Improving Diabetes Control with Accurate Carb Counting Gary Scheiner, MS, CDE

Carbohydrate Counting Advantages Fewer high BGs Fewer low BGs No “off limits” foods Flexibility in meal & snack quantities One major advantage of carbohydrate counting is that it can improve your blood glucose levels. Let’s review blood glucose goals: The A1C test is a long-term test that shows what your “average” blood glucose has been over the past 2-3 months. The American Diabetes Association recommends striving for less than 7%, although some experts are recommending less than 6.5%. Various goals have been assigned to blood glucose goals with the most commonly used a range from 70 – 180. If your blood glucose is less than 7.5%, your most likely problem is post-prandial (after meal) spikes. Accurate carb counting can help improve those numbers. “The Frozen Tundra”

Carbohydrate is the nutrient in food that raises blood glucose the most and the fastest, by far The reason we focus on carbohydrate is because it is the one nutrient that raises blood glucose the most.

Timed Effect on Blood Sugar Levels Carbohydrate…. rapid digestion, total absorption/conversion to glucose (100%)   Sugar Alcohols.. moderate digestion, partial absorption as glucose (50%) Protein…………… slow digestion, partial conversion to glucose* (~40%) Fat…………………. slow digestion, little conversion to glucose** (<20%) The red spike shows the normal effect of carbohydrates on blood sugar levels. You can see that all other components of food have less dramatic spikes. * In absence of dietary carbs ** may cause insulin resistance in large qty

Sugars (aka "simple" carbohydrates) MEET THE CARBS! Sugars (aka "simple" carbohydrates) Glucose Fructose (fruit sugar) Galactose Dextrose Lactose (milk sugar) Sucrose (table sugar) “flavored” simple sugars: Maltose High-Fructose Corn Syrup Molasses Brown Sugar Honey Carbohydrates include all starches and sugars. Examples of starches are bread, rice, potatoes, pasta, corn, peas and beans. Carbohydrates in the form of sugar are found in fruit, milk, regular sodas, (not diet sodas), candy, lemonade, and fruit juice. In addition, carbohydrates are found in a lot of mixed dished or combinations foods like pizza and spaghetti.

Sugars (aka "simple" carbohydrates) MEET THE CARBS! Sugars (aka "simple" carbohydrates) Fruit Fruit Juice Candy Regular Soda Punch Wine Muffins Milk Ice Cream Yogurt Sport Drinks Table Sugar Chocolate Cookies & Cakes Pies & Pastries Raisins/Dried Fruit Syrup Jelly Carbohydrates include all starches and sugars. Examples of starches are bread, rice, potatoes, pasta, corn, peas and beans. Carbohydrates in the form of sugar are found in fruit, milk, regular sodas, (not diet sodas), candy, lemonade, and fruit juice. In addition, carbohydrates are found in a lot of mixed dished or combinations foods like pizza and spaghetti.

Starches (aka "complex" carbohydrates) MEET THE CARBS! Starches (aka "complex" carbohydrates) “straight chain” G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G-G “branched chain” G – G – G – G – G - G G – G / \ / G – G G G – G – G G – G – G \ / \ / G – G – G – G – G – G G – G – G – G – G – G \ \ G – G – G G – G – G – G – G Carbohydrates include all starches and sugars. Examples of starches are bread, rice, potatoes, pasta, corn, peas and beans. Carbohydrates in the form of sugar are found in fruit, milk, regular sodas, (not diet sodas), candy, lemonade, and fruit juice. In addition, carbohydrates are found in a lot of mixed dished or combinations foods like pizza and spaghetti.

Starches (aka "complex" carbohydrates) MEET THE CARBS! Starches (aka "complex" carbohydrates) Potatoes Rice Noodles/Pasta Cereal Oatmeal Bread Tortillas Pancakes Waffles Crackers Bagels Pizza Beans Corn Pretzels Chips Popcorn Beer Carbohydrates include all starches and sugars. Examples of starches are bread, rice, potatoes, pasta, corn, peas and beans. Carbohydrates in the form of sugar are found in fruit, milk, regular sodas, (not diet sodas), candy, lemonade, and fruit juice. In addition, carbohydrates are found in a lot of mixed dished or combinations foods like pizza and spaghetti.

