kathy love, rd, cde - jdrf · kathy love, rd, cde sunday june 28, 2015 . overview carbohydrate...
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Kathy Love, RD, CDE
Sunday June 28, 2015
Overview
Carbohydrate Counting
Sugar alcohols and fiber
Glycemic index
Healthy Food Choices
Fat, protein and carbohydrate
Sugars
Sugar substitutes (if enough time)
Before and after insulin
JL on 12/15/22 and 2 months later
1922 Leonard Thompson
Carbohydrate is the nutrient in
food that raises blood sugar
directly after eating
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What are Carbohydrates?
Starches: breads, cereals, grains,
starchy veggies
Beans and legumes
Milk and yogurt (not cheese)
Fruits and Juices
Sweets
Foods not requiring extra insulin
No or Low carbohydrate foods:
Non-starchy vegetables
Protein foods?
Fats ???
<5 grams of carb per serving x 1
How do I count carbs?
Food Labels
Exchange lists
Calorie King and other
books, phone applications
and websites.
Measuring tools: cups,
spoons, scale
Visual
Websites and Phone Apps
Websites:
Nutrition.self.com
Ndb.nal.usda.gov
Phone apps:
Lenny (game for kids)
My fitness pal
Figwee
Lose it!
Daily carb Premium
Carb Master
Serving size
Servings per container
Total Carbohydrate
New Food Labels
“Sugar-Free” often means Sugar Alcohols
Sugar alcohols are a type of carbohydrate
Partially absorbed
may result in a slower blood sugar rise
may cause gas and diarrhea
Types: sorbitol, maltilol, mannitol, lactilol,
erithritol, glycerol/glycerin, xylitol, isomalt,
hydrogenated starch hydrolysate
“Net” Carbs: Fiber and Sugar Alcohol
Refers to the amount of carbohydrate left after
subtracting some of the fiber and sugar alcohol
If the total fiber or sugar alcohol is >5 grams,
you may subtract half the grams from the total
carb
e.g. Total carb=30 grams, sugar alcohol 10
grams; can subtract 5 grams of sugar alcohol
from the 30 g total for new total of 25 grams
carb
Sugar Alcohols
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Fiber
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“Exchange” Lists
15 grams carbohydrate per portion
below:
• Bagel, 1/4 large (1 oz)
• Cooked rice or pasta, 1/3 cup
• Banana, 1 small (4 oz)
• Milk, 8 oz
Carbohydrate Content by Weight Food Grams of carb per ounce
Apple, banana, pear 3.75
Bread, bagel, brownie 15
Cherries, grapes 5
Orange 2.31
Pasta 11-13
Potato 5
Tangerines 1.88
Watermelon cubes 1.11
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Meal Planning
Identify the carb-containing
foods in the meal
Measure or weigh those foods to
calculate the total grams of carb
Calculate your dose of insulin
Compare recipes to other like
foods OR list ingredients, carb
amount, add the total and divide
by # servings
Glycemic Index (GI)
Numerical index that ranks carbohydrates
based on their rate of conversion to glucose after
eating
Scale of 0-100: The higher the rating the more
rapid the rise in blood sugar
< 55 Low GI
55-70 Moderate GI
>70 High GI
Factors that affect the glycemic index
Raw vs.. Cooked
Whole vs. Juiced or Mashed
Fat content
Protein content?
Fiber
Glycemic Index and Meal Planning
Total amount of carbohydrate is the most
important aspect of blood sugar control, but
fat, high fat proteins, cheese and fiber DO
make a difference
Glycemic Index and Meal Planning
Only ranks individual carbohydrates;
doesn't’account for the effects of other foods
consumed at the same time
Doesn’t account for the total amount of
carbohydrate glycemic load
Some higher glycemic index foods are healthier
choices and shouldn’t be excluded
High GI foods may be desirable at times, e.g.,
when treating a low blood sugar
GI of some foods Low GI <55 Mod GI 55-70 High GI >70
Pumpernickel or whole wheat bread (1oz) 1/2 cup oatmeal
1/2 hamburger bun Whole wheat pita (1/2)
1/4 large bagel 6 saltines 2 rice cakes
1/3 cup pasta 1/2 cup peas
1/3 cup basmati rice
1/3 cup white rice 3/4 cup cheerios
2 oz yams 1 small banana
1/2 cup corn 1/3 cup couscous
1 cup french fries 3 oz boiled potato
1/2 cup lentil, dried beans
2 Tbsp raisins 1 1/4 c melon
5 vanilla wafers 2.1 oz Skittles
1 c milk 1/2 cup ice cream
¾ c pineapple 2.2 oz Snickers
Impact of Fat, Protein, and Glycemic Index of Glucose Postprandially
Fat: High fat meals of ≧40 grams likely require an increase of insulin over the next 2-2.5 hours, less prior to that, and more up to 5 hours. Protein: Protein only: 75 grams does not need add’l insulin, ≧40 g pro + 30 g Carb may require additional insulin High Glycemic Index: Bolus at least 20 min prior or give a ”super bolus”
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Drawbacks of these recommendations
It’s impossible to control for one nutrient in a study of real food without altering the proportions ot the other nutrients in a way that has an impact
There are a lot of variations among the subjects
There are a lot of variations within individuals
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Unanswered questions that need to be studied for insulin dosing
Does a certain amount of fat require higher insulin dosing?
