Carbohydrate Carbohydrate Counting in Youth Counting in Youth

with Type 1 Diabeteswith Type 1 DiabetesManagement of Diabetes in Youth, Biennial Management of Diabetes in Youth, Biennial Conference of the Barbara Davis Center for Conference of the Barbara Davis Center for

Childhood DiabetesChildhood DiabetesJuly 12-16July 12-16thth, Keystone, Colorado, Keystone, Colorado

David Maahs, Darcy Owen, Franziska BishopDavid Maahs, Darcy Owen, Franziska Bishop

OutlineOutlineOverview of data/literature on and Overview of data/literature on and rationale for carbohydrate counting in rationale for carbohydrate counting in diabetesdiabetesOverview of practical aspects of Overview of practical aspects of carbohydrate counting (i.e. what happens carbohydrate counting (i.e. what happens when the MD asks the RD to “teach them when the MD asks the RD to “teach them to carb count”)to carb count”)Current research at the BDC including a Current research at the BDC including a brief carb counting quizbrief carb counting quiz

Youth with Diabetes Do Not Meet Dietary Goals

(Mayer-Davis, JADA, ’06:689-97)

Figure. Percent of male and female youth with diabetes who meet dietary recommendations: SEARCH for Diabetes in Youth participants in the dietary assessment protocol, prevalent 2001 and incident 2002. *P<0.01 for comparison of males vs females, adjusted for clinical site, race/ethnicity, and parental education level. (Mayer-Davis, JADA, ’06:689-97)

Youth with Diabetes Do Youth with Diabetes Do Not Meet Glycemia GoalsNot Meet Glycemia Goals

Hvidore Data, Diabetes Care, 2001

Why Carb Count?Why Carb Count?Need some methodology on which to base Need some methodology on which to base rapid-acting insulin dosing with rapid-acting insulin dosing with meals/snacksmeals/snacks

Can allow for more flexibility with eating for Can allow for more flexibility with eating for people with type 1 diabetespeople with type 1 diabetes

Theoretically, should better match insulin Theoretically, should better match insulin bolus to carb intake and result in reduced bolus to carb intake and result in reduced post-prandial hyper- and hypoglycemiapost-prandial hyper- and hypoglycemia

Why Carb Count?Why Carb Count?Primary goal of diabetes management is Primary goal of diabetes management is to normalize blood glucose concentrationsto normalize blood glucose concentrations

Both MDI and CSII require patient (or Both MDI and CSII require patient (or parent) input of CHO to determine proper parent) input of CHO to determine proper insulin bolus dosesinsulin bolus doses

Other methodsOther methodsSliding scale? Sliding scale?

Consistent CHO intakeConsistent CHO intake

Pattern management principlesPattern management principles

Insulin:CHO ratiosInsulin:CHO ratios

Exchange or portion systemsExchange or portion systems

GI (glycemic index) and GL (glycemic GI (glycemic index) and GL (glycemic load)load)

DATADATADAFNE study: course teaching flexible DAFNE study: course teaching flexible intensive insulin treatment combining with intensive insulin treatment combining with dietary freedom and insulin adjustmentdietary freedom and insulin adjustment– Improved A1c at 6 months (9.4% v. 8.4%, Improved A1c at 6 months (9.4% v. 8.4%,

p<0.0001)p<0.0001)– Improved ‘quality of life’ at one yearImproved ‘quality of life’ at one year

DCCT: using CHO/insulin ratios in DCCT: using CHO/insulin ratios in intensively treated group improved intensively treated group improved glycemic controlglycemic control

Factors relating to post-prandial Factors relating to post-prandial glucose excursionsglucose excursions

Mismatch of amount of insulin to ingested Mismatch of amount of insulin to ingested CHOCHO– Poor CHO countingPoor CHO counting

Failure to account for macronutrient Failure to account for macronutrient content of ingested foodcontent of ingested foodMismatch of the timing of rapid acting Mismatch of the timing of rapid acting insulin bolus delivery and subsequent insulin bolus delivery and subsequent insulin action to CHO absorption with insulin action to CHO absorption with resultant post-prandial hyperglycemiaresultant post-prandial hyperglycemia

Other issuesOther issuesExercise, post-exerciseExercise, post-exercise

Rapid-acting insulin dynamics (onset of Rapid-acting insulin dynamics (onset of action, peak action, etc)action, peak action, etc)

Location of delivery (subcutaneous, not Location of delivery (subcutaneous, not portal)portal)

Psychological factors?Psychological factors?

