any insulin so their cells can't absorb sugartheir cells can't absorb sugar

Individuals with type 2 diabetesIndividuals with type 2 diabetes——the the pancreas does not make enough insulin pancreas does not make enough insulin or the insulin is not effective because or the insulin is not effective because the cells are insulin resistant the cells are insulin resistant

Carbohydrates begin to raise blood Carbohydrates begin to raise blood glucose within approximately 5 minutes glucose within approximately 5 minutes after initiation of food intakeafter initiation of food intake

Carbohydrates are converted to nearly Carbohydrates are converted to nearly 100% blood glucose within about 2 100% blood glucose within about 2 hourshours


The focus of carbohydrate The focus of carbohydrate counting is on the 1 nutrient that counting is on the 1 nutrient that most impacts blood glucosemost impacts blood glucose

Carbohydrate is the primary Carbohydrate is the primary nutrient affecting blood glucose nutrient affecting blood glucose levelslevels

Individuals can learn to relate Individuals can learn to relate carbohydrate intake with their carbohydrate intake with their blood glucose resultsblood glucose results


All patients with diabetes should test their blood glucose before and 2 hours after the first bite of the meal

This is the only way to tell how the choices and amount of carbohydrates consumed affect their blood sugar

Blood Sugar Target Blood Sugar Target RangesRanges

Fasting/before meals: 90-130 Fasting/before meals: 90-130 mg/dLmg/dL

After meals (2 hours after first After meals (2 hours after first bite): bite):

<180 mg/dL or 30-50 mg/dL <180 mg/dL or 30-50 mg/dL increase from premeal to increase from premeal to postmeal postmeal

Carbohydrate and Blood Carbohydrate and Blood Sugar in Diabetes—ExampleSugar in Diabetes—Example Mr. S consumed 90 g of Mr. S consumed 90 g of

carbohydrate for breakfast (day 1)carbohydrate for breakfast (day 1)– Blood sugar premeal=115 mg/dLBlood sugar premeal=115 mg/dL– Blood sugar postmeal=205 mg/dLBlood sugar postmeal=205 mg/dL

Mr. S consumed 45 g of Mr. S consumed 45 g of carbohydrate for breakfast (day 2) carbohydrate for breakfast (day 2) – Blood sugar premeal=125 mg/dLBlood sugar premeal=125 mg/dL– Blood sugar postmeal=150 mg/dL Blood sugar postmeal=150 mg/dL

Carbohydrate Carbohydrate SubstitutingSubstituting

When carbohydrate counting, it is When carbohydrate counting, it is possible to substitute 1 food item possible to substitute 1 food item for another for a similar impact on for another for a similar impact on blood glucoseblood glucose

Example: Exchange 1 small apple Example: Exchange 1 small apple (4 oz) for 2 small cookies for a (4 oz) for 2 small cookies for a similar effect on blood glucosesimilar effect on blood glucose

Food LabelsFood Labels

Total CarbohydrateTotal Carbohydrate——includes grams of includes grams of sugar, sugar alcohol, sugar, sugar alcohol, starch, and dietary starch, and dietary fiberfiber

Total Grams of Total Grams of CarbohydrateCarbohydrate——to to determine amount of determine amount of carbohydrate eaten,carbohydrate eaten,multiply grams of total multiply grams of total carbohydrates on the carbohydrates on the label by the number of label by the number of servings eatenservings eaten

Food LabelsFood Labels

Example: You just ate 10 Example: You just ate 10 crackers from the previous label crackers from the previous label

There are 2 crackers/serving There are 2 crackers/serving How many servings did you eat? How many servings did you eat?

– 55 How many total carbohydrates How many total carbohydrates

did you consume?did you consume?– 10 g/serving x 5 servings=50 g10 g/serving x 5 servings=50 g

Tools for Carbohydrate Tools for Carbohydrate CountingCounting

Nutrition Labels Measuring Tools

Carbohydrate Counting Carbohydrate Counting Hand GuideHand Guide

Carbohydrate Carbohydrate Allowances for Meals Allowances for Meals

and Snacksand Snacks Patients with diabetes should Patients with diabetes should

work with a registered dietitian work with a registered dietitian or certified diabetes educator to or certified diabetes educator to receive an individualized meal receive an individualized meal plan, which includes how many plan, which includes how many total carbohydrates they should total carbohydrates they should consume at meals and snacks consume at meals and snacks

A general guideline for patients is A general guideline for patients is 45-60 g/meal and 15-30 g/snack45-60 g/meal and 15-30 g/snack

Sample Menu BreakfastSample Menu Breakfast

1½ C of Cheerios=?1½ C of Cheerios=?Small banana (4 oz)=?Small banana (4 oz)=?8-fl-oz 1% milk=?8-fl-oz 1% milk=?1 egg=?1 egg=?

