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

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

3. 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

4. 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

5. 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.

6. 2.1. Level 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

7. 2.1. Level 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

8. 2.2. Level 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

9. 2.2. Level 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 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

10. 2.3. Level 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

11. 2.3.Level 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

12. 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

13. 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

14. 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

15. 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

16. 3.4. How Much Carbohydrate is Needed1
Calorie level
~ 1200
~1400
~1600
~1800
~2400
~2800
Calorie range
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.

17. 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

18. 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

19. 3.7. The Actions of Insulins1
Onset
Peak
Duration
Rapid acting
Lispro (Humalg)
Aspart (Novolog)
<15 minutes
hours
hour
2-4 hours
1-3 hours
Short acting
Regular
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

20. 3.8. Insulin:Carbohydrate Ratio
Method #1: Food dairy, insulin dose, and SMBG
information
Method#2: The rule of 450 or 5001
Method#3: Using the insulin sensitivity factor (ISF)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 3.13. Exercise Guidelines1 Type of Exercise If Blood Sugar Is:
Increase Carb. Intake by:
Suggested Food
Short Duration or Moderate intensity
Less than 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 grams/hr, if necessary
½ meat sandwich + milk or fruit
mg/dl
10-15 grams
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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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