Carbohydrate Counting. Who chooses what you eat every day? Setting The Stage. Pre-Test. Pre-Test. Eating for Diabetes Made Easier

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1 Carbohydrate Counting Eating for Diabetes Made Easier Kris Williams, MS RD Department of Health Education Kaiser Permanente, Kern County Setting The Stage Who chooses what you eat every day? Pre-Test. Diabetes nutrition education should be based on the type of medication the patient is currently taking.. The skills and knowledge of the doctor and the RD are more important than the patient s input when selecting the optimum approach for diabetes nutrition education. Pre-Test 4. The Plate Method for portion control is not sensitive to ethnic cuisines. 5. People with diabetes need to be taught to eat six small meals a day. 3. Everyone with diabetes needs to count grams of carbohydrates in order to have optimum blood sugar control.

2 008 American Diabetes Association Position Statement Nutrition Recommendations EFFECTIVENESS OF MEDICAL NUTRITION THERAPY (MNT) Recommendation: Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes 008 ADA Goals of MNT That Apply to Individuals With Diabetes. Achieve and maintain - normal or near-normal blood glucose as is safely possible - a lipid and lipoprotein profile that reduces risk for vascular disease - blood pressure levels in the normal or near-normal range as is safely possible 008 ADA Goals of MNT. To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle. 008 ADA Goals of MNT 3. To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change. 4. To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.

3 ????? What Is Carbohydrate Counting? Who should choose what people with diabetes eat every day? A method of teaching people how to eat consistent amounts of carbohydrate at meals and snacks at similar times each day, with the end goal of achieving glycemic control and other diabetes and metabolic nutrition goals. Hope S. Warshaw and Karen M. Bolderrman, Practical Carbohydrate Counging: A How-to-Teach Guide for Health Professionals, American Diabetes Association 008 Why Carb Counting?. Achievement of glycemic control a primary goal of diabetes management. Improved weight control. American Diabetes Association, Nutrition Recommendations and Interventions for Diabetes, Richard Bergenstal, et al, Adjust to Target in Type Diabetes, Diabetes Care, July 008 and The Look AHEAD Research Group, Reduction in Weight and CVD Risk Factors in Individuals With Type Diabetes, Diabetes Care, June 007 Why Carb Counting 3. Risk for atherosclerosis is more closely associated with post-prandial blood sugar levels than with pre-prandial levels 4. Improved Ac levels 3. Temelkove-Kurktschiev, et al, Postchallenge Plasma Glucose and Glycemic Spikes Are More Strongly Associated with Athersclerosis Than Fasting Glucose or HbAc Level, Diabetes Care, December DAFNE Study Group, Training in flexible, intensive insulin management to enable dietary freedom in people with type diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial, BMJ, October 00 3

4 Who Benefits from Carb Counting? Members Improved blood sugar control provides physical and emotional benefit Educators We can meet members at their own level of readiness Physicians Improved blood sugar control results in fewer diabetes complications Carb Counting: A Continuum Basic Carb Counting: - Learn the foods that contain carbs - Choose and eat these foods in the proper proportions/servings at meals Intermediate Carb Counting: - Actual counting of carbs at meals - Example: 45 grams of carbs per meal Carb Counting: A Continuum Advanced Carb Counting: - Coordinating the amount of diabetes medication taken with the amount of carbs consumed NOTE: Advanced Carb Counting is not the effective mode of nutritional counseling for every person with diabetes 008 American Diabetes Association Position Statement Nutrition Recommendations EFFECTIVENESS OF MEDICAL NUTRITION THERAPY (MNT) Recommendation: Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with diabetes 4

