Carbohydrate Counting

Marjan Shalchi, RD, CDE

Diabetes Education and Management Centre Hotel Dieu HospitalNovember 13, 2015

Outline

Why Carbohydrate Count ? Basic to Advanced Carbohydrate Counting Case Studies

Why Carbohydrate Count ?

The nutrient with the greatest impact on blood glucose levels

50% Post-meal BG

50% Fasting BG

At an A1C ranging from 7.3% to 8.4%, overall glycemia is impacted equally by

fasting blood glucose and post-meal blood glucose

A1C =

5. Monnier L, et al. Diabetes Care 2003;26:881-885.

Why Carbohydrate Count ?

A meal-planning approach for all patients with diabetes

Flexibility in choosing all carbohydrate containing foods, it may increases self management

CDA recommendations: 45-60% carbohydrate, 15-20% protein, and 20-35% fat of total energy

Matching insulin to carbohydrates intake. Being proactive regarding insulin needs.

http://guidelines.diabetes.ca/Browse/Chapter11

Basic Carbohydrate Counting

Keep it Simple!

These Foods Contain Carbohydrate

Food Groups Carbohydrate in One Serving

GRAINS & STARCHES

15 g

FRUITS 15g

MILK & ALTERNATIVES

15g

OTHER CHOICES 15g

EXTRA FOODS 0-5g

http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-the-basics-presentation.ppt

These Foods have Little or No Carbohydrate

Food Groups Carbohydrate in One Serving

MEAT &

ALTERNATIVES

0 grams

(except for ½ cup Legumes 10-15 grams)

VEGETABLES 0grams

(except for ½ cup squash 10 grams, parsnips 10.5 grams

and peas 7 grams)

FATS 0 grams

http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-the-basics-presentation.ppt

Basic Carbohydrate CountingTools

Food Sources of Carbohydrates Handouts, CDA resources Food models Food labels Apps

http://www.diabetes.ca/diabetes-and-you/healthy-living-resources/diet-nutrition

How to Read Labels

1. Look at serving size and compare it to the amount of food being eaten

2. Carbohydrate includes starch, sugars, and fibre

3. Fibre should be subtracted from total carbohydrate because it does not raise blood glucose

http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-the-basics-presentation.ppt

How to Read Labelswith Sugar Alcohols

LABEL READING EXAMPLE

Serving Size: 1 piece

Total Carbohydrate: 32 g

1.Sugar……………… 10 g

2. Starch……………… 11 g

3. Fiber………………… 6 g

4. Sugar Alcohol……….. 2 g(Examples: sorbitol, mannitol, isomalt, lactilol, polyols)

RECIPE FOR READING CARBOHYDRATES

Check the serving size and adjust for your portion

Take the carbohydrate………. 32 g

Subtract from it:*all the fiber value…………. - 6 g*all the sugar alcohol value….. - 2 g

Available Carbohydrate: 24g

Websites

http://www.calorieking.com/

http://www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng.php

http://ndb.nal.usda.gov/ndb/search/list

Apps

You need to know if the app is based on an accurate data base. This is especiallyimportant for insulin dosing.

Calorie King, Eat Wise and USDA are accurate data bases. www.calorieking.com http://www.eatwise.ca/ http://ndb.nal.usda.gov/

https://mysugr.com/apps/ is a useful tracking tool

Recommended carbohydrate intake

Consider individual energy needs Exercise patterns

Individual eating pattern

Food preferences

Carbohydrate Recommendations

Carbohydrates

% of total energy 45% 50% 60%

Women (1300-1800 kcal/day)

145- 200 grams/day

160- 225 grams/day

195-270grams/day

Men (1800-2000 kcal/day)

200-225grams/day

225-250grams/day

270-300grams/day

General Guidelines: Carbohydrates/Meal

Women Men

To lose weight 30-45 g 45-60 g

To maintain weight 45-60 g 60-75 g

For very active

Snacks

60-75 g

15-30 g

60-90 g

15-30 g

IndividualizeDistribute evenly for good blood glucose control

Consider individual energy needs, exercise patterns, individual eating pattern and food preferences

Beyond Carbohydrate CountingDiabet. Med. 27, 348-353 (2010)

A study of 102 children with Type 1 Diabetes and adolescents and 110 caregivers estimating the carbohydrate content of 17 meals containing 8-90 grams of carbohydrates.

Beyond Carbohydrate CountingDiabet. Med. 27, 348-353 (2010)

Results:

73% of all estimates were within 10-15 g of actual carbohydrate content.

It did not matter what method of carbohydrate counting they used.

