Transcript Type 1 Diabetes: CARBOHYDRATE COUNTING & BERTIE Good Hope, May 2012 Annmarie Field Diabetes Specialist Dietitian.

Type 1 Diabetes:
CARBOHYDRATE COUNTING
& BERTIE
Good Hope, May 2012
Annmarie Field
Diabetes Specialist Dietitian
Aims
 Carbohydrate counting.
 What is a CP?
 To look at the advantages / disadvantages of
carbohydrate counting.
 Which insulin bolus?
 Insulin to carbohydrate ratios.
 BERTIE
Carbohydrate Counting
 What is carbohydrate counting?
 A method for controlling blood glucose levels by
accurately matching the amount of carbohydrate
consumed with the amount of insulin taken.
 Who is it suitable for?
 Type 1 on basal bolus or CSII.
 No evidence for Type 2, however it is important
to teach CHO awareness for those patients on a
basal bolus regimen.
Food
 Food is made of 3 main parts - protein, fat and
carbohydrate. When you digest food it is broken
into basic units.
 Protein
 Fat
Amino acids (building blocks)
Fatty acids (energy store)
 Carbohydrate Glucose (energy)
Introduction
 Achieve better glucose control which leads to a greater
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feeling of health and wellbeing.
Helps to reduce the risk of long term complications.
Managing diabetes can feel like a juggling act - insulin,
food, exercise, stress and other life activities.
Carbohydrate counting can help take some of the ‘guess
work’ out of controlling diabetes.
Helps to restore normoglycaemia
Avoid periods of acute metabolic instability- especially
hypoglycaemia
Helps manage times when exercise is included as part of
a healthy lifestyle.
Introduction - Continued
 Carbohydrate counting is a tool used to match the
amount of insulin to the food eaten.
 Matching insulin to food gives flexibility (in the
past prescriptive!)
What is a CP?
CP - A
carbohydrate
portion
Equivalent to
10g of
carbohydrate
Estimate the Carbohydrate
FOOD
2 crumpets with margarine, cup of
coffee.
3oz (75g) turkey, lettuce, 2” slice
of French stick, 1 tablespoon
mayonnaise, 1 muller light yoghurt.
Steamed fish, 4 tbsp boiled rice and veg,
1 can Diet cola, 1 scoop of ice cream
CHO
Background
 Diabetes Control and Complications Trial showed that
tight blood sugar control reduced the complications of
Diabetes.
 New England Journal of Medicine, 329(14), September 30, 1993.
Why Count Carbohydrates?
 90-100% of digestible starches & sugars eaten appear in
the blood as glucose from 15 minutes - 2+ hours after
they are consumed.
 We need to know how much the blood glucose level will
rise after eating carbohydrate and match this with the
correct bolus type and dose of insulin.
 To help achieve optimum glucose control.
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Disadvantages
Takes more time and effort.
More blood testing and keeping a record
Possible weight gain
Advantages
 Helps to improve overall diabetic control.
 No need to snack to avoid hypoglycaemia or to exercise.
 Stabilise blood glucose levels with less fluctuations and
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swings.
Achieve normal post-prandial blood glucose levels.
Predict more easily blood glucose response to different
foods & therefore enjoy a wider variety of foods in the
diet.
More flexibility with portion sizes and meal times.
Enjoy restaurant meals.
Avoids feelings of guilt when eating traditionally
‘forbidden’ ‘sugary’ foods.
No need to snack, eat strict amounts, eat at set meal
times, or to avoid ‘sugary’ foods.
Carbohydrate Counting Steps
 1. Identify which foods contain carbohydrate.
 2. Calculate or estimate the CHO content (CPs) of the
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meal.
3. Calculate the insulin dose needed to cover the CHO
eaten.
4.Consider if a correction dose is needed (high pre meal)
5. Consider fat and glycaemic index.
6. Deliver the food bolus of insulin.
Keep records of food eaten, meal time insulin doses and
blood glucose levels.
Carbohydrate Sources
•Cereal derived starch products: breakfast
cereals, grains, bread, rice, pasta, couscous, flour
based products [pastry, biscuits, cakes] thickening
agents…
•Vegetable starch: potato, legumes [lentils, beans,
peas]
•Fructose: fruit, fruit juice
•Lactose foods: milk, yoghurt, ice cream, custard
•Sucrose (Table Sugar): chocolate & confectionary,
ordinary soft-drinks, desserts, cakes, etc
Identifying Carbohydrates
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Starches:
Breads - all types
Cereals - porridge, cornflakes …
Grains - rice, pasta, cous cous, barley ..
Starch vegetables - potatoes, corn, peas
Legumes - baked beans, kidney beans
Natural Sugar: (Fructose and Lactose)
Fruit - fresh, dried, tinned, juice
Dairy products - milk, yoghurt, ice-cream
Sugars: (Sucrose)
Biscuits
Cakes
Chocolate
Jam, marmalade
Sweets
Identifying Carbohydrates Continued
 Sauces and gravies
 Salad dressings
 Coated foods - batter, bread crumbs
 Pastries, croissants..
 Processed meats e.g.sausages
 Vegetarian foods - often legume based.
Estimating the CHO Content of
Meals
 Weight food (compare with CHO p 100g)
 Refer to carbohydrate counting booklets
 Refer/ use a carbohydrate portion list
 Measure the food using cups, jugs & spoons
 Read the food label
 Use recipe books that list the CHO content
 Carbs and Cals book / phone app
Don’t let the French Fool You!!
Not all Potatoes are the
same!!
Glycaemic Index
 Refers to how quickly CHO is digested & absorbed as
glucose in the blood stream.
