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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????