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Provided Courtesy of Nutrition411.com Carbohydrate Counting for Pediatric Patients With Type 1 Diabetes Review Date 5/13 K-0591 Program Purpose • To increase knowledge of carbohydrate counting and insulin management skills for those caring for patients with type 1 diabetes (T1DM): – A solid knowledge base of carbohydrate counting and insulin management is important – Registered nurses are often the first point of contact with the pediatric patient with T1DM Program Objectives • Identify categories of foods containing carbohydrate • Identify the relationship between carbohydrates and blood sugar • Determine the grams of carbohydrate in foods when using the nutritional food label and other carbohydrate-counting tools • Calculate the total grams of carbohydrate/meal • Use insulin-to-carbohydrate ratios to determine the amount of insulin required during mealtimes Carbohydrate Counting Defined • A meal-planning approach based on the following ideas: – Carbohydrate is the main nutrient affecting postprandial glycemic response – Total amount of carbohydrates consumed is more important than the source of carbohydrates Benefits of Carbohydrate Counting • More flexible than other meal-planning methods • Sugar is not forbidden • Focuses attention on the foods that are most likely to make blood glucose levels go up Foods That Contain Carbohydrate • Breads, cereals, pasta, and grains • Rice, beans, and starchy vegetables (potatoes, corn, and peas) • Fruit and fruit juices • Milk and yogurt • Regular soda and fruit drinks • Jelly beans and gumdrops • Cake, cookies, and chocolate candy Grams of Carbohydrate (per food category) • Starch and Fruit: 1 serving equals about 15 grams (g) carbohydrate • Milk: 1 serving equals about 12 g carbohydrate • Vegetables: 1 serving equals about 5 g carbohydrate Starches Starch Group Each amount listed below=15 g carbohydrate 1 ounce (oz) of bagel, bread, roll (one slice of bread, one-fourth of a bagel) ¾ C unsweetened cereal (Cheerios®, Rice Krispies®, corn flakes) ⅓ C higher-carbohydrate cereals (raisin bran) One-half of an English muffin ⅓ C pasta, spaghetti, macaroni and cheese ⅓ C brown or white rice ½ C mashed potatoes ½ C corn, beans, chickpeas, peas One small baked potato (3 oz) Fruits and Fruit Juices Fruit Group Each amount listed below=15 g carbohydrate One small fresh fruit (4 oz) ½ C canned fruit (in natural juice) ¼ C dried fruit ½ C fruit juice 1 C fresh fruit (cut up) 1 tablespoon (Tbsp) jelly, jam Milk and Yogurt Milk Group Each amount listed below=approximately 12 g carbohydrate 8 fluid ounces (fl oz) skim, 1%, 2%, whole milk 1 C plain yogurt 1 C plain or vanilla soy milk Vegetables Vegetables Vegetables are counted as 5 g carbohydrate for the following serving sizes: •½ C cooked vegetables •1 C raw vegetables Foods Without Carbohydrate Protein and fat groups contain 0 g carbohydrates Examples: • Protein: Meat, fish, poultry, cheese, eggs, peanut butter, cottage cheese, tofu • Fat: Butter, margarine, mayonnaise, cream cheese, sour cream, nuts, seeds, avocado Carbohydrate and Noncarbohydrate Categories Groups/Lists CHO Protein Fat Calories Starch 15 3 ≤1 80 Fruit 15 0 0 60 Milk Skim Low fat Whole 12 12 12 8 8 8 0-3 5 8 90 120 150 Other Carbohydrates 12 varies varies varies Vegetables 5 2 0 25 Meat and Substitute Group Very lean Lean Medium fat High fat 0 0 0 0 7 7 7 7 0-1 3 5 8 35 55 75 100 Fat Group 0 0 5 45 CHO=carbohydrate The Relationship Between Carbohydrate and Blood Sugar • The digestive system converts most digestible carbohydrates into glucose (also known as blood sugar) • Cells are designed to use this as a universal energy source • As blood sugar levels rise in an individual who does not have diabetes, beta cells in the pancreas churn out more and more insulin, a hormone that signals cells to absorb blood sugar for energy or storage Carbohydrate and Blood Sugar in T1DM • People with T1DM do not make enough insulin, so their cells cannot absorb sugar • Carbohydrates begin to raise blood glucose within approximately 5 minutes after initiation of food intake • Carbohydrates are converted to nearly 100% blood glucose