Do all types of protein and fat have similar or different effects?
What are the optimal insulin dose adjustments needed for meals with varying fat and protein content?
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Healthy Eating: What does that look like in the real world?
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2015-2020 Dietary Guidelines
Follow a healthy eating pattern
Focus on variety, nutrient density and amount
Limit calories from saturated fats, added sugars and sodium. (Avoid trans fat)
Shift to healthier food and beverage choices
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Key Recommendations for a Healthy Eating Pattern
Eat a variety of vegetables: dark green, red, orange, legumes, starchy and other
Fruits, especially whole fruits
Grains, at least half of which are whole grains
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Key Recommendations for a Healthy Eating Pattern
Consume fat-free or low-fat dairy and or fortified soy beverages
Eat a variety of protein foods: seafood, lean meats and poultry, eggs, beans, peas, nuts, seeds and soy products. Eat less meat in general.
Use a variety of oils
Limit saturated and trans fats, added sugars, refined grains, and sodium
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Fat and Cholesterol Recommendations
American Heart Association
Dietary Guidelines 2015-2020
Total Fat 25-35% of total calories with most from unsaturated fat
No restriction; replace saturated fat with unsaturated fat
Saturated fat <5-6% of total calories
<10% of total calories
Cholesterol <300 mg/day
No restriction
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Heart Healthy Diet
Are the current recommendations for fat intake for a heart healthy diet correct?
Expect more changes in the future, especially regarding saturated fats.
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Avoid Trans Fats
Trans Fats: hydrogenated or partially hydrogenated
fats
Some margarines, some peanut butters,
shortening, many packaged goods, e.g., crackers,
cookies, etc.
Zero grams trans fat may be <0.5 g Check the
ingredients list
Saturated Fats
Bacon/bacon grease
Creamer, Cream
cheese, sour cream,
whipped cream
Butter
Medium to high fat
meats
Whole and 2% Dairy
products
Mono- and Polyunsaturated Fats
Monounsaturated:
Avocado
Canola, Olive, &
Peanut Oils
Olives
Almonds, peanuts,
cashews, pecans
Sesame/Tahini
Polyunsaturated:
Fatty Fish
Walnuts
Mayo, salad dressings
Pumpkin & sunflower
seeds
Corn, Safflower,
Soybean Oils
Carbohydrates
Healthy Carbs:
Fruits
Nonfat and 1% milk/yogurt
Starches: starchy vegetables, whole grains, beans & legumes
Choose higher fiber
Less Healthy Carbs:
Refined: e.g., white
bread, white rice,
many snack foods
Many sweets
Sugars
Honey, maple syrup, table sugar, & fruit: ~50% glucose, ~50% fructose
High-fructose corn syrup: 42-53% glucose, 42-55% fructose
Agave syrup: 10% glucose, 90% fructose
Fructose
Corn syrup, dextrose, maltose: 100% glucose
Added Sugars
American Heart Association
Dietary Guidelines 2015-2020
Women <100 kcals/day <6 tsp (<24 g)
<10% of total kcals
Men <150 kcals/day <9 tsp (36 g)
<10% of total kcals
Children <2 yrs No added sugar 2-18 yrs <6 tsp (<24 g)
<10% of total kcals
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Sodium Recommendations
American Heart Association
Dietary Guidelines 2015-2020
1-3 years of age <1000 mg/day <2300 mg/day
4-8 years of age <1200 mg/day <2300 mg/day
>9 years <1500 mg/day <2300 mg/day
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Well-balanced Diet
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Adults: 9 inch plate
Children: 7 inch plate
Well-balanced
Portion control
“Natural” Sugar Substitutes
On the FDA GRAS list (Generally regarded as safe).
