KEEPING COUNTBy: Marissa Prieto, RD, LD & Sarah Ruiz RD, LD

OBJECTIVESDefining carbohydrates (CHO)How to apply basic & advanced CHO

counting to diabetes nutrition management.Demonstrate CHO counting using the

nutrition facts label for the patient with diabetes.

Illustrate factors the patient with diabetes should consider when adjusting CHO for physical activity.

DEFINITIONS

Carbohydrate Counting is a method of calculating the number of grams of CHO consumed at meals and snacks. It is not a specific diet, but a meal planning approach to promote glycemic control.

GOALS OF CARBOHYDRATE COUNTING

Maintain consistency of carbohydrate intake at meals and snacks.

Increase flexibility in the patient’s diet using CHO counting skills.

Manage blood glucose as they relate to food intake, diabetes medication, and physical activity.

WHAT ARE CARBOHYDRATES?

Carbohydrates is a macronutrient vital for metabolic functioning.

The digestive system breaks down CHO into simple sugars, known as glucose, which is then absorbed into the bloodstream.

WHAT FOODS CONTAIN CARBOHYDRATE?

STARCH – pasta, rice, cereals, bread, tortilla, grains, crackers

FRUITS & FRUIT JUICE– all fresh, frozen dry, or canned fruits

VEGETABLES – corn, potato, beans, peas DAIRY –cows milk, soy milk, yogurt DESSERTS – candy, cookies, ice cream, sweetened

beverages, cake

WHAT FOODS HAVE LITTLE OR NO CARBOHYDRATES?

Non-starchy vegetablesDark leafy greens, tomato, broccoli, cauliflower, cabbage

Fats: slows glucose absorption, delaying peak glycemic response when CHO are ingested.Nuts, oils, butters, avocado

Protein: minimal effect on raising blood glucoseBeef, poultry, seafoodEggs, cheese, tofu

STEPS TO LEARNING BASIC CARBOHYDRATE COUNTING

Step 1: Identify foods containing CHO, protein, and fat.

Step 2: Define 1 carbohydrate choice as 15 grams carbohydrate.

Step 3: Count total carbohydrates in the meal.

WHAT IS ONE SERVING OF CARBOHYDRATE?

15 grams of carbohydrate = 1 choice of carbohydrate

Examples:- 1/2 cup of cooked beans, corn, or peas- 1/3 cup cooked rice, pasta- 1 corn tortilla, 1 slice of bread- 8 oz milk, ½ cup ice cream- 1 small apple (4 oz), ½ cup fruit cocktail, ½ large

banana

GENERAL GUIDELINES: CARBS PER MEAL

Women Men

To lose weight: 30-45 grams To lose weight: 45-60 grams

To maintain weight: 45-60 grams To maintain weight: 60-75 grams

Snacks: 15 - 30 grams Snacks: 15 - 30 grams

ADVANCED CARBOHYDRATE COUNTING

Match fast-acting insulin doses to grams of CHO intake based on CHO-to-insulin ratios and correction factors.

Willingness/ability to keep food, physical activity, and BG logs.

Multiple visits and ongoing support from a Diabetes Management team is recommended.

HOW TO DETERMINE INSULIN TO CARB RATIO

The insulin : CHO ratio formula

This can be calculated using the Rule of “500.”

500 ÷ Total Daily Insulin Dose (TDD)= 1 unit of insulin to cover X amount of grams of carbohydrate

Example:TDD = 40 units500 ÷ TDD (40 units) = 12.5 (round up to 13)= 1:13 g CHO1 unit is needed per 13 grams of CHO

OTHER METHODS TO MEASURE YOUR CARBS

Plate Method:

Introduced in 2010 when the Dietary Guidelines for Americans was updated.

Portion Measuring Tools:

Use hands and household items to measure out portion sizes.

Reading Food Labels:

Provide guidelines to make healthy food purchases for both meals and snacks.

Mobile/Computer Apps:

Input amounts of daily physical activity and intake of carbohydrates.

IS MY PLATE BALANCED? (EX 1)

GRAMS OF CARBOHYDRATE BREAKDOWN

Food Group/ Type Serving Size Approximate Grams of Carbohydrate

Watermelon 1 cup 12grams

Corn Tortillas 2 30grams

Pinto Beans (no oil) ½ cup 15grams

Raw Vegetables: romaine lettucetomatoes cucumberslime

1 cup3 slices3 slices1 wedge

5grams or less

TOTAL MEAL CARBOHYDRATES:

62 grams

IS MY PLATE BALANCED? (EX 2)

GRAMS OF CARBOHYDRATE BREAKDOWN

Food Group/ Type Serving Size Approximate Grams of Carbohydrates

Grapes 8 small 7.5 grams

Tacos (only ground beef) 2 30 grams

Mexican Brown Rice 1/3 cup 15 grams

Unsweetened Sweet Tea 8 fl oz 0 grams

Raw Vegetables:romaine lettucered onionstomatoes

1 cup9 slices4 slices

5 grams or less

TOTAL MEAL CARBOHYDRATES

57.5 grams

IS MY PLATE BALANCED? (EX 3)

