1. Carbohydrate Counting Marjan Shalchi, RD, CDE Diabetes Education and Management Centre Hotel Dieu Hospital November 13, 2015

2. Outline Why Carbohydrate Count ? Basic to Advanced Carbohydrate Counting Case Studies

3. Why Carbohydrate Count ? The nutrient with the greatest impact on blood glucose levels 50% Post-meal BG 50% Fasting BG At an A1C ranging from 7.3% to 8.4%, overall glycemia is impacted equally by fasting blood glucose and post-meal blood glucose A1C = 5. Monnier L, et al. Diabetes Care 2003;26:881-885.

4. Why Carbohydrate Count ? A meal-planning approach for all patients with diabetes Flexibility in choosing all carbohydrate containing foods, it may increases self management CDA recommendations: 45-60% carbohydrate, 15- 20% protein, and 20-35% fat of total energy Matching insulin to carbohydrates intake. Being proactive regarding insulin needs. http://guidelines.diabetes.ca/Browse/Chapter11

5. Basic Carbohydrate Counting Keep it Simple!

8. These Foods Contain Carbohydrate Food GroupsCarbohydrate in One Serving GRAINS & STARCHES 15 g FRUITS15g MILK & ALTERNATIVES 15g OTHER CHOICES15g EXTRA FOODS0-5g http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-the- basics-presentation.ppt

9. These Foods have Little or No Carbohydrate Food GroupsCarbohydrate in One Serving MEAT & ALTERNATIVES 0 grams (except for ½ cup Legumes 10- 15 grams) VEGETABLES0grams (except for ½ cup squash 10 grams, parsnips 10.5 grams and peas 7 grams) FATS0 grams http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/beyond-the- basics-presentation.ppt

10. Basic Carbohydrate Counting Tools Food Sources of Carbohydrates Handouts, CDA resources Food models Food labels Apps http://www.diabetes.ca/diabetes-and-you/healthy-living-resources/diet-nutrition

12. How to Read Labels 1. Look at serving size and compare it to the amount of food being eaten 2. Carbohydrate includes starch, sugars, and fibre 3. Fibre should be subtracted from total carbohydrate because it does not raise blood glucose http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional- resources/beyond-the-basics-presentation.ppt

13. How to Read Labels with Sugar Alcohols

14. Websites http://www.calorieking.com/ http://www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri- data/index-eng.php http://ndb.nal.usda.gov/ndb/search/list

15. Apps You need to know if the app is based on an accurate data base. This is especially important for insulin dosing. Calorie King, Eat Wise and USDA are accurate data bases. www.calorieking.com http://www.eatwise.ca/ http://ndb.nal.usda.gov/ https://mysugr.com/apps/ is a useful tracking toolhttps://mysugr.com/apps/

16. Recommended carbohydrate intake Consider individual energy needs Exercise patterns Individual eating pattern Food preferences

17. Carbohydrate Recommendations Carbohydrates % of total energy45%50%60% Women (1300- 1800 kcal/day) 145- 200 grams/day 160- 225 grams/day 195-270 grams/day Men (1800-2000 kcal/day) 200-225 grams/day 225-250 grams/day 270-300 grams/day

18. General Guidelines: Carbohydrates/Meal WomenMen To lose weight30-45 g45-60 g To maintain weight45-60 g60-75 g For very active Snacks 60-75 g 15-30 g 60-90 g 15-30 g Individualize Distribute evenly for good blood glucose control Consider individual energy needs, exercise patterns, individual eating pattern and food preferences

19. Beyond Carbohydrate Counting Diabet. Med. 27, 348-353 (2010) A study of 102 children with Type 1 Diabetes and adolescents and 110 caregivers estimating the carbohydrate content of 17 meals containing 8-90 grams of carbohydrates.

20. Beyond Carbohydrate Counting Diabet. Med. 27, 348-353 (2010) Results: 73% of all estimates were within 10-15 g of actual carbohydrate content. It did not matter what method of carbohydrate counting they used. Underestimated larger meals Overestimated snacks Longer diabetes duration had a negative effect on accuracy of carbohydrate estimation More accuracy when using packaged foods

21. Beyond Carbohydrate Counting Diabet. Med. 27, 348-353 (2010) Recommendations: It is suggested that ±10-15 grams difference in Carbohydrate estimation does not significantly changes the post prandial blood glucose levels. Specific advice to regularly check the serving sizes of main meal items such as rice, pasta and starchy vegetables may maintain accuracy as appetite changes. Snack foods such as fruit require size comparisons with food models or real food to improve accuracy. Consistency in carbohydrate estimation have a greater impact on HbA1C than accuracy.

