Transcript Carbohydrate Counting at Different Levels: USA Management Guidelines Suha Khoury, RD Purpose of Presentation  To explain the carbohydrate counting approach and to demonstrate ways for.

Carbohydrate Counting at
Different Levels:
USA Management Guidelines
Suha Khoury, RD
Purpose of Presentation

To explain the carbohydrate counting approach
and to demonstrate ways for applying it in diabetes
nutrition management
1
Topics of Discussion
1.
2.
3.
4.
Defining carbohydrate counting approach and
highlighting reasons behind popularity
Explaining the goals and objectives for the levels
of carbohydrate counting
Presenting recommended teaching aids
Discussing case studies
2
1.
Definition and Reasons Behind
Popularity
 Definition
• Carbohydrate Counting is a meal planning approach
based on the following ideas1 :
• Carbohydrates is the main nutrient affecting post-prandial
•
glycemic response
Total amount of carbohydrates is more important than source
of carbohydrates
 Reasons behind popularity
• Effectiveness2
• Flexibility3
• Ease of implementation4
1. Using Carbohydrate Counting in Clinical Practice, JADA
2,3,4. Practical Carbohydrate Counting, American Diabetes Association, 2001
3
2. The Three Levels of Carbohydrate
Counting1



2.1. Level 1: Getting Started
2.2. Level 2: Moving On
2.3. Level 3: Using Insulin:Carbohydrate Ratios
1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.
4
2.1. Level 1
2.1.1. Goals
 Goals of Level 1 of carbohydrate counting1,2,3
• Regulate blood glucose by balancing carbohydrate
•
intake with the diabetes medication and physical
activity
Achieve and maintain consistency of carbohydrate
intake at meals and snacks at similar times each day
1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.
2. Practical Carbohydrate Counting, American Diabetes Association, 2001.
3. Using Carbohydrate Counting in Clinical Practice, JADA, 1988, v98, n8
6
2.1. Level 1
2.1.2. Objectives
 Objectives of Level 1 of carbohydrate counting1,2,3
• Identify carbohydrate as the primary nutrient affecting
•
•
•
•
•
blood glucose levels
Determine what foods contain carbohydrates, protein,
and fat
Estimate accurately portion sizes
Define 1 carbohydrate choice as 15 grams carbohydrate
and as 1 bread, or 1 fruit, or 1 milk exchange
Count carbohydrate in meal plan
Determine time and carbohydrate goals for meals and
snacks
1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8
7
2.2. Level 2
2.2.1. Goals
 Goals of Level 2 of carbohydrate counting1,2,3
• Improve glycemic control through managing patterns of
•
•
blood glucose as they relate to food intake, diabetes
medication, and physical activity
Increase flexibility in client’s lifestyle through advanced
carbohydrate counting skills
For type 1 diabetes, introduce the concept of insulin
adjustment based on changes in usual carbohydrate
intake
1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8
8
2.2. Level 2
2.2.2. Objectives
 Objectives of Level 2 of carbohydrate counting1,2,3
• Apply concept of pattern management by
•
•
•
Identifying patterns of blood glucose levels
Determining relationships among food, diabetes medication, physical
activity, and glucose levels
Establishing guidelines for managing these variables
• Identify impact of protein and fat on glucose
• Count carbohydrates in choices or grams for
• High fiber foods
• Combination foods
• Food labels
• Restaurant meals
• Recipes
• Add 1 unit of short-acting or rapid-acting insulin for
each additional 10-15 grams carbohydrates
1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8
9
2.3. Level 3
2.3.1. Goals
 Goals of Level 3 of carbohydrate counting1,2,3
• Improve BG control for people using intensive diabetes
