Transcript Carbohydrate Counting

Carbohydrate
Counting
Marjan Shalchi, RD, CDE
Diabetes Education and
Management Centre
Hotel Dieu Hospital
November 13, 2015
Outline
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Why Carbohydrate Count ?
Basic to Advanced Carbohydrate Counting
Case Studies
Why Carbohydrate Count ?
The nutrient with the greatest impact on blood
glucose levels
50%
50%
Fasting BG
Post-meal BG
A1C =
At an A1C ranging from 7.3% to 8.4%, overall glycemia is impacted equally by
fasting blood glucose and post-meal blood glucose
5. Monnier L, et al. Diabetes Care 2003;26:881-885.
Why Carbohydrate Count ?
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A meal-planning approach for all patients with
diabetes
Flexibility in choosing all carbohydrate containing
foods, it may increases self management
CDA recommendations: 45-60% carbohydrate, 1520% protein, and 20-35% fat of total energy
Matching insulin to carbohydrates intake. Being
proactive regarding insulin needs.
http://guidelines.diabetes.ca/Browse/Chapter11
Basic Carbohydrate
Counting
Keep it Simple!
These Foods Contain Carbohydrate
Food Groups
GRAINS &
STARCHES
FRUITS
MILK &
ALTERNATIVES
OTHER CHOICES
EXTRA FOODS
Carbohydrate in One
Serving
15 g
15g
15g
15g
0-5g
http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-thebasics-presentation.ppt
These Foods have Little or No
Carbohydrate
Food Groups
Carbohydrate in One Serving
MEAT &
ALTERNATIVES
0 grams
(except for ½ cup Legumes 1015 grams)
VEGETABLES
0grams
(except for ½ cup squash 10
grams, parsnips 10.5 grams
and peas 7 grams)
FATS
0 grams
http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-thebasics-presentation.ppt
Basic Carbohydrate Counting
Tools
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Food Sources of Carbohydrates
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Handouts, CDA resources
Food models
Food labels
Apps
http://www.diabetes.ca/diabetes-and-you/healthy-living-resources/diet-nutrition
How to Read Labels
1. Look at serving size and compare it to
the amount of food being eaten
2. Carbohydrate includes starch, sugars,
and fibre
3. Fibre should be subtracted from total
carbohydrate because it does not raise
blood glucose
http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professionalresources/beyond-the-basics-presentation.ppt
How to Read Labels
with Sugar Alcohols
LABEL READING EXAMPLE
RECIPE FOR READING
CARBOHYDRATES
Serving Size: 1 piece
Total Carbohydrate:
32 g
Check the serving size and adjust for
your portion
1.Sugar……………… 10 g
Take the carbohydrate……….
2. Starch……………… 11 g
Subtract from it:
*all the fiber value…………. - 6 g
*all the sugar alcohol value….. - 2 g
3. Fiber………………… 6 g
4. Sugar Alcohol……….. 2 g
(Examples: sorbitol,
mannitol, isomalt, lactilol,
polyols)
Available Carbohydrate:
32 g
24g
Websites
http://www.calorieking.com/
http://www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutridata/index-eng.php
http://ndb.nal.usda.gov/ndb/search/list
Apps
You need to know if the app is based on an
accurate data base. This is especially
important for insulin dosing.
Calorie King, Eat Wise and USDA are accurate data bases.
www.calorieking.com
http://www.eatwise.ca/
http://ndb.nal.usda.gov/
https://mysugr.com/apps/ is a useful tracking tool
Recommended carbohydrate intake
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Consider individual energy needs
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Exercise patterns
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Individual eating pattern
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Food preferences
Carbohydrate
Recommendations
Carbohydrates
% of total energy
45%
50%
60%
Women (13001800 kcal/day)
145- 200
grams/day
160- 225
grams/day
195-270
grams/day
Men (1800-2000
kcal/day)
200-225
grams/day
225-250
grams/day
270-300
grams/day
General Guidelines: Carbohydrates/Meal
Women
Men
To lose weight
30-45 g
45-60 g
To maintain weight
45-60 g
60-75 g
For very active
Snacks
60-75 g
15-30 g
60-90 g
15-30 g
Individualize
Distribute evenly for good blood glucose control
Consider individual energy needs, exercise patterns, individual eating pattern and food preferences
Beyond Carbohydrate Counting
Diabet. Med. 27, 348-353 (2010)
A study of 102 children with Type 1 Diabetes
and adolescents and 110 caregivers
estimating the carbohydrate content of 17
meals containing 8-90 grams of
carbohydrates.
Beyond Carbohydrate Counting
Diabet. Med. 27, 348-353 (2010)
Results:
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73% of all estimates were within 10-15 g of actual
carbohydrate content.
It did not matter what method of carbohydrate
counting they used.
Underestimated larger meals
Overestimated snacks
Longer diabetes duration had a negative effect on
accuracy of carbohydrate estimation
More accuracy when using packaged foods
Beyond Carbohydrate Counting
Diabet. Med. 27, 348-353 (2010)
Recommendations:
is suggested that ±10-15 grams difference in
Carbohydrate estimation does not significantly changes the
post prandial blood glucose levels.