Now meet the lesser known carbs (discount 100%!) Fiber (discount 50%!) Sugar Alcohol Sorbitol / Maltitol / Lactitol/ Mannitol / Xylitol Fiber is a carbohydrate that does not enter the blood stream and therefore does not affect blood sugar levels. It stays in the gut and helps slow the digestion of other carbohydrates. You can subtract the fiber from the total grams of carbohydrate in the food. Sugar alcohols are also carbohydrates that are manufactured to resemble sugar in taste but are not completely absorbed. Half of sugar alcohols pass through your body unabsorbed. You can subtract half the sugar alcohols from the total carbohydrate. Glycerine or glycerol also counts as a carbohydrate but does not affect blood sugar. It is similar to carbohydrate in its calorie count, but not on its effect on blood sugar. Glycerine (Rare… can ignore!)

The “fate” of dietary carbohydrates   The “fate” of dietary carbohydrates Simple Carbohydrates (sugars)     Blood Glucose Complex Carbohydrates (starches)  

Does the Type of Carbohydrate Matter? Glycemic Index All carbs (except fiber) convert to blood glucose eventually G.I. Reflects the magnitude of blood glucose rise for the first 2 hours following ingestion G.I. Number is % or rise relative to pure glucose (100% of glucose is in bloodstream within 2 hours) Various types of carbohydrate have slightly difference effects on your blood glucose levels due to what they’re made of, how they’re processed, whether or not they’ve been cooked, and whether you eat them alone or with a meal. If your blood glucose is high before you eat, your blood glucose may increase less than it would if your blood glucose was low before a meal. It’s often difficult to predict how different carbohydrate foods affect your blood glucose because there are so many variables. Some people, however, can identify certain carbohydrate foods that have more or less effect on their blood glucose levels than others (known as the glycemic effect of foods)

Does the Type of Carbohydrate Matter? Glycemic Index (contd.) Example: Spaghetti GI = 37 Only 37% of spaghetti’s carbs turn into blood glucose in the first 2 hours. The rest will convert to blood glucose over the next several hours. Various types of carbohydrate have slightly difference effects on your blood glucose levels due to what they’re made of, how they’re processed, whether or not they’ve been cooked, and whether you eat them alone or with a meal. If your blood glucose is high before you eat, your blood glucose may increase less than it would if your blood glucose was low before a meal. It’s often difficult to predict how different carbohydrate foods affect your blood glucose because there are so many variables. Some people, however, can identify certain carbohydrate foods that have more or less effect on their blood glucose levels than others (known as the glycemic effect of foods)

Does the Type of Carbohydrate Matter? Slow Stuff Average Stuff Fast Stuff Pasta Legumes Salad Veggies Dairy Chocolate Fruit Juice Pizza Soup Cake Breads/Crackers Salty Snacks Potatoes Rice Cereals Sugary Candies Various types of carbohydrate have slightly difference effects on your blood glucose levels due to what they’re made of, how they’re processed, whether or not they’ve been cooked, and whether you eat them alone or with a meal. If your blood glucose is high before you eat, your blood glucose may increase less than it would if your blood glucose was low before a meal. It’s often difficult to predict how different carbohydrate foods affect your blood glucose because there are so many variables. Some people, however, can identify certain carbohydrate foods that have more or less effect on their blood glucose levels than others (known as the glycemic effect of foods)

Ultimately, The Amount of Carbohydrate is More Important Than the Type Years ago we thought that sugars and starches had definite differences in their effect on blood glucose. Now, we have more knowledge of the effects of carbohydrate on blood glucose. Numerous research studies have shown that sugars and starches have very similar effects. Therefore, sugar is not forbidden for people with diabetes. Knowing the total carbohydrate in a food is more important than knowing how much sugar it contains. For most people, 30 grams of carbohydrate will affect their blood glucose the same, regardless of whether it is 2 slices of bread or 1 cup of ice-cream, or a small frosted brownie.

