Carbohydrate Counting Course
A Guide to the Principles of Carbohydrate Counting for Children & Adolescents with Type 1 Diabetes
This document was originally written by Emma Jenkins, Diabetes Specialist Dietitian, BDEC, Royal Bournemouth Hospital Feb 2004 We have modified the content to meet the needs of our education programme. November 2005
Why count carbohydrates?
Learning how to count carbohydrates and how to adjust your insulin doses according to the food and drinks that you eat and the activities that you enjoy will help you to:
Improve your overall diabetes control. Stabilise your blood glucose levels so that there are less fluctuations or swings, particularly after eating. Predict your blood glucose response to eating different foods and drinks. Eat according to your appetite. Vary your meal times and even skip the occasional meal or snack if you do not feel like eating. Enjoy restaurant and takeaway meals. Avoid feeling guilty when eating sugary or sweet foods.
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Learning how to count carbohydrates and how to adjust your insulin doses should give you the freedom to enjoy the foods and drinks that you like, when you like, and according to your appetite. This allows you to manage your diabetes around your diet and lifestyle and not the other way around.
Carbohydrate counting is not difficult. It is important that you are on the appropriate insulin treatment which consists of a background insulin providing 24 hour cover and a quick acting insulin to cover the glucose load from foods which you eat. Initially you will need to put in some extra time and effort, however with practice you will soon become familiar with it. You will also need to test your blood glucose at least four times a day and keep an accurate record of what you eat, your insulin doses and blood glucose levels. These are all essential to help you to master carbohydrate counting and enable you to confidently adjust your insulin doses.
Which foods affect blood glucose levels ?
Food consists of a mixture of three basic nutrients (food components) that provide energy in your diet. These are carbohydrates, proteins and fats.
Effect on blood glucose level
Carbohydrate has the most significant effect on your blood glucose levels. During digestion, carbohydrate is broken down into glucose. This is released into your blood, causing your blood sugar level to rise. It does not matter whether the carbohydrate comes in the form of a starchy food (e.g. bread, potato, cereal, etc.) or as a sugary food (e.g. fizzy drink, cake, biscuits, etc.) all carbohydrates end up as glucose in your blood stream and will need some quick acting insulin, called a bolus, to cover the amount eaten. The majority of carbohydrate enters the bloodstream as glucose between 15 minutes and 23 hours after eating. The more carbohydrate you eat, the higher your blood glucose will rise and the more quick acting insulin you will need. Different types of carbohydrate are digested and absorbed at different rates. Meals high in fat and/or protein can also influence blood glucose response, by delaying the rate of food digestion and absorption.
The seven steps to successful carbohydrate counting
When carbohydrate counting, it is best to work through a series of steps as shown below. If you are new to carbohydrate counting it is important to master steps 1 to 3 before moving onto the remaining steps.
Identify all the foods and drinks that you eat that contain carbohydrate.
Calculate or estimate the carbohydrate content of your meal or snack.
Calculate the insulin dose you need to cover the amount of carbohydrate eaten.
Consider factors that could affect your blood glucose response such as the fat, protein and fibre content of your meal.
Consider your premeal blood glucose level (e.g. hypo or hyper glycaemia) and other factors (e.g. recent exercise, illness, stress, etc.) that could affect your blood glucose level – is a correction dose needed?
Give your mealtime insulin dose.
Keep a record of your blood glucose response before your meal or snack and 23 hours after eating, so that you can learn to adjust your insulin doses better.
Where do you find carbohydrate?
Carbohydrate is found in many foods, in two main forms as sugars and as starch.
There are three different types of sugar: · Sucrose (sweet foods) · Fructose (natural fruit sugars) · Lactose (milk sugar)
Sucrose is found in the form of syrups and table sugar (e.g. white, brown, icing, caster and cane sugar) and is added to many foods including sugary cereals, sweets, chocolate, cake, biscuits, jam, sweet puddings, jelly, ordinary fizzy drinks and squash. Sucrose is quickly digested and absorbed into the blood stream. These foods often contain little fibre or other nourishment, and so are not recommended as every meal foods. Fructose (fruit sugar) is found in fresh, dried, stewed and tinned fruit and in fruit juice. Fructose also affects blood glucose levels, however it also contains some fibre, which helps to slow down digestion and absorption, and is full of vitamins and minerals for good health. Lactose (milk sugar) is found in milk and dairy foods (e.g. yoghurt, fromage frais, ice cream and custard). Lactose also affects blood glucose levels, although the rise in blood glucose tends to be slower. Milk and dairy foods are also important providers of calcium, protein and essential vitamins, and should be included in your diet every day.
