Carbohydrate Counting for

Pediatric Patients With Type 1 Diabetes

Review Date 5/13 K-0591

Provided Courtesy of Nutrition411.com

Program Purpose

•To increase knowledge of carbohydrate counting and insulin management skills for those caring for patients with type 1 diabetes (T1DM):– A solid knowledge base of carbohydrate counting

and insulin management is important– Registered nurses are often the first point of

contact with the pediatric patient with T1DM

Program Objectives

• Identify categories of foods containing carbohydrate• Identify the relationship between carbohydrates and blood sugar•Determine the grams of carbohydrate in foods when using the nutritional food label and other carbohydrate-counting tools•Calculate the total grams of carbohydrate/meal•Use insulin-to-carbohydrate ratios to determine the amount of insulin required during mealtimes

Carbohydrate Counting Defined

•A meal-planning approach based on the following ideas:– Carbohydrate is the main nutrient affecting

postprandial glycemic response– Total amount of carbohydrates consumed is more

important than the source of carbohydrates

Benefits of Carbohydrate Counting

•More flexible than other meal-planning methods•Sugar is not forbidden•Focuses attention on the foods that are most likely to make blood glucose levels go up

Foods That Contain Foods That Contain CarbohydrateCarbohydrate

•Breads, cereals, pasta, and grainsBreads, cereals, pasta, and grains•Rice, beans, and starchy vegetablesRice, beans, and starchy vegetables(potatoes, corn, and peas)(potatoes, corn, and peas)• Fruit and fruit juicesFruit and fruit juices•Milk and yogurtMilk and yogurt•Regular soda and fruit drinksRegular soda and fruit drinks• Jelly beans and gumdropsJelly beans and gumdrops•Cake, cookies, and chocolate candyCake, cookies, and chocolate candy

Grams of Carbohydrate Grams of Carbohydrate (per food category)(per food category)

•Starch and Fruit: Starch and Fruit: 1 serving equals about 1 serving equals about 15 grams (g) carbohydrate15 grams (g) carbohydrate•Milk: Milk: 1 serving equals about 12 g 1 serving equals about 12 g carbohydratecarbohydrate•Vegetables:Vegetables: 1 serving equals about 5 g 1 serving equals about 5 g carbohydratecarbohydrate

Starches

Starch GroupStarch Group

Each amount listed below=15 g carbohydrate1 ounce (oz) of bagel, bread, roll (one 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 pasta, spaghetti, macaroni and cheese

⅓ C brown or white rice

½ C mashed potatoes

½ C corn, beans, chickpeas, peas

One small baked potato (3 oz)

Fruits and Fruit Juices

Fruit Group

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

½ C canned fruit (in natural juice)

¼ C dried fruit

½ C fruit juice

1 C fresh fruit (cut up)

1 tablespoon (Tbsp) jelly, jam

Milk and Yogurt

Milk Group

Each amount listed below=approximately 12 g carbohydrate 8 fluid ounces (fl oz) skim, 1%, 2%, whole milk

1 C plain yogurt

1 C plain or vanilla soy milk

Vegetables

Vegetables

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

Foods Without Carbohydrate

Protein and fat groups contain 0 g carbohydrates

Examples: •Protein: Meat, fish, poultry, cheese, eggs, peanut butter, cottage cheese, tofu•Fat: Butter, margarine, mayonnaise, cream cheese, sour cream, nuts, seeds, avocado

Carbohydrate and Noncarbohydrate Categories

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

355575

100

Fat Group 0 0 5 45

CHO=carbohydrate

The Relationship Between Carbohydrate and Blood Sugar

•The digestive system converts most digestible carbohydrates into glucose (also known as blood sugar) •Cells are designed to use this as a universal energy source•As blood sugar levels rise in an individual who does not have diabetes, beta cells in the pancreas churn out more and more insulin, a hormone that signals cells to absorb blood sugar for energy or storage

Carbohydrate and Blood Sugar in T1DM

•People with T1DM do not make enough insulin, so their cells cannot absorb sugar•Carbohydrates begin to raise blood glucose within approximately 5 minutes after initiation of food intake•Carbohydrates are converted to nearly 100% blood glucose within about 2 hours

Carbohydrate and Blood Sugar in T1DM (cont’d)

•The focus of carbohydrate counting is on the one nutrient that most impacts blood glucose•Carbohydrate is the primary nutrient affecting blood glucose levels• Individuals can learn to regulate carbohydrate intake with their blood glucose results