CARB BASICS QUIZ – True or False Equal amounts of sugar and starch will raise blood glucose the same amount. Fiber will raise blood glucose levels a little bit. “Sugar-Free” chocolate (made with sugar alcohol) will not raise blood glucose levels. Let’s check your label reading skills. 1. TRUE 2. FALSE 3. FALSE

Methods for Counting Carbs Accurately The “Exchange” system Food package labels Resource listings Portion estimation Carb factors You can count carbs in any number of ways.

The “Exchange” System Foods with common nutrient values are grouped together. If you have a Food Exchange booklet, you can use the average values for carbohydrate listed - 15 grams for most portion sizes listed.

Practice Counting Carbs Using the Exchange system Breakfast Exchange/# Grams 1 large bagel (4 oz) starch (4) x 15 60g 1 tsp. margarine fat (1)x0 0g 1/2 cup orange juice fruit (1) 15g 6 oz skim milk milk (3/4) x 12 9g Total Carbs: 84g Let’s practice counting carbohydrates. For those of you familiar with food exchanges, if you have a large bagel (4 ounces), how much carbohydrate will you get? (Bread items all have 15 grams of carbohydrate for 1 ounce. Therefore, the bagel would count at 60 grams or 4 carbohydrate choices.) How about margarine? (Does not contain carbohydrate) ½ cup orange juice? (15 grams or 1carbohydrate choice) 1 cup skim milk? (15 grams or 1carbohydrate choice).

Nutrition Facts Label Method Labels are the best resource for carbohydrate counting Pay attention to: Serving Size Total Carbohydrate Fiber & Sugar Alcohol (if any) The Nutrition Facts label is the most reliable resource for carbohydrate information. It includes two things you need to know to do carbohydrate counting – the Serving Size and the Total Carbohydrate. The amount of carbohydrate you are eating is calculated by multiplying the serving size by the total carbohydrate.

Here is an example of a Nutrition Facts Label. Note where the Serving Size and Total Carbohydrate information are listed. You also see sugar on the label. You do not have to count sugar separately from carbohydrate. Sugar is a type of carbohydrate and is already included in the total. All carbohydrates list under total carbohydrate should add up to the total. Sometimes manufacturer’s leave out some information – like how much starch is in a food. Then the numbers don’t add up. On this label you can assume that the 7 grams of missing carbs are starch (13 – 3 – 3 = 7).

Fiber and Carbohydrate Counting Included in total carbohydrate Does not convert to glucose Subtract fiber from the Total Carbohydrate Although fiber is included in the total carbohydrate on a food label, it does not increase the blood glucose. So, if you eat a high-fiber food, it won’t increase your blood glucose as much as a food with the same amount of carbohydrate that’s low in fiber. If your blood glucose fluctuates a lot due to variations in the amount of fiber you consume, you can do the following: For foods with more than 5 grams of insoluble fiber per serving, subtract the amount of fiber from the Total Carbohydrate.

Fiber and Carbohydrate Counting For example: 13 g Total Carb - 3 g dietary fiber Count as 10 grams carbohydrate For example, a breakfast cereal containing 30 grams of total carbohydrate per serving with 7 grams of insoluble dietary fiber would actually be counted as 23 grams of carbohydrate.

Sugar Alcohols and Carbohydrate Counting Artificial Sweeteners Found in chewing gum, mints, yogurt, ice cream, cookies and candy Digest slowly and partially ( 50%) Can cause diarrhea These artificial sweeteners do contain carbohydrates but they digest more slowly and some of them don’t ever find their way into the blood. About ½ of the sugar alcohols remain unabsorbed, so you can subtract 50% of them from the total carbohydrate. They tend to cause stomach distress and diarrhea, especially if eaten in large quantities. Keep in mind that sugar-free foods can contain sugar alcohol and other carb-rich elements.