Complex or starchy carbohydrates are made up of glucose units and held together in a more complex structure. Starch is found in cerealbased foods such as rice, corn, pasta, couscous, bread, cereals, and in foods made out of flour (e.g. pizza, pastry, biscuits, cake and crackers).
Vegetable starch is found in potatoes, peas, sweet corn, beans and lentils.
Some soups and thickened sauces also contain starch (e.g. corn flour, modified food starch and maltodextrin).
Starchy foods are generally excellent food choices, as they contain more fibre, vitamins and minerals than sugary foods. The effect on your blood glucose levels will depend on the type of starchy food and how much you eat of it.
A summary of foods containing carbohydrate
§ Cereal based starch: breakfast cereal, bread, pasta, rice, couscous, flour based products and thickening agents. § Vegetable starch: potatoes, peas, beans and lentils. § Fructose (fruit sugar): fruit and fruit juice. § Lactose (milk sugar): milk, yoghurt, fromage frais, ice cream and custard. § Sucrose (sweet foods): table sugar, syrup, chocolate.
The CP (Carbohydrate Portion) system
Carbohydrate counting uses the CP (Carbohydrate Portion) system. 1 CP = 10g Carbohydrate 1 CP contains approximately 10g carbohydrate. By adding up the CP portions in a meal or a snack, or by adding up the total grammes of carbohydrate and dividing by 10 to give the CPs. This figure is then used to help determine the insulin needed for the meal or snack.
Estimating the carbohydrate content of meals
Learning about portion sizes is the key to mastering carbohydrate counting. There are various ways to help you to calculate or estimate the carbohydrate content of different foods and drinks. 1. Weighing foods and drinks. 2. Measuring foods and drinks using cups, jugs, scoops, spoons, etc. 3. Using carbohydrate portion lists or booklets. 4. Reading the food label. 5. Using recipes that list the carbohydrate content per serving.
Weighing foods and drinks
Weighing foods with kitchen scales is the most accurate way of working out how much you eat of foods such as breakfast cereal, potato, rice, pasta, etc. You can then calculate the carbohydrate content of the food by looking up the carbohydrate content of the food using carbohydrate counting books, food composition tables or by reading the food label. It is useful to weigh your portion sizes to begin with to get an accurate measure of the carbohydrate content of your foods and drinks. You will soon become familiar with your personal portions. Don’t confuse cooked and dry weights. Cereal foods such as rice and pasta absorb water when cooked, so that the portion looks bigger and weighs more. A baked potato however, loses water during cooking and shrinks in size and weight after cooking. Example: A portion of cooked rice weighs 200g. In food composition tables for the United Kingdom, 100g of cooked rice contains 30g of carbohydrate. This means that in a 200g portion of cooked rice, there is 60g of carbohydrate (= 6CP).
Measuring foods and drinks
You can use “handy” measures such as breakfast bowls, cups, spoons, scoops and measuring jugs to estimate the carbohydrate content of personal portions of food such as breakfast cereal, rice, pasta, mashed potato, etc. and for liquid foods and drinks you have such as orange juice, milk, soup, custard, etc.
Carbohydrate portion lists or booklets
1 carbohydrate portion (CP) = 10 grams (g) of carbohydrate. Carbohydrate portion lists or booklets are useful for estimating the carbohydrate content of foods and drinks, when it is not possible or practical to weigh them. They provide an average carbohydrate content, so should only be used as a guide. The carbohydrate portions at the back of this booklet show foods that contain approximately 10 grams of carbohydrate (similar to carbohydrate “exchanges” used in the past). However, you may find it more useful to make up your own carbohydrate portion list based on your personal portions of foods and drinks.
