1. Dining with Diabetes Ohio State University Extension Signature Program
The OSU Extension Educator welcomes the participants to the Ohio State University Extension program Dining with Diabetes. Introduce Registered Dietitian/Certified Diabetes Educator. Recognize any program sponsors.
The pre-questionnaire should be completed at the beginning of this session. Allow minutes for this, or distribute to participants as they arrive and ask them to complete before the class starts. Encourage the participants to use a code that they will remember for the questionnaire at the third session. Suggestions include: last four digits of their phone number or a parent’s first name.
Collect the pre-questionnaires before the class begins.

2. Program Objectives Increase knowledge about healthy foods
Present healthy versions of familiar foods
Demonstrate new cooking techniques
Provide taste testing of new recipes
Provide basic information regarding diabetes and nutrition
Provide opportunities for sharing and learning from one another and from diabetes health professionals
The OSU Extension Educator reads the goals of the program to participants.
Be sure to state that this program is not intended to provide individual prescriptions for diabetic meal planning and it is not intended to replace diabetes education furnished by qualified health care professionals.

3. Carbohydrates and Sweeteners
The focus of today’s lesson is carbohydrates and sweeteners. We’ll discuss carbohydrates, where they are found in the diet, and how to use the Plate Method as a meal planning tool. We’ll also discuss common artificial sweeteners and provide helpful tips for their use.

4. Day 1 Overview Diabetes: A Balancing Act Meal Planning
Carbohydrates
The Plate Method
Food Labels
Portion Sizes
Artificial Sweeteners
Review what we will discuss today.

5. The Diabetes Balancing Act
Physical Activity
Meals
Sometimes people view diabetes management as a “balancing act”. We know that balancing physical activity, meals and medications can be a challenge, but doing so will help you live longer, healthier lives with diabetes.
As you can see from the illustration, it is important to balance daily physical activity with healthy meal choices. Many people with diabetes need to use special medications, such as pills or insulin, to help keep their glucose, or blood sugar, at desired levels. These medications need to be carefully matched with food and physical activity in order to avoid very high or very low blood sugar levels.
Physical activity is essential for good health and improved glucose control.
While we will touch briefly on physical activity, much of today’s discussion will focus on the meal side of this balancing act.
Medications

6. Exercise: An Important Part of a Healthy Lifestyle
Exercise and diet work together
Aim for 150 minutes of physical activity each week
Check with your physician when starting a new exercise program
You can achieve better blood glucose control by maintaining a healthy diet and exercising regularly. In fact, even moderate weight loss can make a big difference in your blood glucose control. Additionally, when your muscles are active, your body uses glucose more effectively.
The Physical Activity Guidelines for Americans states “All adults should avoid inactivity. Some exercise is better than none. For substantial benefits, adults should get 150 minutes of physical activity per week” This translates to at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week. Increased activity will reap even greater benefits.
This daily exercise can be cumulative. It may be done during one thirty minute session or several shorter sessions throughout the day. The important thing is to be physically active on a regular basis.
Be sure to reinforce this message with participants: You should always check with your health care provider before making changes to your diet or exercise routines!

7. Tests that Help with Diabetes Control
Hemoglobin A1C
Total Cholesterol, LDL, HDL
Triglycerides
Micro albumin
Blood Pressure
Dilated Eye Exam
Foot Exams
Home Glucose Testing
Immunizations
There are several tests that can help you better manage your diabetes.
Hemoglobin A1C is a blood test. You should have this test at least twice a year. It gives you an average of your blood sugar over a three month period.
Cholesterol, LDL, HDL and triglyceride blood tests should be done annually.
The micro albumin test is a urinalysis and should be done annually.
Blood pressure tests should be done during every doctor’s visit.
Individuals with Type 2 Diabetes should have a dilated eye exam annually.
You should do foot exams daily and during each office visit by your doctor.
It is important that you do home glucose testing as advised by your doctor.
Diabetes management includes regular exercise and quitting smoking in addition to medical testing.
Here are some other medical needs for diabetics.
Flu shouts should be given annually.
Pneumonia shots every three to five years as advised by your doctor.
Immunization for shingles is recommended for people over 60. Check with your doctor as well as your insurance company. It may or may not be covered by insurance.
This chart is based on the American Diabetes Association Guidelines for 2007, which are frequently updated and may change. For more information on treatment guidelines, go to:

