carbohydrate counting at different levels: usa management guidelines suha khoury, rd carbohydrate...

Carbohydrate Counting at Carbohydrate Counting at Different Levels: Different Levels:

USA Management GuidelinesUSA Management Guidelines

Suha Suha

Khoury, RDKhoury, RD

Purpose of PresentationPurpose of Presentation

To explain the carbohydrate counting approach and to demonstrate ways for applying it in diabetes nutrition management

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Topics of DiscussionTopics of Discussion

1. Defining carbohydrate counting approach and highlighting reasons behind popularity

2. Explaining the goals and objectives for the levels of carbohydrate counting

3. Presenting recommended teaching aids4. Discussing case studies

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1.1. Definition and Reasons Definition and Reasons Behind PopularityBehind 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

31. Using Carbohydrate Counting in Clinical Practice, JADA

2,3,4. Practical Carbohydrate Counting, American Diabetes Association, 2001

2. The Three Levels of 2. The Three Levels of Carbohydrate CountingCarbohydrate Counting11

2.1. Level 1: Getting Started 2.2. Level 2: Moving On 2.3. Level 3: Using Insulin:Carbohydrate Ratios

41. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.

2.1. Level 12.1. Level 12.1.1. Goals2.1.1. Goals

61. 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

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

2.1. Level 1 2.1. Level 1 2.1.2. Objectives2.1.2. 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

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1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 19952. Practical Carbohydrate Counting, American Diabetes Association, 20013. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8


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

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1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 19952. Practical Carbohydrate Counting, American Diabetes Association, 20013. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8

2.2. Level 22.2. Level 22.2.2. Objectives2.2.2. Objectives


•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

•Add 1 unit of short-acting or rapid-acting insulin for each additional 10-15 grams carbohydrates

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• High fiber foods

• Combination foods

• Food labels

• Restaurant meals

• Recipes

1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 19952. Practical Carbohydrate Counting, American Diabetes Association, 20013. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8


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1. Carbohydrate Counting: Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 19952. Practical Carbohydrate Counting, American Diabetes Association, 20013. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8

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

2.3.Level 32.3.Level 32.3.2. Objectives2.3.2. Objectives

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• 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

1. Carbohydrate Counting: Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 19952. Practical Carbohydrate Counting, American Diabetes Association, 20013. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8


•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

•Correct hypoglycemia and hyperglycemia

3. Recommended Teaching Aids3. Recommended Teaching Aids

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3.1. The Exchange Lists3.2. Carbohydrate Choices3.3. Estimating Portion Sizes and Carbohydrate

Choices3.4. How Much Carbohydrate is Needed3.5. Factors Influencing Glycemic Control3.6. Carbohydrate Counting for Foods Containing

Sugar Alcohols3.7. The Actions of Insulin3.8. Insulin:Carbohydrate Ratio3.9. Calculating Carbohydrates in Recipes3.10. Exchanges for Alcoholic Beverages3.11. Treating Hypoglycemia3.12. Exercise Guidelines3.13. Guidelines for Illness

3.1. The Exchange Lists3.1. The Exchange Lists11

Groups/ Lists Carb.

Protein

Fat Calories

Carbohydrate GroupStarch 15 3 1 or

less80

Fruit 15 ___ ___ 60

Milk Skim Low-fat Whole

121212

888

0-358

90120150

Other carbohydrates 15 varies varies varies

Vegetables 5 2 ___ 25

Meat and Substitute Group Very lean Lean Medium-fat High-fat

____________

7777

0-1358

355575

100

Fat Group ___ ___ 5 451. Exchange Lists for Meal Planning, The American Diabetes Association, The American Dietetic Association, 1995

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3.2. Carbohydrate Choices3.2. Carbohydrate Choices

