1. Carbohydrate Counting for Pediatric Patients With Type 1 Diabetes Review Date 5/13 K-0591 Provided Courtesy of Nutrition411.com

2. 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

3. 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

4. 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

5. 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

6. Foods That Contain Carbohydrate Breads, cereals, pasta, and grains Breads, cereals, pasta, and grains Rice, beans, and starchy vegetables (potatoes, corn, and peas) Rice, beans, and starchy vegetables (potatoes, corn, and peas) Fruit and fruit juices Fruit and fruit juices Milk and yogurt Milk and yogurt Regular soda and fruit drinks Regular soda and fruit drinks Jelly beans and gumdrops Jelly beans and gumdrops Cake, cookies, and chocolate candy Cake, cookies, and chocolate candy

7. Grams of Carbohydrate (per food category) Starch and Fruit: 1 serving equals about 15 grams (g) carbohydrate Starch and Fruit: 1 serving equals about 15 grams (g) carbohydrate Milk: 1 serving equals about 12 g carbohydrate Milk: 1 serving equals about 12 g carbohydrate Vegetables: 1 serving equals about 5 g carbohydrate Vegetables: 1 serving equals about 5 g carbohydrate

8. Starches

9. 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)

10. Fruits and Fruit Juices

11. 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

12. Milk and Yogurt

13. 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

14. Vegetables

15. Vegetables are counted as 5 g carbohydrate for the following serving sizes: ½ C cooked vegetables 1 C raw vegetables

16. 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

17. Carbohydrate and Noncarbohydrate Categories Groups/ListsCHOProteinFatCalories Starch153≤180 Fruit150060 Milk Skim Low fat Whole 12 888888 0-3 5 8 90 120 150 Other Carbohydrates12varies Vegetables52025 Meat and Substitute Group Very lean Lean Medium fat High fat 00000000 77777777 0-1 3 5 8 35 55 75 100 Fat Group00545 CHO=carbohydrate

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Tools for Carbohydrate Counting Nutrition LabelsMeasuring Tools

25. Carbohydrate Counting Hand Guide Fist=8 fl oz or 1 C Handful=½ C Palm=3 oz Thumb= 1 oz Thumb tip=1 tsp C=cup, fl oz=fluid ounce, oz=ounce, tsp=teaspoon

26. 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)=?

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Insulin-to-Carbohydrate Ratio Answers 60 g total carbohydrate/20 insulin-to- carbohydrate ratio=3 Therefore, 3 units of fast-acting insulin (NovoLog) are required for this meal

34. 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.

35. QUESTIONS?