Advanced Skills (PDF) - Diabetes Source

carb counting Participants will have a better understanding of:     

The benefits of carbohydrate counting; What foods contain carbohydrate; How to count carbs using food labels, books and the LMC Carb Counting Meal Plan; How to visualize and estimate serving sizes; Dietary variables that influence absorption of carbs (i.e. glycemic index);

Workshop Outline

100 . 101 . 102 . 103 . 104 . 105 . 106 . 107 .

Introduction Why Carb Count? How to Carb Count? Dietary Variables Group Carb Counting Activity MDI Pump Info Questions?

Handouts The Glycemic Index (CDA) Sugars & Sweeteners (CDA) LMC Carb Counting Meal Plan LMC Guide to Carb Counting LMC Advanced Carb Counting Homework for patients on MDI OR 3-day food record for all other patients DEC Workshop Evaluation DEC Workshop List for Patients

Materials Needed Food Models Folders Pens Food labels Demo pumps and infusion sets

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Introduction

Briefly introduce yourself Be sure that participants are in the correct workshop Find out what they are expecting to gain from the session Find out if anyone is on insulin, and what type of insulin they are on Briefly outline what they can expect to gain from the workshop

My main learning objective for you today is to learn/refresh your memory as to what foods contain carbohydrates and learn how to eat a healthy amount of these carb containing foods each day. Towards the end of the class we’ll talk about future considerations for those on insulin or those considering pump therapy. 101

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Why Carb Count?

Carb counting helps you understand how the foods you’re about to eat impact your blood glucose levels Helps you learn the serving sizes of the carbohydrate foods you eat to help you with meal planning, balancing your meals, maintain a healthy weight, etc Can help keep your blood sugars within a healthy range by balancing your carb intake throughout the day. More flexibility in making food choices

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How to Carb Count

Record on the white board the following 3 steps: Step 1: Know your sources of carbs (i.e. what foods contains carbohydrates?) Step 2: Know your carb servings Step 3: Know how many carbs you can have Step 1: Sources of Carbs ► Quiz the participants: Where are the carbs? Hand out food models to each patient and ask them to put them in the appropriate pile (carbs? or no carbs?). Review and discuss.

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Step 2: Know your Carb Servings So now that you all know what foods have carbs in them, the next step is learning what a serving of these foods look like. (Use food models as much as possible).  ►Provide and review the LMC Carb Counting Meal Plan handout  15 grams of carbohydrate per serving (point out that all choices on the page are equivalent to 15 g of carbohydrate).  ►Give examples of serving sizes in each food group  ►Point out a few food items from each food group and ask them to tell you the serving size 

Grains & Starches (measure after cooking) o Whole-wheat bread: 1 slice (reinforce that the whole grain is in the green box and the white is in the yellow box) o Bagel: ¼ o Rice: 1/3 cup o Pasta 1/2 cup o Potato: ½ medium

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Fruit: o Apple: 1 medium o Banana: 1 small o Strawberries: 2 cups

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Milk Products: o 1% milk: 1 cup o Plain yogurt: 3/4 cup o Artificially Sweetened Yogurt: ½ to ¾ Cup please read the label

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Other choices (sweet foods and snacks): o Low fat popcorn: 3 cups (after cooking) o Arrowroot cookies: 3 o Muffin: ½ small

Q. How can we find out the carbohydrate content of the foods we eat? Use responses to lead you into each method.

1. Estimate Portions:  If you’re not one to pull out a measuring cup each time you eat, then being able to estimate a serving based on the visual size of the food along is important.  ►Review the “LMC Guide to Carb Counting ” hand-out.  ►Demonstrate each with its corresponding measurement: o Hockey Puck (1/2 cup) 2012 Advanced Carb Counting 111220

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Golf Ball (1/3 cup) Tennis Ball (3/4 cup) Baseball (1 cup) Deck of Cards (3 oz) 6 Dice (1 oz) 1 fist = ~ 1 cup, 2 handfuls = ~ 2 cups

This information will come in handy when you’re eating out or need to quickly estimate how many carb servings you’re having. Using these guidelines can be helpful for weight loss but if you’re adjusting your insulin for the carbs at your meals or working towards getting on an insulin pump, these guidelines might not be precise enough. A more precise way to carb counting is to use labels and measuring cups.

