Embed Size (px)
Citation preview
Carbohydrate Counting Masterclass
Dale Cooke
Accredited Practising Dietitian
Diabetes Queensland
Diabetes Queensland is a member-based, non-profit
organisation.
We aim to improve the lives of people affected by all types
of diabetes and those at risk, through advocacy, support
and education in partnership with the Queensland
community.
DIABETES QUEENSLAND
We will:
• Examine the factors affecting carbohydrate counting
from a whole diet perspective;
• Identify the effects of different dietary patterns on
carbohydrate counting;
• Discuss the importance of diet quality in addition to
carbohydrate counting; and
• Understand the challenges of carbohydrate counting
OBJECTIVES
WHO SHOULD CARB COUNT?
Pre-diabetes – maybe for weight loss
Type 1 diabetes – yes
Type 2 diabetes – maybe for weight loss;
generally depends on meds
Gestational diabetes – depends on meds
• Health literacy & numeracy
• Time & motivation
• Taking insulin &
• desires carb flexibility
• able to adjust insulin
• Or taking sulfonylureas
REQUIREMENTS
Fortin, A., Rabasa-Lhoret, R., Roy-Fleming, A., Desjardins, K., Brazeau, A., Ladouceur, M., & Gingras, V. (2017). Practices, perceptions and expectations for
carbohydrate counting in patients with type 1 diabetes - results from an online survey. Diabetes Research and Clinical Practice, 126, 214-221.
10.1016/j.diabres.2017.02.022
Kulkarni, K. D. (2005). Carbohydrate counting: a practical meal-planning option for people with diabetes. Clinical Diabetes, 23(3)
Insulin adjust insulin to match carbs
Sulfs ensure an even distribution and
consistent intake of carbs
MEDS
Safety – reduce likelihood of hypoglycaemic events
Flexibility – allows carbs to be interchanged (sulfs/insulin)
– allows variable carb intake (insulin)
Improved
outcomes – intensive blood glucose management reduces
the risk of complications (eye disease 76%,
kidney disease3 50%, nerve disease 60%)
WHY CARB COUNT?
Stratton, I. M., Adler, A. I., Neil, H. A. W., Matthews, D. R., Manley, S. E., Cull, C. A., … Holman, R. R. (2000). Association of glycaemia with macrovascular and microvascular complications of type 2
diabetes (UKPDS 35): prospective observational study. BMJ : British Medical Journal, 321(7258), 405–412.
Shamoon, H., Duffy, H., Fleischer, N., Engel, S., & al, e. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent
diabetes mellitus. The New England Journal of Medicine, 329(14), 977-986.
Group, D. S., DAFNE Study Grp, & DAFNE Study Group. (2002). Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Dose adjustment for normal
eating (DAFNE) randomised controlled trial. British Medical Journal, 325(7367), 746-749. 10.1136/bmj.325.7367.746
General nutrition education*^
Carb recognition *^
Carb counting* – Exchanges 15g
Advanced carb counting* – Portions 10g (OzDAFNE)
– Grams (pumps)
Scope of practice:
^CDE/DE
*APD
WHAT CARB COUNTING ENTAILS
The Role of Credentialled Diabetes Educators and Accredited
Practising Dietitians in the Delivery of Diabetes Self Management
and Nutrition Services for People with Diabetes (2015)
1. General nutrition education
2. Carb recognition
3. Carb counting
4. Advanced carb counting
HOW TO CARB COUNT
GENERAL NUTRITION EDUCATION
National Health Medical Research Council
(2013), Australian Dietary Guidelines,
Canberra, National Health and Medical
Research Council retrieved from
https://www.nhmrc.gov.au/_files_nhmrc/file
/publications/n55_australian_dietary_guide
lines1.pdf
Grains & cereals
Legumes
Milk, yoghurt
Legumes, potato, sweet
potato, corn
Fruit
Cakes, biscuits, lollies,
chocolate, chips,
crackers, sugar, ice
cream, pastry, juice,
soft drink, cordial etc.
CARB RECOGNITION
Desmond Australia, (2017), Carb Smart resources
National Health Medical Research Council (2013), Australian Dietary Guidelines, Canberra, National Health and Medical Research Council
retrieved from https://www.nhmrc.gov.au/_files_nhmrc/file/publications/n55_australian_dietary_guidelines1.pdf
• Grain/cereals: breakfast cereals, bread, rice, pasta,
couscous etc.
• Vegetables: potato, sweet potato, corn, legumes
(lentils, beans, peas)
• Fructose: fruit, fruit juice
• Lactose: milk, yoghurt
• Added sugar: ice cream, custard, pastry, biscuits,
cake, chocolate, confectionery, sugary soft drinks etc.
