Carbohydrate Counting at Different Levels USA Management Guidelines

Carbohydrate Counting at Different Levels: USA Management Guidelines Suha Khoury, RD

Purpose of Presentation l 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. l Definition and Reasons Behind Popularity Definition • Carbohydrate Counting is a meal planning approach based on the following ideas 1 : • Carbohydrates is the main nutrient affecting post-prandial glycemic • l response Total amount of carbohydrates is more important than source of carbohydrates Reasons behind popularity • Effectiveness 2 • Flexibility 3 • Ease of implementation 4 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 Counting 1 2. 1. Level 1: Getting Started l 2. 2. Level 2: Moving On l 2. 3. Level 3: Using Insulin: Carbohydrate Ratios l 1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995. 4

2. 1. Level 1 2. 1. 1. Goals l Goals of Level 1 of carbohydrate counting 1, 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, v 98, n 8 6

2. 1. Level 1 2. 1. 2. Objectives l Objectives of Level 1 of carbohydrate counting 1, 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, v 98, n 8 7

2. 2. Level 2 2. 2. 1. Goals l Goals of Level 2 of carbohydrate counting 1, 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, v 98, n 8 8

2. 2. Level 2 2. 2. 2. Objectives l Objectives of Level 2 of carbohydrate counting 1, 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, v 98, n 8 9

2. 3. Level 3 2. 3. 1. Goals l Goals of Level 3 of carbohydrate counting 1, 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, v 98, n 8 10

2. 3. Level 3 2. 3. 2. Objectives l Objectives of Level 3 of carbohydrate counting 1, 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, v 98, n 8 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 Lists 1 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 Vegetables 5 2 ___ 25 ___ ___ 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 Carbohydrates 1 One Carbohydrate Choice 2 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 Sizes 1 and Carbohydrate Choices 2 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 Needed 1 Calorie level ~ 1200 ~1400 ~1600 ~1800 ~2400 ~2800 Calorie range 12001500 13001600 14001700 16001900 18002300 22002800 Carbohydrate grams 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 4 Milk 2 2 2 -3 2 -3 Meats 2 (4 oz) 2 (5 oz) 2 (6 oz) 3 (70 z) 40/4 47/5 54/6 60/7 74/9 93/12 Fats g/servings 1. Practical Carbohydrate Counting, American Diabetes Association, 2001. 16

3. 5. Factors Influencing Glycemic Control 1, 2 High-fiber Meal Subtract from total carbohydrate content the amount of fiber in foods and meals containing more than 5 grams of carbohydrate l High-protein and/or High-fat Meal Take rapid-acting insulin after, rather than before, the meal l Split the dose of rapid-acting insulin and take half before the meal and half after the meal l 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 l Total carbohydrate comes from polyols l There are less than 10 grams of carbohydrates per serving l l Total carbohydrate comes from polyols l There are more than 10 grams of carbohydrates per serving l Polyols are just one source of carbohydrates l l 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 Insulins 1 Insulin Onset Peak Duration <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 l Rapid acting Lispro (Humalg) Aspart (Novolog) l Short acting Regular l Intermediate NPH lente l 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 information 1, 2 Insulin: Carbohydrate ratio = Grams of carbohydrate at a given meal ÷ number of units of insulin taken at that meal l Example Client needs 4 units of insulin to cover 45 grams of carbohydrates l Insulin: Carbohydrate ratio = 45 ÷ 4 = 11. 25 Ratio = 1: 11 l 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) l Example TDD = 36 units l Glucose levels are within target range l Insulin: Carbohydrate ratio = 500 ÷ 36 = 13. 8 (rpund up to 14) Ratio = 1: 14 l 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 l Insulin: Carbohydrate ratio = ISF× 0. 33 l Example TDD = 25 units l ISF = 1800 ÷ 25 = 72 mg/dl l Insulin: Carbohydrate ratio = 72 × 0. 33= 23. 8 (round up to 24) Ratio = 1: 24 l 2. Practical Carbohydrate Counting, American Diabetes Association, 2001 23

3. 9. Calculating Carbohydrates in Recipes 1 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 1. Food Composition Tables, Israeli Ministry of Health, 1996 24

3. 10. Exchanges for Alcoholic Beverages 1 Beverage Serving Carb. (gms) Calories Exchanges for Type 2 DM 12 oz. 13. 7 6 9. 7 151 90 50 1 bread + 2 fat 1 bread 1 ½ oz. Trace 107 2 fat 4 oz. 12 oz. 1. 0 0. 4 4. 9 22. 0 85 80 102 192 2 fat 1/3 bread + 2 fat 1 fat 4 oz 1. 5 73 2 fat l Beer Regular beer Light beer Nonalcoholic beer l Distilled spirits 86 proof l Table wines Red or Rose Dry white Sweet wine Wine coolers l Sparkling wines Champagne 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987 25

3. 12. Treating Hypoglycemia 1 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 Guidelines 1 Type of Exercise If Blood Sugar Is: Increase Carb. Intake by: l Short Duration or Moderate intensity Less than 80 -100 mg/dl 10 -15 grams. 100 mg/dl or above Not necessary l Moderate intensity Less than 80 -100 mg/dl l Strenuous activity or exercise Suggested Food 1 fruit or 1 bread ___ 25 -50 grams before ½ meat sandwich + exercise then 10 -15 milk or fruit grams/hr, if necessary 80 -170 mg/dl 10 -15 grams 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 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987 1 fruit or 1 bread ___ 27

3. 14. Guidelines for Illness 1 l l 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 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 l l l l 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 Goals 1 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 Fiber 1 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 Management 1 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 0 g 43 g 30 g 73 g Watch TV 20: 00 201 18: 30 105 Spaghetti Marinara sauce Total 2 cups ½ cup 60 g 10 g 70 g Read 20: 30 221 18: 20 117 Grilled chicken Bun French fries Diet drink Total 3 oz 2 oz 9 oz 12 oz 0 g 30 g 45 g 0 g 75 g Computer work 20: 30 215 Mon 6/11 Tues 6/12 1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995 32

4. 4. Applying Carbohydrate: Insulin Ratio 1 Food Carbohydrate Gram Method Carbohydrate Choices Method 3. 5 oz broiled hamburger 0 g 0 2 oz hamburger bun 30 g 2 ½ cup low-fat cottage cheese 4 g 0 4 oz sliced tomato 5 g 0 1 cup homemade coleslaw 15 g 1 Totals 54 g 3 choices or 45 g 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 Dose 1 Example l Glucose = 264 mg/dl Target glucose level is 100 mg/dl l ISF = 53 mg/dl l Answer l Difference between target and actual glucose levels = 264 – 100 = 164 mg/dl l 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 Dose 1 Example TDD= 34 units l Target glucose levels = 100 mg/dl l Premeal glucose level = 226 mg/dl l 60 grams of carbohydrates are to be consumed l Answer ISF = 1800 34 = 52. 9 (round up to 53) l Difference between target and actual glucose levels = 226 – 100 =126 mg/dl l Units of insulin to decrease high preprandial glucose levels= 126 ÷ 53 = 2. 3 units l Insulin: carbohydrate ratio • 500 ÷ 34 = 14. 7 l • Ratio= 1: 15 l 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 Hypoglycemia 1 Example Insulin: carbohydrate ratio = 1: 13, ISF = 35 l 40 grams of carbohydrate will be consumed l Actual glucose level = 57 mg/dl l Target glucose level= 110 mg/dl l Answer #1: Increase amount of carbohydrate l 13 grams of carbohydrate will raise blood glucose by 35 mg/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