•
management by matching the amount of insulin with
carbohydrate intake
To offer greater flexibility in food choices and portion
sizes
1. Carbohydrate Counting: Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8
10
2.3.Level 3
2.3.2. Objectives
 Objectives of Level 3 of carbohydrate counting1,2,3
• Explain insulin action; basal and bolus
• Count carbohydrates using Carbohydrate Gram Method
•
•
or Carbohydrate Choices Method
Calculate insulin:carbohydrate ratio and ISF
Adjust insulin for
• Varying amounts of carbohydrates
• High-protein and/or high-fat meals
• Foods containing fiber
• Physical activity and exercise
• Vacations and holidays
• Alcohol use
• Sick days and stress
• Restaurant meals
• Correct hypoglycemia and hyperglycemia
1. Carbohydrate Counting: Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8
11
3. Recommended Teaching Aids
3.1. The Exchange Lists
3.2. Carbohydrate Choices
3.3. Estimating Portion Sizes and Carbohydrate Choices
3.4. How Much Carbohydrate is Needed
3.5. Factors Influencing Glycemic Control
3.6. Carbohydrate Counting for Foods Containing Sugar
Alcohols
3.7. The Actions of Insulin
3.8. Insulin:Carbohydrate Ratio
3.9. Calculating Carbohydrates in Recipes
3.10. Exchanges for Alcoholic Beverages
3.11. Treating Hypoglycemia
3.12. Exercise Guidelines
3.13. Guidelines for Illness
12
3.1. The Exchange Lists1
Groups/ Lists
Carb.
Protein
Fat
Calories
Starch
15
3
1 or less
80
Fruit
15
___
___
60
Milk
Skim
Low-fat
Whole
12
12
12
8
8
8
0-3
5
8
90
120
150
Other carbohydrates
15
varies
varies
varies
Vegetables
5
2
___
25
___
___
___
___
7
7
7
7
0-1
3
5
8
35
55
75
100
___
___
5
45
Carbohydrate Group
Meat and Substitute Group
Very lean
Lean
Medium-fat
High-fat
Fat Group
1. Exchange Lists for Meal Planning, The American Diabetes Association, The American Dietetic Association, 1995
13
3.2. Carbohydrate Choices
Foods that Contain
Carbohydrates1
One Carbohydrate Choice2
Bread, cereals, pasta, and grains
1 slice of bread
Rice, beans, and starchy
vegetables: potatoes, corn, peas
½ cup pasta
Fruit and fruit juices
½ cup legumes
15 grams of carbohydrate
1 small potato
Milk and yogurt
½ cup cereal
Sugars foods: regular soda, fruit
drinks, jelly beans
1 fruit
Sweets: cake, cookies, chocolate
candy
1 cup milk
1 cup yogurt
1. Practical Carbohydrate Counting, American Diabetes Association, 2001.
2. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
14
3.3. Estimating Portion Sizes1 and
Carbohydrate Choices2
Hand Guide
Example
Thumb = 1 oz
1 serving cheese
Palm = 3 oz
1 serving cooked meat
Tight fist = ½ cup
1 serving frozen yogurt
Loose fist or handful = 1 cup
1 serving pasta
Carbohydrate
Choices
Target Total Grams
of Carbohydrate
Range of Total Grams
of Carbohydrate
1
15
8-22 grams
2
30
23-37 grams
3
45
38-52 grams
4
60
53-65 grams
1. Practical Carbohydrate Counting, American Diabetes Association, 2001.
2.Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
15
3.4. How Much Carbohydrate is
Needed1
Calorie level
~ 1200
~1400
~1600
~1800
~2400
~2800
Calorie range
12001500
13001600
14001700
16001900
18002300
22002800
Carbohydrate grams
180
180
195
210
240
300
Carbohydrate choices
12
12
12-13
13-14
15-16
18-20
Grains, beans, &
starchy vegetables
6
6
6
7
9
11
Vegetables
3
3
3
4
4
5
Fruits
3
3
3
3
3
4
Milk
2
2
2-3
2-3
2-3
2-3
2 (4oz)
2 (4oz)
2 (5oz)
2 (5oz)
2 (6oz)
3 (70z)
40/4
47/5
54/6
60/7
74/9
93/12
Meats
Fats g/servings
1. Practical Carbohydrate Counting, American Diabetes Association, 2001.
16
3.5. Factors Influencing Glycemic
Control1,2
High-fiber Meal
Subtract from total carbohydrate content the amount of fiber in foods
and meals containing more than 5 grams of carbohydrate