CARB RECOGNITION
Desmond Australia, (2017), Carb Smart resources
WHAT ABOUT PROTEIN & FAT?LF/LP
• 30g carbs
• 4g fat
• 5g protein
LF/HP
• 30g carbs
• 4g fat
• 40g protein
HF/LP
• 30g carbs
• 35g fat
• 5g proteinSmart, C., Evans, M., O'Connell, S., McElduff, P., Lopez, P., Jones, T., King, B. (2013). Both dietary protein and fat increase
postprandial glucose excursions in children with type 1 diabetes, and the effect is additive. Diabetes Care, 36(12), 3897-
3902. 10.2337/dc13-1195
• Need carb recognition first
• 1 exchange of carbohydrate = 15g of carb
• Teach number of exchanges per day based on the ADG &
the client’s needs
• Encourage carbohydrate consistency (amount and timing) ***
• Encourage SMBG & record keeping
• Medical team adjusts medication, with dietitian
recommending adjustments to carbohydrate intake according
to pre & post meal BGLs & MNT
CARBOHYDRATE COUNTING
Buethe, M. (2008). C-O-U-N-T C-A-R-B-S: A 10-step guide to teaching carbohydrate counting. The Diabetes Educator, 34(1), 67-74. 10.1177/0145721707312206
INTERCHANGABLE CARB SERVES
Diabetes Western Australia, Carbsmart facilitator resources
National Diabetes Services Scheme, Consumer information: Carbohydrate counting and diabetes, retrieved from
https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/685c04ca-60d7-49bc-b596-09cc29d61a1b.pdf
Encourage clients to develop
‘Ready Reckoner’ of favourite
foods
EXCHANGES
Carb Exchanges
15g 1 exchange
30g 2 exchanges
45g 3 exchanges
60g 4 exchanges
75g 5 exchanges
90g 6 exchanges
How many exchanges in
the following:
• 1 slice of bread
• 1 cup cooked couscous
• 1 cup cooked rice
• 1 cup cooked pasta
ACTIVITY
1 cup mashed potato
1 cup raw oats
1 cup plain Greek yoghurt
1 cup of milk
1 cup of sugary soft drink
• Ready reckoner eg Carbohydrate counting in
exchanges – NDSS fact sheet
• Apps eg Calorie King
• Hands
TOOLS
National Diabetes Services Scheme, Consumer information: Carbohydrate counting and diabetes, retrieved from
https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/685c04ca-60d7-49bc-b596-09cc29d61a1b.pdf
OZDAFNE, The DAFNE principles, retrieved from http://www.dafne.org.au/health-professionals/dafne-principles
Borushek, A., (2018) ,The Calorie King, Calorie and fat counter, 45th Annual Edition, Hinkler Books pty ltd, Heatherton, Australia
ESTIMATING
Thumb = 1 tablespoon
Tight fist = ½ cup Cupped hand = 1 cup
Thumb tip = 1 teaspoon
Gibson, A. A., Hsu, M. S. H., Rangan, A. M., Seimon, R. V., Lee, C. M. Y., Das, A., . . . Sainsbury, A. (2016).
Accuracy of hands v. household measures as portion size estimation aids. Journal of Nutritional Science, 5, 11.
Calculate the number of exchanges in these two breakfasts
• Breakfast 1:
2 slices wholegrain toast with avocado and vegemite
+ 150ml of 100% orange juice
+ a piece of fruit
• Breakfast 2:
1 cup muesli
+ 1 cup milk
+ 1 sliced banana
+ milk coffee
ACTIVITY
Increased precision:
• Uses grams, ½ exchanges or ½ portions
Why use advanced carb counting?