8. Know Your Numbers Blood Pressure Cholesterol and Triglycerides
Fasting Glucose
A1C
BMI
Waist Circumference
By knowing your numbers, you can gauge your risk for serious health problems. Below are the healthy ranges to work toward.
** Please distribute the DWD Know Your Numbers Handout/Worksheet
Blood Pressure (per American Heart Association)      Normal blood pressure: Less than 120/80 mmHg
Prehypertension: 120/80 mmHg to 139/89 mmHg Hypertension:
Stage 1: between 140/90 mmHg and 159/99 mmHg
Stage 2: 160/100 mmHg or higher
Cholesterol Total - below 200 (per American Heart Association)      LDL - below 130 (ideal below 100)      HDL - above 50 for women. above 40 for men (ideal above 60)      Triglycerides - below 150
Glucose (fasting)      between 70 and 110 (per American Association of Clinical Endocrinologists)
A1C
less than 7 percent (per American Diabetes Association)
An A1C of 7 percent equates to about 154 mg/dl estimated average blood glucose. For people without diabetes, an A1C of 4-6 percent is normal. An A1C of less than 7 percent is also linked with reduced diabetes-related complications.
BMI      between 18.5 and To calculate your own BMI, use this formula: BMI = [weight in pounds / (height in inches x height in inches)] / 703
Waist Circumference (per research reported in New England Journal of Medicine)
< 35 inches for women, < 40 inches for men (this is particularly important if your BMI is >25)

9. Meal Planning
The rest of today’s presentation will focus on how what we eat affects the balance. We will talk about The Plate Method as a tool for meal planning and how this method compliments other methods you may already be using, such as Exchanges or Carbohydrate Counting. We encourage you to talk with your registered dietitian or certified diabetes educator to determine the specific meal pattern that is right for you.

10. Blood glucose, or blood sugar, is the fuel our bodies run on.
Glucose, or blood sugar, is vital to life itself. It is the required fuel for the brain.
Our bodies can make glucose from all foods we eat, but some foods are better sources of glucose than others.
Carbohydrate-containing foods are the best and most available sources of glucose.

11. What is Carbohydrate 1 carbohydrate serving = 15 grams of carbohydrate
Food groups containing carbohydrates
Grain
Fruit
Starchy vegetable
Milk/yogurt
You have no doubt heard the word “carbohydrate” a lot since learning that you have diabetes, but you may not have been told what they are or why they are important.
(RD/CDE or RN explains further what carbohydrates do to blood glucose and why they are important. Possible script follows.).
Carbohydrates are changed into blood glucose during digestion. When someone has diabetes, their body does not use blood glucose the way that it should. You can help your body use glucose better by having consistent amounts of carbohydrate-containing foods at regular intervals. Your health care team can help you determine how many servings you need per day and the timing of those servings.
Throughout this session, we will talk about carbohydrate servings. 1 carbohydrate serving is equal to 15 grams of carbohydrate.
In the slides that follow, we will talk about food labels and The Plate Method. As we learn more about The Plate Method, I will point out which groups contain carbohydrates. Keep in mind that both starchy and sweet foods are rich in carbohydrates, but they can be very nutritious, too.

12. The Plate Method: A Tool for Diabetes Meal Planning
Fruit
Milk
Meat
Starches
Meal planning for people with diabetes is not easy. And there is no “one-size-fits-all” when it comes to a diabetic meal plan.
The Plate Method was introduced by dietitians in Idaho.
Using the Plate Method, no more than one-fourth of the plate should be covered by starchy foods such as bread, grains, or potatoes.
For Heart Healthy eating, no more than one quarter of the plate should be covered by something from the meat group.
Vegetables should cover the rest of the plate.
The small circles represent single servings of milk and fruit.
Since milk, fruit, and starches raise blood sugar in the same way, they can be exchanged sometimes to match your taste and nutrition needs.
A “9” plate is a good size dinner plate. (Show different sizes of plates to demonstrate the point).
Balancing your intake of food is a good way to start balancing your diabetes.
Activity suggestion for teaching the slides that follow - pass out a variety of foods from each group. Make sure participants have at least two different foods, possibly more depending upon class size. As you go through the next 5 slides, ask participants to hold up foods from the food group being discussed. Then ask them to hold up foods from that group that contain carbohydrate.
Vegetables