2. Food Labels

Most packaged foods will come with a “Nutrition Facts” label on them. They make carb counting much easier because they give the exact number of grams of carbohydrate in a serving. Reading Food Labels Review:  Review rules: o First look at serving size. This is what everything is based on. o Look at the amount of carbs in that serving. o Subtract fibre and sugar alcohols from the carbs o Limit foods with added sugar if possible 

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Q. What are the 3 components of Carbohydrates on a label? o Fibre o Sugars o Starch (sometimes not listed) Q. Do all 3 components raise blood sugars? o Fibre does not raise your blood sugar so you can subtract the fibre from the total carbs to figure out the amount of carbs that will affect your blood sugar. o ►Provide labels(i.e. cereal) for the participants to review together. o As well, sugar alcohols only raise your blood sugar slightly. o Q. Has anyone heard of sugar alcohols before? o ►Bring attention to CDA Sugars & Sweeteners Handout o You can also subtract the full amount of sugar alcohols from the total amount of carbs. Sugar alcohols are usually only found in "diabetic" foods, or foods labeled as "sugar free". o Give each person a label to read to the class (carbs, fibre, sugar alcohols). Provide some “shocking” labels and ideally some that have sugar alcohols in them. 2012 Advanced Carb Counting 111220

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o If you are still uncertain about the amount of carbs in a certain food, you can get the book “Nutrient Values of Common Foods” from Health Canada.

3. Other Resources Also useful, are carb counting books, cookbooks or websites that list foods:  Books o i.e. The Carbohydrate Gram Counter by Corinne Netzer, lists over 10, 000 foods. o Your local book store will have many other available resources.  Cookbooks o Many healthy cookbooks will list the nutrition information for each recipe. o Example: Simply Great Food by Dietitians of Canada OR Choice Menus by Marjorie Hollands & Margaret Howard – published in cooperation with CDA  Food Scales o Salter Nutritional Scale - weights food and provides calories, carbs, fat etc ($70-80 -can buy on-line or at William Sonoma)  Websites o There are various sites that offer nutritional information, great for fast food or specific products. o www.calorieking.com -type in any food to discover the nutrition facts o Free to download, Nutrient Values of Some Common Foods, Health Canada o www.dietitians.ca/eattracker  Software o Various apps for iPhone and BlackBerry such as “Carbs&Cals” or “MyFood” or “Loseit” Step 3: Know how many carbs you can have  The amount of carbs that should be eaten a day varies person to person depending on their body size, gender, age, and activity level.  Q. How many carbs CAN you have at a meal?


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If you’re looking to lose weight or have a smaller appetite aim for 30-45g per meal. If you have a larger appetite or you just want to maintain your weight 4560g/meal is usually appropriate. For those people on meal-time insulin, if you know how to adjust your insulin for the amount of carbs you’re eating, then you don’t necessarily need to restrict your carb intake. If you’d like to learn more about adjusting your meal-time insulin, book an individual appointment with your educator For good health and balanced eating, choose a variety of foods – rather than having all 45 grams come from starches, try to have 15g from fruit, 15 grams from milk/yogurt, 15 grams from starch. The biggest challenge is being sure that you are choosing the healthiest carb option, most of the time.

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Dietary Variables?

All dietary choices can have an impact on how quickly or slowly your body handles carbohydrate. One thing we know is that are all carbohydrates are not the same. We know that they all raise our blood sugar, however, we all know that some carbs are healthier choices than others. For example, what happens to your blood sugar after you eat a bowl of candy vs. a slice of whole grain bread? Use feedback from the participants to lead you into a discussion about the Glycemic Index.  ►Provide “The Glycemic Index” hand-out  The glycemic index is a scale that ranks carbohydrate servings by how much they raise your blood glucose levels. Foods with a low glycemic Index: 1. help to control your blood glucose levels 2. help to control your appetite  ►Have patients look at “The Glycemic Index” hand-out ►Point out some low GI and high GI foods Q. As well, you will notice other dietary factors that will influence the effect that a meal can have on your blood sugar. Does anyone know what they are? 