Not as extensively studied as the other non-nutritive sugar substitutes that don’t effect the blood sugar.
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“Natural” Sugar Substitutes
Stevia:
Shrub from South America
Glycosides: sugar bound to non-sugar substances that can’t be metabolized
Only highly refined preparations, such as Reb A are approved.
Monk Fruit Extract:
Luo han guo from Southern China
Glycosides like Stevia
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FDA Approved Sugar Substitutes: Acceptable Daily Intake (ADI)
The amount that can be consumed daily
over a lifetime without any adverse effects
Reflects a 100 fold safety factor
Sugar Substitutes
Non-nutritive sweeteners
Don’t affect the blood sugar
Types:
Aspartame
Sucralose
Saccharin
Acesulfame K (AceK)
Neotame
Aspartame
Brands: Equal, NatraTaste, store brands
Not heat stable
Broken down to aspartic acid (asp),
phenylalanine (phe), methanol
8 oz Aspartame sweetened beverage vs.
8 oz nonfat milk 6x phe, 13 x asp
8 oz tomato Juice: 6 x Methanol
Aspartame
ADI 50 mg/kg/day
1 packet 35 mg
12 oz diet soda 90-200 mg
8 oz Crystal Light 100 mg
60 lb. child = 27.2 kg x 50 mg/kg = 1360 mg/d
=81 oz. diet soda per day (6-7 cans/day) or
=109 oz. Crystal light (13-14 cups/day)
Sucralose
Brand: Splenda, store brand equivalents
Sucrose modified (3 hydroxyl groups are
replaced with 3 chlorine molecules
ADI 5 mg/kg/d
12 oz diet soft drink 70 mg
1 packet 5 mg
No safety issues have been identified
Heat stable
Saccharin
Brands: Sweet ‘n’ Low, Sugar Twin
Removed from the cancer list in 2000
Heat stable
No US ADI
WHO ADI is 5 mg/kg/day
1 packet 40 mg
12 oz diet beverages 140 mg
Packaged foods <30 mg/serving
Acesulfame K
Brands: Sweet One, Sunnett
Not easily found on the market, but often an
ingredient with other sugar substitutes
Heat stable
ADI 15 mg/kg/d
12 oz. diet soft drink 40 mg (based on usual
blend w/ 90 mg aspartame)
1 packet 50 mg
References Nutritional management in children and
adolescents with diabetes: Smart CE, Annan F, Bruno LPC, et al. Pediatric Diabetes 2104:V15(supplement 20): 135-153.
Effect of dietary protein on post-prandial glucose in patients with type 1 diabetes. Borie-Swinburne C, Soal-Gazagnes A, Gonfroy-Leymarie C, et al. Journal of Human Nutrition and Dietetics 2013: 606-611.
American Heart Association Guidelines 9/2014
Dietary Guidelines for Americans 2015-2012
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References
Dietary fat acutely increases glucose concentrations and insulin requirements in patients with type 1 diabetes. Worfort HA, Atakov-Castillo A, Smith SA, Steil GM. Diabetes Care, 2013; V36:810-816
Both dietary protein and fat increase postprandial glucose excursions in children with type 1 diabetes, and the effect is additive. Smart C, Evans M, O’Connell SM, et al. Diabetes Care, 2013; V36: 3897-3902.
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References
Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Bell K, Smart C, Stell G, et al. Diabetes Care, 2015; V38:1008-1015.
Glycemic Index variability. American Journal of Clinical Nutrition, Sept 7, 2016.
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Evidence-based studies refuting fat guidelines for cardiovascular health
Evidence from Randomized Controlled Trials Did Not Support the Introduction of Dietary Fat Guidelines in 1977 and 1983: A Systematic Review and Meta-analysis. Zoe Harcombe, Julien Baker, Stephan Mark Cooper, et al. Open Heart. 2015;2(1)
The Cardiometabolic Consequences of Replacing Saturated Fats with Carbohydrates or Omega 6 polyunsaturated fats: Do the dietary guidelines have it wrong? Open Heart 2014;1:e00032
Association of Dietary, Circulating and Supplement Fatty Acids with Coronary Risk: A Systematic Review and Meta-analysis. Annals of Internal Medicine 2014;160:398-406
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