• Allows bolus insulin dose to be calculated
• Insulin to carb ratio & correction factors to be used
• Allows for a more flexible eating patterns
ADVANCED CARB COUNTING
Buethe, M. (2008). C-O-U-N-T C-A-R-B-S: A 10-step guide to teaching carbohydrate counting. The Diabetes Educator, 34(1), 67-74. 10.1177/0145721707312206
EXCHANGES
Carbs Exchanges
0 - 6g Do not count
7 - 11g ½ exchange
12 - 18g 1 exchange
19 - 26g 1½ exchanges
27 - 33g 2 exchanges
34 - 31g 2 ½ exchanges
42 - 48g 3 exchanges
• Ready reckoner/apps
• Nutrition information panels
• Smart meters (e.g. Accu-Chek Aviva Expert, Freestyle InsuLinx)
• Insulin pump bolus wizards with or without wireless glucose monitors
• Calculator
• Scales
• Measuring cups and spoons
• Pen and paper
• Insulin : carb and correction factor (ISF)
TOOLS
Must be able to understand:
• Target BGLs
• Role of carbs
• Action of insulin
• Basal-bolus insulin concept
• Carb counting tools
Must be willing to:
• Carry out pattern management/problem solving
• Regularly SMBG and keep records
CLIENT REQUIREMENTS
Kulkarni, K. D. (2005). Carbohydrate counting: a practical meal-planning option for people with diabetes. Clinical Diabetes, 23(3)
• Education time for dietitian and client
• Labour/time intensive for client
• More advanced health literacy/maths
• More SMBG
• Must have an interest in food & having flexible eating patterns
• Awareness of other factors affecting BGLs e.g. fibre, fat, alcohol,
stress, illness, hormones, individual variation
LIMITATIONS
Kulkarni, K. D. (2005). Carbohydrate counting: a practical meal-planning option for people with diabetes. Clinical Diabetes, 23(3)
• Difficult to be exact – aim for “best estimate” rather than
“guess”
• Better accuracy leads to more predictable BG response
• +/- 10g carb does not have significant affect on BGLs
• SBGM will help to assess accuracy
PRECISION
Calculate the grams of carb:
• Per serve
• Per 100g
Calculate the number of
exchanges:
• Per serve
• Per 100g
LABEL READING
LABEL READING
What if the amount I am eating is not the same as the
serve size or 100g?
CARB COUNTING EQUATION
Carbohydrates in
reference food (g)
Weight of
our food (g)C
W
x
Weight of
reference food (g)
Your serve of weighs 47g
How many carb is in your serve?
C carbs per serve = 21.2g
W suggested serve = 30g
Y your serve = 47g
x 47 = 33g carbohydrate or 2 exchanges
PER SERVE
Nutrition Information
Servings per package: 12
Serving size: 30g (3/4 metric cup)
Per serve Per 100g
Energy 472kJ 1573kJ
Protein 5.9g 19.7g
Total Fat
- saturated
0.1g
<0.1g
0.4g
0.1g
Carbohydrates
- total
- sugars
21.2g
4.4g
70.8g
14.5g
Dietary Fibre 0.8g 2.5g
Sodium 161mg 536mg
C
Wx
21.2
30
Your serve of weighs 47g
How many carb is in your serve?
C carbs per 100g = 70.8g
W = 100g
Y your serve = 47g
x 47 = 33g carbohydrate or 2 exchanges
PER 100g
Nutrition Information
Servings per package: 12
Serving size: 30g (3/4 metric cup)
Per serve Per 100g
Energy 472kJ 1573kJ
Protein 5.9g 19.7g
Total Fat
- saturated
0.1g
<0.1g
0.4g
0.1g
Carbohydrates
- total
- sugars
21.2g
4.4g
70.8g
14.5g
Dietary Fibre 0.8g 2.5g
Sodium 161mg 536mg
C
Wx
70.8
100
APPSCalorie King - www.calorieking.com.au (free)
• Contains over 22,000 Australian foods including many restaurants
• iPhone only
Easy Diet Diary - https://easydietdiary.com/ (free)
• Nutrient data based on official Australian food data
• iPhone only
My Fitness Pal - https://www.myfitnesspal.com (free for basic version)
• Similar to Easy Diet Diary but American-based food data
• iPhone & Android
The Traffic Light Guide to Food - www.thetrafficlightguide.com.au (free)
• Shows carbohydrates in exchanges or portions
• iPhone & Android
Work in teams of 2-3.
Measure out what you would normally serve yourself and
calculate the amount of carb in grams and exchanges for each
food using cups/scales/your hands for measuring.
For calculations, use multiple references
- A food label
- Calorie king book
- DQ carb counting booklet
and compare the results.
PRACTICAL ACTIVITIES
• ‘C’ calories Vs. ‘C’ carbohydrate
• Forgetting to ‘zero’ on the scales
• Ounces vs. grams on the scales
• Raw vs. cooked foods
• Food label: incorrect information, small print, confusion & poor interpretation
• Using the calculator
• Using ‘sugars’ and not ‘total carbohydrate’
• Forgetting to count the extras (e.g. cup of soup, sauces)
• Your serve size isn’t their serve size
STUMBLING BLOCKS
• A meal with minimal carb needs no additional insulin
• However, a small amount of insulin may be required to
“supplement” the basal insulin
• The general idea of a meal containing no carb needs
consideration about balance in food over the day
WHAT ABOUT CARB FREE MEALS?
We‘ve covered:
• Who should carb count and to what level
• How to carb count (and you’ve practiced this!)
• And why we carb count.
CONCLUSION
QUESTIONS?