*See handout*See handout

How many carbohydrates are in How many carbohydrates are in this meal?this meal?

Sample Menu Breakfast Sample Menu Breakfast AnswersAnswers

1½ C Cheerios=30 g1½ C Cheerios=30 g

Small banana (4 oz)=15 gSmall banana (4 oz)=15 g

8-fl-oz 1% milk=12 g8-fl-oz 1% milk=12 g

1 egg=0 g 1 egg=0 g

TOTAL= 57 gTOTAL= 57 g

Sample Menu LunchSample Menu Lunch

2 slices of bread=?2 slices of bread=?17 grapes=?17 grapes=?1 C raw carrots=?1 C raw carrots=?3 oz tuna fish=?3 oz tuna fish=?1 tsp mayonnaise=?1 tsp mayonnaise=?



Sample Menu Lunch Sample Menu Lunch AnswersAnswers

2 slices of bread=30 g2 slices of bread=30 g

17 grapes=15 g17 grapes=15 g

1 C raw carrots=5 g1 C raw carrots=5 g

3 oz tuna fish=0 g3 oz tuna fish=0 g

1 tsp mayonnaise=0 g 1 tsp mayonnaise=0 g

TOTAL= 50 g TOTAL= 50 g

Sample Menu DinnerSample Menu Dinner

1½ C pasta=?1½ C pasta=?1 oz of bread=?1 oz of bread=?1 C salad =? 1 C salad =? 1 tsp olive oil=?1 tsp olive oil=?



Sample Menu Dinner Sample Menu Dinner AnswersAnswers

1½ C pasta=68 g1½ C pasta=68 g

1 oz of bread=15 g1 oz of bread=15 g

1 C salad =5 g1 C salad =5 g

1 tsp olive oil= 0 g1 tsp olive oil= 0 g

TOTAL=88 g TOTAL=88 g

ConclusionsConclusions Carbohydrate counting is a meal-Carbohydrate counting is a meal-

planning approach to help people planning approach to help people with diabetes attain and maintain with diabetes attain and maintain blood sugar control blood sugar control

Carbohydrate counting provides Carbohydrate counting provides flexibility and helps people increase flexibility and helps people increase their confidence to manage diabetes their confidence to manage diabetes

Patients should consult a registered Patients should consult a registered dietitian or certified diabetes dietitian or certified diabetes educator to help them master educator to help them master carbohydrate-counting skills carbohydrate-counting skills

ReferencesReferences Thomas E. Survey reveals shortfall in pediatric nurses' Thomas E. Survey reveals shortfall in pediatric nurses'

knowledge of diabetes. knowledge of diabetes. J Diabetes NursJ Diabetes Nurs. 2004;8:217-. 2004;8:217-221.221.

American Dietetic Association, American Diabetes American Dietetic Association, American Diabetes Association. Association. Exchange Lists for Meal PlanningExchange Lists for Meal Planning. 2nd ed. . 2nd ed. Alexandria, VA: American Diabetes Association; 2003. Alexandria, VA: American Diabetes Association; 2003.

American Diabetes Association. American Diabetes Association. Standards of Medical Standards of Medical Care in DiabetesCare in Diabetes. Diabetes Care. 2007;30:S4-S41.. Diabetes Care. 2007;30:S4-S41.

Warshaw H, Kulkarni K. Warshaw H, Kulkarni K. American Diabetes Association American Diabetes Association Complete Guide to Carbohydrate CountingComplete Guide to Carbohydrate Counting. . Alexandria, VA: American Diabetes Association; 2004.Alexandria, VA: American Diabetes Association; 2004.

Warshaw H, Bolderman K. Warshaw H, Bolderman K. Practical Carbohydrate Practical Carbohydrate Counting. A How to Teach Guide for Health Counting. A How to Teach Guide for Health ProfessionalsProfessionals. Alexandria, VA: American Diabetes . Alexandria, VA: American Diabetes Association; 2001.Association; 2001.

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Carbohydrate Counting for Patients With Diabetes