•Specific advice to regularly check the serving sizes of main
meal items such as rice, pasta and starchy vegetables may
maintain accuracy as appetite changes.
•Snack foods such as fruit require size comparisons with
food models or real food to improve accuracy.
•Consistency in carbohydrate estimation have a greater
impact on HbA1C than accuracy.
•It
Advanced Carbohydrate Counting
… Use All the Basic Teachings
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Handouts, Food models, food Labels, Apps and Carbohydrate
Targets, etc
PLUS some more …
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Carbohydrates are not all equal
High protein and fat containing foods
Matching Carbohydrates to Insulin; Insulin to
Carbohydrate Ratio and Correction Factor
Glycemic Index
2013 CDA guidelines suggest choosing lower glycemic index
carbohydrates to help optimize blood glucose
 For the same number of carbohydrate grams, low or medium GI
foods may raise blood glucose less than high GI foods.
 Mismatch between insulin action and carbohydrate absorption
following a high GI foods may lead to a rapid glucose spike.
• Glucose determinations at 1-2 hours postprandial will be
instructive.
 Low GI foods with high fructose and/or sucrose content (e.g. fruit
juice) lead to a rapid glucose spike
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Fats
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Late post prandial hyperglycemia is the
predominant effect of dietary fat
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Some studies show lower glucose concentrations
in the first 2-3 hours due to delayed gastric
emptying*
Addition of 50 grams of fat can increase insulin
requirements by twofold.
*Diabetes Care 2015; 38:1008-1015
Proteins
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Protein affects blood glucose in the late post
prandial period.
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If 30 g protein is consumed with minimum 30 grams of
carbohydrate containing foods, blood glucose levels rise
after 3-4 hours (2-3 numbers). This is the amount of protein
in 4 oz cooked lean meat.
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If at least 75 grams of protein (8 oz of lean steak) is
consumed without carbohydrates, blood glucose increases
in 1.5 hours after consumption similar to about 20 grams of
carbohydrates.
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There is an additive effect of protein and fat consumed
together at a meal, up to 5.5 number increase at 5 hours
post meal.
Diabetes Care 2015; 38:1008-1015
Teach Advanced Carbohydrate
Counting
… if a person is on INSULIN and is willing to
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Do simple mathematics
Use nutrient analysis information, websites
Have and know how to use measuring cups, spoons and
scales
Keep accurate and detailed records
To test his/her blood glucose before and 2 hours after the
first bite of a meal
Be motivated and able to take the time required to improve
his/her diabetes management
The Basal/Bolus Insulin Concept
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Basal insulin
 Suppresses glucose production between meals
and overnight
 50% of total daily insulin needs
Bolus (mealtime) insulin
 rapid- or short-acting insulin given just before a
meal in anticipation of the glycemic spike that
occurs due to carbohydrate ingestion
 50% of total daily insulin needs
 Given usually as three equally divided doses
before meals
Blood Glucose Targets for Most People with
Diabetes
• Pre-meal blood glucose: 4.0 – 7.0 mmol/L.
• 2 hour post-meal blood glucose: 5.0 – 10.0
mmol/L.
• A rise of 2.0 to 3.0 mmol/L is normal after
eating.
Insulin to Carbohydrate (I:C) Ratio
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This is the amount of insulin needed to cover the
carbohydrate being consumed at a meal.
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For example: I:C ratio of 1:10 means 1 unit of insulin would
be taken for every 10 grams of carbohydrate
Post prandial blood glucose rise of 2- 3 mmol/L is
expected when I:C ratio is correct.
Ways to determine I:C ratio
1) Quick and Easy Method
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Starting ratios: 1:15 (1 unit of fast-acting insulin
for 15 grams of carbohydrate)
Ratios vary
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10:1 for insulin resistance/obese individuals
20:1 for young, thin individuals
Ways to determine I:C ratio
2) Pattern Management
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Review food, insulin and blood glucose records
Identify trends
For example:
70 grams of carbohydrates
7 units of fast acting insulin
Blood glucose before lunch: 7 mmol/L
Blood glucose 2 hours later: 9.5 mmol/L
70 g carb ÷ 7 units of insulin = 10 I:C is 1:10
Ways to determine I:C ratio
3) 500 Rule
Divide 500 by the total daily dose of insulin
I:C Ratio = 500 ÷ total daily dose of insulin
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Example: The total daily dose of insulin = 35 units
500 ÷ 35 = 14
I:C ratio = 1:14
So for every 14 grams of carbohydrate the patient
eats, they will take 1 unit of rapid- or short-acting
insulin
Many Variables Influence Glycemic
Control....
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Food
Exercise/activity
Illness
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Insulin absorption
Insulin resistance
Stress/coping
Always assess the variables and keep this in mind when considering an
insulin dose adjustment.