GRAMS OF CARBOHYDRATES BREAKDOWN

Food Group/Type Serving Size Approximate Grams of Carbohydrates

Apple (small) 4 oz 15grams

Brown Rice 1/3 cup 15 grams

Tilapia Fillet 3 oz 0 grams

Milk 1% 1 cup 12 grams

Mixed Vegetables: (cooked)carrotszucchini squashceleryonion

1 cup total 10grams

TOTAL MEAL CARBOHYDRATES

52 grams

TOOLS FOR PORTION CONTROL

HOW TO READ A FOOD LABEL

The total grams of carbohydrate includes the carbohydrate in fiber, sugars, and sugar alcohols.

Sugar alcohol is INCOMPLETELY absorbed. Estimate that only half of the sugar in sugar alcohol will be absorbed and impact your blood sugar. Ex: 18g Cho/ 2= 9grams of CHOTOTAL CARBOHYDRATE PER SERVING is29 grams CHO minus 9 grams CHO for the sugar alcohol= 20 grams CHO

FOOD LABELS CONTINUED….

Fiber has to be subtracted from the Total CarbohydrateTotal CHO (10g)-Fiber 5g (half) (5g/ 2= 2.5g) =7.5 grams of CHO

The total carbohydrate tells how many grams of carbohydrate are in 1 serving

MOBILE AND COMPUTER APPS MyFitnessPal: Allows easy and

up to date tracking of daily intake and physical activity.

CarbsControl: Keeps a carbohydrate diary, has a large nutrition database, and set daily goals.

Track3: Tracks high and low blood glucose levels, records workout sessions, and produces email log to self or diabetes management team.

TYPE 2 DIABETES AND EXERCISE Individuals with Type 2

diabetes can decrease insulin resistance through exercise.

Studies have shown that exercise regimens can lower A1c and glucose levels.

When combined with proper nutrition an individual can lower medication needs

TYPE 1 DIABETES AND EXERCISE Moderate Intensity: After 20-30 minutes Type 1 diabetics

have a higher disposition to hypoglycemia. Ex: walking briskly or general gardening

Endurance Activities: They are also more likely to experience hypoglycemia following these types of activities. Ex: swimming pool laps or jogging

Short and High Intensity: Immediately following a quick and intense type of exercise Type 1 diabetics have a greater chance of hyperglycemia. Ex: kickboxing or running

RULE OF 151.) Check blood glucose and proceed if below 70.

2.) Eat or drink 15 grams of carbohydrates.

3.) Wait 15 minutes re-check if still below 70 repeat step 2.

4.) If next meal is more than 1 hour away eat one carbohydrate choice. Ex: granola bar (15grams)

5.) Always carry something on your person to treat hypoglycemia.

15 GRAM CARBOHYDRATE EXAMPLES FOR TREATMENT

3-4 glucose tablets 1 tube of glucose gel

4 ounces fruit juice

4 ounces sugar sweetened soda

5 life savers

Types of Physical Activity

Glucose Ranges Grams of carbohydrates

Examples

Short Duration -80-99mg/dl

- 100mg/dl or above

-10 to 15 grams

-not required

1 fruit or granola bar

Moderate Intensity -80-99mg/dl or less

-100-179mg/dl

-180-299mg/dl

-300mg/dl or greater

-25 to 50 grams pre-workout then 10 to 15grams/hr if needed

-10 to 15 grams

-not required

-Don’t exercise

½ turkey sandwich with 1 fruit or milk

2 graham crackers-------------

-------------

Strenuous Activity -80-100mg/dl

-180-299mg/dl

-300mg/dl or greater

-50 grams

-10 to 15 grams

-Don’t exercise

1 ham sandwich with milk1 fruit

-------------

THINGS TO REMEMBER

Discuss the role and types of macronutrients there are with patients.

Pick the carbohydrate counting method that will be suit each individual’s needs.

Encourage individuals to track their carbohydrate intake and physical activity level to achieve glucose goals.

RESOURCES Carbohydrate Counting: A Practical Meal-Planning Option for People with

Diabetes, Clinical Diabetes, 2005, v23, n3. Dietary Carbohydrate (Amount and Type) in the Prevention and

Management of Diabetes, The American Diabetes Association, 2004. Carbohydrate Counting for People with Type 2 Diabetes, Diabetes

Spectrum, 2008, v13, n8. Carbohydrate Counting and Meal Planning, Novo Nordisk, 2013. Practical Carbohydrate Counting, The American Diabetes Association, 2001. Exchange Lists for Meal Planning, The American Diabetes Association, The

American Dietetic Association, 1995. Andrews, R C., Cooper A. R., Montgomery, A.A., Norcross, A. J., Peters, T. J.,

et al. (2011). Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes. The Lancet. V378: 129-139

QUESTIONS????