Underestimated larger meals Overestimated snacks Longer diabetes duration had a negative effect on

accuracy of carbohydrate estimation More accuracy when using packaged foods

Beyond Carbohydrate CountingDiabet. Med. 27, 348-353 (2010)

Recommendations:•It is suggested that ±10-15 grams difference in Carbohydrate estimation does not significantly changes the post prandial blood glucose levels.•Specific advice to regularly check the serving sizes of main meal items such as rice, pasta and starchy vegetables may maintain accuracy as appetite changes.•Snack foods such as fruit require size comparisons with food models or real food to improve accuracy.•Consistency in carbohydrate estimation have a greater impact on HbA1C than accuracy.

Advanced Carbohydrate Counting

… Use All the Basic Teachings− Handouts, Food models, food Labels, Apps and Carbohydrate

Targets, etc

PLUS some more …- Carbohydrates are not all equal- High protein and fat containing foods- Matching Carbohydrates to Insulin; Insulin to

Carbohydrate Ratio and Correction Factor

Glycemic Index

2013 CDA guidelines suggest choosing lower glycemic index carbohydrates to help optimize blood glucose

For the same number of carbohydrate grams, low or medium GI foods may raise blood glucose less than high GI foods.

Mismatch between insulin action and carbohydrate absorption following a high GI foods may lead to a rapid glucose spike.

• Glucose determinations at 1-2 hours postprandial will be instructive.

Low GI foods with high fructose and/or sucrose content (e.g. fruit juice) lead to a rapid glucose spike

Fats

Late post prandial hyperglycemia is the predominant effect of dietary fat Some studies show lower glucose concentrations

in the first 2-3 hours due to delayed gastric emptying*

Addition of 50 grams of fat can increase insulin requirements by twofold.

*Diabetes Care 2015; 38:1008-1015

Proteins

Protein affects blood glucose in the late post prandial period. If 30 g protein is consumed with minimum 30 grams of

carbohydrate containing foods, blood glucose levels rise after 3-4 hours (2-3 numbers). This is the amount of protein in 4 oz cooked lean meat.

If at least 75 grams of protein (8 oz of lean steak) is consumed without carbohydrates, blood glucose increases in 1.5 hours after consumption similar to about 20 grams of carbohydrates.

There is an additive effect of protein and fat consumed together at a meal, up to 5.5 number increase at 5 hours post meal.

Diabetes Care 2015; 38:1008-1015

Teach Advanced Carbohydrate Counting

… if a person is on INSULIN and is willing to − Do simple mathematics− Use nutrient analysis information, websites − Have and know how to use measuring cups, spoons and

scales− Keep accurate and detailed records− To test his/her blood glucose before and 2 hours after the

first bite of a meal − Be motivated and able to take the time required to improve

his/her diabetes management

The Basal/Bolus Insulin Concept

Basal insulin Suppresses glucose production between meals

and overnight 50% of total daily insulin needs

Bolus (mealtime) insulin rapid- or short-acting insulin given just before a

meal in anticipation of the glycemic spike that occurs due to carbohydrate ingestion

50% of total daily insulin needs Given usually as three equally divided doses

before meals

Blood Glucose Targets for Most People with Diabetes

• Pre-meal blood glucose: 4.0 – 7.0 mmol/L.

• 2 hour post-meal blood glucose: 5.0 – 10.0 mmol/L.

• A rise of 2.0 to 3.0 mmol/L is normal after eating.

Insulin to Carbohydrate (I:C) Ratio

This is the amount of insulin needed to cover the carbohydrate being consumed at a meal. For example: I:C ratio of 1:10 means 1 unit of insulin would

be taken for every 10 grams of carbohydrate

Post prandial blood glucose rise of 2- 3 mmol/L is expected when I:C ratio is correct.

Ways to determine I:C ratio

1) Quick and Easy Method Starting ratios: 1:15 (1 unit of fast-acting insulin

for 15 grams of carbohydrate) Ratios vary

10:1 for insulin resistance/obese individuals 20:1 for young, thin individuals

Ways to determine I:C ratio

2) Pattern Management Review food, insulin and blood glucose records Identify trends

For example:

70 grams of carbohydrates

7 units of fast acting insulin

Blood glucose before lunch: 7 mmol/L

Blood glucose 2 hours later: 9.5 mmol/L

70 g carb ÷ 7 units of insulin = 10 I:C is 1:10

Ways to determine I:C ratio

3) 500 Rule Divide 500 by the total daily dose of insulin

I:C Ratio = 500 ÷ total daily dose of insulin 

Example: The total daily dose of insulin = 35 units 500 ÷ 35 = 14 I:C ratio = 1:14

So for every 14 grams of carbohydrate the patient eats, they will take 1 unit of rapid- or short-acting

insulin

Many Variables Influence Glycemic Control....

Food Exercise/activity Illness

Insulin absorption Insulin resistance Stress/coping

Always assess the variables and keep this in mind when considering an insulin dose adjustment.