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Fat: o The fat in certain foods may delay the absorption of carbohydrate from the intestine and reduce the expected rise in blood sugars. Protein 2012 Advanced Carb Counting 111220

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o Normal portions of protein have little impact on blood sugars and are recommended as a part of every balanced meal. o VERY large quantities of protein however, can cause blood sugars to rise. Some 50% of protein calories are slowly converted to glucose over a period of several hours (ex. A 12-ounce steak or several ounces of cheese may cause blood sugars to rise 4-12 hours after). 104

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Group Carb Counting Activity

On the back of LMC Guide to Carb Counting let’s practice together. Add up the number of carbohydrates/meal and per day. Review if these meals are balanced – remember the plate method. How can we make them healthier?

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MDI ?

Educator Note: some people in the class will not be on insulin at all, may be on mixed or just basal. This next section of the class is an explanation for future consideration for these patients. For pts on MDI they might want to leave the class with an IC ratio or ISF – use your discretion on how much detail to go into here. Consider calculating their ISF. Do not calculate IC ratio – encourage pt to book 1:1 f/u for this.

Step 1: Basal vs. Bolus 

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A “bolus” of insulin should be taken before a meal, and the timing depends on the type of insulin you’re using (ex. Rapid insulin should be taken 0-15 minutes before a meal). Your basal insulin (once or twice/day) should be taken at approximately the same time everyday. Or, if you are on pump therapy your basal insulin is simply a slow infusion of rapid/fast acting insulin. ►Review different types of insulin in chart and their actions. ►Demonstrate the action of a normal pancreas compared to a MDI regimen (i.e. they are the same).

Step 2: Insulin to Carb Ratios


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Insulin:Carb ratios are used to determine how much insulin you should take according to how many carbs you’re eating. This allows you to have more flexibility! Your I:C ratio may be different for each meal. As well, your insulin requirements might change over time, and therefore you may require a new I:C ratio. We will help you along the way!

Example: If you have a 60g carb meal and your IC ratio is 1u:15g, how much insulin would you take?

Step 3: Insulin Sensitivity Factors    

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An Insulin Sensitivity Factor is the amount of mmol/L your blood sugar will drop with just 1 unit of fast acting insulin. Your educator can help you determine what your ISF is – It can be determined using your total daily dose of insulin. You use your ISF to calculate a correction dose of insulin when your blood sugars are high before a meal Your correction dose is the amount of extra insulin that you take, IN ADDITION to the amount you have calculated to cover your meal, to bring your BS within target. (Current BG – Goal BS) ÷ ISF ____ = ____ U of extra insulin to take with meal

Example : educators to explain how to use ISF with the numbers below Current BG = 12.0 Goal BG = 6.0 ISF = 2 Educator Note: if there are any patients on MDI who want to know their ISF the calculations is: 100/TDD = ISF

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Pump Info

Has anyone seen an insulin-pump before or know how they work? Few people will really know how they work so this will likely need to be explained in detail. Pumps work more similarly to a pancreas for a few reasons: 1. Only uses 1 type of insulin – rapid acting insulin (Humalog, Novorapid or Apidra) 2012 Advanced Carb Counting 111220

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2. The pump gives a small pulse every few minutes which adds up to an hourly rate called a basal rate. This is the background insulin keeping blood sugars in control overnight or when you’re not eating. This replaces Lantus/Levemir/NPH 3. The pump has a bolus calculator to determine meal-time or correction boluses. You count up your carbs and enter that info into the pump, you check your blood sugars and enter that info into the pump and the pump uses both the carbs and BG to calculate the bolus. You confirm and then its delivered. This replaces your meal-time injections Connecting to the pump:  Show a reservoir and explain this gets filled with rapid acting insulin either from a vial or the cartridges pts are familiar with.  Then show the tubing and insertion site and explain that the patient would insert the site, connect the tubing to the reservoir and put the reservoir into the pump.  Remind pt that they must change the entire infusion set – site, tubing and reservoir – every 3 days. Cost of the pump: Explain that there is a government program called ADP which will cover the cost of the pump and give annual support for pump supplies for those Type 1 patients who qualify. For Type 2 patients, they need to look into private insurance coverage. If you’re interested in going on a pump and you’d like more information or to see if you qualify for ADP, please book an individual appointment.

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Questions ?

Follow-up note: Have 2 options – pts interested in learning IC ratio and ISF can take MDI homework sheets and book 1:1 counseling. Pts not concerned about insulin but who want f/u for meal planning can take 3-day food record and book 1:1 counseling


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