Carbohydrate Counting for Pediatric Patients With Type 1 Diabetes

1. Carbohydrate Counting for Pediatric Patients With Type 1 Diabetes Review Date 4/08 K-0591

2. Program Purpose • To increase knowledge of carbohydrate counting and insulin management skills for those caring for patients with Type 1 diabetes (T1DM) • A solid knowledge base of carbohydrate counting and insulin management is important • RNs are often the first point of contact with the pediatric patient with T1DM

3. Program Objectives At the end of the session, you will know how to: • Identify categories of foods containing carbohydrate • Identify the relationship between carbohydrates and blood sugar • Determine the grams of carbohydrate in foods when using the nutritional food label and other carbohydrate-counting tools • Calculate the total grams of carbohydrate/meal • Use insulin-to-carbohydrate ratios to determine the amount of insulin required during mealtimes

4. Carbohydrate (CHO) Counting Defined • A meal-planning approach based on the following ideas • Carbohydrate is the main nutrient affecting postprandial glycemic response • Total amount of carbohydrates consumed is more important than the source of carbohydrates

5. Benefits of Carbohydrate Counting • More flexible than other meal-planning methods • Sugar is not forbidden • Focuses attention on the foods that are most likely to make blood glucose levels go up

6. Foods That Contain Carbohydrates • Breads, cereals, pasta, and grains • Rice, beans, and starchy vegetables (potatoes, corn, peas) • Fruit and fruit juices • Milk and yogurt • Regular soda, fruit drinks, jelly beans, and gum drops • Cakes, cookies, and chocolate candy

7. Grams of Carbohydrate(per Food Category) • Starch and Fruit: 1 serving equals about 15 g carbohydrate • Milk: 1 serving equals about 12 g carbohydrate • Vegetables: 1 serving equals about 5 g carbohydrate *Please see handout on carbohydrate foods

8. Starches

9. Starch Group

10. Fruits and Fruit Juices

11. Fruit Group

12. Milk and Yogurt

13. Milk Group

14. Vegetables

15. Vegetables Vegetables are counted as 5 g carbohydrate for the following servings sizes: • ½ C cooked vegetables • 1 C raw vegetables

16. Foods Without Carbohydrate Protein and fat groups contain 0 g carbohydrates Examples: • Protein: Meat, fish, poultry, cheese, eggs, peanut butter, cottage cheese, tofu • Fat: Butter, margarine, mayonnaise, cream cheese, sour cream, nuts, seeds, avocado

17. Carbohydrate and Noncarbohydrate Categories

18. The Relationship Between Carbohydrate and Blood Sugar • The digestive system converts most digestible carbohydrates into glucose (also known as blood sugar) • Cells are designed to use this as a universal energy source • As blood sugar levels rise in a nondiabetic individual, beta cells in the pancreas churn out more and more insulin, a hormone that signals cells to absorb blood sugar for energy or storage

19. Carbohydrate and Blood Sugar in T1DM • People with T1DM don't make enough insulin, so their cells can't absorb sugar • Carbohydrates begin to raise blood glucose within approximately 5 minutes after initiation of food intake • Carbohydrates are converted to nearly 100% blood glucose within about 2 hours

20. Carbohydrate and Blood Sugar in T1DM • The focus of carbohydrate counting is on the 1 nutrient that most impacts blood glucose • Carbohydrate is the primary nutrient affecting blood glucose levels • Individuals can learn to relate carbohydrate intake with their blood glucose results

21. Carbohydrate Substituting • When carbohydrate counting, it is possible to substitute 1 food item for another for a similar impact on blood glucose • Example: Exchange a small apple (4 oz) for 2 small cookies for a similar effect on blood glucose

22. Food Labels Total Carbohydrate— includes grams of sugar, sugar alcohol, starch, and dietary fiber Total Grams of Carbohydrate—to determine amount of carbohydrate eaten,multiply grams of total carbohydrates on the label by the number of servings eaten

23. Food Labels • Example: You just ate 10 crackers from the previous label • There are 2 crackers/serving • How many servings did you eat? • 5 • How many total carbohydrates did you consume? • 10 g/serving x 5 servings=50 g

24. Tools for Carbohydrate Counting Nutrition Labels Measuring Tools

25. Carbohydrate Counting Hand Guide

26. Sample Menu #1 How many carbohydrates are in this meal? 6 chicken nuggets=? 2 packets of ketchup=? Small banana=? 8-fl-oz 2% milk=? Small bag of potato chips=? 8-fl-oz iced tea (unsweetened)=? *See handout

27. Sample Menu #1 Answers 6 chicken nuggets=15 g 2 packets of ketchup=6 g Small banana=15 g 8-fl-oz 2% milk=12 g Small bag of pretzels=15 g Iced tea (unsweetened)=0 g TOTAL=63 g

28. Sample Menu #2 Breakfast 2 slices of toast, 4-fl-oz juice, 6-fl-oz milk Snack 1 3 graham crackers, 1 slice of cheese Lunch Hot dog on bun, 15 French fries, 4-fl-oz milk, 2 ketchup packets Snack 2 1 slice of bread, 1 slice of cheese Dinner 1 C macaroni and cheese, 1 small fruit Snack 3 4 graham crackers, 1 Tbsp peanut butter

29. Sample Menu #2 Answers Breakfast=50 g Snack 1=15 g Lunch=72 g Snack 2=15 g Dinner =60 g Snack 3=20 g TOTAL FOR DAY=232 g

30. Insulin-to-Carbohydrate Ratio • Insulin-to-carbohydrate ratio: The units of insulin needed to "cover" a specified number of carbohydrate grams • An important tool for intensive diabetes management • Divide the total grams of carbohydrate consumed by the carbohydrate-to-insulin ratio

31. Insulin-to-Carbohydrate Ratio • To improve blood glucose control for people using intensive diabetes management, match the amount of insulin with carbohydrate intake • Understanding carbohydrate counting is required: • To assure the administration of the appropriate insulin-to-carbohydrate ratio at mealtimes in hospitalized patients • For glycemic control • For the prevention of hypoglycemia and/or hyperglycemia

32. Insulin-to-Carbohydrate Ratio • Example: A child is to consume 60 g carbohydrate • Her premeal blood glucose is within normal range • Her insulin to carbohydrate ratio is 1:20 • For every 20 g carbohydrate eaten, 1 unit of fast-acting insulin (NovoLog®) is required

33. Insulin-to-Carbohydrate Ratio Answer: • 60 g total carbohydrate/20 insulin-to-carbohydrate ratio=3 • Therefore, 3 units of fast-acting insulin (NovoLog) is required for this meal

34. Thank you for attending this education program on carbohydrate counting.

35. References • Thomas E. Survey reveals shortfall in pediatric nurses' knowledge of diabetes. J Diabetes Nurs. 2004;8:217-221. • American Dietetic Association, American Diabetes Association. Exchange Lists for Meal Planning. 2nd ed. Alexandria, VA: American Diabetes Association; 2003. • American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2007;30:S4-S41. • Warshaw H, Kulkarni K. American Diabetes Association Complete Guide to Carbohydrate Counting. Alexandria, VA: American Diabetes Association; 2004. • Warshaw H, Bolderman K. Practical Carbohydrate Counting. A How to Teach Guide for Health Professionals. Alexandria, VA: American Diabetes Association; 2001. • International Diabetes Center at Park Nicollet. My Food Plan for Kids and Teens. Minneapolis, MN: Park Nicollet; 2006.

36. QUESTIONS?