High-protein and/or High-fat Meal
Take rapid-acting insulin after, rather than before, the meal
 Split the dose of rapid-acting insulin and take half before the meal and
half after the meal

1.Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
17
3.6. Carbohydrate Counting for Foods
Containing Sugar Alcohols (Polyols)1
Conditions
Recommendation

Total carbohydrate comes from polyols
 There are less than 10 grams of
carbohydrates per serving


Total carbohydrate comes from polyols
 There are more than 10 grams of
carbohydrates per serving

Polyols are just one source of
carbohydrates


1. Practical Carbohydrate Counting, American Diabetes Association, 2001
Do not count if three or less
servings are eaten per day
Divide total carbohydrate in
half then count it
Divide grams of polyols in
half and subtract the amount
from total carbohydrate
18
3.7. The Actions of Insulins1
Insulin
Onset
Peak
Duration
<15 minutes
<15 minutes
0.5-1.5 hours 2-4 hours
0.5-1.0 hour 1-3 hours
0.5- 1 hour
2-3 hours
3-6 hours
2-4 hours
3-4 hours
4-10 hours
4-12 hours
10-16 hours
12-18 hours
6-10 hours
2-4 hours
10-16 hours
peakless
18-20 hours
24 hours
 Rapid acting
Lispro (Humalg)
Aspart (Novolog)
 Short acting
Regular
 Intermediate
NPH
lente
 Long acting
Ultralente
Glargine (Lantus)
1. Practical Carbohydrate Counting, American Diabetes Association, 2001
19
3.8. Insulin:Carbohydrate Ratio
3.8.1. Method #1: Food dairy, insulin dose, and SMBG
information
3.8.2. Method#2: The rule of 450 or 5001
3.8.3. Method#3: Using the insulin sensitivity factor (ISF)
3.8.1. Method #1
Food dairy, insulin dose, and SMBG information1,2
Insulin:Carbohydrate ratio = Grams of carbohydrate at a given
meal ÷ number of units of insulin taken at that meal

Example
Client needs 4 units of insulin to cover 45 grams of carbohydrates
 Insulin:Carbohydrate ratio = 45 ÷ 4 = 11.25
Ratio = 1:11

1. Carbohydrate Counting:: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
21
3.8.2. Method #2
The rule of 450 or 5001
Insulin:Carbohydrate ratio = 450 or 500 ÷ total daily insulin dose
(TDD)

Example
TDD = 36 units
 Glucose levels are within target range
 Insulin:Carbohydrate ratio = 500 ÷ 36 = 13.8 (rpund up to 14)
Ratio = 1:14

2. Practical Carbohydrate Counting, American Diabetes Association, 2001
22
3.8.3. Method #3
Method # 3: Using the insulin sensitivity factor (ISF)1
ISF = 1500 or 1800 ÷ TDD
 Insulin:Carbohydrate ratio = ISF× 0.33

Example
TDD = 25 units
 ISF = 1800 ÷ 25 = 72 mg/dl
 Insulin:Carbohydrate ratio = 72 × 0.33= 23.8 (round up to 24)
Ratio = 1:24