GoalsGoalsImprove understanding of the role of Improve understanding of the role of dietary factors and physical activity in dietary factors and physical activity in glucose excursionsglucose excursions

Reduce glucose variability for Reduce glucose variability for patients/improve quality of lifepatients/improve quality of life

?Potential application for clinical care now, ?Potential application for clinical care now, for closing the loop for an artificial for closing the loop for an artificial pancreas later?pancreas later?

Tips for Carb CountingTips for Carb Counting

Benefits of Adjusting Insulin for Benefits of Adjusting Insulin for CarbohydratesCarbohydrates

Allows More FlexibilityAllows More Flexibility– No need to stay within carb ranges for mealsNo need to stay within carb ranges for meals– For patients on pump therapy or MDI eating For patients on pump therapy or MDI eating

schedule can be much more flexibleschedule can be much more flexible

More Advanced Form of Diabetes More Advanced Form of Diabetes ManagementManagementPotential for more accurate dosingPotential for more accurate dosingPump therapy requires carb inputPump therapy requires carb input

Other ConsiderationsOther Considerations

Who will be responsible for carbohydrate Who will be responsible for carbohydrate countingcounting– Parent, child or bothParent, child or both

Math skillsMath skills

Carbohydrate counting at schoolCarbohydrate counting at school– MDIMDI– CSIICSII

Focus on CarbohydrateFocus on Carbohydrate

Main nutrient that is converted to blood sugarMain nutrient that is converted to blood sugar

Emphasize Emphasize total amount of carbohydratetotal amount of carbohydrate not not the sourcethe source

Carbohydrates are:Carbohydrates are:– Starches- grains, beans, starchy vegetablesStarches- grains, beans, starchy vegetables– FruitsFruits– Milk and YogurtMilk and Yogurt– Other Carbohydrates (i.e. sweets, desserts etc)Other Carbohydrates (i.e. sweets, desserts etc)

Diabetes Food PyramidDiabetes Food Pyramid

Food LabelsFood Labels

Locate Serving SizeLocate Serving Size

Locate total grams of Locate total grams of carbohydratecarbohydrate

Rules for fiber and Rules for fiber and sugar alcoholssugar alcohols

StarchesStarches

15 gm carb servings15 gm carb servings

1 slice bread1 slice bread

1/2 cup mashed potato1/2 cup mashed potato

1 dinner roll1 dinner roll

1/2 cup corn1/2 cup corn

1/3 cup cooked pasta, rice or beans1/3 cup cooked pasta, rice or beans

FruitsFruits

15 gm carb servings15 gm carb servings

1 small piece of fruit1 small piece of fruit

1/2 cup (4 oz) juice1/2 cup (4 oz) juice

1 cup cubed melon1 cup cubed melon

1/2 cup canned fruit, light or juice packed1/2 cup canned fruit, light or juice packed

1/2 cup applesauce, unsweetened1/2 cup applesauce, unsweetened

Milk and YogurtMilk and Yogurt

1/2 pint or 1 cup (8 fl oz) milk = 1/2 pint or 1 cup (8 fl oz) milk = 12 gm 12 gm carbcarb

Go Gurt = Go Gurt = 13 gm carb13 gm carb

Yogurt, light (6-8 oz)= Yogurt, light (6-8 oz)= 15 gm carb15 gm carb

½ pint or 1 cup chocolate milk = ½ pint or 1 cup chocolate milk = 25-30 gm 25-30 gm carbcarb

ResourcesResources

The Calorie King Calorie, Fat and The Calorie King Calorie, Fat and Carbohydrate Counter- Allan BorushekCarbohydrate Counter- Allan Borushekwww.calorieking.comwww.calorieking.comwww.diabetesnet.com- Salter 1400 www.diabetesnet.com- Salter 1400 Nutritional scaleNutritional scalewww.nutritiondata.com- recipe evaluationwww.nutritiondata.com- recipe evaluationText messaging service: Diet1 (34381)Text messaging service: Diet1 (34381)Palm pilotsPalm pilots