23. Advanced Carbohydrate Counting … Use All the Basic Teachings − Handouts, Food models, food Labels, Apps and Carbohydrate Targets, etc PLUS some more … - Carbohydrates are not all equal - High protein and fat containing foods - Matching Carbohydrates to Insulin; Insulin to Carbohydrate Ratio and Correction Factor

24. Glycemic Index 2013 CDA guidelines suggest choosing lower glycemic index carbohydrates to help optimize blood glucose For the same number of carbohydrate grams, low or medium GI foods may raise blood glucose less than high GI foods. Mismatch between insulin action and carbohydrate absorption following a high GI foods may lead to a rapid glucose spike. Glucose determinations at 1-2 hours postprandial will be instructive. Low GI foods with high fructose and/or sucrose content (e.g. fruit juice) lead to a rapid glucose spike

25. Fats Late post prandial hyperglycemia is the predominant effect of dietary fat Some studies show lower glucose concentrations in the first 2-3 hours due to delayed gastric emptying* Addition of 50 grams of fat can increase insulin requirements by twofold. * Diabetes Care 2015; 38:1008-1015

26. Proteins Protein affects blood glucose in the late post prandial period. If 30 g protein is consumed with minimum 30 grams of carbohydrate containing foods, blood glucose levels rise after 3-4 hours (2-3 numbers). This is the amount of protein in 4 oz cooked lean meat. If at least 75 grams of protein (8 oz of lean steak) is consumed without carbohydrates, blood glucose increases in 1.5 hours after consumption similar to about 20 grams of carbohydrates. There is an additive effect of protein and fat consumed together at a meal, up to 5.5 number increase at 5 hours post meal. Diabetes Care 2015; 38:1008-1015

27. Teach Advanced Carbohydrate Counting … if a person is on INSULIN and is willing to − Do simple mathematics − Use nutrient analysis information, websites − Have and know how to use measuring cups, spoons and scales − Keep accurate and detailed records − To test his/her blood glucose before and 2 hours after the first bite of a meal − Be motivated and able to take the time required to improve his/her diabetes management

29. The Basal/Bolus Insulin Concept Basal insulin Suppresses glucose production between meals and overnight 50% of total daily insulin needs Bolus (mealtime) insulin rapid- or short-acting insulin given just before a meal in anticipation of the glycemic spike that occurs due to carbohydrate ingestion 50% of total daily insulin needs Given usually as three equally divided doses before meals

30. Blood Glucose Targets for Most People with Diabetes Pre-meal blood glucose: 4.0 – 7.0 mmol/L. 2 hour post-meal blood glucose: 5.0 – 10.0 mmol/L. A rise of 2.0 to 3.0 mmol/L is normal after eating.

31. Insulin to Carbohydrate (I:C) Ratio This is the amount of insulin needed to cover the carbohydrate being consumed at a meal. For example: I:C ratio of 1:10 means 1 unit of insulin would be taken for every 10 grams of carbohydrate Post prandial blood glucose rise of 2- 3 mmol/L is expected when I:C ratio is correct.

32. Ways to determine I:C ratio 1) Quick and Easy Method Starting ratios: 1:15 (1 unit of fast-acting insulin for 15 grams of carbohydrate) Ratios vary 10:1 for insulin resistance/obese individuals 20:1 for young, thin individuals

33. Ways to determine I:C ratio 2) Pattern Management Review food, insulin and blood glucose records Identify trends For example: 70 grams of carbohydrates 7 units of fast acting insulin Blood glucose before lunch: 7 mmol/L Blood glucose 2 hours later: 9.5 mmol/L 70 g carb ÷ 7 units of insulin = 10 I:C is 1:10

34. Ways to determine I:C ratio 3) 500 Rule Divide 500 by the total daily dose of insulin I:C Ratio = 500 ÷ total daily dose of insulin Example: The total daily dose of insulin = 35 units 500 ÷ 35 = 14 I:C ratio = 1:14 So for every 14 grams of carbohydrate the patient eats, they will take 1 unit of rapid- or short-acting insulin

35. Many Variables Influence Glycemic Control.... Food Exercise/activity Illness Insulin absorption Insulin resistance Stress/coping Always assess the variables and keep this in mind when considering an insulin dose adjustment.