2. Practical Carbohydrate Counting, American Diabetes Association, 2001
23
3.9. Calculating Carbohydrates in
Recipes1
Food
Amount Weight
Carb.
Exch.
White flour
1 cup
113 g
87 g
6
Whole wheat flour
1 cup
111 g
77.7 g
5
Oatmeal
1 cup
84
55.2
4
White sugar
1 cup
200 g
199 g
13
Honey
1 cup
336 g
277 g
17
Raisins
2/3 cup
100 g
79.1 g
5
Cocoa
1/3 cup
28 g
12.8 g
1
¼ cup
43 g
31.3
2
Chocolate chips
1. Food Composition Tables, Israeli Ministry of Health, 1996
24
3.10. Exchanges for Alcoholic
Beverages1
Beverage
Serving
Carb.
(gms)
Calories
Exchanges for
Type 2 DM
12 oz.
12 oz.
12 oz.
13.7
6
9.7
151
90
50
1 bread + 2 fat
2 fat
1 bread
1 ½ oz.
Trace
107
2 fat
4 oz.
4 oz.
4 oz.
12 oz.
1.0
0.4
4.9
22.0
85
80
102
192
2 fat
2 fat
1/3 bread + 2 fat
1 fat
4 oz
1.5
73
2 fat
 Beer
Regular beer
Light beer
Nonalcoholic beer
 Distilled spirits
86 proof
 Table wines
Red or Rose
Dry white
Sweet wine
Wine coolers
 Sparkling wines
Champagne
1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987
25
3.12. Treating Hypoglycemia1
Blood Glucose
Amount of Carbohydrate Recommended
51-70 mg/dl
15 grams
41-50 mg/dl
20 grams
<40 mg/dl
30 grams
Amount of
Carbohydrates
Apple or
Orange Juice
Grape
juice
Milk
Cola/
Sprite
15 grams
120 cc
90 cc
300 cc
125 cc
20 grams
180 cc
120 cc
420 cc
190 cc
30 grams
240 cc
180 cc
600 cc
250 cc
1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987
26
3.13. Exercise Guidelines1
Type of Exercise
If Blood Sugar Is:
Increase Carb.
Intake by:
 Short Duration or
Moderate intensity
Less than 80-100 mg/dl
10-15 grams.
100 mg/dl or above
Not necessary
 Moderate
intensity
Less than 80-100 mg/dl
25-50 grams before
exercise then 10-15
grams/hr, if
necessary
½ meat sandwich
+ milk or fruit
80-170 mg/dl
10-15 grams
1 fruit or 1 bread
180-300 mg/dl
Not necessary
___
300 mg/dl or greater
Don’t exercise
___
Less than 80-100 mg/dl
50 grams
1 meat sandwich
+ milk or fruit
180-300 mg/dl
10-15 grams/hr
1 fruit or 1 bread
300 mg/dl or greater
Don’t exercise
 Strenuous activity
or exercise
1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987
Suggested
Food
1 fruit or 1 bread
___
___
27
3.14. Guidelines for Illness1


To replace 10 grams of carbohydrates
Food
Quantity
Carbonated beverage containing sugar
½ cup (4 oz.)
Popsicle
½ twin bar
Corn syrup or honey
2 tsp
Sweetened gelatin (Jell-O)
¼ cup
To replace 15 grams of carbohydrates
Food
Quantity Food
Quantity
Ice cream
½ cup
Saltine crackers
6
Cooked cereal
½ cup
Toast
1 slice
Milk shake
¼ cup
Sherbet
¼ cup
Orange or grapefruit juice
½ cup
Jell-O
1/3 cup
Grape juice
1/3 cup
Cream soups or broth based
1 cup
Custard
½ cup
Yogurt, plain
1 cup
1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987
28
4. Case Studies
4.1. Setting Carbohydrate Goals
 4.2. Impact of Fiber
 4.3. Applying Pattern Management
 4.4. Applying Insulin:Carbohydrate Ratio
 4.5. Determining Premeal Insulin Dose
 4.6. Correcting Premeal Hypoglycemia
 4.7. Correcting or Supplementing Insulin Dose