Carbohydrate Substituting

•When carbohydrate counting, it is possible to substitute one food item for another for a similar impact on blood glucose•Example: Exchange a small apple (4 oz) for two small cookies for a similar effect on blood glucose

Food Labels

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

Total Grams of Carbohydrate—used to determine amount of carbohydrate eaten;multiply grams of total carbohydrates on the label by the number of servings eaten

Food Labels

•Example: You just ate 10 crackers from the previous label•There are 2 crackers/serving•How many servings did you eat? – 5

•How many total carbohydrates did you consume?– 10 g/serving x 5 servings=50 g

Tools for Carbohydrate Counting

Nutrition Labels Measuring Tools

Carbohydrate Counting Hand Guide

Fist=8 fl oz or 1 C

Handful=½ C

Palm=3 oz

Thumb= 1 oz

Thumb tip=1 tsp

C=cup, fl oz=fluid ounce, oz=ounce, tsp=teaspoon

Sample Menu #1

How many carbohydrates are in this meal?

Six chicken nuggets=?Two packets of ketchup=?One small banana=?8 fl oz of 2% milk=?Small bag of potato chips=?8 fl oz of iced tea (unsweetened)=?

Sample Menu #1 Answers

How many carbohydrates are in this meal?

Six chicken nuggets=15 gTwo packets of ketchup=6 gOne small banana=15 g8 fl oz of 2% milk=12 gSmall bag of potato chips=15 g8 fl oz of iced tea (unsweetened)=0 g

TOTAL=63 g

Sample Menu #2

BreakfastTwo slices of toast, 4 fl oz of juice, 6 fl oz of milkSnack 1Three graham crackers, one slice of cheeseLunchHot dog on bun, 15 French fries, 4 fl oz of milk, two ketchup packets Snack 2One slice of bread, one slice of cheeseDinner 1 C macaroni and cheese, one small piece of fruit Snack 3Four graham crackers, 1 Tbsp peanut butter

Sample Menu #2 Sample Menu #2 AnswersAnswers

Breakfast=50 g

Snack 1=15 g

Lunch=72 g

Snack 2=15 g

Dinner=60 g

Snack 3=232 g

Insulin-to-Carbohydrate Ratio

• Insulin-to-carbohydrate ratio: The units of insulin needed to "cover" a specified number of carbohydrate grams•An important tool for intensive diabetes management•Divide the total grams of carbohydrate consumed by the carbohydrate-to-insulin ratio

Insulin-to-Carbohydrate Ratio (cont’d)

•To improve blood glucose control for people using intensive diabetes management, match the amount of insulin with carbohydrate intake•Understanding carbohydrate counting is required:– To assure the administration of the appropriate

insulin-to-carbohydrate ratio at mealtimes in hospitalized patients

– For glycemic control– For the prevention of hypoglycemia and/or

hyperglycemia

Insulin-to-Carbohydrate Ratio (cont’d)

•Example: A child is to consume a 60-g carbohydrate diet•The child’s premeal blood glucose is within the normal range•The child’s insulin-to-carbohydrate ratio is 1:20•For every 20 g of carbohydrate eating, 1 unit of fast-acting insulin (NovoLog®) is required

Insulin-to-Carbohydrate Ratio Answers

•60 g total carbohydrate/20 insulin-to-carbohydrate ratio=3•Therefore, 3 units of fast-acting insulin (NovoLog) are required for this meal

References

• American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66. doi:10.2337/dc13-S011. • American Dietetic Association, American Diabetes Association.

Exchange Lists for Meal Planning. 2nd ed. Alexandria, VA: American Diabetes Association; 2003. • International Diabetes Center at Park Nicollet. My Food Plan for

Kids and Teens. Minneapolis, MN: Park Nicollet; 2006.• Thomas E. Survey reveals shortfall in pediatric nurses'

knowledge of diabetes. J Diabetes Nurs. 2004;8(6):217-221.• Warshaw H, Bolderman K. Practical Carbohydrate Counting. A

How to Teach Guide for Health Professionals. Alexandria, VA: American Diabetes Association; 2001. • Warshaw H, Kulkarni K. American Diabetes Association

Complete Guide to Carbohydrate Counting. Alexandria, VA: American Diabetes Association; 2004.

QUESTIONS?