One Carbohydrate Choice2 15 grams of carbohydrate

1 slice of bread

½ cup pasta

1 small potato

½ cup legumes

½ cup cereal

1 fruit

1 cup yogurt

1 cup milk

Foods that Contain Carbohydrates1 Bread, cereals, pasta, and grains

Rice, beans, and starchy vegetables: potatoes, corn, peas

Fruit and fruit juices

Milk and yogurt

Sugars foods: regular soda, fruit drinks, jelly beans

Sweets: cake, cookies, chocolate candy

1. Practical Carbohydrate Counting, American Diabetes Association, 2001. 2. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995

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3.3. Estimating Portion Sizes3.3. Estimating Portion Sizes11 and Carbohydrate Choicesand Carbohydrate Choices22

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

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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

3.4. How Much Carbohydrate is 3.4. How Much Carbohydrate is NeededNeeded11

Calorie level ~ 1200

~1400

~1600

~1800

~2400

~2800

Calorie range 1200-1500

1300-1600

1400-1700

1600-1900

1800-2300

2200-2800

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

Meats 2 (4oz)

2 (4oz)

2 (5oz)

2 (5oz)

2 (6oz)

3 (70z)

Fats g/servings 40/4 47/5 54/6 60/7 74/9 93/12

1. Practical Carbohydrate Counting, American Diabetes Association, 2001. 16

3.5. Factors Influencing 3.5. Factors Influencing Glycemic ControlGlycemic Control1,21,2

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, 19952. Practical Carbohydrate Counting, American Diabetes Association, 2001 17

3.6. Carbohydrate Counting for 3.6. Carbohydrate Counting for Foods Containing Sugar Alcohols Foods Containing Sugar Alcohols

(Polyols)(Polyols)11 Conditions Recommendation Total carbohydrate comes from polyols There are less than 10 grams of carbohydrates per serving

Do not count if three or less servings are eaten per day

Total carbohydrate comes from polyols There are more than 10 grams of carbohydrates per serving

Divide total carbohydrate in half then count it

Polyols are just one source of carbohydrates

Divide grams of polyols in half and subtract the amount from total carbohydrate

1. Practical Carbohydrate Counting, American Diabetes Association, 200118

3.7. The Actions of Insulins3.7. The Actions of Insulins11

Insulin Onset Peak Duration

Rapid acting

Lispro (Humalg) Aspart (Novolog)

<15 minutes<15 minutes

0.5-1.5 hours0.5-1.0 hour

2-4 hours1-3 hours

Short acting

Regular 0.5- 1 hour 2-3 hours 3-6 hours Intermediate

NPH lente

2-4 hours3-4 hours

4-10 hours4-12 hours

10-16 hours12-18 hours

Long acting

Ultralente Glargine (Lantus)

6-10 hours2-4 hours

10-16 hourspeakless

18-20 hours24 hours


3.8. Insulin:Carbohydrate Ratio3.8. Insulin:Carbohydrate Ratio

3.8.1. Method #1: Food dairy, insulin dose, and SMBG

information3.8.2. Method#2: The rule of 450 or 5001 3.8.3. Method#3: Using the insulin sensitivity

factor (ISF)

3.8.1. Method #13.8.1. Method #1

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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 mealExample 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


3.8.2. Method #23.8.2. Method #2

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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


3.8.3. Method #33.8.3. Method #3

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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


3.9. Calculating Carbohydrates 3.9. Calculating Carbohydrates in Recipesin Recipes11

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

Chocolate chips ¼ cup 43 g 31.3 2

241. Food Composition Tables, Israeli Ministry of Health, 1996

3.10. Exchanges for Alcoholic 3.10. Exchanges for Alcoholic BeveragesBeverages11

Beverage ServingCarb.(gms) Calori

es

Exchanges for

Type 2 DM Beer Regular beer Light beer Nonalcoholic beer

12 oz.12 oz.12 oz.

13.76

9.7

1519050

1 bread + 2 fat2 fat

1 bread

Distilled spirits 86 proof 1 ½ oz. Trace 107 2 fat

Table wines Red or Rose Dry white Sweet wine Wine coolers

4 oz.4 oz.4 oz.