Calculating a DoseCalculating a Dose

3 Step Process3 Step Process

11stst Step: Insulin to Carb Ratio Step: Insulin to Carb Ratio

Determine how much insulin is needed forDetermine how much insulin is needed for

carbs eaten at meal or snack:carbs eaten at meal or snack: Count up total carb gramsCount up total carb grams Divide total grams by ratioDivide total grams by ratio

Calculating a DoseCalculating a Dose

22ndnd Step: Blood Glucose Correction Step: Blood Glucose CorrectionDetermine How Much Insulin is Needed to correctDetermine How Much Insulin is Needed to correctblood sugar (bg) to targetblood sugar (bg) to target Check bgCheck bg Calculate insulin amount needed toCalculate insulin amount needed to

bring bg into target range (i.e. … 1 unit per bring bg into target range (i.e. … 1 unit per 50 50 over 150- Individualized)over 150- Individualized)

33rdrd Step: Total Dose Step: Total Dose = Insulin needed for = Insulin needed for carbs plus insulin needed for bgcarbs plus insulin needed for bg

Calculating a DoseCalculating a Dose

Insulin to carb ratio = 1 unit per 15 gm carbInsulin to carb ratio = 1 unit per 15 gm carb

BG correction = 1 unit per 50 over 150BG correction = 1 unit per 50 over 150

Carb component: 60gm Carb component: 60gm ÷÷15 = 15 = 4 units4 units

Blood sugar correction: 250 -150 = 100Blood sugar correction: 250 -150 = 100100100÷÷50 = 50 = 2 units2 units

Total DoseTotal Dose = = 4 units4 units + + 2 units 2 units = = 6 units6 units

““Smart Pumps”- Smart Pumps”- Do the math for you!Do the math for you!

How do you determine a ratio How do you determine a ratio and blood sugar correction and blood sugar correction

factor?factor?Rules Rules – 1500 Rule1500 Rule

Blood Sugar Correction FactorBlood Sugar Correction Factor1500 divided by TDD = # of points (mg/dl) blood sugar will be 1500 divided by TDD = # of points (mg/dl) blood sugar will be lowered by 1 unit of REGULAR insulinlowered by 1 unit of REGULAR insulin

– 1700, 1800, 2000 Rule1700, 1800, 2000 RuleCorrection FactorCorrection FactorSame principle as above – however for RAPID ACTING insulinSame principle as above – however for RAPID ACTING insulinDepends on proportion of basal to bolus doseDepends on proportion of basal to bolus dose

– 500 Rule 500 Rule Insulin to Carb RatioInsulin to Carb Ratio500 divided by the TDD500 divided by the TDDFor RAPID ACTING insulinFor RAPID ACTING insulin

How do you determine a ratio How do you determine a ratio and correction factor?and correction factor?

Food RecordsFood Records– Time of day meal or snack is occurringTime of day meal or snack is occurring– Insulin – type and amountInsulin – type and amount– Blood sugar valuesBlood sugar values

Pre-prandialPre-prandial2 hour post prandial2 hour post prandial

– Food – type and amountFood – type and amount– Estimated grams of carbohydrates in individual food Estimated grams of carbohydrates in individual food

itemsitems– ActivityActivity

Poor Food RecordPoor Food Record

Excellent Food RecordExcellent Food Record

ExamplesExamples

Excellent Food Excellent Food RecordRecord– All food amounts listedAll food amounts listed– Details about food Details about food

itemsitems– Accurate carb Accurate carb

countingcounting– Adequate blood sugar Adequate blood sugar

readings, including 2 readings, including 2 hour post prandial hour post prandial valuesvalues

Poor Food RecordPoor Food Record– Patient did not list food Patient did not list food

amountsamounts– Not enough blood Not enough blood

sugar readings and/or sugar readings and/or no 2 hour post-no 2 hour post-prandial blood sugar prandial blood sugar readingsreadings

– Inaccurate carb Inaccurate carb countingcounting

Food RecordsFood Records

From food records we can determine:From food records we can determine:– If the patient is carb counting accuratelyIf the patient is carb counting accurately– An insulin to carb ratioAn insulin to carb ratio

Amount of insulin the patient requires per grams of Amount of insulin the patient requires per grams of carbs consumedcarbs consumed

2 hour post prandial blood sugars2 hour post prandial blood sugars

– Effects of exercise Effects of exercise – Other potential dose adjustmentsOther potential dose adjustments

