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

Purpose of Presentation To explain the carbohydrate counting approach and to demonstrate ways for applying it in diabetes nutrition management 1

Topics of Discussion 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

Definition and Reasons Behind Popularity 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 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 Counting1 2.1. Level 1: Getting Started 2.2. Level 2: Moving On 2.3. Level 3: Using Insulin:Carbohydrate Ratios 4 1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.

2.1. Level 1 2.1.1. Goals 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 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, v98, n8 6

2.1. Level 1 2.1.2. 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 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, v98, n8 7

2.2. Level 2 2.2.1. Goals 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 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, v98, n8 8

2.2. Level 2 2.2.2. Objectives Objectives of Level 2 of carbohydrate counting1,2,3 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 Add 1 unit of short-acting or rapid-acting insulin for each additional 10-15 grams carbohydrates High fiber foods Combination foods Food labels Restaurant meals Recipes 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, v98, n8 9

2.3. Level 3 2.3.1. Goals 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 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, v98, n8 10

2.3.Level 3 2.3.2. Objectives Objectives of Level 3 of carbohydrate counting1,2,3 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 Correct hypoglycemia and hyperglycemia 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, 1995 2. Practical Carbohydrate Counting, American Diabetes Association, 2001 3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8 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 Lists1 Groups/ Lists Carb. Protein Fat Calories Carbohydrate Group Starch 15 3 1 or less 80 Fruit ___ 60 Milk Skim Low-fat Whole 12 8 0-3 5 90 120 150 Other carbohydrates varies Vegetables 2 25 Meat and Substitute Group Very lean Lean Medium-fat High-fat 7 0-1 35 55 75 100 Fat Group 45 13 1. Exchange Lists for Meal Planning, The American Diabetes Association, The American Dietetic Association, 1995

3.2. Carbohydrate Choices 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 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 14 1. Practical Carbohydrate Counting, American Diabetes Association, 2001. 2. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995

3.3. Estimating Portion Sizes1 and Carbohydrate Choices2 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 15 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 Needed1 Calorie level ~ 1200 ~1400 ~1600 ~1800 ~2400 ~2800 Calorie range 1200-1500 1300-1600 1400-1700 1600-1900 1800-2300 2200-2800 Carbohydrate grams 180 195 210 240 300 Carbohydrate choices 12 12-13 13-14 15-16 18-20 Grains, beans, & starchy vegetables 6 7 9 11 Vegetables 3 4 5 Fruits Milk 2 2-3 Meats 2 (4oz) 2 (5oz) 2 (6oz) 3 (70z) Fats g/servings 40/4 47/5 54/6 60/7 74/9 93/12 16 1. Practical Carbohydrate Counting, American Diabetes Association, 2001.

3.5. Factors Influencing Glycemic Control1,2 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, 1995 2. Practical Carbohydrate Counting, American Diabetes Association, 2001 17

3.6. Carbohydrate Counting for Foods Containing Sugar Alcohols (Polyols)1 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 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 18 1. Practical Carbohydrate Counting, American Diabetes Association, 2001

3.7. The Actions of Insulins1 Onset Peak Duration Rapid acting Lispro (Humalg) Aspart (Novolog) <15 minutes 0.5-1.5 hours 0.5-1.0 hour 2-4 hours 1-3 hours Short acting Regular 0.5- 1 hour 2-3 hours 3-6 hours Intermediate NPH lente 3-4 hours 4-10 hours 4-12 hours 10-16 hours 12-18 hours Long acting Ultralente Glargine (Lantus) 6-10 hours peakless 18-20 hours 24 hours 19 1. Practical Carbohydrate Counting, American Diabetes Association, 2001

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 information1,2 Insulin:Carbohydrate ratio = Grams of carbohydrate at a given meal ÷ number of units of insulin taken at that meal Example 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 2. Practical Carbohydrate Counting, American Diabetes Association, 2001 21

3.8.2. Method #2 The rule of 450 or 5001 Example 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 22 2. Practical Carbohydrate Counting, American Diabetes Association, 2001