Carbohydrate Counting Using Books Use for foods without a Nutrition Facts Label Fresh fruits Fresh vegetables Ethnic foods Fresh baked goods Restaurant foods Some foods do not have package labels. You can find carbohydrate information for fresh fruits, vegetables, and bakery goods and other foods in reference books.

Carbohydrate Counting Using Websites USDA Food Composition www.nal.usda.gov/fnic/foodcomp/search/ Calorie King www.calorieking.com Fast food companies’ or food manufacturers’ websites

Arby’s: www.arbys.com/nutrition/ Boston Market: www.bostonmarket.com/restaurant Burger King:www.bk.com/Food/Nutrition/NutritionWizard/index.aspx Dairy Queen: www.dairyqueen.com/en-US/Menus+and+Nutrition/Nutrition+Charts/default.htm Denny’s: www.dennys.com/en/cms/Nutrition/Allergens/23.html Dunkin’ Donuts: www.dunkindonuts.com/aboutus/nutrition/ KFC: www.kfc.com/kitchen/nutrition.htm McDonald’s: www.mcdonalds.com/usa/eat/nutrition_info.html Old Country/Hometown Buffet: www.buffet.com/nutritioncontent.htm Pizza Hut: www.pizzahut.com/menu/nutritioninfo.asp Starbuck’s: www.starbucks.com/retail/nutrition_info.asp Subway: www.subway.com/applications/NutritionInfo/index.aspx Taco Bell: www.tacobell.com/ Wendy’s: www.wendys.com/food/NutritionLanding.jsp

Insulin Pump Carb Databases Accu-Chek Spirit Palm Software Animas IR 1200, 1250, 2020 Deltec Cozmo 1800 OmniPod PDM If you eat too much carbohydrate at one time, your blood glucose will increase too much.

Portion Estimation Method Use common, everyday objects to measure the portion size of food Soda can (12 fl.oz.) = 1 ½ cups Baseball or adult’s fist = 1 cup Child’s fist = ½ cup Adult’s spread hand = 8” diameter Adult’s palm = 4” diameter Estimating your portions can make a big difference in carb counting.

Portion Estimation Method Examples of 1-cup Carb Estimates: Corn: 30g Peas: 30g Beans: 40g Pretzels: 25g Chips: 15g Popcorn: 5g Ice Cream: 35g Cake: 45g Potato: 40g Pasta: 40g Rice: 50g Rolls: 25g Cereal: 25g Fruit: 20g Cooked Veggies: 10g Salad Veggies: 5g Estimating your portions can make a big difference in carb counting.  

Portion Estimation Method Estimate the carbs: 20g/cup X 1 ¼ cups  25g Estimating your portions can make a big difference in carb counting.  

Portion Estimation Method Estimate the carbs: 5g / cup X 3 cups  15g Estimating your portions can make a big difference in carb counting.  

Portion Estimation Method Estimate the carbs: 25g / cup X 1 ½ cups 38g 12g / cup X 1 cup = 12g Total = 50g Estimating your portions can make a big difference in carb counting.  

Portion Estimation Method   Other “tricks”: Long Sandwiches 8g per inch Pizza 30g per adult hand-sized piece (fingers together) Cookies 20g per adult-sized palm Breaded meat/veg/cheese 4g small (“thumb/nugget sized”) 10g large (“patty/palm-sized”) Estimating your portions can make a big difference in carb counting.    

Portion Estimation Method Estimate the carbs: 30g / hand X 1 1/3 hands  40g Estimating your portions can make a big difference in carb counting.  