Compensate for
unanticipated high blood
sugar, using “correction
insulin”
This is called Insulin Sensitivity
Factor or Correction Factor (CF)
How to Determine a starting Correction
Factor
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100 Rule:
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Divide 100 by the total daily dose of insulin
For example, if total daily dose is 50 units:
100 ÷ 50 = 2 , CF is 1:2
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Individualize, this varies by weight of the person, time of
the day and with hormonal fluctuations and very high
blood glucose
So, if the person’s blood glucose is 9 mmol/L, and
their target glucose is 7 mmol/L, then:
Current blood glucose – target blood glucose
÷ CF
(9 –7) ÷ 2 = 1
Therefore, if the persons blood glucose is 9.0
mmol/l and they want to bring it down or “correct” it
to 7.0mmol/, they need to take 1 unit of rapid- or
short-acting insulin.
Case Studies
Mary has been taking insulin for 3 months. She has been
following a consistent carbohydrate meal plan and has adjusted
her insulin doses using pattern management. She has good
comprehension of carbohydrates and is ready to start learning
how to self-adjust her insulin based on carbohydrate counting.
She attends a “Carb-counting class” at her local diabetes
education centre and has a follow up with the dietitian today.
Mary’s current insulin doses are:
Long-acting Insulin 20 units QHS
Rapid-acting Insulin 10/8/12 units at Breakfast, Lunch and
Supper respectively.
What is Mary’s estimated I:C ratio?
Total insulin: 50 units
500 ÷ 50 = 10
Joe is placed on multiple daily insulin injections
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He weighs 100 kg. His insulin requirements are 0.5 units/kg
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His total daily dose is:
100 kg x 0.5 units/kg = 50 units
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His insulin dosage:
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Glargine (long acting) - 26 units QHS
Aspart (rapid acting) - 8 units at each meal
Joe is working with his diabetes educators learning to adjust his
insulin using carb-counting and correction factor.
Question: What is Joe’s estimated I:C ratio and CF?
I:C 500 ÷ 50 = 10
CF: 100 ÷ 50 = 2
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Joe is about to eat breakfast and figure out how much rapid insulin he
needs to take for breakfast:
2 fried eggs 3 slices of bacon (0 gms))
2 slices of whole wheat toast 2 teaspoons of jam (40 gms)
1 glass of orange juice (26 gms)
1 cup of black coffee (0 gms)
Total carbs = 66 grams
Blood glucose =11.1 mmol/L,Joe’s target range is 4.0 to 7.0
mmol/L
I:C ratio = 1:10, CF = 2.0
Question: How much insulin aspart (NovoRapid®) should Joe take?
Answer:
1. Insulin to carbohydrate ratio is 1 unit for every 12 grams of carbohydrate
66 ÷ 10 = 6.6 units of insulin for food round to 7, PLUS
2. His blood glucose is 11.1 mmol/L and his target range is 4.0 to 7.0 mmol/L
Correction factor is 1 unit to lower her blood glucose by 2 mmol/L
11.1 – 7 (his target glucose)] ÷ 2 = 2 units
Total dose : 7 + 2 units = 8 units of insulin aspart
Adjusting Insulin for Exercise
Effects of Exercise on Blood Glucose
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Physical activity includes more than formal exercise; everyday activity
such as yard work, lawn mowing and shopping are activities that can
have an impact on blood glucose.
Physical activity increases the body’s sensitivity to insulin and the
speed that it is absorbed.
Physical
Activity
can cause
Blood Sugar
The effects of exercise can last up to 24 hrs
When planning for increased physical activity,
individuals should consider decreasing insulin,
increasing food or a combination of both.
Ex-Carbs for Exercise Guidelines (adult)*
Exercise
BG (mmo/L)
Carbohydrate
Snack type/portions
Light x 60 min.
- Walking, bowling
Less than 6.0
15 gms
1 starch or fruit
Moderate x 60 min.
-Tennis
- Swimming
- House cleaning
- Golf
Less than 6.0
30 gms before exercise.
An additional 10-15 gms
for each additional hour.
2 starch or fruit
6.0 - 10.0
15 gms
1 starch or fruit
11.0 – 17.0
(no ketones)
No food increase
17.0 or greater and
moderate ketones
Do not exercise until
diabetes control improves
Strenuous x 60 min.
- Hockey
- Racquetball
- Competitive sports
Less than 6.0
45 gms before exercise.
Additional 10-15 gms for
each additional hour.
2 starch , 1 protein &
1 fruit
6.0 – 10.0
30 gms
2 starch & 1 protein
Note: Small amounts at
frequent intervals are
preferable for prolonged
activity
11.0 – 17.0
(no ketones)
15 gms
1 starch or fruit
14.0 or greater and
moderate ketones
Do not exercise until
diabetes control improves
*Adapted from Saskatchewan Insulin Adjustment Module, December 2005
Adjusting Insulin for Exercise/activity….
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Light activity (walking)
– 10-20% reduction
Moderate (brisk walking,
jog, fitness class,
swimming)
– 30-40% reduction
Strenuous (hard run,
sprints, sports)
– 50% or more reduction
*Remember, these are
guidelines only, individual
responses vary!
Questions?