13. Grains and Starches Contain carbohydrates
1 serving = 15 grams of carbohydrate
Note these equivalents:
1 slice bread
½ cup cooked cereal
¾ cup dry cereal
½ cup beans
⅓ cup cooked pasta or rice
½ cup starchy vegetables
Potatoes, peas, corn, lima beans
Milk
Fruit
Meat
Starches
Vegetables
Foods in this group contain carbohydrate. A serving of grains has roughly 15 carbohydrates (discuss 15 gram carbohydrate equivalents).
Notice that this portion of the plate should be filled with grain, bread and other starches. These may include breads, cereals, pasta, starchy vegetables, beans and rice.
While desserts should not take the place of healthy foods, it is important to note that they should be included in this portion of the plate as well. Studies show us that sugar and sweets do not raise blood glucose more than other foods rich in carbohydrates. Desserts should not be looked at as a separate category but carefully considered within a balanced meal plan.
Talk with your health care team to determine the number of servings you need.
As a point of reference, the MyPlate recommendation ranges from 6 to 8 oz.. per day, depending upon individual calorie needs. Note the one-ounce equivalents on the slide.

14. Vegetables Includes non-starchy vegetables
Spinach, broccoli, Brussels sprouts, cauliflower, kale, carrots, tomatoes, cucumbers, lettuce, etc.
Note ½ cup equivalents
½ cup raw dense vegetables
½ cup cooked vegetables
1 cup raw, leafy vegetables
6 baby carrots
Milk
Fruit
Meat
Starches
Vegetables
When meal planning with diabetes, it is important to separate starchy vegetables from non-starchy vegetables. As we noted on the previous slide, starchy vegetables, such as corn, peas, lima beans and potatoes should be included in the “starchy” quarter of your plate. Remember that starchy vegetables contain carbohydrates and affect your blood glucose level.
Non-starchy vegetables, such as broccoli, tomatoes, spinach, and cucumbers, are a great choice because they help fill you up and fulfill the need to munch on something, but do not have as great of an impact on blood glucose. Fill half your plate with non-starchy vegetables. Note that while non-starchy vegetables are an excellent source of many nutrients and fiber, they are not a completely “free” food. Since they do contain small amounts of carbohydrate (up to 5 grams of carbohydrate per serving) large portions (i.e. a triple portion) can still affect blood glucose.
As a point of reference, the MyPlate recommendation ranges from a 2 to 3 cup equivalent per day, depending upon caloric need. A half-cup equivalent is ½ cup of dense uncooked vegetables (i.e. chopped celery or raw broccoli), ½ cup of a cooked vegetable (regardless of whether initially a dense or leafy vegetable), 1 cup of a raw, leafy vegetable, or 6 baby carrots.

15. Fruit Contain carbohydrates 1 serving = 15 grams of carbohydrate
Note these ½ cup equivalents:
1 small fresh fruit
½ cup cut fresh fruit
½ cup canned fruit
Canned in its own juice
¼ cup dried fruit
½ cup fruit juice
Milk
Fruit
Meat
Vegetables
Starches
Fruits contain carbohydrates. Check with your health care team to determine the specific number of fruit you need in your diet daily.
You may choose fresh fruit, fruit canned in its own juice, or dried fruit. Whole fruit is preferred over juices, but 100% fruit juices may be used in the diet (discuss fruit servings).
As a point of reference, the MyPlate recommendation ranges from a 1.5 to 2 cup equivalent per day, depending upon caloric need. A half-cup equivalent is 1 small piece of fruit, ½ cup of cut fruit, a 4-ounce “snack size” serving of canned fruit, ¼ cup dried fruit, ½ cup fruit juice.
Note: carbohydrate levels among different fruit vary widely. Participants should be encouraged to use the MyPlate Super Tracker or other tool to find out the specific carbohydrate content of fruits they eat on a regular basis.