 CHO that is broken down quickly and releases glucose
into the blood quickly is said to have a high G.I
 CHO that breaks down slowly and releases glucose
slowly are said to have a low G.I
Average Glycaemic response to
Carbohydrates
Low
Apple
All Bran
Porridge
Mixed grain
breads
Medium
Figs
Beetroot
Instant
porridge
Croissant
Wholemeal
bread
High
Dried dates
Baked potato
Cornflakes
Brown and
white bread
Takeaway & Eating out
- possible reasons for poor
control
 Carbohydrate often poorly estimated
 Number & timing of courses
 Rate of glycaemic change differs due to
nutritional composition
Total Carbohydrate/Fat/Protein
 Alcohol
 Activity/exercise e.g. dinner dance
 Consider the type of bolus - multiwave /
extended?
Restaurant Meals
 Carbohydrate counting booklets give the CHO content of take
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away foods.
‘Google’ the restaurant - nutritional information available.
Look at the wrapper on a frozen pizza before ordering a take
away pizza
Weighing & measuring food at home will help when estimating the
CHO content when eating out. Use your knowledge - e.g egg size
potato - 10g. 1 tablespoon cooked rice = 10g etc.
Often the meal will be high in fat / low G.I so it may be beneficial
to use a multi-wave or extended bolus.
Consider the quantity of carbohydrate, amount of meal eaten,
alcohol, activity.
Alcohol
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Combine alcohol with food
Alcohol has a hypoglycaemic response
Alcohol
Carbohydrate
Dry white or red wine
trace
Sweet wine
4.5g per 125ml glass
Beer
13g per pint
Dry cider
15g per pint
Spirits
nil
Liqueurs
6-8g per 25ml glass
Alco pops
18-24g per 275ml
Alcohol - Continued
 Patients should not give a normal bolus for alcohol
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unless they know the real effect.
Bolus for carbohydrate in the first drink only.
Often advised to reduce the basal rate overnight.
Carbohydrate snack before bed
Young adults -Clubbing - alternate normal and diet
mixers with spirits
Alcohol advice (DAFNE)
 Beware, alcohol can cause severe hypoglycaemia.
 1-2 glasses of wine / beer with a meal requires no action.
 For alcoholic drinks containing CHO take 1/2 of your usual
quick acting insulin per CP e.g. if usually 2u:10g take 1u:10g.
 To prevent a hypo after drinking alcohol, reduce the basal
rate and/or eat additional carbohydrate without taking
quick acting insulin.
 Remember to consider the effects of exercise e.g. dancing
/ sex / football.
Checklist - Basic
 Identify carbohydrates
 Link between carbohydrate and bolus doses.
 Glycaemic effects of foods
 How to interpret if the correct bolus has been
taken with a meal
 Understand pre and post prandial readings
Checklist - Intermediate
 Calculation of carbohydrate - scales / lists
 Timing of / type of bolus - fat / G.I
 Alcohol
 Snacks
 Exercise
 Ratios - calculated from food diary
Checklist - Advanced
 Using ratios successfully
 Corrections given appropriately
 Correct type of bolus given
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Don’t Give Insulin for
Carbohydrate When..
 The carbohydrate is used to treat a hypo.
 When you are compensating BG effects with
carbohydrate during exercise.
 For total carbohydrate in alcoholic drink.
Insulin:CP Ratios
 Range ½ unit insulin : CP to 3 units per CP
 Usually start with 1 unit:CP
 Look at pre and post prandial BMs - do they match?
 Some education programs look at pre meal only - therefore,
look at ratios and correction doses.
Practicalities of carbohydrate
counting
 Know all carbohydrate sources
 Changes in carbohydrate content with cooking
 Digestion may vary, consider effect of fat,
protein, total CHO, Glycaemic Index
 Insulin required for CHO consumed either in
meal or snack – does not relate to size of total
meal.
Tips for Patients
 Handy things to have in kitchen;
Scales, calculator, measuring cups., favourite plate
 Serve food in kitchen
 Serve rice/pasta, etc, separate to sauce
 Become familiar with personal portions & create own lists
 Practice makes perfect!
BERTIE
 Bournemouth Insulin Dose Adjustment Course - BIDAC (For HCPs)
 The course will cover the following topics
Defining training goals
Essential principles of carbohydrate counting and calculation
of insulin ratios.
Practical insulin adjustment scenarios
Effect of exercise
Sick day rules
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Learning theories
- Fulfilling NICE criteria
- Planning your course - timetables & lesson planning, curriculums,
recruitment
- Data collection
- Psychological aspects
BERTIE
 4 consecutive Tuesdays – off site at W.I
 DSN and Dietitian (Dr on day 4)
 Different education covered on each day
 Hypos
 DKA
 Exercise
 Travel
 Carbohydrate counting
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Basic
Eating out and take aways
Weight and measure
Conclusion
 CHO counting can help improve glycaemic
control.
 It allows individuals to be flexible.
 It has time implications for HCPs, but in
the long term helps patient empowerment &
gives patients the confidence to manage
their own diabetes.
 BERTIE also helps empowerment & DM self
management skills
 Trial and error!
Resources
Carbohydrate Counting….
Have you got it?!
References:
 Gallen I (2005) The management of insulin treated
diabetes and sport PDI 22(8) 307-12.
 Http://www.runsweet.com
 AIS (Australian Institute of Sport)
 Colberg S (2001) The Diabetic Athlete.\Human
Kinetics : Champaign IL.
 Useful Websites:
 http://www.mendosa.com/gi.htm
 Diabetes UK -carbo counting
 Carbs and Cals - book / phone app