Carbohydrate counting books
Carbohydrate counting books and food composition tables list either the amount of carbohydrate found in a 100g serving or average food portion. They are useful for calculating the carbohydrate content of food after it has been weighed or measured out. The definitive guide to the carbohydrate content of different foods and drinks in the United Kingdom is the sixth edition of McCance and Widdowson’s The Composition of Foods published by the Royal Society of Chemistry and the Food Standards Agency, 2002. There are also carbohydrate counting books, available from most good book stores such as: Collins Gem Calorie Counter. Harper Collins Publishers, Glasgow, 2003, ISBN 0007144342 The Fat, Fibre and Carbohydrate Counter by Dell Stanford, Murdoch Books Ltd., London, 1999, ISBN 1853918022 The Calorie, Carb and Fat Bible by Jeremy Sims, Penhaligon Press Ltd., 2002, ISBN 1862266832 Check that the carbohydrate counting book you use reflects foods eaten in the United Kingdom, as there is some variability in the type of foods eaten and in the nutritional content of foods, between different countries. 8
Reading the food label
Reading food labels can tell you a lot about the food you are eating, which is important if you are trying to count carbohydrates and to eat a healthy, balanced diet. The nutrition information panel always shows the amount of food energy (calories), protein, carbohydrate and fat per 100g of a food. Values may also be shown for sugar, saturated fat, fibre and sodium (salt) and per serving. Example Pepperoni Pizza (300g) Nutrition Information : Typical values Energy Protein Carbohydrate (of which sugars) Fat (of which saturates) Fibre Sodium Per ½ pizza 2316kJ 550Kcals 25.0g 70.8g 5.2g 18.6g 6.8g 3.4g 1.4g Per 100g (3.5oz) 1158kJ 275Kcals 12.5g 35.4g 2.6g 9.3g 3.4g 1.7g 0.7g
When calculating the carbohydrate content of a food, look at the total carbohydrate, not just the “of which sugars” value. The carbohydrate figure given on the nutrition information panel includes all starches, sugars and dietary fibre in the food. You can calculate the amount of carbohydrate in your food portion by multiplying the amount of carbohydrate per 100g of the food by the weight of your food portion in grams (g), and then dividing this by 100. Using the food label above as an example, there is 35.4g of carbohydrate in 100g of pepperoni pizza. Therefore the carbohydrate content of 300g of pepperoni pizza is: Carbohydrate content of pizza per 100g X weight of individual food portion(g) 100 = 35.4 x 300 100 = 106.2g of carbohydrate = 10 CPs 9
Check whether the carbohydrate content is referring to the dry or cooked weight. If the carbohydrate value listed for a product is that when cooked (e.g. rice, pasta, couscous, etc.), then cook the food according to the instructions on the packet, and then weigh or measure out your individual portion.
You can save time calculating the carbohydrate content of a dish if you look for recipes that list the carbohydrate content per serving (e.g. Diabetes UK cook books). Check that your individual portion is the same as that of the recipe book.
Tips for carbohydrate counting
§ Handy things to keep in the kitchen are a calculator, food weighing scales, measuring cups, jugs, spoons or scoops. § Serve your food in the kitchen. § Serve rice and pasta separate to the sauce. § Become familiar with your personal portions by using favourite plates, bowls, cups and spoons. § Create a list of the foods you commonly eat and the number of carbohydrate portions (or grams of carbohydrate) each food contains. § Remember practice makes perfect!
Calculating the Insulin Doses
The amount of insulin required for carbohydrate is described as units per CP. Typical range is ½ 3 units per CP. This is worked out on an individual basis and takes into account insulin sensitivity. This will be calculated during the course. There are many ways of calculating this; we use Total Daily Insulin 50 Example: If a persons total daily insulin dose = 75 units 75 / 50 = 1.5 So this person could try a 1.5 units per CP (10g carbohydrate) The insulin that would be required for each CP is show below, Round down the dose. Number of CPs 1 2 3 4 5 6 7 8 9 10 Insulin units needed None needed 3 4.5 6 7.5 9 10.5 12 13.5 15 Amount of insulin required for each CP eaten
To test the bolus ratio it is useful to check the blood glucose responses before the next meal. When testing responses, it is important that the carbohydrate is calculated correctly and that the patient hasn’t exercised or experienced a hypo on that day.
Extra insulin can also be added to this as a corrective dose to correct for hyperglycemia (blood glucose above 10 mmol/l).
Calculating your insulin to carbohydrate ratio
After estimating the carbohydrate content of your meal, the next step is to calculate how much insulin you need to cover the amount of carbohydrate eaten. This is worked out on an individual basis and takes into account your insulin sensitivity. This will be calculated for each person during the course and may need to be reviewed as we learn more about you and the way your body handles glucose.
Testing your insulin to carbohydrate ratio
When testing your insulin to carbohydrate ratio, you will need to check your blood glucose level before and after eating your meals. It is important that the amount of carbohydrate you have eaten is calculated correctly and that you have not experienced a “hypo”, exercised strenuously or exercised over a long period of time in the last 24 hours. You should avoid eating foods that have a very high carbohydrate content, or are very high in fat, protein or fibre. Instead choose simple meals to test your ratio, such as: § A bowl of breakfast cereal with semiskimmed milk. § Toast with a moderate amount of spreading fat. § A sandwich. § A bowl of soup and a bread roll. § Grilled chicken breast, jacket potato and vegetables. Test your blood glucose level just before eating your meal to make sure that your blood glucose level is within your target range. Then recheck your blood again 23 hours after eating your meal. Your insulin to carbohydrate ratio is correct if your post meal blood glucose 2 – 3 hours after eating is within 1.5 – 2 mmol/l of your premeal glucose level. Try also testing your insulin to carbohydrate ratio at different times of the day (e.g. breakfast, lunch and evening meal), as it is possible that your insulin to carbohydrate ratio will differ depending on the time of day.