16. Milk and Yogurt Contain carbohydrates
1 serving = 15 grams of carbohydrate
Choose low fat and fat free options
Note these equivalents:
8 fluid ounces milk
1 cup yogurt (plain)
Milk
Fruit
Meat
Vegetables
Starches
Milk and yogurt contain carbohydrate, however cheese contains very little. Check with your health care team to determine how much milk and yogurt you should include in your diet.
Fat-free and low-fat milk are the best choices because they contain fewer calories and are lower in saturated fat. They contain the same amount of other vitamins and minerals as milk with higher fat contents contain.
Notice, 1 cup of plain, low-fat yogurt contains approximately 15 grams of carbohydrates. Check the carbohydrate content if you select varieties that contain fruit or have special preparations, such as “whipped” yogurt, as these yogurts tend to have much higher carbohydrate levels.
As a point of reference, the MyPlate recommendation is 3 cups per day, regardless of caloric need. One cup equivalents include 8 ounces of fluid milk or 1 cup of yogurt. While dairy foods are encouraged due to the important combination of nutrients they contain, 1 cup of calcium-fortified soymilk is a suitable substitution for individuals who are lactose intolerant.
Note: cheese is typically counted as a protein since it contains little carbohydrate but is a good source of protein.

17. Meat and Meat Alternatives
Go lean with protein
Note these 1 ounce meat equivalents:
1 oz.. meat, poultry or fish
½ cup beans, peas, or tofu
Contribute carbohydrates
1 egg
1 oz.. cheese
¼ cup cottage cheese
1 tablespoon peanut butter
Milk
Fruit
Meat
Vegetables
Starches
People with diabetes have no less or more need for protein than the general public. Plus, they have a greater risk of heart disease earlier in life, so choosing lean meats low in saturated fat is recommended. Low-fat meat options include chicken and turkey breast, fish, low-fat beef (round, chuck, sirloin and tenderloin) and low-fat pork (tenderloin and loin chops).
Nut butters and soy products can be good protein options, too. Beans and peas are good sources of protein as well, however they contain carbohydrates; make sure you count them as both a carbohydrate and a protein if you choose these protein options. Seeds and nuts contain protein, but in diabetic meal planning these foods are often considered a fat rather than a protein. These plant proteins are cholesterol free.
As a point of reference, the MyPlate recommendation ranges from a 5.5 to 6.5 ounce equivalent per day, depending upon caloric need. 1-ounce equivalents include 1-ounce of cooked meat, 1 egg, 1 Tablespoon of peanut butter or almond butter, ½ cup of tofu, 1/3 cup hummus
Beans and peas count as 1 protein, plus 1 starch. Equivalents include ½ cup of cooked beans (such as black, kidney, pinto, or white beans, refined beans), ½ cup of cooked peas (such as chickpeas, cowpeas, lentils, or split peas), 1/3 cup of baked beans.
Remember that cheese is considered a protein food for purposes of diabetic meal planning. Equivalents include 1 ounce cheese, ¼ cup cottage cheese. Low-fat choices (those with 3 grams fat or less per ounce) should be encouraged.

18. Sample Day – 1800 Calories
Remember, 1 carbohydrate serving equals 15 grams of carbohydrates
Breakfast – 3 carb servings (45 g)
Snack – 2 carb servings (30 g)
Lunch – 3 carb servings (45 g)
Dinner – 3 carb servings (45 g)
People often have questions about how their day’s intake should “look”. We have included a sample day’s intake of carbohydrates to give you an idea of how your intake of carbohydrates might be spaced throughout the day. Keep in mind that your body converts all starches and sugars to blood glucose regardless of whether the carbohydrates come from grains and starches, fruit, milk, or even desserts.
Everyone is different. This plan may not be right for you, even if you require 1500 calories a day. This meal plan would provide 225 grams of carbohydrate and allow for 60% of the calories for an 1500 kcal diet. When you sit down with your dietitian or certified diabetes educator, they will give you specifics about the number of carbohydrates you need for your age, weight, and activity. They will show you how to incorporate all of the food groups into your plan.
Activity idea: based on servings and carbohydrate equivalents, talk about how these grams of carbohydrate might look in terms of actual foods. For example, breakfast (45 grams of carbohydrate) could be 1 slice of bread, a small grapefruit, and a glass of milk. Complete the meal with an egg and 1 teaspoon of margarine.