3.8.3. Method #3 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 23 2. Practical Carbohydrate Counting, American Diabetes Association, 2001

3.9. Calculating Carbohydrates in Recipes1 Food Amount Weight Carb. Exch. White flour 1 cup 113 g 87 g 6 Whole wheat flour 111 g 77.7 g 5 Oatmeal 84 55.2 4 White sugar 200 g 199 g 13 Honey 336 g 277 g 17 Raisins 2/3 cup 100 g 79.1 g Cocoa 1/3 cup 28 g 12.8 g 1 Chocolate chips ¼ cup 43 g 31.3 2 24 1. Food Composition Tables, Israeli Ministry of Health, 1996

3.10. Exchanges for Alcoholic Beverages1 Serving Carb. (gms) Calories Exchanges for Type 2 DM Beer Regular beer Light beer Nonalcoholic beer 12 oz. 13.7 6 9.7 151 90 50 1 bread + 2 fat 2 fat 1 bread Distilled spirits 86 proof 1 ½ oz. Trace 107 Table wines Red or Rose Dry white Sweet wine Wine coolers 4 oz. 1.0 0.4 4.9 22.0 85 80 102 192 1/3 bread + 2 fat 1 fat Sparkling wines Champagne 4 oz 1.5 73 25 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

3.12. Treating Hypoglycemia1 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 420 cc 190 cc 30 grams 240 cc 600 cc 250 cc 26 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

3.13. Exercise Guidelines1 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 180-300 mg/dl 300 mg/dl or greater Don’t exercise Strenuous activity or exercise 50 grams 1 meat sandwich + milk or fruit 10-15 grams/hr 27 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

3.14. Guidelines for Illness1 To replace 10 grams of carbohydrates To replace 15 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 Food Quantity Ice cream ½ cup Saltine crackers 6 Cooked cereal Toast 1 slice Milk shake ¼ cup Sherbet Orange or grapefruit juice Jell-O 1/3 cup Grape juice Cream soups or broth based 1 cup Custard Yogurt, plain 28 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

4. 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 29

4.1. Setting Carbohydrate Goals1 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 Dinner Total 165 grams 11 choices 30 1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995

4.2. Impact of Fiber1 Breakfast Meal Total Carbohydrate (grams) Fiber Available Breakfast A ½ grapefruit 1 oz bran cereal (1/2 cup) 1 oz slice whole-wheat bread 15 22 1.7 10.0 1.5 12 52 13.2 42 Breakfast B ½ c orange juice 1 oz corn flakes (1 cup) 1 oz slice white bread 24 0.4 1.0 0.5 54 1.9 31 1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995

4.3. Applying Pattern Management1 Day/Date Time BG Food Serving Size Carbohydrate Activity Sun 6/10 18:00 20:00 99 201 steak baked potato corn Total 4 oz 8 oz 1 cup 0g 43g 30g 73g Watch TV Mon 6/11 18:30 20:30 105 221 Spaghetti Marinara sauce 2 cups ½ cup 60g 10g 70g Read Tues 6/12 18:20 117 215 Grilled chicken Bun French fries Diet drink 3 oz 2 oz 9 oz 12 oz 45g 75g Computer work 32 1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995

4.4. Applying Carbohydrate:Insulin Ratio1 Food Carbohydrate Gram Method Carbohydrate Choices Method 3.5 oz broiled hamburger 0g 2 oz hamburger bun 30g 2 ½ cup low-fat cottage cheese 4g 4 oz sliced tomato 5g 1 cup homemade coleslaw 15g 1 Totals 54g 3 choices or 45g 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 33 1. Carbohydrate Counting: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995

4.5. Correcting or Supplementing Insulin Dose1 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 1. Practical Carbohydrate Counting, American Diabetes Association, 2001

4.6. Determining Premeal Insulin Dose1 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 units 35 1. Practical Carbohydrate Counting, American Diabetes Association, 2001

4.7. Correcting Premeal Hypoglycemia1 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 36 1. Practical Carbohydrate Counting, American Diabetes Association, 2001