5 The (Dreaded?) Exchange System The Exchange System vs. Carb Counting 500 Calorie Meal Plan with Exchanges Br Lun Din Starch Fruit Milk Non- Starchy Vegs Protein 3 Fat Exchange System Carb Counting - Technique driven - Person driven - Perceived as a diet - Allows for greater freedom in eating choices - Eat what the plan tells - The individual chooses what to eat you to eat - Lesser long-term compliance - Greater long-term compliance Sn Basic Carb Counting via The Plate Method Ethnic Plates ¼ plate Lean Meat ¼plate Starch Hispanic cuisine Arroz con pollo with chayote squash Asian cuisine fish and rice, with cabbage and long beans Indian cuisine Chicken Tikka with naan and eggplant curry ½plate Non-Starchy Vegetables 5

6 MYTHS & MISCONCEPTIONS Myth #: People with diabetes cannot eat white bread, white rice, white pasta, or potatoes. Fact: People with diabetes CAN eat these foods keeping in mind healthy portions. Higher fiber foods such as brown rice or whole grain breads are better but are not required. Marion J. Franz, MS RD CDE, Carbohydrate and Diabetes: Is the Source or the Amount of More Importance, Current Diabetes Reports, 00 MYTHS & MISCONCEPTIONS Myth #: People with diabetes cannot eat sweets: Fact: Occasional sweets and desserts can fit in with carb counting, just like any other carb-rich food. Marion J. Franz, MS RD CDE, Carbohydrate and Diabetes: Is the Source or the Amount of More Importance, Current Diabetes Reports, 00 MYTHS & MISCONCEPTIONS Myth #3: People with diabetes have to eat six small meals a day. Fact: Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with diabetes. 008 American Diabetes Association Position Statement Nutrition Recommendations Case Study # Francine is a 45-year-old single woman who works long hours in a factory. She is single and lives alone. She is dyslexic with very limited reading skills, although she is very bright. She finds numbers to be particularly confusing. She has always tried to make healthy eating choices, but now she is not sure how to eat with her new diabetes diagnosis. She has been referred to the Health Education Department for diabetes nutrition education. What approach to carb counting might be most beneficial for Francine? 6

7 Case Study # Francine is likely to benefit most from the Plate Method form of carb counting because reading and numbers are difficult for her Case Study # Eric is 50 years old, married with three kids, and works as an engineer in the City Planning office. He has had diabetes for 3 years and has taken the diabetes classes at his local Health Education Department. He found them to be very helpful, so he actually attended the series twice. Eric loves numbers and he thrives on structure. He takes a standard amount of insulin in the morning and at bedtime, but is having high and low swings in his blood sugar. Often, his schedule prevents him from eating at regularly scheduled times. He has requested a referral to the Health Education Department for additional diabetes nutrition education. What approach to carb counting might be most beneficial for Eric? Case Study # Eric might be a good candidate for Advanced Carb Counting, using an insulin-to-carb ratio, since he is comfortable with numbers and structure. Case Study #3 Abby is a 5-year-old school teacher with a roomful of third graders. She has just recently developed type diabetes. She would like to try controlling her blood sugar with diet and exercise, and her doctor is willing to go along with this approach, as long as Abby can show she can successfully manage her diabetes without the help of medication. She has attended the diabetes classes and requested individual help from the dietitian. She is motivated to keep her blood sugars in good control. What approach to carb counting might be most beneficial for Abby? 7

8 Case Study #3 Abby is likely to benefit from learning about portion sizes and limiting carbs to a specified amount at each meal. Post-Test. Diabetes nutrition education should be based on the type of medication the patient is currently taking.. The skills and knowledge of the doctor and the RD are more important than the patient s input when selecting the optimum approach for diabetes nutrition education. 3. Everyone with diabetes needs to count grams of carbohydrates in order to have optimum blood sugar control. Post-Test Final Thought 4. The Plate Method for portion control is not sensitive to ethnic cuisines. 5. People with diabetes need to be taught to eat six small meals a day. EFFECTIVENESS OF MEDICAL NUTRITION THERAPY (MNT) Recommendation: Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with diabetes 8

9 Thank You! 9