19. to determine the carbohydrates in a food item
Food Labels
Total Carbohydrate 31 g
Dietary Fiber 3 g
Look at the
“Total Carbohydrate”
to determine the carbohydrates in a food item
A good way to know how many grams of carbohydrate a food item contains is to look at the nutrition label. This is an example.
Look at the portion of the label that tells how much “Total Carbohydrate” is in the food in order to decide how much it might raise your blood glucose. This includes all of the carbohydrate in a product, whether it is in the form of a complex carbohydrate (sometimes referred to as starch), added sugar, or fiber. (Notice that one muffin contains 31 total grams of carbohydrate. This would be equal to 2 carbohydrate servings).
For comparison, one slice of bread, ½ cup of mashed potato, or one small fruit has about 15 grams of carbohydrate.
One teaspoon of table sugar, or sucrose, has 4 grams of carbohydrate.
Our bodies change all the starch, as well as the sugar, into glucose, or blood sugar.
According to American Diabetes Association recommendations, fiber should not be subtracted out of the total carbohydrate unless a food item has greater than 5 grams of fiber. This factor takes into account that some types of fiber are not digested. If a food item contains more than 5 grams of fiber, ½ of the fiber can be subtracted from the “Total Carbohydrate”. For example, if a product has 8 grams of fiber, 4 grams of fiber can be subtracted from the Total Carbohydrate.
It is important to look at the nutrition label carefully when you are shopping, particularly the serving size indicated on the label. All nutrition information on the label applies to only 1 serving. Crackers, for example, may list a serving as few as 3 or as many as 6 crackers. You may be able to find low carbohydrate options for common foods like orange juice, milk, and yogurt. Look around to see what is available.
Activity Idea: Distribute food labels and ask participants to share their food label and discuss how much fiber, sugar and starch are in each food.

20. Downsize Portion Sizes
The bigger the portion, the more people tend to eat
Larger portions add up!
100 extra calories per day will add up to a 10 pound weight gain in one year
Know the right sized portion to keep calorie intake in check
This is a good place to use visuals, such as various sized plates, cups, utensils.

21. A Few Serving Size Visuals
4 stacked dice = 1 oz. of cheese
Deck of cards = 3 oz.. of meat
Baseball = medium potato or fruit
1 cup cold cereal
Compact disk = pancake

22. Artificial Sweeteners
Artificial sweeteners are often used to reduce calories in a food product, but they are also carbohydrate free, making them a good choice for individuals with diabetes.
Are artificial sweeteners safe?
Artificial sweeteners must undergo years of testing before manufacturers were permitted to add them to foods. They have each been determined by the Food and Drug Administration to be safe for use by all people.
The exception is for those very rare people who are born with a condition called phenylketonuria (PKU). These people cannot metabolize foods containing large amounts of phenylalanine, one of the ingredients in aspartame. They must avoid aspartame and many other high-protein foods.
There have been some scary reports on the internet about artificial sweeteners.
While the internet can be a wonderful source of information, it is also a place where incorrect information can be distributed quickly and widely.

23. Types of Artificial Sweeteners
Aspartame
Stevia
Saccharin
Sucralose
There are many artificial sweeteners on the market. Let’s discuss some of the most common ones available at this time.
Aspartame, also known as NutraSweet™ or Equal™ has very little aftertaste but it tends to denature or lose its sweet taste, when it is heated.
It is 200 times sweeter than sugar.
Saccharin, sold as Sweet n’ Low™ and as a brown sugar substitute, Sugar Twin, and Sweet Thing are very stable for baking, but it has a noticeable aftertaste when used in large quantities.
It is 300 times sweeter than sugar.
Acesulfame potassium, sold as Sweet One™ has less aftertaste than saccharin and is more stable when heated than aspartame.
It is 200 times sweeter than table sugar.
Sucralose, also known as Splenda™, is made from sugar with certain chemical changes. It has the same volume and taste as sugar and it is stable when heated. Brown sugar is also available.
It is 600 times sweeter than table sugar.
Stevia may be sold under the approved names of Only Sweet, PureVia, SweetLeaf, and Truvia. It is stable for baking. Check packaging as may vary from one brand to another and depending upon form (liquid, packet, loose powder). Generally substitute ¼ tsp. or ½ packet stevia for every 1 tsp. in a recipe.
Handout idea: Refer to “Using Artificial Sweeteners In Cooking” and “Sugar Substitute Guide”
You may want to bring in examples of each type of substitute for the participants to see.
Acesulfame
Potassium