within about 2 hours Carbohydrate and Blood Sugar in T1DM (cont’d) • The focus of carbohydrate counting is on the one nutrient that most impacts blood glucose • Carbohydrate is the primary nutrient affecting blood glucose levels • Individuals can learn to regulate carbohydrate intake with their blood glucose results Carbohydrate Substituting • When carbohydrate counting, it is possible to substitute one food item for another for a similar impact on blood glucose • Example: Exchange a small apple (4 oz) for two small cookies for a similar effect on blood glucose Food Labels Total Carbohydrate— includes grams of sugar, sugar alcohol, starch, and dietary fiber Total Grams of Carbohydrate— used to determine amount of carbohydrate eaten; multiply grams of total carbohydrates on the label by the number of servings eaten Food Labels • Example: You just ate 10 crackers from the previous label • There are 2 crackers/serving • How many servings did you eat? –5 • How many total carbohydrates did you consume? – 10 g/serving x 5 servings=50 g Tools for Carbohydrate Counting Nutrition Labels Measuring Tools Carbohydrate Counting Hand Guide Thumb= 1 oz Fist=8 fl oz or 1 C Palm=3 oz Handful=½ C C=cup, fl oz=fluid ounce, oz=ounce, tsp=teaspoon Thumb tip=1 tsp Sample Menu #1 How many carbohydrates are in this meal? Six chicken nuggets=? Two packets of ketchup=? One small banana=? 8 fl oz of 2% milk=? Small bag of potato chips=? 8 fl oz of iced tea (unsweetened)=? Sample Menu #1 Answers How many carbohydrates are in this meal? Six chicken nuggets=15 g Two packets of ketchup=6 g One small banana=15 g 8 fl oz of 2% milk=12 g Small bag of potato chips=15 g 8 fl oz of iced tea (unsweetened)=0 g TOTAL=63 g Sample Menu #2 Breakfast Two slices of toast, 4 fl oz of juice, 6 fl oz of milk Snack 1 Three graham crackers, one slice of cheese Lunch Hot dog on bun, 15 French fries, 4 fl oz of milk, two ketchup packets Snack 2 One slice of bread, one slice of cheese Dinner 1 C macaroni and cheese, one small piece of fruit Snack 3 Four graham crackers, 1 Tbsp peanut butter Sample Menu #2 Answers Breakfast=50 g Snack 1=15 g Lunch=72 g Snack 2=15 g Dinner=60 g Snack 3=232 g Insulin-to-Carbohydrate Ratio • Insulin-to-carbohydrate ratio: The units of insulin needed to "cover" a specified number of carbohydrate grams • An important tool for intensive diabetes management • Divide the total grams of carbohydrate consumed by the carbohydrate-to-insulin ratio Insulin-to-Carbohydrate Ratio (cont’d) • To improve blood glucose control for people using intensive diabetes management, match the amount of insulin with carbohydrate intake • Understanding carbohydrate counting is required: – To assure the administration of the appropriate insulin-to-carbohydrate ratio at mealtimes in hospitalized patients – For glycemic control – For the prevention of hypoglycemia and/or hyperglycemia Insulin-to-Carbohydrate Ratio (cont’d) • Example: A child is to consume a 60-g carbohydrate diet • The child’s premeal blood glucose is within the normal range • The child’s insulin-to-carbohydrate ratio is 1:20 • For every 20 g of carbohydrate eating, 1 unit of fast-acting insulin (NovoLog®) is required Insulin-to-Carbohydrate Ratio Answers • 60 g total carbohydrate/20 insulin-tocarbohydrate ratio=3 • Therefore, 3 units of fast-acting insulin (NovoLog) are required for this meal References • American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66. doi:10.2337/dc13-S011. • American Dietetic Association, American Diabetes Association. Exchange Lists for Meal Planning. 2nd ed. Alexandria, VA: American Diabetes Association; 2003. • International Diabetes Center at Park Nicollet. My Food Plan for Kids and Teens. Minneapolis, MN: Park Nicollet; 2006. • Thomas E. Survey reveals shortfall in pediatric nurses' knowledge of diabetes. J Diabetes Nurs. 2004;8(6):217-221. • Warshaw H, Bolderman K. Practical Carbohydrate Counting. A How to Teach Guide for Health Professionals. Alexandria, VA: American Diabetes Association; 2001. • Warshaw H, Kulkarni K. American Diabetes Association Complete Guide to Carbohydrate Counting. Alexandria, VA: American Diabetes Association; 2004. QUESTIONS?