Carbohydrate Factor Method Weigh a portion of food Multiply the weight by its carb factor* Get total carb count *A carb factor is the percentage of the food’s weight that is carbohydrate. The rest is water, protein, fat, minerals There are books and websites devoted to finding the carb factors of food. You can also calculate your own carb factors if you have complete nutrition information, including the weight of a portion of the food, on any food.

Carbohydrate Factor Method There are books and websites devoted to finding the carb factors of food. You can also calculate your own carb factors if you have complete nutrition information, including the weight of a portion of the food, on any food. Salter 1450

Carbohydrate Factor Method Carb Factor Examples: Apple: .13 Apple Pie: .32 Bagel: .51 Carrot (raw): .06 Chocolate Cake: .51 Cornbread: .45 Pancake: .28 Pizza (cheese): .32 Potato, baked: .22 Potato Salad: .09 Rice: .27 Spaghetti: .26 Vanilla Ice Cream: .23 Watermelon: .06 There are books and websites devoted to finding the carb factors of food. You can also calculate your own carb factors if you have complete nutrition information, including the weight of a portion of the food, on any food. For carb factors for more than 6000 foods (in Excel spreadsheet format), go to: www.friendswithdiabetes.org/files/Carb factor.xls

Carbohydrate Factor Method How much carb is in a baked potato weighing exactly 300 grams?   36g 46g 66g 86g 300 x .22g = 66g carb There are books and websites devoted to finding the carb factors of food. You can also calculate your own carb factors if you have complete nutrition information, including the weight of a portion of the food, on any food.

Measuring and Weighing Foods To be an accurate carb counter, weigh/measure at least once a week Practice, practice, practice! Test yourself against the label Although you don’t need to weigh and measure at every meal, you should practice measuring and weighing foods in the beginning until you can estimate portions more accurately. Then check yourself about once a week. It’s impossible to count carbohydrate if you don’t know how much carbohydrate you’re eating.

Other Factors to Consider Fat Lengthens time your stomach takes to empty Delays rise in blood glucose May cause temporary insulin resistance Protein Very little effect on blood glucose (unless  carb diet) Usually combined with fat Fat and protein have very little effect on blood glucose levels. That’s why we focus on carbohydrate. However, a high fat meal takes longer to be digested. Therefore, the rise in blood glucose following the meal may be delayed. For example, your blood glucose may still be high at bedtime after a high fat dinner.

Weight Gain and Carbohydrate Counting Your can gain weight if: Count carbohydrate, but ignore fat/calorie content of foods No limits placed on portion sizes Frequent snacking A word of caution to those of you whose children now feel liberated regarding your food options – counting only carbohydrate can result in weight gain! Weight gain can result in insulin resistance; your child could end up need more insulin. If your child eats 2 carbohydrate choices of Haagen-Dazs ice-cream in place of a fruit and a slice of bread at dinner very often, a lot of extra calories and fat will be added.

Physical activity/exercise Write it down! Blood glucose results Carbohydrate eaten Insulin or other meds Physical activity/exercise It’s important to keep track of how much carbohydrate you have eaten at each meal and snack, the times you eat, your blood glucose results, dosages of diabetes medication, and your physical activity. This helps you see the patterns in your blood glucose and what affects your blood glucose – like exercise, eating too much carbohydrate, etc. It helps you and your doctor see what things need to be changed. Be sure to take your log to your doctor visits.

Only count the carbs you actually consume! It’s important to keep track of how much carbohydrate you have eaten at each meal and snack, the times you eat, your blood glucose results, dosages of diabetes medication, and your physical activity. This helps you see the patterns in your blood glucose and what affects your blood glucose – like exercise, eating too much carbohydrate, etc. It helps you and your doctor see what things need to be changed. Be sure to take your log to your doctor visits. Jackie Scheiner Age 1

The Ultimate Guide to Accurate Carb Counting Gary Scheiner MS, CDE Integrated Diabetes Services In-Office, Phone & Online Consults 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 USA (877) 735-3648 www.integrateddiabetes.com Gary@integrateddiabetes.com