24. Baking with Artificial Sweeteners
Sugar
Sweet Taste
Color
Tenderness
Moisture
Volume
Artificial Sweeteners
Sweet Taste
In today’s demonstrations, you will see some ways to reduce the extra carbohydrates in desserts.
Familiar home recipes for desserts may contain large portions of sugar.
Sugar does more than just make a recipe sweet. It helps a recipe to be tender and moist and contributes to the familiar golden brown color of baked desserts and breads. In cake and cookie recipes, sugar makes up a lot of the volume. Replacing sugar entirely with artificial sweeteners may produce a tough, flat, dry, as well as gray in color cake.
Remember artificial sweeteners only make a recipe sweet.

25. Tips for Using Artificial Sweeteners
Check official websites
Replacing sugar with artificial sweeteners
Start with a little and add more if needed
Combine different classes of sweeteners
Different recipes work well with different sweeteners
Checking the official website for a particular artificial sweetener can be a good source of recipes and ideas because the manufacturer has tested the recipes for acceptability.
You can usually reduce the amount of sugar and fat by ¼ to ⅓ in cookies, quick breads and pies without affecting the product. This may not work well with cakes. You should not replace more than ½ cup of the total amount of sugar with an artificial sweetener.
a. Artificial sweeteners need to be used in small amounts at first and increased only gradually to avoid an overly sweet taste or unpleasant aftertaste.
b. When two different classes of artificial sweeteners are combined (such as saccharin with aspartame or Acesulfame potassium with aspartame), the result is a much sweeter taste than it is when one kind is used alone in cooking. If a recipe calls for 6 packages of saccharin sweetener, for instance, try using a total of only 3 packages of sweetener, but use two different kinds, such as one package of saccharin and two packages of aspartame.
Some sweeteners work better in cold items and some are acceptable in heated items. For example, we know aspartame loses its sweet taste when exposed to high heat in baking. When combined with another sweetener or acid, it becomes more stable. Aspartame may also be added to a product after it has been baked. Sucralose, on the other hand, is more frequently used in baked items because it is more stable and does not lose its sweet taste.

26. More Tips Try flavoring agents
Using pudding or dry milk to add volume and moisture
Small amounts of sugar are acceptable
Cinnamon and vanilla may help add sweetness to a recipe without adding carbohydrate. Other spices may also mask the aftertaste of some sweeteners.
Add sugar free pudding or ¼ cup nonfat dry milk powder to increase the volume and moistness. Note this option may add carbohydrates.
Usually 1 teaspoon of sugar per serving is acceptable for most people with diabetes.
1 teaspoon of sugar has only 4 grams of carbohydrate
This is news to many people with diabetes, but studies show that this amount of added sugar does not seem to raise blood sugar significantly.

27. Try These Websites Artificial Sweeteners WebMD Mayo Clinic
caloriecontrol.org
WebMD
diabetes.webmd.com/artificial-sweeteners-diabetes-patients
Mayo Clinic
mayoclinic.com/health/artificial-sweeteners/AN00348
Academy of Nutrition and Dietetics
eatright.org
American Diabetes Association
diabetes.org
Artificial sweeteners can be a useful tool in helping to maintain your blood glucose levels within a normal range while eating some of the foods and beverages you enjoy. There are often questions about how to use artificial sweeteners and their safety. We mentioned on an earlier slide that a sweetener’s website can be good source of recipe information. We also encourage you to look for information about artificial sweeteners from reliable sources, such as the websites listed on this slide.
You may want to have these websites written down on a board or flip chart, or have copies available for participants.

28. What’s Next Fats and Sodium More about the Plate Method
Heart Healthy Tips
More Recipes to Sample
Remind participants the date for the next class and the topics to be covered.

29. What Questions Do You Have?
CREDITS:
American Diabetes Association
Food and Drug Administration
Ohio State University Extension Diabetes Education Team
West Virginia University Extension
Christine Kendle, MS, RD, LD, Tuscarawas County
Family and Consumer Sciences Educator,
Ohio State University Extension
Thank participants for their attention.
Ask for questions?