Challenges to Establishing Challenges to Establishing RatiosRatios

Patient is in their honeymoon and/or requires Patient is in their honeymoon and/or requires very small amounts of insulinvery small amounts of insulinPoor food recordsPoor food recordsInaccuracy with carb countingInaccuracy with carb countingErratic blood sugarsErratic blood sugarsInconsistent activity levelsInconsistent activity levelsIllnessIllnessInsulin resistanceInsulin resistance

Carbohydrate Counting in Carbohydrate Counting in Adolescents with Type 1 Adolescents with Type 1 Diabetes (CCAT) StudyDiabetes (CCAT) Study

Franziska Bishop, David Maahs, Gail Spiegel, Franziska Bishop, David Maahs, Gail Spiegel, Darcy Owen, Georgeanna Klingensmith, Andrey Darcy Owen, Georgeanna Klingensmith, Andrey Bortsov, Joan Thomas, Elizabeth Mayer-DavisBortsov, Joan Thomas, Elizabeth Mayer-Davis

Management of Diabetes in Youth, Biennial Conference of the Management of Diabetes in Youth, Biennial Conference of the Barbara Davis Center for Childhood DiabetesBarbara Davis Center for Childhood Diabetes

July 12-16July 12-16thth, Keystone, Colorado, Keystone, Colorado

IntroductionIntroduction

CSII and MDI require patient input of carbohydrate amount to determine proper bolus insulin dosing.

Pilot study results evaluating the accuracy of carbohydrate counting among adolescents with T1DM are reported.

SubjectsSubjects

Adolescents (ages 12-18) seen at the BDC (using insulin-to-carbohydrate ratios at least 1 meal/day)

MethodsMethods

Study VisitStudy Visit

Subjects recorded their estimate of portion size, carbohydrate content, and frequency of consumption.

Subjects assessed the carbohydrate content for 32 foods commonly consumed by youth.

Food presented as food models or actual food in common serving sizes or self-served by subject..

ResultsResultsStudy participants: n=48, age=15.2±1.8, HbA1c=8.0±1.0%

For each meal, accuracy categorized as “accurate (within 10 g)”, “overestimated (by>10 g)”, “or underestimated (>10 g).”

For dinner meals, subjects with “accurate” estimate of carbohydrates had the lowest HbA1c (7.7±1.0%) compared to HbA1c of 8.5±1.2% and 7.9±1.0% for “overestimated,” and “underestimated,” respectively (p=0.04)

ResultsResults

Statistically significant overestimation observed for 15 of 32 foods (including syrup, hash browns, rice, spaghetti, and chips)

Statistically significant underestimation observed for 8 of 32 foods (including cereal, French fries, and soda).

ResultsResults

Only 23% (11 of 48) of adolescents estimated daily carbohydrates within 10 g of true amount despite selection of commonly consumed foods.

Only 31% (15 of 48) of adolescents estimated daily carbohydrates within 20g/day.

What does this mean?What does this mean?

If an adolescent is overestimating how much If an adolescent is overestimating how much carbohydrates they eat by 17 g at dinner, and they are carbohydrates they eat by 17 g at dinner, and they are using a 1:8 carbohydrate ratio, then 2 extra units of using a 1:8 carbohydrate ratio, then 2 extra units of insulin are being taken which could result in a low blood insulin are being taken which could result in a low blood sugar.sugar.

Or . . .Or . . .

An adolescent underestimates the carbohydrates in a An adolescent underestimates the carbohydrates in a given meal by 10 grams, and they are using a 1:5 given meal by 10 grams, and they are using a 1:5 carbohydrate ratio, then they would take 2 units less carbohydrate ratio, then they would take 2 units less than needed likely resulting in a high blood sugarthan needed likely resulting in a high blood sugar

ConclusionConclusion

Adolescents with T1DM do not Adolescents with T1DM do not accurately count carbohydrates accurately count carbohydrates and commonly either over or and commonly either over or underestimate carbohydrates in a underestimate carbohydrates in a given meal.given meal.

The Carbohydrate Counting Quiz . . .The Carbohydrate Counting Quiz . . .

Your Turn!Your Turn!

22?

34?

Instructions for Carbohydrate Quiz Instructions for Carbohydrate Quiz

The AnswersThe Answers

Label Reading QuizLabel Reading Quiz

How well do How well do you do?you do?

The AnswersThe Answers