Compensate for unanticipated high blood

sugar, using “correction insulin”

This is called Insulin Sensitivity Factor or Correction Factor (CF)

How to Determine a starting Correction Factor

100 Rule: Divide 100 by the total daily dose of insulin

For example, if total daily dose is 50 units:

100 ÷ 50 = 2 , CF is 1:2

Individualize, this varies by weight of the person, time of the day and with hormonal fluctuations and very high blood glucose

So, if the person’s blood glucose is 9 mmol/L, and their target glucose is 7 mmol/L, then:

Current blood glucose – target blood glucose ÷ CF

(9 –7) ÷ 2 = 1

Therefore, if the persons blood glucose is 9.0 mmol/l and they want to bring it down or “correct” it to 7.0mmol/, they need to take 1 unit of rapid- or short-acting insulin.

Case Studies

Mary has been taking insulin for 3 months. She has been following a consistent carbohydrate meal plan and has adjusted her insulin doses using pattern management. She has good comprehension of carbohydrates and is ready to start learning how to self-adjust her insulin based on carbohydrate counting. She attends a “Carb-counting class” at her local diabetes education centre and has a follow up with the dietitian today.

Mary’s current insulin doses are:

Long-acting Insulin 20 units QHS

Rapid-acting Insulin 10/8/12 units at Breakfast, Lunch and Supper respectively.

What is Mary’s estimated I:C ratio?

Total insulin: 50 units

500 ÷ 50 = 10

Joe is placed on multiple daily insulin injections He weighs 100 kg. His insulin requirements are 0.5 units/kg 

His total daily dose is:100 kg x 0.5 units/kg = 50 units 

His insulin dosage: Glargine (long acting) - 26 units QHS Aspart (rapid acting) - 8 units at each meal

Joe is working with his diabetes educators learning to adjust his insulin using carb-counting and correction factor.

Question: What is Joe’s estimated I:C ratio and CF?

I:C 500 ÷ 50 = 10CF: 100 ÷ 50 = 2

Joe is about to eat breakfast and figure out how much rapid insulin he needs to take for breakfast:

2 fried eggs 3 slices of bacon (0 gms))2 slices of whole wheat toast 2 teaspoons of jam (40 gms)1 glass of orange juice (26 gms)1 cup of black coffee  (0 gms)

Total carbs = 66 grams Blood glucose =11.1 mmol/L,Joe’s target range is 4.0 to 7.0 mmol/L I:C ratio = 1:10, CF = 2.0

Question: How much insulin aspart (NovoRapid®) should Joe take?

Answer:1. Insulin to carbohydrate ratio is 1 unit for every 12 grams of carbohydrate

66 ÷ 10 = 6.6 units of insulin for food round to 7, PLUS

2. His blood glucose is 11.1 mmol/L and his target range is 4.0 to 7.0 mmol/L Correction factor is 1 unit to lower her blood glucose by 2 mmol/L11.1 – 7 (his target glucose)] ÷ 2 = 2 units

Total dose : 7 + 2 units = 8 units of insulin aspart

Adjusting Insulin for Exercise

Effects of Exercise on Blood Glucose

Physical activity includes more than formal exercise; everyday activity such as yard work, lawn mowing and shopping are activities that can have an impact on blood glucose.

Physical activity increases the body’s sensitivity to insulin and the speed that it is absorbed.

Physical can cause Blood Sugar

Activity

The effects of exercise can last up to 24 hrs

When planning for increased physical activity, individuals should consider decreasing insulin, increasing food or a combination of both.

Exercise BG (mmo/L) Carbohydrate Snack type/portions

Light x 60 min.- Walking, bowling

Less than 6.0 15 gms 1 starch or fruit

Moderate x 60 min.-Tennis- Swimming- House cleaning- Golf

Less than 6.0 30 gms before exercise. An additional 10-15 gms for each additional hour.

2 starch or fruit

6.0 - 10.0 15 gms 1 starch or fruit

11.0 – 17.0(no ketones)

No food increase

17.0 or greater and moderate ketones

Do not exercise until diabetes control improves

Strenuous x 60 min.- Hockey- Racquetball- Competitive sports

Note: Small amounts at frequent intervals are preferable for prolonged activity

Less than 6.0 45 gms before exercise. Additional 10-15 gms for each additional hour.

2 starch , 1 protein & 1 fruit

6.0 – 10.0 30 gms 2 starch & 1 protein

11.0 – 17.0(no ketones)

15 gms 1 starch or fruit

14.0 or greater and moderate ketones

Do not exercise until diabetes control improves

Ex-Carbs for Exercise Guidelines (adult)*

*Adapted from Saskatchewan Insulin Adjustment Module, December 2005

Adjusting Insulin for Exercise/activity….

Light activity (walking)

– 10-20% reduction Moderate (brisk walking, jog,

fitness class, swimming)

– 30-40% reduction Strenuous (hard run, sprints,

sports)

– 50% or more reduction

*Remember, these are guidelines only, individual responses vary!

Questions?