36. Compensate for unanticipated high blood sugar, using “correction insulin” This is called Insulin Sensitivity Factor or Correction Factor (CF)

37. How to Determine a starting Correction Factor 100 Rule: Divide 100 by the total daily dose of insulin For example, if total daily dose is 50 units: 100 ÷ 50 = 2, CF is 1:2 Individualize, this varies by weight of the person, time of the day and with hormonal fluctuations and very high blood glucose

38. So, if the person’s blood glucose is 9 mmol/L, and their target glucose is 7 mmol/L, then: Current blood glucose – target blood glucose ÷ CF (9 –7) ÷ 2 = 1 Therefore, if the persons blood glucose is 9.0 mmol/l and they want to bring it down or “correct” it to 7.0mmol/, they need to take 1 unit of rapid- or short-acting insulin.

39. Case Studies

40. Mary has been taking insulin for 3 months. She has been following a consistent carbohydrate meal plan and has adjusted her insulin doses using pattern management. She has good comprehension of carbohydrates and is ready to start learning how to self-adjust her insulin based on carbohydrate counting. She attends a “Carb-counting class” at her local diabetes education centre and has a follow up with the dietitian today. Mary’s current insulin doses are: Long-acting Insulin 20 units QHS Rapid-acting Insulin 10/8/12 units at Breakfast, Lunch and Supper respectively. What is Mary’s estimated I:C ratio? Total insulin: 50 units 500 ÷ 50 = 10

41. Joe is placed on multiple daily insulin injections He weighs 100 kg. His insulin requirements are 0.5 units/kg His total daily dose is: 100 kg x 0.5 units/kg = 50 units His insulin dosage: Glargine (long acting) - 26 units QHS Aspart (rapid acting) - 8 units at each meal Joe is working with his diabetes educators learning to adjust his insulin using carb-counting and correction factor. Question: What is Joe’s estimated I:C ratio and CF? I:C 500 ÷ 50 = 10 CF: 100 ÷ 50 = 2

42. Joe is about to eat breakfast and figure out how much rapid insulin he needs to take for breakfast: 2 fried eggs 3 slices of bacon (0 gms)) 2 slices of whole wheat toast 2 teaspoons of jam (40 gms) 1 glass of orange juice (26 gms) 1 cup of black coffee (0 gms) Total carbs = 66 grams Blood glucose =11.1 mmol/L,Joe’s target range is 4.0 to 7.0 mmol/L I:C ratio = 1:10, CF = 2.0 Question: How much insulin aspart (NovoRapid®) should Joe take? Answer: 1. Insulin to carbohydrate ratio is 1 unit for every 12 grams of carbohydrate 66 ÷ 10 = 6.6 units of insulin for food round to 7, PLUS 2. His blood glucose is 11.1 mmol/L and his target range is 4.0 to 7.0 mmol/L Correction factor is 1 unit to lower her blood glucose by 2 mmol/L 11.1 – 7 (his target glucose)] ÷ 2 = 2 units Total dose : 7 + 2 units = 8 units of insulin aspart

43. Adjusting Insulin for Exercise

44. Effects of Exercise on Blood Glucose Physical activity includes more than formal exercise; everyday activity such as yard work, lawn mowing and shopping are activities that can have an impact on blood glucose. Physical activity increases the body’s sensitivity to insulin and the speed that it is absorbed. Physical can cause Blood Sugar Activity The effects of exercise can last up to 24 hrs When planning for increased physical activity, individuals should consider decreasing insulin, increasing food or a combination of both.

45. ExerciseBG (mmo/L)CarbohydrateSnack type/portions Light x 60 min. - Walking, bowling Less than 6.015 gms1 starch or fruit Moderate x 60 min. - Tennis - Swimming - House cleaning - Golf Less than 6.030 gms before exercise. An additional 10-15 gms for each additional hour. 2 starch or fruit 6.0 - 10.015 gms1 starch or fruit 11.0 – 17.0 (no ketones) No food increase 17.0 or greater and moderate ketones Do not exercise until diabetes control improves Strenuous x 60 min. - Hockey - Racquetball - Competitive sports Note: Small amounts at frequent intervals are preferable for prolonged activity Less than 6.045 gms before exercise. Additional 10-15 gms for each additional hour. 2 starch, 1 protein & 1 fruit 6.0 – 10.030 gms2 starch & 1 protein 11.0 – 17.0 (no ketones) 15 gms1 starch or fruit 14.0 or greater and moderate ketones Do not exercise until diabetes control improves Ex-Carbs for Exercise Guidelines (adult)* *Adapted from Saskatchewan Insulin Adjustment Module, December 2005

46. Adjusting Insulin for Exercise/activity…. Light activity (walking) – 10-20% reduction Moderate (brisk walking, jog, fitness class, swimming) – 30-40% reduction Strenuous (hard run, sprints, sports) – 50% or more reduction *Remember, these are guidelines only, individual responses vary!

47. Questions?