12 oz.

1.00.44.9

22.0

8580

102192

2 fat2 fat

1/3 bread + 2 fat1 fat

Sparkling wines Champagne 4 oz 1.5 73 2 fat

251. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

3.12. Treating Hypoglycemia3.12. Treating Hypoglycemia11

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Blood Glucose Amount of Carbohydrate Recommended

51-70 mg/dl 15 grams

41-50 mg/dl 20 grams

<40 mg/dl 30 grams

Amount ofCarbohydrates

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


3.13. Exercise Guidelines3.13. Exercise Guidelines11

Type of Exercise

If Blood Sugar Is:

Increase Carb. Intake by:

Suggested Food

Short Duration or Moderate intensity

Less than 80-100 mg/dl

10-15 grams. 1 fruit or 1 bread

100 mg/dl or above Not necessary ___

Moderate intensity


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 ___

Strenuous activity or exercise


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 ___


3.14. Guidelines for Illness3.14. Guidelines for Illness11

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

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

To replace 10 grams of carbohydrates

To replace 15 grams of carbohydrates


4. Case Studies4. 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

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4.1. Setting Carbohydrate Goals4.1. Setting Carbohydrate Goals11

Meal Grams of Carbohydrates

Carbohydrate Choices

Breakfast 30 grams 2 choices

Snack 15 grams 1 choice

Lunch 45 grams 3 choices


Dinner 45 grams 3 choices


Total 165 grams 11 choices

301. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995

Example: 1300 Kcal/day diet

1300 Calories ÷ 8 (½ calories as carbohydrates and ¼ gram per calorie) = 162 grams carbohydrates

4.2. Impact of Fiber4.2. Impact of Fiber11

Breakfast Meal

TotalCarbohydrat

e(grams)

Fiber(gram

s)

Available Carbohydra

te(grams)

Breakfast A½ grapefruit1 oz bran cereal (1/2 cup)1 oz slice whole-wheat bread

152215

1.710.01.5

151215

Total 52 13.2 42

Breakfast B½ c orange juice1 oz corn flakes (1 cup)1 oz slice white bread

152415

0.41.00.5

152415

Total 54 1.9 54

311. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995

4.3. Applying Pattern 4.3. Applying Pattern ManagementManagement11

1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995

Day/Date Time BG Food Serving Size

Carbohydrate

Activity

Sun6/10

18:00

20:00

99

201

steakbaked potatocornTotal

4 oz8 oz1 cup

0g43g30g73g

Watch TV

Mon6/11

18:30

20:30

105

221

SpaghettiMarinara sauceTotal

2 cups½ cup

60g10g70g

Read

Tues6/12

18:20

20:30

117

215

Grilled chickenBunFrench friesDiet drinkTotal

3 oz2 oz9 oz12 oz

0g30g45g0g75g

Computer work

32

4.4. Applying 4.4. Applying Carbohydrate:Insulin RatioCarbohydrate:Insulin Ratio11

FoodCarbohydrate 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 45gMethod Amount of Insulin

Carbohydrate Gram Method 54 grams ÷ 9 = 6 units R

Carbohydrate Choices Method 45 grams ÷ 9 = 5 units R

Example: Insulin:carbohydrate ratio = 1:9

1. Carbohydrate Counting: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995

33

4.5. Correcting or 4.5. Correcting or Supplementing Insulin DoseSupplementing Insulin Dose11


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

34

4.6. Determining Premeal Insulin 4.6. Determining Premeal Insulin DoseDose11

35

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 units1. Practical Carbohydrate Counting, American Diabetes Association, 2001

4.7. Correcting Premeal 4.7. Correcting Premeal HypoglycemiaHypoglycemia11

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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

carbohydrate counting at different levels: usa management guidelines suha khoury, rd carbohydrate...

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