29
4.1. Setting Carbohydrate Goals1
Example: 1300 Kcal/day diet
1300 Calories ÷ 8 (½ calories as carbohydrates and ¼ gram per calorie) =
162 grams carbohydrates
Meal
Grams of Carbohydrates
Carbohydrate Choices
Breakfast
30 grams
2 choices
Snack
15 grams
1 choice
Lunch
45 grams
3 choices
Snack
15 grams
1 choice
Dinner
45 grams
3 choices
Snack
15 grams
1 choice
Total
165 grams
11 choices
1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
30
4.2. Impact of Fiber1
Total
Carbohydrate
(grams)
Fiber
(grams)
Available
Carbohydrate
(grams)
½ grapefruit
1 oz bran cereal (1/2 cup)
1 oz slice whole-wheat bread
15
22
15
1.7
10.0
1.5
15
12
15
Total
52
13.2
42
½ c orange juice
1 oz corn flakes (1 cup)
1 oz slice white bread
15
24
15
0.4
1.0
0.5
15
24
15
Total
54
1.9
54
Breakfast Meal
Breakfast A
Breakfast B
1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
31
4.3. Applying Pattern Management1
Day/Date
Time
BG
Food
Serving Size
Carbohydrate
Activity
Sun
6/10
18:00
99
steak
baked potato
corn
Total
4 oz
8 oz
1 cup
0g
43g
30g
73g
Watch TV
20:00
201
18:30
105
Spaghetti
2 cups
Marinara sauce ½ cup
Total
60g
10g
70g
Read
20:30
221
18:20
117
Grilled chicken
Bun
French fries
Diet drink
Total
0g
30g
45g
0g
75g
Computer
work
20:30
215
Mon
6/11
Tues
6/12
3 oz
2 oz
9 oz
12 oz
1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
32
4.4. Applying Carbohydrate:Insulin
Ratio1
Food
Carbohydrate
Gram Method
Carbohydrate
Choices Method
3.5 oz broiled hamburger
0g
0
2 oz hamburger bun
30g
2
½ cup low-fat cottage cheese
4g
0
4 oz sliced tomato
5g
0
1 cup homemade coleslaw
15g
1
Totals
54g
3 choices or 45g
Example: Insulin:carbohydrate ratio = 1:9
Method
Amount of Insulin
Carbohydrate Gram Method
54 grams ÷ 9 = 6 units R
Carbohydrate Choices Method
45 grams ÷ 9 = 5 units R
1. Carbohydrate Counting: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
33
4.5. Correcting or Supplementing
Insulin Dose1
Example
 Glucose = 264mg/dl
Target glucose level is 100 mg/dl
 ISF = 53 mg/dl

Answer
 Difference between target and actual glucose levels = 264 – 100 = 164 mg/dl

ISF= 164 mg/dl ÷ 53 mg/dl = 3.1 units
The correction dose of insulin is 3 units
1. Practical Carbohydrate Counting, American Diabetes Association, 2001
34
4.6. Determining Premeal Insulin Dose1
Example
TDD= 34 units
 Target glucose levels = 100 mg/dl
 Premeal glucose level = 226 mg/dl
 60 grams of carbohydrates are to be consumed

Answer
ISF = 1800 34 = 52.9 (round up to 53)
 Difference between target and actual glucose levels = 226 – 100 =126 mg/dl

Units of insulin to decrease high preprandial glucose levels= 126 ÷ 53 = 2.3 units
 Insulin:carbohydrate ratio
• 500 ÷ 34 = 14.7

• Ratio= 1:15

Units of insulin to cover carbohydrates = 60 ÷ 15 = 4 units
Premeal insulin = 2.3 units + 4 units = 6.3 units
1. Practical Carbohydrate Counting, American Diabetes Association, 2001
35
4.7. Correcting Premeal Hypoglycemia1
Example
Insulin:carbohydrate ratio = 1:13, ISF = 35
 40 grams of carbohydrate will be consumed
 Actual glucose level = 57 mg/dl
 Target glucose level= 110 mg/dl

Answer #1: Increase amount of carbohydrate

13 grams of carbohydrate will raise blood glucose by 35mg/dl
Answer # 2: Decrease preameal insulin dose
• Amount of insulin to cover carbohydrates= 40 ÷ 13 = 3 units of insulin
• Amount of insulin to be subtracted= Difference between target and actual
blood glucose levels ÷ ISF = 53 mg/dl ÷ 35 = 1.5 units insulin
• Premeal insulin = 3 units – 1.5 units = 1.5 units
Answer # 3: Delay premeal insulin
1. Practical Carbohydrate Counting, American Diabetes Association, 2001
36