Adjusting your insulin to carbohydrate ratio
Always consult your diabetes specialist nurse or doctor before making any changes to your insulin doses. Blood glucose level too low after meals? If your blood glucose levels are too low after eating, then you need less mealtime insulin. You will need to increase your insulin to carbohydrate ratio. For example, if your previous insulin to carbohydrate ratio was 1 unit for every 10 grams of carbohydrate, you may need to increase your insulin to carbohydrate ration to 1 unit of insulin for every 15 grams of carbohydrate. Blood glucose level too high after meals? If your blood glucose levels are too high after eating, then you will need more mealtime insulin. You will need to decrease your insulin to carbohydrate ratio. For example, if your previous insulin to carbohydrate ratio was 1 unit for every 10 grams of carbohydrate, you may need to decrease your insulin to carbohydrate ratio to 1 unit of insulin for every 5 grams of carbohydrate.
Provided your basal (bedtime) insulin dose is correct and your diabetes is well controlled, then you can skip or delay the occasional meal, if you do not feel like eating. Skipping meals on a regular basis is not recommended though, as you may end up not eating enough foods to meet all of your body’s nutritional needs.
Eating meals that do not contain any carbohydrate
You will only need to inject insulin if your meal, drink or snack contains some carbohydrate. However it is not healthy to follow a diet that does not contain any carbohydrate, as carbohydrate is the body’s preferred source of energy. A varied diet that consists of adequate amounts of carbohydrate and moderate amounts of protein and fat is recommended.
Splitting your insulin dose
Once you have calculated the carbohydrate content of your meal and the amount of insulin needed, you may need to consider splitting some of your mealtime insulin doses. Most foods produce a peak in blood glucose 1 – 2 hours after eating. However, foods with a high fat, protein or fibre content can delay this peak from occurring until 4 – 6 hours after having eaten. Glucose may then continue to be released into the bloodstream for up to 8 – 12 hours after eating, long after the insulin you have injected has stopped working. When deciding on splitting your insulin doses, you will need to consider: § The protein and/or fat content of the meal. § The type of carbohydrate food eaten (its glycaemic index). § The size of the meal. § The way in which the meal is served
Blood glucose response after eating different types of meals and after splitting the insulin dose.
Standard insulin dose given with a normal meal Standard insulin dose given with a high fat, protein or fibre meal Two smaller insulin doses given with a high fat, protein or fibre meal
B G L
B G L
B G L
BGL = Blood glucose level
High fat and high protein meals
Meals containing moderate amounts of fat or protein will not significantly affect your blood glucose levels and therefore only need a standard insulin dose based on the amount of carbohydrate eaten. High fat (more than 15 – 20 grams of fat) and high protein (more than 20 – 30 grams of protein) meals slow down the rate of digestion by holding food in your stomach for longer and delay the blood glucose response. In addition, some of the protein may be converted into glucose raising blood glucose levels 4 – 12 hours or more after eating. A single large dose of insulin may reduce your blood glucose levels too quickly, increasing your risk of hypoglycaemia, followed several hours later by the blood glucose rising too high, as the insulin is no longer acting to bring the blood glucose level back down. You may benefit by having half of the total insulin dose before or just after your meal and the remainder 15 – 60 minutes later. High fat and high protein foods that delay the blood glucose response and may need a split insulin dose include: High Fat Takeaway foods such as hamburgers, fried potato chips, thick milk shakes, deep fried meat, chicken and fish dishes. High Protein More than 34oz (100120 grams) of cooked meat, chicken or fish – that is a portion larger than the size of a pack of playing cards.
Restaurant meals based on large Pizza and lasagne dishes, mixed grills servings of protein rich foods (e.g. and fried breakfasts. steaks, chicken, eggs, cheese or fish). Some Indian meals (e.g. korma, masala, bhaji, samosa and biryani rice). Barbeque meals containing large quantities of meat, chicken or fish.
Takeaway foods such as Some Chinese meals (e.g. deep fried hamburgers. prawn balls, crispy fried duck, sesame prawn roll and egg fried rice). Some Mexican dishes (e.g. enchiladas, tortillas, fried rice, guacamole and sour cream dips). Cream and cheese based sauces. Nuts, chocolate, gateau and cheesecakes.
High fibre and high carbohydrate meals
Dietary fibre has great benefits to our health, including improving insulin sensitivity and digestive health, lowering blood cholesterol and helping control our appetite so that we feel full for longer – important if you are trying to lose excess weight. Dietary fibre also slows down digestion by holding food in the stomach for longer, delaying the blood glucose response. The glycaemic index (GI) refers to how quickly carbohydrate is digested and absorbed as glucose into the blood stream. Foods that break down quickly during digestion and release glucose into the bloodstream very quickly have a high glycaemic index (e.g. white bread, low fibre breakfast cereals, Lucozade, etc.). Foods that break down slowly during digestion and release glucose more slowly into the bloodstream have a lower glycaemic index (e.g. beans, lentils, peas, most fruits, nuts, seeds, oats, whole grain bread and cereals. The following table lists certain foods according to whether they have a high, medium or low glycaemic index: High GI Glucose and Lucozade. White, brown and wholemeal breads, Corn Flakes and Rice Krispies. Mashed, boiled and baked potatoes. Watermelon. Medium GI Granary and multigrain breads, basmati rice, sweetcorn and new potatoes, wholegrain breakfast cereals (e.g. Weetabix, Shredded Wheat), bananas, grapes and fruit juice Low GI Pasta, macaroni and noodles (all types), porridge oats, unsweetened muesli, apples, oranges, pears, plums, strawberries, nuts, peas, beans and lentils
For more information on the glycaemic index, please ask your Dietitian for a copy of the leaflet The Glycaemic Index and Diabetes. Remember that whilst the glycaemic index refers to how quickly carbohydrate is digested and absorbed as glucose into the bloodstream, it does not take account of the amount of carbohydrate in food. It is the total amount of carbohydrate eaten that has the most effect on your blood glucose level. If you eat a meal with a low glycaemic index or a meal with very large carbohydrate content (e.g. a meal needing ⅓ – ½ more insulin compared with your usual insulin dose) you may find that a single large dose of insulin reduces your blood glucose level too quickly, increasing your risk of hypoglycaemia. This may be followed several hours later by blood glucose rising too high, as the insulin is no longer acting to bring the blood glucose level back down. You may benefit by splitting your mealtime insulin dose into two smaller doses, injecting ½ before or just after your meal and the remainder 15 – 60 minutes later. 16
Splitting the insulin dose can also be useful when eating out or attending a special function where foods are served as separate courses over a prolonged period of time, with differing amounts of carbohydrate. Some people find it easier to take some insulin along with the starter, the main course and again at dessert, so that they can estimate better how much carbohydrate each course contains. This helps to ensure that they give the correct amount of insulin for the meal that they eat.
th and Alcohol (in anticipation of your 18 birthday!)
Alcohol is made by fermenting either sugar or starch. Pure alcohol alone does not raise the blood glucose; it is the remaining starch or sugar, fruit and addition of sugarbased flavours that increase the carbohydrate content of the drink. The carbohydrate content of different drinks is found in separate tables accompanying this booklet. Giving a normal insulin dose for the carbohydrate is not usually recommended because of the risk of hypoglycaemia. If a consistent problem of hyperglycaemia is observed after drinking, then you may benefit from giving half the usual units per CP. For example, 4 pints of beer contain 40g carbohydrate (4CPs) so give 2 units if on 1 unit per CP ratio. The blood glucose responses need to be carefully monitored particularly before bed and the next morning. Because there is a risk of hypoglycaemia during the next morning, the breakfast insulin may need to be reduced by as much as 50%. Remember! Alcohol can effect the ability to recognise a hypo and can impair reasoning. Care needs to be taken when calculating insulin does when drinking.
Some people are anxious that the concept of “Food freedom” will encourage an unhealthy diet and excessive weigh gain. Achieving good blood glucose control is the key to being healthy with diabetes and the process of carbohydrate counting can help this to be achieved. You may also want to consider the fat, fibre and overall nutrient content of your diet. Weight gain or loss is determined by balancing food and exercise.
Potential Reasons for Weight Gain § Eating more/larger servings. § Eating higher calorie foods (chocolate, biscuits, etc.) § Forgetting about healthy eating principles. § Efficient glucose storing. § Underlying medical problem.
Potential Reasons for Weight Loss § Less insulin. § Fewer snacks – less insulin. § Skipping meals/smaller servings. § Eating to huger, rather than to prevent hypos. § Feel well – more exercise.
Produced by the
Nutrition and Dietetic Department Salisbury District Hospital
November 2005, review November 2007
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